Every finding on record at Western Horizons Care Center

Based on record review, review of the facility reported incident (FRI), and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #1) injured during a transfer. Failure to utilize the appropriate equipment and staff assistance resulted in an injury to Resident #1 and placed all residents at risk for injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented.Findings Include:The surveyor determined a deficient practice existed on 11/23/25. The facility implemented and completed corrective actions by 03/24/26. Review of the facility policy titled Safe Resident Handling/Transfers With Use of Mechanical lifts occurred on 04/28/26. This policy, dated 05/23/25, stated, . All residents require safe handling when transferred to prevent or minimize risk of injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and nobility, the use of mechanical lifts are a safer alternative and should be used. Two staff members must be utilized when transferring residents with a mechanical lift.Review of the initial FRI, dated 11/23/25, stated, . Laceration to right side of head and right hand. Bruising to right eye . It is noted the resident cannot self-transfer. Resident sent to ER [emergency room] for further evaluation.Review of Resident #1's medical record occurred on 04/28/26. Diagnoses included Parkinson's disease and Alzheimer's disease. The care plan stated, . [Resident #1's name] requires substantial assistance by (2) staff to move between surfaces upon waking in the morning until evening. [Resident #1's name] then uses the sit to stand lift and assistance from (2) staff to complete transfers after 5 PM.Resident #1's progress notes, dated 11/23/25 at 11:12 p.m. stated, . I seen that there was a small amount of blood on the floor. Looking at [Resident #1's name], she has a significant lump to her right forehead with small laceration noted above right eye also a laceration noted to right hand. Pt [patient] is non-verbal and non-ambulatory. Unable to do a complete neuro [neurological] assessment R/T [related to] pt's condition. EMS [emergency medical services] called.Review of the facility incident investigation report, dated, 11/29/25, stated, . Conclusions Injuries likely occurred during or shortly after an improper transfer. CNA [certified nurse aide] failed to follow care plan requiring sit-to-stand with two staff.The facility failed to ensure staff preformed a safe resident transfer for Resident #1 which resulted in a transfer to ER and treatment of a head contusion and lacerations. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the following corrective actions to ensure all residents affected by the deficient practice were transferred in an appropriate manner. * 11/24/25, Reported the incident to the State Survey Agency. * 11/24/25, Suspended and later terminated the staff member involved in the improper transfer. * 11/29/25, Completed an investigation into Resident #1's injuries. * November 24-28, 2025, Charge nurses completed verbal review of residents care plans to nursing staff during morning report. * March 23-24, 2026, Education completed for all staff on fall prevention and skills competency regarding use of sit-to-stand and full mechanical lifts.

Based on record review, facility policy review, and review of the facility reported incident (FRI) investigation, the facility failed to ensure residents remained free from abuse for 1 of 1 closed record (Resident #40) who experienced sexual abuse from another resident. Failure to protect residents from sexual abuse resulted in fear, anxiety, and mental anguish. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include:The survey team determined a deficient practice existed on 04/27/25. The facility implemented corrective action immediately, completed corrective action on 04/28/25, and continued with staff education and monitoring. Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 09/03/25. This policy, revised May 2025, stated, Each resident has the right to be free from abuse . Residents must not be subject to abuse by anyone, including . other residents . Sexual Abuse is non-consensual sexual contact of any type .The initial FRI, dated 04/28/25, stated, On 4/28/25 OT [occupational therapy] approached DON [director of nursing] and administrator stating [Resident #40] had reported to her that [Resident #15] had put her [sic (his)] hand down her shirt while she was sitting in the dining room, asked her if she liked it, in which [Resident #40] shook her head no. The 5-day FRI investigation, dated 05/01/25, indicated at the end of a therapy session on 04/28/25 staff asked Resident #40 if she would like to stay in her room or go out to main area. Resident #40 replied, I am kind of scared to go out of my room. When asked why, she explained being left alone in the dining room the night before with Resident #15. Resident #40 stated, He touched me, and it really upset me. He reached his hand down my shirt, between my breast, and began rubbing up and down.I don't ever want it to happen again. The facility's review of the dining room video surveillance showed on 04/27/25 at 6:55 p.m. Resident #15 approached Resident #40, rubbed his hand on her chest, and walked away a few moments later.Review of Resident #40's medical record occurred on 09/03/25. Diagnoses included anxiety and post-traumatic stress disorder. An admission Minimum Data Set (MDS), dated [DATE], identified Resident #40 as cognitively intact. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented correction actions for all resident who may be affected by the deficient practice as follows:* Completed an immediate investigation following the incident. * Notified both residents' families of the incident. * Notified the physician of the incident. * Moved Resident #15 to another hallway of the building, occupied by male residents only.* Implemented one-hour checks on Resident #15's location.* Required staff to ensure Resident #15's is not left alone in same room with a female resident. * Educated all staff present during 04/28//25 shift and each shift thereafter, regarding the incident and monitoring Resident #15's location. * Updated care plans for Resident #15 and Resident #40. * Conducted a staff meeting on 05/01/2025 to further educate regarding abuse, and Responding to Resident's Sexually Inappropriate Behavior.

Based on record review, review of facility procedure, review of manufacturer's use instructions, and staff interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #8) who fell from a mechanical lift. Failure to safely use the mechanical lift resulted in a fall with injury. Findings include:Review of the facility procedure Use of Hoyer (Full Body) Lift occurred on 09/04/25. This undated procedure stated, . Mechanical Lift from Bed to Chair . Positioned the lift under the bed and widened the base of the lift.Review of the Volaro Series 4 Lift Operator's Manual occurred on 09/04/24. This manual, dated March 2019, stated, . Safety Notes . Lift legs must be fully extended into the wide position when lifting a patient or resident. Lifting from Bed to Chair using the Divided Leg Sling: . If the base is in the narrow position, adjust it to the widest position once you are clear from the bed and always before turning the lift. General Procedure Guide for Training . 19. Check the legs are in the wide position . If base position must remain in a narrow position, make sure the lift area between the bed and chair are clear of any obstacles. Widen once clear from bed.Review of Resident #8's medical record occurred on all days of survey. Diagnoses included hemiplegia [paralysis of one side of the body]. The current care plan stated, . requires Mechanical Lift (hoyer) with (2) [two] staff assistance for transfers.Review of Resident #8's nurse's notes identified the following:*09/02/25 at 9:10 a.m., . [Resident #8] was in the process of being transferred from the bed to the Broda [tilt-in-space mobile positioning chair] chair. [Resident#8] is tall and his legs do not bend so he needs to be placed in the Broda chair sideways. His legs will hit the bar of the lift if he is put in the chair forward. [Resident #8's] foot became entangled in the Broda chair and as a result the hoyer lift began to tilt sideways. One aid grabbed his feet and the other grabbed his head and [Resident #8] was placed on the ground. RN [registered nurse] was paged to the room patient was laying on his back on the floor. Asked patient from top to bottom if any area was hurting him and he stated 'no'. It was noted that his left great toe had a laceration at the time and was bleeding. ER [emergency room] nurse called and EMS [emergency medical services] called. Family notified of transfer to the hospital.*09/02/25 at 09:18 a.m., . Received report from [name] RN at hospital. [Resident #8] has no injuries from the fall. dermabond [a sterile liquid skin adhesive] on . left great toe and steristrips .*09/04/25 at 2:25 a.m., . resident moaned in pain. Knee has some swelling now to it, and he complained of pain upon ROM [range of motion] of Left knee and leg. Will continue to evaluate this leg. Will offer resident an ice pak [sic] to knee.*09/04/25 at 6:55 a.m., . Resident has swelling in his left knee which is migrating up to his Left hip. Ice was applied x2 [two times] which did not offer reduced swelling. Patient c/o [complained of] 10/10 pain upon moving him. This nurse called his son . who requested him being sent to ER for evaluation that may have not been noted on his last ER visit.*09/04/25 at 11:11 a.m., . This nurse spoke to nurse . at [critical access hospital] who stated resident would be transferred out due to left hip fracture .Interviews with staff identified the following:*09/02/25 at 10:50 a.m. a certified nurse aide (CNA) (#3) confirmed the resident fell while she and another CNA (#4) transferred the resident from the bed to the Broda chair. The CNA (#3) confirmed the base/legs of the mechanical lift were closed while they moved Resident #8 from the bed to the Broda chair, the resident's leg caught on the chair, and the lift tipped on it's left side with the resident landing on the floor. The CNA (#3) confirmed staff kept the base/legs closed in order to get the lift under the Broda chair. *09/03/25 at 3:35 p.m., two CNAs (#5 and #6) confirmed they approach Resident #8's Broda chair from the side and the base/legs of the mechanical lift stay closed during transfers. The facility failed to ensure staff widened the base/legs of the mechanical lift while transferring Resident #8. The facility implemented corrective actions for all residents who may be affected by the deficient practice as follows:*Completed an investigation into Resident #8's fall.*Assessed and transferred Resident #8 for treatment.*Educated CNAs and nurses on proper mechanical lift use.*Sent an educational message to all CNAs and nurses via the HomeBase scheduling app regarding proper mechanical lift use on 09/04/25.*Educated all CNAs and nurses working 09/04/25 on proper mechanical lift use.

Based on observation, review of facility policy, and staff interview, the facility failed to store meds and biologicals appropriately in 2 of 4 medication storage and supply areas (West Wing medication cart and [NAME] Wing medication room). Failure to secure medications in the medication cart and to dispose of expired needles has the potential for unauthorized access of medications and has the potential for inaccurate laboratory results. Findings include:Review of the facility policy titled Expiration of Medications and Supplies occurred on [DATE]. This policy, dated [DATE], stated, . 2. Weekly on every Wednesday, the CMA [certified medication aide]/nurse working on the East and [NAME] Nurses' station will check . the medication room . for . supply expiration dates . Any expired . supplies will be disposed of after removal from . medication rooms .The facility failed to provide a policy regarding locking the medication cart.-Observation on [DATE] of the [NAME] wing medication cart showed the cart unlocked and unattended from 11:51 to 11:56 a.m. and from 12:30 to 12:34 p.m. with residents nearby. -Observation of the [NAME] wing medication storage room occurred on [DATE] at 1:44 p.m. and showed the following:* Three boxes of needles used for lab draws expired in [DATE].* Three individually wrapped needles used for lab draws expired in [DATE].During an interview on [DATE] at 4:20 p.m., two administrative staff members (#1 and #2) stated they expected staff to close and lock the medication carts when unattended and audit the medication rooms for expired supplies.

Based on observation and staff interview, the facility failed to promote privacy and confidentiality of the electronic medication administration record (EMAR) on 1 of 2 units (West Wing) observed. Failure to promote resident privacy and lock computer screens may result in unauthorized viewing of resident records by other residents, visitors, or unlicensed staff. Findings include:A review of facility policy titled Violation Sanctions HIPPA Policies occurred on 09/04/25. This policy, dated June 2020, stated, . Confidentiality: It is the right of an individual to have personal, identifiable information kept private . Violations are defined into categories . failure to properly sign off from or lock computer when leaving a workstation.Observation on 09/02/25 of the [NAME] wing medication cart showed the EMAR open and visible to visitors and residents at 11:51 a.m. and 12:30 to 12:34 p.m. without a nurse present.During an interview on 09/03/25 at 4:20 p.m., two administrative staff members (#1 and #2) stated they expected staff to close and lock the EMAR when unattended.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and the State Long Term Care Ombudsman a written notice of transfer and bed-hold notice for 1 supplemental resident (Resident #10) reviewed for hospitalizations. Failure to provide a notice of transfer and a bed-hold notice does not allow the resident and/or their representative to make informed decisions regarding their rights, or inform the Ombudsman of the transfer. Findings include:Review of the facility policy titled Bed Hold Policy occurred on 09/04/25. This policy, dated 05/15/25, stated, . will provide written information to the resident or resident's representative regarding the bed hold policy prior to a transfer . the resident or resident's representative will be provided written information regarding the bed hold policy. will be notified in writing the reasons for the move in a language and manner they understand. The facility will send a copy of the notice to a representative of the Office of the State Long term Care Ombudsman.Review of Resident #10's medical record occurred on 09/03/25. A nurse's note, dated 04/28/25 at 3:09 p.m., stated, . Clinic called at 1500 [3:00 p.m.] and stated that [Resident #10] was admitted for hyponatremia and hypoxia. The medical record lacked a written notice of transfer, a written notice of bed-hold, and notification of the transfer to the State Long Term Care Ombudsman.During an interview on 09/03/25 at 9:15 a.m., two administrative staff members (#1 and #7) confirmed the facility failed to complete a written notice of transfer form, a written bed-hold, and notify the Ombudsman.

Based on observation, and staff interviews, the facility failed to obtain a physician's order for 1 of 1 supplemental resident (Resident #17) observed receiving crushed medications. Failure to notify the provider regarding the resident's ability to swallow whole medications and obtain an order for crushed medications may result in an inconsistency in care and choking. Review of a nurse's report sheet occurred on 09/04/25. This form, dated 08/15/25, showed Resident #17 takes her medications Whole.Observation of medication administration occurred on 09/02/25 at 12:42 p.m. and showed a nurse (#11) crush Resident #17's medication, placed them in pudding, and administered them to the resident. The medication administration record (MAR) lacked documentation indicating staff were to crush the resident's medications. During an interview on 09/02/25 at 12:43 p.m. a staff nurse (#11) stated, We have been crushing her meds for a couple of weeks now since she (Resident #17) came back from the hospital after her stroke.During an interview on the morning of 09/04/25, two administrative staff members (#1 and #10) confirmed Resident #17's medical record lacked an order to crush Resident #17's medications.

Based on observation, record review, review of a dietary document, and staff interview, the facility failed to provide food in a form to meet individual needs for 2 of 2 sampled residents (Resident #15 and #20) with a physician's order for a minced and moist diet. Failure to provide minced and moist food as ordered may result in reduced meal intake, choking, and aspiration pneumonia. Findings include: Review of a document titled Hormel Health Labs Checklists for IDDSI [International Dysphagia Diet Standardization Initiative - standardized system for classifying food and drink textures for individuals with swallowing difficulties] Levels 7, 6, 5, and 4 provided by the dietary manager (#14) occurred on 09/04/25. This undated document described Level 5 Minced and Moist requirements as Soft and moist particle size - very small pieces ([less than] 1/8 inch - adults); Pieces fit between fork tines; Mimics a soft chewed bolus [a soft round mass] . -Review of Resident #20's medical record occurred on all days of survey. Diagnoses included cerebral infarction (stroke) and dysphagia (difficulty swallowing). A physician's order, dated 02/28/25, stated, Regular diet, Minced texture, Honey consistency. Observation of the lunch meal on 09/02/25 showed the facility served Resident #20 cooked peas and diced carrots along with the rest of his meal. Observation on 09/04/2025 at 8:17 a.m. showed Resident #20 ate approximately half of an egg omelet with small pieces of chopped peppers and ham, larger than 1/8 inch. At 8:30 a.m., a dietary manager (#14) attempted to mash the peppers in the eggs and noted the skins did not mash. The dietary manager agreed the peppers were not appropriate for the minced and moist diet. When asked about the cooked peas and carrots served on 09/02/25, she stated staff should have mashed them for Resident #20. -Review of Resident #15's medical record occurred on all days of survey. Diagnoses included dementia and dysphagia, oropharyngeal phase (difficulty transferring food from mouth to throat). A physician's order, dated 07/28/25, stated, Regular diet, Minced texture, Regular consistency. Observation on 09/02/25 of the lunch meal showed the facility served Resident #15 cooked peas and diced carrots along with the rest of his meal.During an interview on 09/03/2025 at 12:40 p.m., a dietary consultant (#15) stated a minced and moist diet required food no larger size than the tine of a fork, and the cooked peas and carrots would not be appropriate.

Based on observation and policy review, the facility failed to follow standards of infection control and prevention for 1 of 6 sampled residents (Resident #19) and 1 of 1 supplemental resident (Resident #17) observed during cares. Failure to practice infection control standards related to hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 09/04/25. This policy, revised December 2024, stated, Hand hygiene is the act of cleaning one's hands to remove potentially harmful substances and organisms. Hand hygiene . highly effective method for preventing the spread of pathogens, such as bacteria and viruses, which can lead to infections. PROCEDURE Indications for Performing Hand Hygiene: Before moving from work with a soiled body site . to a clean body site . After contact with . body fluids . -Observation on 09/02/25 at 10:18 a.m. showed two certified nurse aides (CNAs) (#8 and #9) applied gloves and provided perineal cares for Resident #17. The CNAs removed their soiled gloves and provided perineal cares for Resident #17. The CNAs removed their gloves and failed to perform hand hygiene before moving on to other tasks. -Observation on 09/02/25 at 11:33 a.m. showed two CNAs (#8 and #9) transferred Resident #19 from the wheelchair to the bed. With gloved hands, the CNAs provided perineal cares, removed the soiled gloves, applied clean gloves, replaced clothing, transferred the resident to the wheelchair, and touched various items in the room before removing gloves and performing hand hygiene.

Based on observation, record review, review of the facility reported incident (FRI) report, review of facility investigation documents and camera footage, and staff interview, the facility failed to ensure resident safety for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to ensure door alarms are engaged and in working order allowed Resident #1 to elope from the facility and sustain injuries. Findings include: Review of the Initial Allegation of Mistreatment, Abuse, Neglect, or Theft and Facility Reported Incidents Reporting Form occurred on 01/14/25. This form, dated 01/10/25, stated, . Date of the allegation: 01/10/25 . Time of the allegation: 0215 am [2:15 a.m.] . [Resident #1] . Amount of injury unknown at this time. Awaiting additional report from hospital. At this time, we only know resident has a cut on his head and abrasions to his body. Resident is frequently exit-seeking and attempts elopement. It is unknown at this time how resident was able to elope the building as all doors were checked by Charge Nurse and all found to be locked, and door alarms are in working order. Resident wears wander guard. At approximately 0215 [2:15 a.m.] Charge Nurse received a call from the hospital asking if resident was missing . Review of Resident #1's medical record occurred on 01/14/25. Diagnoses included dementia and adjustment disorder. A quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition. The current care plan stated, . has an elopement risk/wanderer r/t [related to] impaired safety awareness . wander guard as ordered . is a HIGH risk for falls r/t Confusion, Deconditioning, Gait/balance problems . A Wandering Risk Assessment, dated 10/04/24, identified the resident at moderate risk for wandering. Review of Resident #1's nurses' notes identified the following: * 01/10/25 at 6:02 a.m., (late entry for a call received at approximately 2:45 a.m.), Facility phone rang and it was the ER [emergency room ] nurse from the hospital. We were asked if there were any of our resident's [sic] missing, as the ambulance was dispatched for an elderly man in his socks and brief. This nurse stated that there have been no alarms that havegone [sic] off as the door [sic] all have alarms on them. After call ended, all staff went and looked in rooms. This nurse found resident's [Resident #1] room to be empty.This shift he had been to the nurses [sic] station multiple times to ask for coffee. He would then go to his room, or to the recliner to watch TV. Resident was not found in the building. This nurse called ER back and stated that we could not find this particular resident. Gave the ER nurse a description of resident and name. While on the phone with the ER, the nurse stated that the resident was able to give his name and it was our resident. Ambulance was going to transport resident to ER to get a full check-up. * 01/10/25 at 9:03 a.m., . returned to [facility] from the hospital ER [sic] .When asked how he was able to get out . said 'I just walked out' but he could not recall where and when. [Resident #1] stated that it was 'dark and cold' and when he asked if he fell he stated 'more than once.' . There were no scrapes or bruises on his head. He has a tegaderm [transparent dressing] on his right wrist, and he has scrapes on the second, third and forth [sic] digits on his right hand. The left hand has scrapes on the second and third digits. The left knee is scraped, the right knee is scraped. The right great toe is missing the toenail. * 01/11/25 at 2:16 a.m., Resident has a blister that has formed on his right second digit/index finger. The tip of the thumb is also reddened and firm. He has complaints of pain/discomfort of that thumb. Clear dressing was applied to the blister for now. The blister is fluid filled and intact. Blister may be related to latent frost bite effects. Paperwork from Hospital Doctor also states to monitor hand and feet for any evidence of frost bite for the next 48-72 hours. The ER note, dated 01/10/25 at 5:58 a.m., stated, . He [Resident #1] was out in the cold for an undertermined [sic] period of time in light clothing and no shoes. His body temp [temperature] was 36 degrees [Celsius/96.8 degrees Fahrenheit] on arrival to the ER. He was found by travelers passing through town and they put him in their vehicle until the ambulance arrived. It was likely lower prior to getting in the vehicle. He fits the category [sic] of mild hypothermia [dangerously low body temperature]. there is slight swelling in the soft tissue above the patella [knee cap] in the right knee. Review of the facility investigation documents occurred on 01/14/25. These documents identified the following: * The DON (Director of Nursing) called the administrator at 3:00 a.m. on 01/10/25 and informed her Resident #1 eloped from the facility and transferred to the local emergency department. DON and administrator arrived at facility at approximately 4:00 a.m., interviewed staff, and confirmed ER contacted facility at 2:45 a.m. to ask if a resident was missing from the facility due to ambulance call. * Review of camera footage identified Resident #1 ambulated throughout the facility from 12:15 a.m. to 12:58 a.m. then entered his room at 12:58 a.m. At 1:59 a.m. Resident #1 exited his room and at 2:00 a.m. exited the building through an emergency exit [Door 4A]. The alarm failed to sound. The camera footage showed Resident #1 dressed in long pants, a long sleeve shirt, and gripper socks. * A community member found Resident #1 0.2 miles to the east of the facility at approximately 2:30 a.m. Emergency medical services arrived at 3:00 a.m. and transported the resident to the ER. * An audit of all emergency exit door alarms on 01/10/25 showed two of six door alarms were not engaged. * Initiation of documented checks of all emergency exit alarms on each shift to ensure alarms are engaged began on 01/10/25. * Initiation of documented 30-minute visual checks on Resident #1 began on 01/10/25 upon return from ER. Further review of Resident #1's nurses' notes identified the following: * 01/14/25 at 2:53 a.m., Resident was reported by CNA [certified nurse aide] to be outside from the patio door. He was shaking the fence at the gate trying to get it open. He walked out with no coat on and no shoes. Just had grip socks on. CNA was able to redirect him back inside and resident cooperated with the redirection. CNA reported that the resident stated he was trying to go home. Observation on 01/14/25 at 9:36 a.m. showed a staff member (#4) opened the patio door. The alarms failed to sound. The staff member (#4) identified both alarms were battery powered and he needed to replace them. The staff member (#4) stated he noticed he noted the alarms to sound funny on 01/13/25 and indicated he planned to replace the batteries on 01/13/25 but failed to do so. Review of the facility camera footage occurred on 01/14/24 at 2:10 p.m. with an administrative staff member (#1). The footage showed Resident #1 exited the patio door at 1:16 a.m., the door alarms failed to sound. A CNA (#7) exited the nurses' station report room approximately one minute later at 1:17 a.m. and redirected the resident back into the facility. Observation of all facility doors and door alarms occurred on the morning of 01/14/25 and showed 12 exit doors with three different alarm systems in place. The six emergency exit doors (door 1A, 2A, 2B, 3A, 3B, and 4A) showed alarms that required a key to turn the alarm on and off. Resident #1 eloped from door 4A. Four doors (main entrance, door 2, 3, and 4) utilized the wander guard alarm system. The two remaining doors, one leading onto the enclosed patio, and one on the east side of the building, utilized two window/door alarms on each door. Audit forms for all emergency exit doors attached to each emergency exit and showed sign off each shift for engagement of the alarm. All emergency exit alarms were in on position. During an interview on 01/14/25 at 9:00 a.m., an administrative staff member (#1) confirmed two of the emergency exit door alarms were in the off position when checked by her on 01/10/25. She stated the only way to clear/stop the alarm sound required staff to turn it off then back on with the key, and the nurses and maintenance staff have keys to reset the alarms. She stated she expected staff to check the function of all door alarms weekly and confirmed the facility lacked documentation of the weekly alarm function tests.

Based on record review, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from resident to resident abuse for 1 of 1 sampled residents (Resident #3) who experienced unwanted sexual contact with another resident. Failure to identify sexual abuse placed residents at risk for mental and emotional distress. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 11/14/24. This policy, revised 03/02/22, stated, . Each resident has the right to be free from abuse . Residents must not be subject to abuse by anyone, including, but not limited to; . other residents . 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.'Sexual Abuse' is non-consensual sexual contact of any type with a resident . The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: . Provide education on what constitutes abuse . Assess, monitor and develop appropriate plans of care for residents with inappropriate sexual behavior, whether towards staff or other residents. - Review of Resident #1's medical record occurred on 11/14/24. Diagnoses included dementia, adjustment disorder, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairment and independent for ambulation with an assistive device. The care plan, dated 04/11/24, stated, . has also been sexually inappropriate to female staff. Intervene as necessary to protect the rights and safety of others. Review of progress notes identified the following: * 11/20/23 at 2:57 p.m., . [provider name] saw resident r/t [related to] female staff reports of resident's continued inappropriate behavior towards them . new order as follows: 'Start Paxil [an antidepressant used to treat sexual inhibition].' * 01/05/24 at 11:31 p.m., . Resident does have sexually inappropriate behaviors to female resident/staff at times. * 06/20/24 at 2:48 p.m., Resident was sitting next to a female resident [Resident #3] and put his hand on the upper part of her leg. I removed it and placed it on his knee. later [sic] he again had it on her crotch. I removed his hand and put her at the front table. - Review of Resident #3's medical record occurred on 11/14/24. Diagnoses included depression, and anxiety. A quarterly MDS, dated [DATE], identified severe cognitive impairment. Resident #3's medical record lacked documentation of the interaction with Resident #1 on 06/20/24. During an interview on 11/14/24 at 1:20 p.m., administrative nurse (#2) reported being unaware of the incident of touching between Resident #1 and #3, and confirmed she expected staff to report it. During an interview on 11/14/24 at 1:47 p.m., staff member (#4) confirmed she witnessed the touching between Resident #1 and #3, stated she separated the residents, and explained to Resident #1 that the touch was inappropriate. The staff member (#4) identified Resident #3 as uncomfortable with Resident #1's touch and unsure if she reported it to anyone.

Based on record review, review of facility policy, and staff interview the facility failed to report an incident of resident-to-resident abuse to the State Survey Agency (SSA) for 1 of 1 sampled residents (Resident #3) who experienced abuse. Failure to report resident-to-resident abuse allegations and the results of the facility's investigation to the SSA placed all residents at risk for possible abuse. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 11/14/24. This policy, revised 03/02/22, stated, . Each resident has the right to be free from abuse . Residents must not be subject to abuse by anyone, including, but not limited to; . other residents . 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.'Sexual Abuse' is non-consensual sexual contact of any type with a resident . Anyone in the facility can report suspected abuse . When abuse, neglect or exploitation is suspected . Notify the Director of Nursing and Administrator . In response to allegations of abuse . the facility must: . Ensure that all alleged violations involving abuse . are reported . not later than 24 hours . to the administrator of the facility and to other official (including the State Survey Agency . ) in accordance with State law . - Review of Resident #1's medical record occurred on 11/14/24. Diagnoses included dementia, adjustment disorder, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairment and independent for ambulation with an assistive device. The care plan, dated 04/11/24, stated, . has also been sexually inappropriate to female staff. Intervene as necessary to protect the rights and safety of others. A progress note, dated 6/20/24 at 2:48 p.m., stated, Resident was sitting next to a female resident [Resident #3] and put his hand on the upper part of her leg. I removed it and placed in on his knee. later [sic] he again had it on her crotch. I removed his hand and put her at the front table. - Review of Resident #3's medical record occurred on 11/14/24. Diagnoses included depression, and anxiety. A quarterly MDS, dated [DATE], identified severe cognitive impairment. Resident #3's medical record lacked documentation of the interaction with Resident #1 on 06/20/24. The facility failed to report the above incident to the administrator and the SSA. During an interview on 11/14/23 at 1:20 p.m., administrative nurse (#2) reported being unaware of the incident between Resident #1 and #3, and confirmed the incident had not been reported to the SSA.

Based on observation, review of facility policy, and staff interview, the facility failed to prepare and/or store food in a sanitary manner in 1 of 1 kitchen and 2 of 2 kitchenettes. Failure to ensure proper concentration of the sanitizer solution and failure to apply an identifying label and/or open date to food items has the potential to affect food quality/preparation and may result in the spread of foodborne illness to residents, staff, and visitors. Findings include: SANITIZING FOOD PREP AREAS During an interview on 07/22/24 at 10:25 a.m., when asked to test the solution in the sanitizing bucket, a dietary staff member (#4) stated, EcoLab was here a couple of weeks ago to replace some parts [of the automatic dispenser]. The sanitizer is not working. The sanitizer bucket isn't right. I just have hot water in there. LABELING/DATING FOODS Review of the facility policy titled Food Receiving and Storage occurred on 07/24/24. This policy, revised 05/18/09, stated, . Food shall be . stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated . Observations on 07/21/24 at 12:15 p.m. and 2:10 p.m. and on 07/22/24 at 10:25 a.m. showed the following: * [NAME] Kitchenette Refrigerator - cranberry juice with a resident's name, but no open date - a sandwich and two slices of pie undated * Kitchen Silver Refrigerator - noodles undated * Kitchen Big Chest Freezer - staff identified cod in an unsealed bag undated * Kitchen Little Chest Freezer near Big Chest Freezer - churros undated * Kitchen Chest Freezer near Kitchen - bread dough and garlic bread undated * Kitchen Chest Freezer near Water Heater - donuts undated * Kitchen Upright Freezer - staff identified chicken cordan blue, chicken strips, and fish sticks with no identifying label or date - corn dogs in an unsealed bag - staff identified pork patties with no open date During an interview on 07/21/24 at 12:15 p.m. and 2:10 p.m., a dietary staff member (#3) confirmed she expected staff to label and date food items when opened and throw away outdated food items. During an interview on 07/22/24 at 10:25 a.m., a dietary staff member (#4) also confirmed she expected staff to label and date food items when opened and throw away outdated food items.

Based on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 2 of 2 multi-compartment sinks observed in the main kitchen. Failure to provide the required air gap for a multi- compartment sink has the potential to allow contamination of the sink in the event of a sewer back-up. Findings include: Review of the 2018 North Dakota Plumbing Code, Section 801.2 Air Gap or Air Break Required, stated, Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. Where a drainage air gap is required by this code, the minimum vertical distance as measured from the lowest point of the indirect waste pipe or the fixture outlet to the flood-level rim of the receptor shall be not less than 1 inch (25.4 mm). Section 801.3.3 Food-Handling Fixtures, stated, Food-preparation sinks, steam kettles, potato peelers, ice cream dipper wells, and similar equipment shall be indirectly connected to the drainage system by means of an air gap. Bins, sinks, and other equipment having drainage connections and used for the storage of unpackaged ice used for human ingestion or used in direct contact with ready-to-eat food, shall be indirectly connected to the drainage system by means of an air gap. Each indirect waste pipe from food-handling fixtures or equipment shall be separately piped to the indirect waste receptor and shall not combine with other indirect waste pipes. The piping from the equipment to the receptor shall be not less than the drain on the unit and in no case less than 1/2 of an inch (15 mm). Observations on all days of survey showed the end of a two-compartment sink drainpipe joined with the end of a three-compartment sink drainpipe ending approximately two inches below the rim of a cut out in the tiled flooring that contained the floor drain. The facility failed to provide the required air gap for the multi-compartment sinks. During an interview on 07/21/24 at 12:15 p.m., a dietary staff member (#3) indicated the three-compartment sink was used to thaw something in water and to drain vegetables. During an interview on 07/22/24 at 10:25 a.m., a dietary staff member (#4) indicated the two-compartment sink was used for food prep. During an interview on 07/24/24 at 7:45 a.m., a maintenance staff member (#5) reported a plumber recently worked on the drainpipe and informed him that's how it has to be.

Based on observation, review of facility policy, and resident and staff interviews, the facility failed to maintain an effective pest control barrier for 1 of 1 kitchen and 1 of 2 dining rooms (West). Failure to maintain the integrity of the doors has the potential to allow the entrance of mice and other pests. Finding included: Review of the facility policy Pest Control occurred on 07/24/24. This policy, dated 01/01/09, stated, . This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Windows are screened at all times. During an interview on 07/21/24 at 1:38 p.m., Resident #31 indicated there is an ant and fly problem in the west dining room and the facility was not doing anything about it. Observations showed the following: * 07/21/24 at 12:15 p.m., Rows of glasses air-drying on a shelved cart in the dishwashing area with two flies walking across the clean glasses and gnats flying in the food prep area in the kitchen. * 07/21/24 at 1:52 p.m., Several dead flies and gnats lying on the window ledge and floor and a large winged bug on the floor near the ice machine in the west dining room. * 07/22/24 10:21 a.m., Ants and a centipede crawling on the west dining room floor. * During the evening meal on 07/22/24, a menu plan located on the hood of the steam table with two flies walking across the paper and flying under the hood and directly above the food. A dietary staff member (#4) attempted to deter the flies from landing on the food. Observation on all days of survey showed: * Several gnats crawling/flying on or near the plants in the plant center near the facility entrance. * An open window with no screen in a glass-enclosed entrance to the dining room with visible gaps between the interior door and door frame. During an interview on 07/21/24 at 12:15 p.m., a dietary staff member (#3) stated, We have both bugs, flies and gnats, and mice. I haven't seen that many gnats today. We found a mouse in the sticky trap last week. The back door doesn't fit the foundation. You can see dirt coming through. During an interview on 07/22/24 at 7:45 a.m., a maintenance staff member (#5) stated, The delivery guys don't close the door [kitchen entrance] behind them. I am going to replace the weather strip on the door to the outside. We had one mouse this year. 46477

Based on observation, record review, review of facility policy, and staff interview, the facility failed to assess for self-administration of medications for 1 of 1 supplemental resident (Resident #19) observed with medications at bedside. Failure to evaluate the resident's ability to safely self-administer medications may result in medication errors and/or harm to the resident. Findings include: Review of the facility policy Resident Self-Administration of Medication occurred on 07/24/24. This policy, dated August 2017, stated, . Each resident who desires to self-administer medication may be permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. Self-administration should be written in the care plan once safety has been established. Observation on 07/21/24 at 3:09 p.m., showed one bottle of Visine [eye drop], one bottle of Clear Eyes [eye drop] and one small container of Vicks [vapor rub] in an open bedside dresser drawer, all the containers were unlabeled. Review of Resident #19's medical record occurred on all days of survey. The record lacked an assessment and a physician's order for Resident #19 to self-administer medications and lacked orders for all three medications. During an interview on 07/24/24 at 12:17 p.m., an administrative nurse (#1) confirmed the facility failed to complete an assessment and obtain a physician's order for Resident #19 to self-administer medications, and stated she would expect the facility to assess the resident's ability to independently administer these medications.

Based on record review and review of Medicare Part A letters/notices, the facility failed to ensure the resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 1 of 3 residents (Resident #40) reviewed for termination of Medicare Part A services. Failure to ensure the completion of the SNFABN limited the resident/representative's ability to exercise their rights regarding Medicare Part A services. Findings include: Review of Medicare Part A beneficiary notices identified Resident #40 discharged from Medicare Part A on 03/20/24. The SNFABN failed to identify if the resident/her representative chose to continue services, discontinue services, or request a demand bill. Review of Resident #40's medical record occurred on 07/24/24. The record lacked documentation indicating whether the resident/resident representative wanted services to continue with the understanding they would be responsible for payment or wanted services to discontinue when the Medicare Part A coverage ended.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 13 sampled residents (Resident #11 and #32). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages N-6 to N-7 stated, . N0415: High-Risk Drug Classes: Use and Indication . Coding Instructions . N0415B1. Antianxiety: Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period . N0415C1. Antidepressant: Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period . N0415D1. Hypnotic: Check if a hypnotic medication was taken by the resident at any time during the 7-day look-back period . N0415F1. Antibiotic: Check if an antibiotic medication was taken by the resident at any time during the 7-day look-back period. - Review of Resident #11's medical record occurred on all days of survey. The annual MDS, dated [DATE], showed the facility coded N0415C1 and N0415F1, indicating the resident received an antidepressant and antibiotic during the seven-day look back period. The medical record failed to identify an antidepressant or an antibiotic administered in the look-back period. - Review of Resident #32's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], showed the facility coded N0415B1 indicating the resident received an antianxiety during the seven-day look back period. The medical record failed to identify an antianxiety administered during the look-back period. The Resident's #32's Medicare five-day MDS, dated [DATE], showed the facility coded N0415B1 and N0415D indicating the resident received a hypnotic during the seven-day look back period. The medical record failed to identify an antidepressant or hypnotic administered during the look-back period. During an interview on 07/24/24 at 12:17 p.m., an administrative nurse (#1) confirmed staff coded Section N of the MDS's incorrectly for Resident #11 and Resident #32.

Based on record review and staff interview, the facility failed to ensure an accurate Pre-Admission Screening and Resident Review (PASARR) for 1 of 2 sampled residents (Resident #31) reviewed with PASARR services. Failure to accurately complete the PASARR screening created the potential for not identifying/providing needed mental health services. Findings include: Review of Resident #31 medical record occurred on all days of survey. Admission diagnoses included dementia, anxiety, dissociative identity disorder, major depression, PTSD [post-traumatic stress disorder], and bipolar disorder. A Level 1 PASARR screening completed by the facility prior to admission failed to include Resident #32's diagnoses of PTSD and bipolar disorder. During an interview on 07/24/24 at 12:17 p.m., an administrative staff (#1) stated he/she would expect provider diagnoses to be reviewed and entered correctly on the PASARR screening.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans for 3 of 13 sampled residents (Resident #3, #9 and #36). Failure to review and revise the care plan limited staff's ability to communicate needs, ensure the continuity of care, and may negatively impact the care provided to residents. Findings include: Review of the facility policy titled COMPREHENSIVE CARE PLANS occurred on 07/24/24. This policy, dated 01/30/18, stated, The facility will develop and implement a baseline care plan for each resident . 6. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment, and any significant changes. 7. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs. - Review of Resident #3's medical record occurred on all days of survey. Diagnoses included malignant neoplasm of unspecified site of right female breast cancer. An admission Minimum Data Set (MDS) dated [DATE], identified a weight loss of 5% or more in the last month or 10% or more in last 6 months. A nutrition/dietary Note, dated 07/03/24, stated, . Nutr. [nutrition] Dx [diagnosis]: Unintentional wt. [weight] loss r/t [related to] poor appetite, nausea & [and] vomiting w/ [with] reduced oral intake secondary to chronic medical condition (cancer) as evidenced by approximate 20 lb [pound] or 9.5% unintentional wt. loss in 6 months or less per patient report and confirmed via past weight records . Resident #3's care plan lacked a problem, goals, and interventions related to weight loss. During an interview on 07/24/24 at 9:09 a.m. an administrative staff member (#1) confirmed staff failed to update Resident #3's care plan with a problem, goals, and interventions related to weight loss. - Observation on all days of survey showed Resident #9 without dentures. Review of Resident #9's medical record occurred on all days of survey. Diagnoses included Bipolar Disorder, Anxiety Disorder, Mood Disorder, Spinal Stenosis, and Weakness. The current care plan stated: Focus: [resident name] has an ADL (Activities of Daily Living) self-care performance deficit . Interventions: ORAL CARE: [resident name] has upper dentures . needs substantial assistance to complete oral care. Coordinate arrangements for dental care. A Mini Nutritional Assessment completed on 05/06/24 showed a score of 5.0 which indicated Resident #9 malnourished. The care plan lacked nutritional interventions. During an interview on 07/22/24 at 9:30 a.m., Resident #9 stated she has upper dentures which do not fit right and would like to have new shiny ones that work. During an interview on 07/24/24 at 10:30 a.m., a certified nurse aide (CNA) (#2) stated Resident #9 did not have dentures for a long time. - Review of Resident #36's medical record occurred on all days of survey. Diagnoses included Chronic Kidney Disease, Hypertension, Edema, Diabetes, Altered Mental Status, and Anemia. The care plan lacked problems, goals and interventions related to diabetes, diuretic use, anemia, and excessive weight loss. During an interview on 07/24/24 at 11:45 a.m., an administrative staff member (#1) confirmed resident's care plans have not been reviewed/or revised timely. 47896

Based on observation, record review, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 3 of 4 sampled residents (Resident #19, #23, and #29) observed during a transfer. Failure to provide adequate assistance and/or use the assistive devices appropriately during transfers placed the residents at risk for accidents, falls, and/or injuries. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 08/15/23 at 7:55 a.m. The IJ resulted from staff failure to provide sufficient supervision and use the assistive device (mechanical lift) in a manner to avoid a fall and/or potential injury. * 08/15/23 at 8:12 a.m., The survey team contacted the State Survey Agency (SSA) to report the findings and discuss potential immediate jeopardy (IJ). * 08/15/23 at 8:25 a.m., The SSA contacted the survey team after discussion with the CMS (Centers for Medicare & Medicaid Services) location and verified the presence of IJ. *08/15/23 at 8:35 a.m., The survey team notified the administrator, the administrator in training (AIT), and the director of nursing (DON), of the IJ situation, provided them with the IJ template, and requested they develop a plan for removal of the immediate jeopardy. * 08/15/23 at 2:55 p.m., The AIT, and the DON presented the IJ removal plan for the survey team to review. The removal plan contained the following: * Inservice and education on facility policy/procedure for mechanical lifts, appropriate actions/interventions to ensure resident safety and dignity with the staff member directly involved in the deficient practice, all nursing staff on duty, and on-coming staff. * Review of each resident's transfer requirements as outlined in their individual care plans. * Review of facility policies and resources for questions/concerns. * Review and revision of staff orientation with clear and defined roles/responsibilities defined to ensure all staff receive the necessary orientation in a timely manner. * 08/15/23 at 4:15 p.m., The survey team reviewed and accepted the facility's removal plan for the IJ. The survey team verified the implementation of the removal plan. The deficient practice remained at an E scope and severity following the removal of the IJ. Findings include: Review of the facility policy titled Transferring a Resident Using a Mechanical Lift occurred on 08/15/23. This policy, dated July 2018, stated, . General Guidelines At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Before using the lift device, assess the resident's current condition, including: . Does the resident express fear or appear anxious about the use of a lift? Is the resident agitated, resistant, or combative? . The manufacturer's instructions for the Volaro Series 5 Stand stated, . The most important part of the lifting experience is applying the SLING properly. Position the wings of the sling under the arms and make sure they are centered. Be sure the person's arms are located outside the fabric. Attaching Sling to Lift . The shin rest has a built-in safety support strap. The strap helps those who need the added security and support. This will keep their shins and feet securely in place. - Review of Resident #23's medical record occurred on all days of survey. The current care plan stated, . ADL [activity of daily living] performance deficit r/t [related to] Dementia, Pain (chronic back pain), and SOB [shortness of breath] due to diagnosis of COPD [chronic obstructive pulmonary disease]. Toilet use: [resident name] requires extensive assistance of (2) staff for toileting. Transfer: [resident name] is able to: use sit to stand lift and staff assistance x's 2 to complete transfers. behavior problem of exhibiting s/s [signs and symptoms] of physical aggression and verbal abuse directed at staff. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Observation on 08/14/23 at 3:11 p.m. showed a certified nurse aid (CNA) (#3) utilized the sit-to-stand lift to toilet Resident #23. The CNA attempted to maneuver the lift into the resident's bathroom. Resident #23 stated, No, it's not going to work, No, No, No! The CNA realized she could not get the lift into the bathroom and the resident stated, I told you so. The CNA transferred Resident #23 into the wheelchair and instructed the resident to lift his feet as she pushed the wheelchair. The wheelchair foot pedals remained out to the sides of the chair and caught on the door frame as the CNA (#3) exited the room, the left foot pedal caught on a cart located in the hallway. The CNA stopped, adjusted the foot pedals, placed Resident #23's feet onto the pedals, and continued to the main bathroom located adjacent to the nurse station. The CNA utilized the sit-to-stand lift and placed Resident #23 onto the toilet, the resident stated, I don't want to be in here. At 3:24 p.m., the CNA (#3) utilized the sit-to-stand lift to transfer Resident #23 off the toilet. With the upper body sling in place, the CNA raised the resident to a standing position without applying the shin/leg strap. With the resident in a standing position on the lift, the CNA proceeded to remove the incontinent product and tore the side seam of the product. Resident #23 yelled, Don't tear that! Don't tear that! The CNA continued to remove the product. Resident #23 released his hands from the handle grips and brought both arms inside the sling and held onto the bar directly in front of him. The CNA instructed Resident #23 she needed to remove his pants, the CNA attempted to lift the residents' left leg out of the pant leg. Resident #23 yelled, Don't do that! as he made a fist with his left hand and hit the CNA on her shoulder two to three times. The resident's upper body began to slide out from under the sling. The CNA (#3) stood behind the resident and wrapped her arms around the resident's upper body and under his arms to hold him up until a wheelchair was placed under the resident and additional staff arrived to provide assistance. During an interview on 08/15/23 at 2:55 p.m., two administrative staff members (#1 and #2) confirmed staff are expected to follow the resident care plans and stated it is facility policy for two staff to assist with all mechanical lift transfers. Facility staff failed to: * Communicate with the resident in a manner that maintained and enhanced the resident's individuality which resulted in psychosocial distress for the resident. * Follow the care plan to provide sufficient supervision and assistance with transferring and toileting a resident. * Secure the safety straps on the mechanical lift device appropriately which resulted in a near fall from the mechanical lift. 31725 - Review of Resident #19's medical record occurred on all days of survey. The care plan stated, .Transfers . requires 2 assistance using the sit to stand lift. Observation on 08/14/23 at 2:20 p.m. showed two CNAs (#4 and #6) transferred Resident #19 from the wheelchair to the bed by each CNA lifting under the resident's axilla and pulling up on her pants. The CNAs failed to use the sit to stand lift to transfer Resident #19. 13101 - Review of Resident #29's medical record occurred on all days of survey. The care plan stated, . Transfer: . able to: independently transfer. Please provide stand by assistance . Observation on 08/15/23 at 10:45 a.m. showed two CNAs (#6 and #7) assisted Resident #29 with toileting. The CNAs (#6 and #7) used the walker, a gait belt, and assist of two onto the toilet. When finished, the two CNAs (#6 and #7) assisted the resident to stand, without using the walker, one CNA (#6) lifted under the resident's right axilla, and one (#7) used the gait belt. The CNA (#6) grabbed the back of Resident #29's pants, pushed the resident around to line up with the wheelchair and the resident sat down in the wheelchair.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY CONDUCTED ON 03/17/21 Based on observations, record review, information from the complainant, review of facility policy, review of the mechanical lift operator's manual, review of facility's fall investigation report, and staff and service technician interviews, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #1). Failure to safely utilize/maintain a mechanical lift with a sling resulted in a fall with injury for Resident #1. Failure to complete a thorough investigation and immediately educate nursing staff on safe mechanical lift procedures placed all residents requiring this type of transfer at risk for accidents and/or injury. During the complaint survey on July 12, 2021, the team determined a potential Immediate Jeopardy (IJ) situation existed. The IJ potential resulted from observation of the mechanical lift, review of Resident #1's medical record regarding a fall with injury, the facility fall investigation, staff training records, and staff interview. These findings placed residents in immediate danger due to a need for education on the use of the safety clips on the Hoyer (full body mechanical lift) lift and the importance of staff not physically altering the rubber safety clips to prevent additional serious injury as the lift remained in service. * 07/12/21 at 2:52 p.m. - The survey team contacted the management staff at the State Survey Agency (SSA) to report the findings and to discuss a potential IJ situation. * 07/12/21 at 4:35 p.m. - The survey team notified the Co-Director of Nursing [DON] of the IJ situation and requested they develop a plan for abatement of the immediate jeopardy. * 07/13/21 at 9:19 a.m. - The facility provided a written plan (via email) of correction for the IJ. * 07/13/21 at 9:50 a.m. - The survey team reviewed and accepted the facility's written plan. * 07/13/21 at 1:00 p.m. - The survey team determined the IJ situation at a scope/severity of J was abated and reduced to a scope and severity of G. * 07/13/21 afternoon - The SSA notified the regional office of the immediate jeopardy situation. Findings include: Review of the facility policy titled Lifting Machine, Using a Portable occurred on 07/12/21. This undated policy stated, . To transfer a resident from the bed to a chair . 5. Attach the hooks to the sling. Be sure the hooks are placed so that they are facing away from resident. 7. Attach the sling to the lift . Review of the facility's Vancare (Vanderlift II) mechanical lift operator's manual occurred on 07/13/21. This manual stated . It is also required that qualified maintenance staff inspect the lift at least monthly for missing parts and excessive wear that might cause the lift to fail. A permanent record of each of these inspections and repairs made should be kept by the facility . The facility failed to provide records of monthly inspections and operator's instructions addressing the use/maintenance of the rubber safety clips. Review of Resident #1's medical record occurred on all days of survey. Diagnoses included [CONDITION(S)] (stroke) affecting the right side and [CONDITION(S)] (difficulty speaking). The current care plan stated, [Resident's nickname] requires extensive assistance with adls [activities of daily living] . Assist with transfers using the Hoyer lift and 2 persons . COGNITION: The resident has impaired cognitive function . BIMS [Brief Interview for Mental Status] is a 2 [Severe cognitive impairment]. Resident #1's nurses' notes identified the following: * 07/01/21 at 9:34 a.m. This nurse was called to resident room by staff. This nurse observed resident on the floor. 2 staff members where [sic] in the room with the resident and the Hoyer lift. Per staff reports, one of the handles that they hook the resident sling in tilted downwards and the clamps to assist with keeping the lift slings in place while lifting the [sic] resident allowed the sling to come off the left [sic] causing the [sic] resident to fall out of the Mechanical lift. Resident assessed immediately, denies pain, PROM [passive range of motion] to all extremities, no deformities noted. Skin intact. Assisted resident to his wheel chair 3 person assist with another Hoyer lift Immediately [sic] removed the malfunctioning lift out of use to be looked at by maintenance. immediately [sic] checked all lifts in facility for functionality. MD [Medical Doctor] notified via fax communication, Family [sic] member [name] contacted and a VM [voice message] left to contact the facility. * 07/01/21 at 11:26 p.m. Fall f/u: [follow up] resident lying in bed in supine position, HOB [head of bed] elevated, denies pain when asked by this nurse, however CNAs [certified nursing assistants] reported grimacing when placing resident in bed, CNAs also reported that resident appeared to have difficulty breathing. Tylenol PRN [as needed] given as ordered. Resident refused O2 [oxygen] via NC [nasal cannula]. *07/02/21 10:11 a.m. The resident is being monitored status post fall day # 1. He has generalized pain to the abdominal area. No bruising noted. He was medicated with Tylenol which was helpful. Also received back the faxed communication to MD that they are aware of this Fall [sic]. At 10:57 p.m. fall day #2. He has generalized pain in the abdominal area. The resident wants the HOB elevated . medicated with Tylenol this evening for pain. * 07/04/21 at 4:10 a.m. The resident is being monitored for a fall on 7/1/2021, fall day #3. He continues to C/O [complain of] generalized pain in the abdominal area, the pain [sic]. The resident wants the HOB elevated and had O2 on at 2 L [liters]. No bruising noted. He was medicated with Tylenol this evening and night for pain. * 07/05/21 at 8:35 a.m. (Restorative Program Note) Resident seen today for restorative nursing services. Resident propelled self down to therapy room in his w/c [wheelchair]. Resident completed AROM [active range of motion]/PROM exercises, and refused walking. Resident did wince when performing ROM on his R [right] UE [upper extremity] and is leaning to the left while sitting in his w/c. Resident did cough, and did have an expression of pain on his face with this, and grabbed for his ribs. Charge Nurse [nurse initials] was notified. * 07/05/21 at 8:54 a.m. Resident winces during exercises with CPTA [certified physical therapy assistant], CPTA asked resident where did it hurt, . pointed to his ribs. CPTA notified the nurse, and the nurse asked the resident did his ribs hurt, resident nodded yes. No wincing observed while the resident is breathing. No labored respirations noted. No bruising observed during the assessment. Notified MD via fax, awaiting a response. * 07/05/21 at 10:22 a.m. CMA [certified medication aide] reported that while residents [sic] was being toleilting [sic], he was wincing and facial grimacing and was hollowing [sic]. Nurse called [name] Clinic Nurse [name] and gave her an status update regarding resident complaining about pain in the rib region, getting a possible x-ray then possibility of him being seen also. Clinic nurse stated that she will speak to [name] FNP [Family Nurse Practitioner] to [sic] Residents PCP [Primary Care Physician]. * 07/05/21 at 12:16 p.m. Received a phone call back from [clinic nurse] stating that [name] FNP would like him seen by one of the residents [doctor in training] today in the clinic. Clinic appointment scheduled for 1400 [2:00 p.m.]. Transportation is being provided by the facility and he will have a staff escort. Called and spoke to [name of power of attorney (POA)] about residents status and the appointment scheduling. She voiced understanding. * 07/06/21 at 13:12 CPTA alerted nurse that resident is wincing and having a lot of pain on his right side. Called and left a message for [MD name] inquiring about some more pain medication other that Tylenol. * 07/06/21 at 1:29 p.m. [MD name] returned phone message and instructed nurse to give [MEDICATION(S)] 400mg [milligrams] Alternating [sic] from [sic] Tylenol PRN Q [every] 4-6 hours to a max [maximum] of 2400 mg/day. Incentive Spirometer Q30 mins [minutes] 2 deep breaths. MD informed nurse that resident has a liner [sic] rib fx [fracture] and a possible stress leg fx. Called and left a message for [Name of POA] to call the facility. A fall investigation report, dated 07/01/21, stated, The Nurse was called to [Resident name] room by staff. The Nurse observed the resident on the floor. Two staff members were in the room with the resident and the hoyer lift. One of the handles that they hook the resident sling in was slightly tilted downwards and the clamp to assist with keeping the lift slings in place while lifting the resident allowed the sling to come off the lift causing the resident to fall out of the mechanical lift. The nurse assessed the resident immediately. [Resident name] denied pain, PROM to all extremities. No deformities noted. Skin intact. Three staff members assisted resident to his wheelchair with another hoyer lift. The hoyer lift that was used when the fall occurred was immediately taken out of service. All lifts were immediately checked for functionality. MD was notified regarding fall. POA was notified by phone with a voice message to contact the facility. 7/2/21 [Resident name] c/o generalized pain in abdominal area when he coughed . 7/5/21 [Resident name] c/o increased pain in right abdominal area. Practitioner was notified and x-rays were ordered. Clinic appointment on 7/5/21. Linear right rib fracture and possible stress fx to right leg noted. [MEDICATION(S)] alternating with APAP [acetaminophen] was ordered. Incentive spirometer was also ordered. Resident #1's clinic report dated 07/05/21 stated, The patient . presents with complaints of pain. The pain is described as being located in the right side ribs and right arm. The onset of pain has been acute and had been occurring in a persistent pattern for 4 days. The course has been increasing. The pain is described as moderate . CNA states that hoyer lift tipped over on patient causing patient to fall to ground . The chest pain has been occurring for 4 days in a persistent pattern. The course has been constant. The level of severity is moderate. There has been associated trauma. Pain was precipitated by a fall in the nursing home, pt [patient] was being moved by the halter-swing, and the machine tipped over a [sic] dropped him on his right side [This report conflicted with the nursing facility's fall investigation report, dated 07/01/21]. Pain is worse with inspiration . Assessment and Plan . Pt had a fall at the NH [nursing home] while using the transfer lift. Pt was dropped, likely on the Rt [right] side. Tylenol 500mg q4-6 hours as needed for pain control . [MEDICATION(S)] 400mg q4-6 hours as needed for pain control. Review of Resident #1's Medication Administration Record (MAR) for July 1-12, 2021 identified the following: * 07/01/21 Acetaminophen 650 mg by mouth every 4 hours as needed for pain for 7 days. Resident #1 received 12 doses of prn acetaminophen from 07/02/21 through 07/07/21. * 07/06/21 [MEDICATION(S)] 400 mg by mouth every 4 hours as needed for pain control alternate acetaminophen and [MEDICATION(S)]. Resident #1 received 4 doses of [MEDICATION(S)] from 07/07/21 thru 07/09/21. Review of Resident #1's chest x-ray report, completed on 07/05/21, identified . suspicious for nondisplaced right eighth rib fracture. Observations on the morning and afternoon of 07/12/21 showed the Vancare (Vanderlift II) lift used to transfer residents and had a thick glue around the top of the rubber safety clip. Interviews on the morning and afternoon of 07/12/21 identified three of four CNAs (#3, #6, and #7) interviewed lacked education on the Vancare (Vanderlift II) lift including the importance of not altering the safety clips after Resident #1 experienced a fall from the mechanical lift. During an interview on 07/12/21 at 2:01 p.m., when asked if he/she has ever turned a rubber safety clip or observed the clips turned the CNA staff member (#3) stated, I have not turned them, but I have observed them turned and I notified maintenance. During an interview on 07/12/21 at 2:12 p.m., a CNA (#5) identified by the facility as a CNA trainer, stated the rubber safety clips move in all directions and are not safe to use when they are turned. During an interview on 07/12/21 at 2:42 p.m. with a maintenance staff member (#2) and an administrative nurse (#1) the staff member (#2) stated he/she provided maintenance repair on the Vancare (Vanderlift II) mechanical lift after Resident #1's fall from the lift. He/she reported two of the safety clips, one on each side of the lift, were turned outward. When asked how this happened, he/she stated nursing staff turn these rubber safety clips outward as it easier for the staff to use the lift. He/she then replaces the safety clips or re-glues them. He/she used rubber safety clips designed for the sit to stand lift in place of the original metal clips. When asked how often facility staff perform routine maintenance on the mechanical lifts, he/she stated only when staff have an issue with the lift. During a phone interview on 07/12/21 at 3:57 p.m., a mechanical lift service technician (#4) stated, I have not seen rubber safety clips used at other places as I don't usually service Vancare (Vanderlift II) lifts. The rubber safety clips are a bad design and the facility said they are ordering upgraded spring safety clips. I complete annual lift inspections and additional inspections when the facility requests them, but the operator manual does recommend the facility complete a monthly inspection. When asked if he/she completes monthly inspections the technician (#4) stated he/she did not. The facility placed the Vanderlift II back into service for staff utilization of resident transfers on 07/07/21 after the inspection completed by the service technician (#4) on 07/06/21. A letter from the technician's service company, dated 07/20/21, stated, The performance test did not present evidence of problems on asset [Vanderlift II] . and 'passed' the annual inspection . there are rubber clips available for safety purposes that are not necessary but an additional safety feature. The review/letter failed to note any mechanical problem noted in the facility's Fall Investigation Report, dated 07/01/21. Review of staff education showed five Vander-Lift, Vander-Lift II & Vango Skills Observation Assessment sheets completed by staff from 07/07/21 through 07/12/21. The facility failed to immediately educate nursing staff after Resident #1's fall and injury from a mechanical lift on 07/01/21. Lack of staff education to ensure competency regarding proper utilization of a mechanical lift and the importance of not physically altering the rubber safety clips placed other residents at risk for injury during transfer with a mechanical lift. The facility failed to complete a thorough investigation regarding a mechanical failure and/or possible operator failure including a clinic report, dated 07/05/21, documenting the lift tipping over versus the Fall Investigation documenting the sling came off the lift causing the resident to fall. The facility failed to complete monthly lift inspections as required/stated in the Vanderlift II Operating Manual and failed to ensure operating instructions included the utilization of the rubber safety clips and appropriate/safe process for gluing/maintenance of the safety clips on the mechanical lift.

Based on observation, information provided by the complainant, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 1 of 6 sampled residents (Resident #4) who use a mechanical device to assist with transfers. Failure to assess Resident #4 for the ability to appropriately and safely use an electric lift recliner chair and monitor the resident while in the chair resulted in the resident's fall from the chair and subsequent hospitalization with injuries. Findings include: Information provided by the complainant indicated facility staff placed Resident #4 in a lift recliner chair with a remote control while unsupervised in her room, even though she had severe dementia. The resident elevated the chair and fell face first on the floor resulting in a dislocated right shoulder, a C1 (1st cervical vertebrae) fracture, and seven stitches to her forehead, along with a skin tear, abrasions, and bruising. Facility staff removed the lift chair from the resident's room after the fall. Review of the facility policy titled Recliner Use and Evaluation occurred on 07/06/20. This policy, dated 07/01/20 (developed after Resident #4's fall/injury), stated, Policy: It is the policy of this facility to ensure residents can safely use their recliners independently to maintain a safe and restraint free environment. Policy Explanation . Upon admission and in change of condition PT (physical therapist)/OT (occupational therapist)/Cpta (certified physical therapy assistant)/RN (registered nurse) will evaluate the resident for use of their recliner to ensure that they are able to safely operate. An administrative nurse (#1) confirmed the facility did not have a recliner policy prior to 07/01/20. On 07/06/20 at 10:00 a.m., observation showed Resident #4 in a non-electric (non-lift) recliner chair in her private room on the COVID-19 (coronavirus disease 2019) isolation unit. The resident had a cervical collar in place on her neck. A nurse (#3) gave her pain medication and water to drink. Resident #4 then closed her eyes and fiddled with the call light attached to her chair. On 07/06/20 at 4:47 p.m., observation showed Resident #4 in bed playing/fiddling with the television remote. A staff member sat in the doorway of another room across the hall from the resident's room to watch her at all times and provide one-on-one care. Review of Resident #4's medical record occurred on 07/06/20. The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition, extensive assistance of two or more staff for bed mobility, transfers, and toileting, and walking did not occur. Resident #4's current care plan stated, . ADL's (activities of daily living): (Resident #4's name) requires extensive assistance with adl's related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. uses (full body mechanical) lift staff assist x (times) 2 for transfers . FALLS: (Resident #4's name) has a [DIAGNOSES REDACTED]. She has a history of falls. She has impaired balance and right leg contracture. She is a fall risk since she does attempt to self transfer. fall on 6/26 (06/26/20) forehead lac (laceration) and cervical dx (sic) (fracture) . Fall mat while in bed, bed will be kept in the lowest position (implemented 06/30/20) . One on one staffing 24 hours/day until out of isolation (implemented 06/29/20) . Cognition: The resident has impaired cognitive function r/t (related to) Senile Degeneration of Brain, TIA ([MEDICAL CONDITION]), and Dementia. BIMS (Brief Interview for Mental Status) score is a 2 (0-7 is severe cognitive impairment) . Communicate with the resident/family/caregivers regarding resident's capabilities and need. The facility failed to consider Resident #4's limited mental capabilities with use of an electric lift recliner chair and failed to implement increased monitoring of this quarantined resident until after she fell out of the recliner. The physician's history and physical, dated 06/26/20 following Resident #4's fall from the lift chair, stated the resident had a 6 centimeter [MEDICAL CONDITION], a non-displaced C1 fracture, and a right shoulder dislocation, possibly chronic. Resident #4's progress notes stated the following: * 06/22/20 at 1:54 p.m., . continues on isolation since her return back to the facility (hospital return on 06/15/20) . * 06/26/20 at 3:40 p.m., At 1540 (3:40 p.m.), Resident found laying on the floor in front of her recliner. Recliner in the standing position. Resident face down with pool of blood around her face and head. Ambulance called . transferred to the ER (emergency room ). Change of shift was completed 40 minutes prior to fall both oncoming and off going CNA's (certified nurse aides) completed rounds together, Walking rounds checklist completed and signed right before CNA clocked out for shift at 1502 (3:02 p.m.). (Resident #4 was unobserved in her room for at least 38 minutes). * 06/29/20 at 12:19 p.m., Resident readmitted from hospital . has laceration to the forehead and with stiches (sic) . Skin tear to forehead . bruises to BUE (bilateral upper extremities) and right shoulder. Bruise on right temple. Left eye bluish. has C1 non-displaced fracture and wears soft collar for at least 6 weeks . Right shoulder dislocation chronic VS (versus) acute. [MEDICATION NAME] 5mg (milligrams) QID (four times daily) with 2.5 mg PRN (as needed) for break through pain. (Physician previously increased [MEDICATION NAME] 5 mg from three times daily to QID on 06/03/20 for [MEDICAL CONDITION] of the right knee. Resident has received the 2.5 mg PRN dose on two occasions since her return from the hospital). During an interview the afternoon of 07/06/20, a nurse aide (#4) and an unidentified activity staff member stated Resident #4 didn't have a recliner in her old room due to lack of space and she always sat in a recliner in the day room before she was put in isolation. The staff were unsure if Resident #4 sat in a regular or a lift recliner in the day room. Observation of the day room showed many recliners, a few of them electric. During an interview on 07/06/20 at 4:50 p.m., when asked the frequency of rounds on residents in quarantine per COVID-19 guidelines, a nurse administrator (#1) stated staff round on the residents in isolation hourly. She agreed Resident #4 would have been checked on at least hourly during her quarantine upon return from the hospital on [DATE] until her return to the hospital on [DATE]. This nurse stated the facility provided one-on-one staffing for Resident #4 upon her recent return from the hospital on [DATE]. During an interview on 07/06/20 at 4:55 p.m., a nurse administrator (#1) and an administrative staff member (#2) stated Resident #4 did not have a recliner in her room prior to hospitalization on [DATE]. Facility staff added the recliner to Resident #4's quarantine room for off-loading purposes after the resident returned from the hospital on [DATE]. They said prior to Resident #4 being placed in quarantine, she used a wheelchair most of the day pushing herself in the hallways holding the handrails. They were unable to answer why a lift chair was selected for the resident's use or if staff assessed the resident's ability to safely use the lift chair prior to putting it in her room.

Based on closed record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment and services to prevent the occurrence and promote the healing for 1 of 1 resident (Resident #40) reviewed who developed a pressure ulcer after a decline in health condition. Failure to evaluate risk factors that may impact the development/healing of a pressure ulcer, implement, monitor, and modify interventions to reduce risk factors, and/or provide treatment to prevent and/or heal the development of new pressure ulcers resulted in Resident #40 developing an avoidable, facility-acquired pressure ulcer. Findings include: Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol occurred on 12/19/19. This policy, revised (MONTH) 2010, stated, Assessment and Recognition: The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss . the nurse shall assess and document/report the following: . full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue . Resident's mobility status, current treatments, including support surfaces, . The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc). and application of topical agents. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated . Review of Resident #40's medical record occurred on 12/19/19. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment and extensive assistance of one to two staff for all activities of daily living. The care plan stated, . Focus: Pressure Ulcers/Skin Issues: (name of resident) may be at risk related to decreased mobility . Interventions: . check all skin areas with am and pm cares and with showers for reddened or open skin areas. If noted, report to charge nurse . selan cream to buttocks and coccyx after each incontinent episode . A dietary note, dated 10/04/19, stated, Nutrition/Dietary note: nutrition screening indicates malnutrition . weight has decreased from 105-108 % range last year to 88# (pounds) on hospital admission this week. She has significant weight loss and underweight status. Patient was hospitalized with pneumonia and readmitted to Care Center today. A Restorative Program note, dated 10/05/19, stated, Resident returned from hospital on [DATE]. Spoke with resident's son (name) today re: (regarding) restorative nursing. He (son) would like walking program discontinued at this time, but would like to cont (continue) the AAROM (assisted active range of motion) / PROM (passive range of motion) program to her B (bilateral) UE (upper extremities)/LEs (lower extremities). Also spoke with resident's granddaughter who is a nurse, and she would like a w/c (wheelchair seating) evaluation for resident, as she is not sitting well when eating and up in w/c. The Occupational Therapy (OT) documentation showed the following: * 10/08/19 at 1:10 p.m., . has been experiencing a significant decline and was recently hospitalized for [REDACTED]. OT recommended device for neck positioning. A small soft cervical collar was trialed by OT . which did provide improved neck and head position. Resident did not voice any concerns, pain, behaviors, or behaviors indicating discomfort. * 10/15/19 at 11:55 a.m., . has improved position with her neck during meals with the use of the soft cervical collar. She is eating better due to this. The nursing documentation showed the following: * 09/26/19 at 10:56 a.m., . Resident admitted to hospital for pneumonia/observation. * 10/04/19 at 6:31 p.m., Resident returned from the hospital to facility @ (at) 10:30 via wheelchair. * 10/05/19 at 10:46 p.m., Resident on [MEDICATION NAME] antibiotic for pneumonia. Tolerating the medication well. No rash, nausea, vomiting or diarrhea noted. On 2L (liters) of continuous oxygen per nasal cannula. Turned every 2 hours. * 10/08/19 at 6:39 p.m., Resident completed Cefuroxine treatment for [REDACTED]. * 10/19/19 at 2:40 p.m., Resident was being cleaned and changed by aide (name of aide) and discovered a small pressure ulcer on the sacrum area, Nurse (name of nurse) came in and measured the area, which was 1.5 inches x 1 inch. Barrier cream was applied and we have started a turning sheet for all aides to sign when the resident is repositioned, which will be every 2 hours. There was no depth measured. (name of physician) was notified via fax * 10/20/19 at 11:38 a.m., . Resident has been refusing to eat or drink over the weekend. Family is aware and wants her to be kept comfortable. * 10/25/19 at 11:52 a.m., Received a verbal order from provider for comfort measures only. * 10/28/19 at 2:13 p.m., CNA (certified nurse aide) (name of staff) and CMA (certified medication aide) (name of staff) was in changing the brief of the resident and noticed a pressure sore in the sacrum area. I went in to measure it. It was 6 x 4 inches. The area was cleansed and barrier cream applied. A physician visit note, dated 10/24/19, stated, . (name of resident) has been placed on comfort care by her family. She is resting quietly. Most of her medications have been stopped. She had a small skin tear on her right arm. This is healing well . Weight 95.2 pounds which is stable. She is resting quietly in bed. She moans occasionally when she is examined. Her mucous membranes are slightly dry. The skin is supple. As per facility policy, the facility failed to: * Assess and document an individual's significant risk factors for developing pressure sores, * Document the stage of the ulcer, characteristics of the ulcer, and presence of pain, * Failed to obtain pertinent orders related to wound treatments, wound cleansing, dressings, and application of topical agents, * During resident visit, the physician failed to evaluate and document the progress of wound healing of a pressure ulcer, * Update the care plan at the time Resident #40's pressure ulcer was first identified. During an interview on 12/19/19 at 10:20 a.m., when asked what is expected once a pressure ulcer is identified, an administrative nurse (#5) stated, an order would be placed on the treatment record for skin assessment and wound measurement to be completed weekly. The administrative nurse (#5) confirmed staff failed to implement skin assessments, monitoring, and treatment or modify the plan of care. The record identified staff failed to respond timely to a change in the resident condition and lacked communication with the physician at the time a pressure ulcer was first identified. Staff failed to update the care plan or complete a full assessment of the pressure ulcer to include stage, skin condition, or take measurements from 10/19/19 to 10/28/19 (nine days later) which resulted in deterioration and increase in size of the pressure ulcer to Resident #40.

During the complaint survey on May 30-June 7, 2017, the team determined a potential Immediate Jeopardy (IJ) situation existed. The IJ resulted from lack of Director of Nursing (DON) coverage from May 1-June 5, 2017 and Registered Nurse (RN) coverage from June 1-5, 2017. After observation, record review, and interview with facility staff, the survey team met on 06/05/17 at 9:45 a.m. and determined corrective action needed to occur. At 10:00 a.m., the team contacted the managerial staff at the State Agency (SA) to report the findings and to discuss the potential IJ situation. At 10:10 a.m., the survey team notified the facility administrator of the IJ and that they must develop a plan for abatement. At 2:15 p.m., observation and interview of an RN confirmed the nurse arrived at the facility on 06/05/17 at 1:15 p.m. and would provide RN coverage until 9:15 p.m. At 3:00 p.m. the survey team notified the chief executive officer (CEO) of the facility of the IJ and that they must develop a plan for abatement. On 06/06/17 at 12:45 p.m., the facility provided a written plan of abatement for the IJ. The team reviewed and rejected the plan. At 2:00 p.m., the facility provided a revised written plan of abatement for the IJ for DON coverage. The team reviewed and accepted the plan regarding DON and RN coverage after requesting and receiving two additional revisions. The team was unable to abate the portion of the IJ regarding DON coverage while on site, as the plan showed the facility will not have a full time DON until 06/15/17, at the earliest. On 06/19/17 at 9:15 a.m. the North Dakota Department of Health, Division of Health Facilities conducted an on-site review which identified the facility remained without a Director of Nursing. An interview with the Administrator (#1) occurred on 06/19/17 at 9:35 a.m. and identified an interim DON had planned to assume the position on 06/19/17, but sustained an injury over the weekend and would not be present at the facility until 06/21/17. Review of the facility's current nursing schedule occurred on 06/19/17 and identified the interim DON scheduled to begin work on 06/21/17 and would provide RN coverage from June 21-24 and 26-30, 2017. Review of the nursing schedule identified lack of RN coverage on 07/01/17 and showed a travel RN scheduled to provide RN coverage as follows: * 06/19/17: from 6 p.m. to 12 a.m. (6 hours) * 06/20/17: from 12 a.m. to 6:30 a.m. (6.5 hours) * 06/25/17: from 12 a.m. to 6:30 a.m. (6.5 hours) Based on the absence of a full time Director of Nursing and lack of eight consecutive hours of RN coverage on 06/19/17, 06/20/17, 06/25/17 and 07/01/17 the Immediate Jeopardy remained unabated.

Based on findings of Immediate Jeopardy under 483.45 Nursing Services and Substandard Care under 483.24 Quality of Care, review of the North Dakota Department of Health, Division of Health Facilities Provider Files, review of the administrator's job description, and deficiencies cited at F497 Regular in-service education and F498 Proficiency of nurse aides, the facility had not been administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's failure to be administered effectively and efficiently has resulted in findings of Immediate Jeopardy and Substandard Care and placed residents residing in the facility at actual harm. Findings include: Immediate Jeopardy was identified at: F354 - Registered Nurse: The facility was without a Director of Nursing from May 1 - June 6, 2017 and was without eight consecutive hours of Registered Nurse coverage from June 1-5, 2017. During an on-site review on 06/19/17, surveyors identified the facility remained without a full-time Director of Nursing and lacked eight consecutive hours of Registered Nurse (RN)coverage on 06/19/17, 06/20/17, 06/25/17 and 07/01/17. Based on the absence of a full time Director of Nursing and lack of eight consecutive hours of RN coverage the Immediate Jeopardy remained unabated. Substandard Care was identified at: F253 - Housekeeping and Maintenance: the facility failed to provide housekeeping services necessary to maintain a sanitary and comfortable interior on 2 of 2 resident care units, affecting all residents residing on the units. F254 - Linen, Clean and Good Condition: the facility failed to provide laundry services necessary to ensure the availability of bath linens on 2 of 2 resident care units, affecting all residents residing on the units. F310 - Assistance with Activities of Daily Living: the facility failed to provide care and services (bathing) for 20 of 38 sampled residents who required assistance with bathing. Review of the North Dakota Department of Health, Division of Health Facilities Provider files identified the facility failed to maintain compliance in the following areas cited during the 10/27/16 survey: F225 Investigate and Report Abuse F241 Dignity F253 Housekeeping and Maintenance F273 Admission Assessment F275 Annual Assessment F278 Accuracy of Assessment - also cited 10/29/15 F280 Review and Revise Care Plans F287 Submission of Assessments F323 Prevention of Accidents - also cited 10/29/15 F441 Infection Control

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY CONDUCTED ON 10/27/16. Based on observation, record review, and resident and family interview, the facility failed to provide care in a manner and environment that maintained, enhanced, and respected each resident's dignity and individuality for 10 of 38 sampled residents (Resident A, C, E, H, I, K, L, M, O, Q, and A1). Failure to ensure residents received baths, had clean clothing, and were treated respectfully did not enhance the residents' dignity and/or quality of life and resulted in psycho-social harm for Resident A and potential harm for Resident C, E, H, I, K, L, M, O, Q, and A1. Findings include: The facility failed to provide a copy of their policy addressing dignity, as requested. Random interviews identified the following information: * 05/30/17 at 9:55 a.m., Resident H expressed concerns regarding an administrative staff member's (#1's) treatment of [REDACTED].#1). He's not very nice. Old people need to be treated nicely. * On 05/30/17 at 10:35 a.m., family member F expressed concerns regarding her relative (Resident K) stating he was to have a shower every other day, but went five days without one. * 05/30/17 at 10:40 a.m., Resident A stated staff are to assist her with bathing twice a week, but she has only received a shower two times this month. The resident also stated she informed the administrative staff member (#1) that she hadn't had a bath in a long time. The resident indicated the facility is short handed because several staff have recently resigned. On 06/01/17 at 8:10 a.m., Resident A reported, I still haven't gotten a shower yet, and I have no idea when I will get one. The resident stated she wore the same underwear for past three days, because she didn't have any clean clothing to change into. * 05/30/17 at 2:54 p.m., Resident C stated she had not received a bath for a long time. The resident stated she bathes and washes her hair in the sink. * 05/31/17 at 8:38 a.m., Resident L stated, Staff have not changed (my) bedding weekly as they have done in the past. (I) changed the bedding (myself). * 05/31/17 at 9:00 a.m., staff member (AA), stated that the facility staff were told that resident bathing was not a priority, and the bath aide is often pulled to work on the floor, so baths don't get done. The staff member also confirmed that Resident C had not received a bath for a month. * 05/31/17 at 9:55 a.m., Resident (E) stated the bath aide was on vacation and she had not received a shower as scheduled. * 06/01/17 at 7:30 a.m., staff member (AA) reported Resident Q is usually saturated with urine in the morning and went three days without his pants being changed because he didn't have any clean clothing to change into. The staff member (AA) also stated Resident Q had not had a bath for over two weeks and had a yellow, scaly build-up on his scalp. Observation at 8:00 a.m., showed Resident Q's black pants as visibly soiled with food on both thighs. * 06/01/17 at 8:45 a.m., a staff member (BB) stated no showers will be given this week because there aren't enough staff available to provide them. * 06/04/17 at 2:19 p.m., Resident I expressed concerns regarding not receiving showers twice a week. On 06/06/17 at 8:42 a.m., he again stated he is not satisfied with the frequency of showers and stated he has gone up to 10 days without a shower. * 06/04/17 at 2:23 p.m., Resident A1 smelled her armpit and stated that woman quit, so (we aren't bathed as often. If they don't have the time . I last showered a couple of weeks ago. * 06/06/17 at 9:40 a.m., family member P stated, (Resident O) has been here (less than a year). Bathing has been horrible. She's lucky if she gets a bath one time a week. She voiced concerns regarding the Laundry service as well, stating, (There is) a long time between sending and receiving (clothing). The family member P also reported she has witnessed Resident O ask facility staff to toilet her in the bathroom, to which the staff members have replied, No, you have a brief. Random observation showed the following: * 05/30/17 at 10:20 a.m., Resident A cried as she spoke to an unidentified staff member, explaining how she had no clean underwear and hadn't had a bath. Observation on May 30-June 01, 2017 showed Resident A's hair greasy and unkempt. * 05/31/17 at 9:22 a.m., Resident M spoke to the managerial nurse (#2) at the West wing nurses' station. Resident M stated, I'm supposed to shower, but I don't have no clean clothes. I don't have any clean jeans. They've (My jeans) been gone a week already. When the managerial nurse (#2) suggested he speak to laundry staff, he stated, (Environmental/Laundry services manager (#9)) said there ain't none in there. When the managerial nurse (#2) replied, We don't have full time Laundry service, Resident M became angry, turned, and walked back to his room. Facility staff failed to search for clean clothing and failed to encourage the resident to bathe. Failure to ensure adequate nursing, laundry, and housekeeping staff resulted in psycho-social harm for Resident A, as evidenced by her crying over her current condition, and potential harm for Resident C, H, I, K, L, M, O, and Q. Refer to F166, F254, and F310

Based on information provided by the complainants, record review, review facility policy, Behavior/Mental Health meeting minutes, and staff interview, the facility failed to provide medically-related social services for 1 of 1 discharged resident (Resident #41) who displayed combative and aggressive behaviors. Failure to address the psychosocial needs of Resident #41 and implement interventions related to those needs resulted in the resident continuing to display aggressive combative behaviors throughout his stay and in his removal from the facility in handcuffs on 04/17/17 which resulted in psychosocial harm for Resident #41. Findings include: Information provided by the complainants indicated the facility failed to provide staff education on how to deal with demented residents. As an example, the complainants reported direct care staff were directed to call the cops and request assistance to transport an agitated resident with dementia to the emergency room . The complainants voiced concerns regarding removing a demented gentlemen (sic) out of his home in handcuffs. Review of the facility policy Behavior Assessment and Monitoring occurred on 06/05/17. The policy, revised April 2007, stated, . Problematic behavior will be identified and managed appropriately. The staff will identify and discuss with the practitioner situations where non-pharmacological approaches are indicated, and will institute such measures to the extent possible. The staff will document (in nursing notes and/or on behavior/mood documentation forms) the following information about specific problem behaviors: a. Number and frequency of episodes; b. Preceding or precipitating factors; c. Interventions attempted; and d. Outcomes associated with interventions. Review of the facility policy Admissions Policies occurred on 06/07/17. The policy, dated 09/01/07, stated, . 3. The objectives of our admission policies are to: . b. Admit residents who can be adequately cared for by the facility. Review of Resident #41's record occurred on all days of survey. An admission Minimum Date Set (MDS), dated [DATE], identified the resident continuously displayed inattention and disorganized thinking; had delusions; physical, verbal and other behaviors that impacted the resident and others; and rejected care. Although Resident #41 triggered Care Area Assessments for cognitive loss, psychosocial well-being, mood state, and behavior symptoms, the MDS showed staff chose not to proceed to care planning for those triggered areas and failed to developed a care plan to address the resident's behaviors. The record showed Resident #41 displayed behaviors of agitation, wandering, and combativeness nearly daily throughout his stay - culminating in an episode on 04/17/17 when the resident obtained a golf club from the administrator's office and threatened another resident with the club. Staff contacted law enforcement, a deputy restrained Resident #41, and ambulance personnel then transported him to a local hospital. An ambulance report, dated 04/17/17 at 2:05 p.m., stated, dispatched . to a 91 y/o (year old) male with dementia . responded immediately, (sheriff's office) was already on scene . arrived . to find a 91 y/o male . being physically restrained by (deputy) and a nursing home staff member. (Deputy) had also placed the pt (patient) in handcuffs prior to our arrival. Nursing home staff informed us that the pt has become increasingly aggressive and combative over the last few days. Pt seemed much more calm if he was talking with someone. Pt stated that he was very upset with how he has been treated. (deputy) stated that he was pretty sure that the pt has a small laceration (not actively bleeding at this time) to his left wrist, and that it was from the handcuffs the deputy had placed on the pt. Review of the weekly Behavior/Mental Health team meeting minutes showed discussion of the Resident #41's behaviors, but lacked evidence the team developed an individualized plan staff could implement to address the combative aggressive behaviors displayed by the resident. An interview with the social services designee (#20) occurred on 06/07/17 at 9:30 a.m. The staff member confirmed staff did not develop a care plan to address Resident #41's behaviors. The staff member stated she did not know how to handle behaviors and acknowledged she had not contacted the facility's consulting social worker for advice regarding Resident #41's difficult behaviors. The facility's failure to admit only residents for whom staff could provide adequate care and failure to develop and implement individualized interventions to address Resident #41's agitation, combativeness, and aggressive behaviors towards staff resulted in the resident using a golf club to threaten another resident on 04/17/17. Following this incident, a local deputy arrived and handcuffed the resident. This episode caused psychosocial harm to Resident #41. Refer to F221 and F280

INCONTINENCE 1. Based on observation, record review, review of the facility's certified nursing assistant (CNA) orientation packets, and resident and family interviews, the facility failed to provide toileting cares in a timely manner for 1 of 6 sampled residents (Resident #11) observed during toileting cares. Failure to respond appropriately to and/or toilet residents in a timely manner did not allow Resident #11 to attain/maintain her highest practicable physical and psychosocial well-being and resulted in her avoidable anxiety, psychosocial harm, and incontinence. Findings include: Review of the facility's CNA Orientation packet occurred on 06/07/17. This undated packet stated, . Provide maximum resident-care services to assure well-being of resident to greatest degree. Care for incontinent residents. Random interviews identified the following information regarding toileting cares: * 05/31/17 at 9:55 a.m., Resident (E) reported staff should take her to the bathroom every two hours, but they don't. She also stated staff take her three times a day and is usually incontinent by then. * 06/06/17 at 9:40 a.m., family member P reported she has witnessed Resident O ask facility staff to toilet her in the bathroom, to which the staff members have replied, No, you have a brief. Resident 11's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition, extensive-to-total assistance required for transfers and toileting, and bowel and bladder continence. Observations 06/01/17 showed the following: * 9:00 a.m., Resident #11 sat in her wheel chair near the East wing central bath area and asked four different staff members to take her to the bathroom. One of the unidentified staff members told Resident #11 she would find another staff member to help her, and walked away. Resident #11 then began yelling, Please, please, please! I have to go to the bathroom. I can't hold it any longer. All three of the other staff members walked by Resident #11 while she was yelling. * 9:20 a.m., Resident #11 knocked on the bathroom door numerous times as she yelled, Please, someone help me, please! When Resident #11 started waving her arms, one of the CNAs (#5) stated, Just a minute, and walked away. * 9:30 a.m. (30 minutes after the first request), a CNA (#11) wheeled Resident #11 into the bathroom and closed the door. The CNA (#11) later verified Resident #11's brief was wet. * 12:33 p.m., Resident #11 sat in her wheelchair near the East wing central bath area and waited 23 minutes to be toileted. * On 06/05/17 at 1:45 p.m., Resident #11 sat in her wheelchair in the hallway directly outside her room. She asked an unidentified staff member for assistance. The staff member replied, I'm busy right now, and walked away. Random interviews identified the following information regarding toileting cares: * 05/31/17 at 9:55 a.m., Resident (E) reported staff should take her to the bathroom every two hours, but they don't. She also stated staff take her three times a day and is usually incontinent by then. * 06/06/17 at 9:40 a.m., family member P reported she has witnessed Resident O ask facility staff to toilet her in the bathroom, to which the staff members have replied, No, you have a brief. Facility staffs' failure to respond appropriately to Resident #11's persistent requests for toileting assistance and their failure to respond to her in a timely manner resulted avoidable anxiety, psychosocial harm, and incontinence. URINE CULTURES 2. Based on record review and staff interview, the facility failed to provide services to treat urinary tract infections (UTIs) for 1 of 1 sampled resident (Resident #2) with a history of UTIs. Failure to contact the physician immediately after being notified of a positive urine culture resulted in Resident #2 receiving delayed treatment for [REDACTED]. Findings include: The facility failed to provide a copy of their policy addressing UTIs, as requested. Resident #2's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident was independent with toileting cares. The progress notes identified the following: * 12/28/16, . Res (resident) c/o (complains of) burning during urination, res encouraged to drink water, (physician) was called, new order received to observe to collect urine for UA/UC (urine analysis/culture). urine collected (and) taken to lab. * 12/31/16, UC lab results done, message left for (physician) . when he comes for rounds to review results. The final urine culture, dated 12/30/16, identified Escherichia Coli (bacteria from the bowel) and indicated the bacteria was susceptible to all antibiotics tested . * 01/03/17, (Physician) called, new order received (and) observed to start AB (antibiotic) therapy for UTI. During an interview on the morning of 06/07/17, the managerial nurse (#2) confirmed staff should immediately contact the physician after being notified of a positive urine culture. Facility staff failed to contact Resident #2's physician for four days, after being notified of Resident #2's positive urine culture, delaying her antibiotic treatment.

Based on record review and staff interview, the facility failed to provide care and services in a manner that promoted physical, mental, and psychosocial well-being for 1 of 1 sampled resident (Resident #2) who exhibited behaviors and expressed distress during a nursing procedure (urinary catheterization). Failure to contact the medical provider to determine the necessity of the follow-up urinalysis (UA) resulted in Resident #2 displaying combative behaviors, receiving psychopharmacological medication, and unnecessary procedures which caused avoidable mental distress and psychosocial harm. Findings include: Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The resident's current Minimum Data Set (MDS), dated [DATE], identified short and long term memory problems and severely impaired daily decision making skills. Record review identified a urine culture positive for Proteus mirabilis (a bacteria commonly found in the gastrointestinal tract) on 09/11/14 which was treated with Keflex (an antibiotic) from 09/12/14 through 09/18/14. A physician's orders [REDACTED]. Nurses' notes identified the following: *09/20/14 at 7:00 a.m.: ". . . Resident laid down by nursing personnel and explained procedure to resident. Resident mumbles and says 'I don't like this' - Resident told step by step re: (regarding) obtaining a cath (catheter) UA, what was being done - Resident would holler out et (and) scream during cathing procedure. Unable to get sample - 2nd attempt at cathing was done by (staff name) - two other nurses present. One helped holding legs apart et other nurse was holding hands of Resident et enc. (encouraged) her to hold on real tight. Was a little cooperative. UA obtained, was obtained and was sent (down) to lab. . . ." *09/20/14 at 7:20 a.m.: ". . . UA (urinalysis) taken (down) to Lab. . . ." *09/20/14 at 8:20 a.m.: ". . . Lab informed this facility that UA was unable to be done b/c (because) no personnel to check it into the system. . . ." *09/22/14 at 9:20 a.m.: ". . . Another UA sent to lab today. Resident pre-medicated (with) topical [MEDICATION NAME] (an anxiolytic) prior to procedure. Resident combative during procedure. . . ." (A nursing staff member identified the entries dated 09/20/14 actually occurred on 09/21/14 (a Sunday).) A written note to the physician identified the following: ". . . We got a follow up UA for (Resident #2) on Sunday morning. Lab refused to take it. (Resident #2) screamed et fought us on the first UA. She had behaviors (after) the first UA. The lab wouldn't accept the UA unless we brought her to the ER (emergency room ). We drew second UA on 9-22-14 but we gave her topical [MEDICATION NAME] first and she still screamed et fought us. . . ." Although Resident #2 expressed extreme distress during the procedures, staff failed to contact the medical provider and continued to obtain a follow-up UA three times. As a result, Resident #2 displayed combative behaviors, received psychopharmacological medication, and was subjected to unnecessary procedures against her will which caused avoidable mental distress and psychosocial harm. Refer to F502.