Every finding on record at Wibaux County Nursing Home

Based on interview and record review, the facility failed to ensure the designated infection preventionist was qualified by education, training, or experience to oversee the infection prevention and control program for the facility. The failure placed all residents at increased risk for the development and transmission of infections. Findings include:During an interview on 4/8/26 at 1:33 p.m., staff member A stated staff member B started in her role at the facility on 11/4/25, and had been taking the CDC Infection Preventionist certification training, but was only up to module eight because she was busy filling in on the floor as needed and had not had time to complete the training. During an interview on 4/9/26 at 9:13 a.m., staff member B stated she started in November 2025 and was responsible for the facility's infection prevention and control program. Staff member B stated, I am still learning . I haven't finished the infection preventionist course yet. Staff member B explained that some of the information she was learning was new to her. Review of a facility document titled Infection Surveillance, revised February 2026, showed: The infection preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility .Review of CDC's Nursing Home Infection Preventionist training, located online at https://www.cdc.gov/long-term-care-facilities/hcp/training/index.html and accessed on 4/13/26, showed the Infection Preventionist course contained 23 required modules and the course completion time was approximately 20 hours.

Based on observation, interview, and record review, the facility failed to implement an effective infection prevention and control program, including failure to ensure Enhanced Barrier Precautions (EBP) were implemented for 2 (#s 1 and 4) of 13 sampled residents; and failed to implement a system for the ongoing surveillance, identification, and prevention of infections for all residents. The failures placed residents at risk for developing and transmitting infections. Findings include: Enhanced Barrier Precautions: 1. During an interview on 4/8/26 at 11:52 a.m., staff member J stated resident #1 had an open pressure wound on her left heel and coccyx area. Staff member J stated she was not aware enhanced barrier precautions should be used when providing care for resident #1 due to the pressure ulcers. During an interview on 4/8/26 at 12:10 p.m., staff member K stated she usually works on the Keys unit and was not aware of any residents on enhanced barrier precautions. Staff member K stated resident #1 had two pressure wounds, one on her left heel and one on her coccyx area. Staff member K stated she was not aware she needed to use enhanced barrier precautions when providing care to resident #1. Review of resident #1's physician's order, dated 4/1/26, showed an order for a dressing change to the resident's right heel with a diagnosis of a pressure ulcer of the left heel, which was documented as Unstageable, for the severity. The second order showed a dressing change to the resident's coccyx area, with a diagnosis of pressure ulcer of the sacral region, which was documented as a Stage II for severity. 2. During an observation and interview on 4/6/26 at 2:33 p.m., resident #4 was observed in his room with heel protector boots on over bilateral foot dressings. Resident #4 stated he was unaware that he was on enhanced barrier precautions, which would require a gown and gloves for high-contact care. Resident #4 stated staff only wore gloves when changing his foot dressings or when helping him with personal care. During an interview on 4/8/26 at 11:45 a.m., staff member C stated there were no residents in the facility who were currently on enhanced barrier precautions. Staff member C did not know when enhanced barrier precautions should be used for a resident. During an interview on 4/8/26 at 3:02 p.m., staff member H stated the facility did not have anyone on enhanced barrier precautions at that time. During an interview on 4/8/26 at 3:45 p.m., staff member C stated she changed all wound dressings in the facility weekly and completed a wound assessment. Staff member C stated she had not been wearing a gown (for adhering to enhanced barrier precautions) when changing wound dressings and stated, I guess I should be. During an interview on 4/9/26 at 8:00 a.m., staff member L stated they would wear personal protective equipment (PPE) whenever there was a sign (for infection control precautions) posted on the resident's door, and there currently were no signs posted on any rooms to reflect the need for PPE to be used. When interviewed, staff member L was unable to differentiate between the different types of infection control precautions or when they would be used. Staff member L stated, We haven't had anyone on precautions since the Norovirus outbreak. During an interview on 4/9/26 at 8:25 a.m., staff member M stated, We would only wear (a) gown and gloves (for enhanced barrier precautions) if we emptied a catheter bag. We don't wear a (protective) gown if we are doing personal care. In the shower, we just wear the shower apron, so we don't get wet. A request for documentation of staff education provided on enhanced barrier precautions was made on 4/9/26. No documentation was provided by the end of the survey. Review of a facility policy titled Enhanced Barrier Precautions, revised 3/1/26, showed: .1. a. All staff receive training on Enhanced Barrier Precautions upon hire and at least annually and are expected to comply with all designated precautions . 2. b. An order for Enhanced Barrier Precautions will be obtained for residents with any of the following: . I. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices, even if the resident is not known to be infected or colonized with an MDRO. 3. a. Personal protective equipment (PPE) for Enhanced Barrier Precautions is only necessary when performing high-contact care activities . 4. High-contact resident care activities include: a. Dressingb. Bathingc. Transferringd. Providing hygienee. Changing linensf. Changing briefs or assisting with toiletingg. Device care or useh. Wound care: any skin opening requiring a dressing. [sic] Infection Prevention and Control Program: During an interview on 4/9/26 at 9:13 a.m., staff member B stated she started in November 2025 and was responsible for the infection prevention and control program. Staff member B stated, I am still learning. I haven't finished the infection preventionist course yet. Staff member B stated that infections and pathogens were not being tracked or mapped within the facility. Staff member B stated the facility had a significant Norovirus outbreak in February of 2026 that was reported to the health department; however, the information was not added to the infection control logbook. Review of a facility document titled Infection Control Log book, undated, showed a monthly report generated from the facility's electronic health record system; however, infections listed included non-specific diagnoses such as UTI unspecified, history of UTI, and respiratory infection unspecified, and the information lacked infection surveillance and or any analysis of infections. The logbook did not show any information pertaining to the Norovirus outbreak, and the infection summary report for February 2026 showed no gastrointestinal infections. Review of a facility document titled Infection Surveillance, revised February 2026, showed, Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections.

Based on interview and record review, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency within the required timeframe for 1 (#13); failed to ensure allegations of abuse by staff were reported to the administrator and State Survey Agency within the required timeframe for 3 (#s 12, 19, and 25) of 6 residents sampled for abuse and neglect reporting. The failures placed the residents at risk for continued abuse or neglect and delayed investigation and intervention by the State Survey Agency. Findings include:1. Review of a facility-reported event, submitted to the State Survey Agency on 3/20/26, showed an event involving resident #13 that occurred on 3/17/26 during the night shift and involved a lack of hygiene care and a lack of monitoring following episodes of vomiting. During an interview on 4/7/26 at 10:51 a.m., staff member A stated the event with resident #13 was identified on the morning of 3/18/26 after review of video surveillance. Staff member A stated the facility reported the concerns to the travel staffing agency and terminated the contracts of the involved staff on 3/18/26. Staff member A stated the facility did not report the event to the State Survey Agency until 3/27/26, after being notified that the involved staff had been reported to their respective regulatory boards. Staff member A stated, That's when we realized we should have reported it to the state. 2. Review of a facility-reported event, submitted to the State Survey Agency on 3/10/26, showed on 3/9/26 resident #19 was allegedly pushed by a facility staff member, resulting in the resident falling to the ground. The event was not reported to the State Survey Agency until 3/10/26; after a facility staff member failed to report the event immediately to the nurse. During an interview on 4/8/26 10:01 a.m., NF7 stated that on 3/9/26, while providing care to resident #19, the resident became aggressive. NF7 stated she was trying to keep her distance from resident #19, and as she put her hand out, it contacted the resident's left shoulder, causing the resident to lose his balance, which resulted in NF7 assisting the resident #19 to the ground in the sitting position. NF7 stated she did not report the event to the nurse. NF7 stated that at the time the event occurred, she did not feel it was reportable, but after she spoke to staff member A, she realized she should have reported the event to the nurse immediately after it occurred. During an interview on 4/8/26 at 2:29 p.m., NF2 stated on 3/9/26 that she had witnessed the event between NF7 and resident #19. NF2 stated she did not report the event to the nurse until the following day (3/10/26) because she was trying to process what had happened. NF2 stated she should have reported the event to the nurse immediately after it occurred. 3. Review of a facility-reported event, submitted to the State Survey Agency on 3/13/26, showed an allegation that on 3/10/26, residents #12 and #25 were verbally abused by a facility staff member. The alleged event was not reported to the State Survey Agency until 3/13/26, after a facility staff member failed to report the event immediately to the nurse on 3/10/26. During an interview on 4/8/26 at 2:35 p.m., NF2 stated on 3/10/26 she had worked with NF7 helping prepare resident #12 for a bath. NF2 stated resident #12 displayed behaviors prior to her bath. NF2 stated NF7 made a remark with the resident present in her room, stating, Maybe a cold shower would cool you (resident #12) off. NF2 stated on the same day (3/10/26) NF7 also told resident #25 to sit down and be quiet when the resident was entering the dining area. NF2 stated she did not report the events involving resident #12 until 3/12/26. NF2 stated she should have reported the events to the nurse immediately after they occurred. Review of a facility document titled Abuse, Neglect, and Exploitation, with a revision date of January 2026, showed: . VII. Reporting/Response A. [Facility Name] will have written procedures that include: 1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies . within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review, the facility failed to develop and implement a baseline care plan, which included the minimum necessary instructions needed to provide effective and person-centered care of a resident for 1 (#2) of 13 sampled residents. Findings include:During an interview on 4/9/26 at 8:56 a.m., staff member B stated nursing was responsible for starting baseline care plans for residents on admission. Staff member B stated that the baseline care plan should include the health information necessary to care for a resident properly. Staff member B stated the facility used a software program to develop the baseline care plans, and facility staff were not able to include all the information related to a resident's care due to limitations with the program. Staff member B stated she would need to research options available for the completion of a thorough baseline care plan. Review of resident #2's physician progress note, dated 3/8/26, showed the resident was to be admitted to the facility on [DATE] and continue using the following medications:- Lantus insulin 60 units subcutaneous nightly,- Levothyroxine 75 mcg by mouth daily,- Lithium 300 mg by mouth twice daily,- Melatonin 3 mg by mouth nightly,- Olanzapine 10 mg by mouth nightly,- Olanzapine 5 mg by mouth daily,- Pioglitazone 30 mg by mouth daily and,- Rosuvastatin 5 mg by mouth daily.Review of resident #2's document titled, Baseline Care Plan, dated 3/9/26, did not include a problem, goals, or interventions for medication management.Review of the facility document titled Baseline Care Plan, with a revision date of 9/29/25, showed: . Policy Explanation and Compliance Guidelines:I. The baseline care plan will:a. Be developed within 48 hours of a resident's admission.b. Include the minimum healthcare information necessary to properly care for a resident, including, but not limited to:. II. Physician orders.

Based on interview and record review, the facility failed to implement an effective antibiotic stewardship program, including monitoring of antibiotic use within the facility. The failure placed residents at increased risk for inappropriate antibiotic use, adverse drug reactions, and development of antibiotic-resistant organisms. Findings include:During an interview on 4/9/26 at 9:13 a.m., staff member B stated she started in November 2025 and was responsible for the infection prevention and control program, including oversight of antibiotic use. Staff member B stated providers were good about obtaining cultures and changing or discontinuing antibiotics based on culture and sensitivity reports; however, she was not currently tracking the information. Staff member B stated, I am just learning. It makes perfect sense to track the pathogens and antibiotics, and I will start tracking and monitoring them now.Review of a facility document titled Infection Control Log Book, undated, showed monthly reports generated from the facility's electronic health record system of antibiotics in use; however, infections listed included non-specific entries such as UTI unspecified, history of UTI, and respiratory infection unspecified. The logbook contained no identified pathogen or culture and sensitivity information for prescribed antibiotics, and antibiotic use was not being meaningfully tracked or analyzed to support appropriate prescribing.Review of a facility document titled Antibiotic Stewardship Program, revised February 2026, showed: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use . 11. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to:- a. Action plans and/or work plans associated with the program.- b. Assessment forms.- c. Antibiotic use protocols/algorithms.- d. Data collection forms for antibiotic use, process, and outcome measures.- e. Antibiotic stewardship meeting minutes.- f. Feedback reports.- g. Records related to education of physicians, staff, residents, and families.- h. Annual reports . [sic]

Based on observation, interview, and record review, the facility failed to provide necessary care and services to maintain a resident's quality of life for personal dignity, comfort, and safety for 1 (#13) of 13 sampled residents. The failure resulted in the resident remaining in vomit-soiled conditions for an extended period of time. The resident refused care and was periodically checked on by staff, but did not receive the level of care or assessment necessary related to her emesis episodes or risks related to them. Findings include: Review of a facility-reported event submitted to the State Survey Agency on 3/20/26 showed NF8 and NF9 failed to provide hygiene care and failed to assist resident #13 from a recliner following episodes of vomiting. Resident #13 was periodically checked on by staff but did not receive an appropriate assessment or care related to her vomiting episodes. During an observation on 4/8/26 at 7:35 a.m., resident #13 was observed with no skin breakdown. Resident #13 kept her eyes closed and was verbally and physically aggressive to staff during repositioning for skin observation.Review of a facility document titled [Resident #13] camera footage timeline, dated 3/17/26, showed resident #13 vomited at 6:45 p.m. and 7:51 p.m. The document showed no hygiene care was provided following these episodes. The document showed resident #13 was checked on periodically throughout the early evening, and restless and coughing until 8:48 p.m.; however, NF8 did not check on the resident again until 10:51 p.m. The document showed no physical assessment, monitoring, or interventions were implemented despite the resident's condition, except placement of a towel and a shirt change shortly before shift change.Review of resident #13's nursing progress notes dated 2/1/26 to 3/31/26 showed the resident had a history of aggressive behaviors and language, which at times made it difficult for staff to provide care.Review of resident #13's nursing progress notes dated 3/18/26 at 2:30 a.m. showed no documentation of physical assessment or increased monitoring following vomiting episodes.During an interview on 4/7/26 at 10:51 a.m., staff member A stated NF8 and NF9 were travel staff assigned to resident #13 on the night shift of 3/17/26. Staff member A stated video surveillance was reviewed after concerns were identified and reported on the morning of 3/18/26.

Based on observation, interview, and record review, the facility failed to ensure nursing staff documented wound care, wound status, and dressing changes in accordance with professional standards of practice for 1 (#4) of 3 residents sampled for wounds. The failure placed the resident at increased risk for ineffective wound healing, undetected changes in condition, and infection. Findings include:During an observation on 4/6/26 at 2:33 p.m., resident #4 was observed in his room with heel protector boots in place over bilateral foot wound dressings.During an interview on 4/7/26 at 4:02 p.m., staff member H stated he only documented wound treatments or dressing changes .if the wound looked a lot better or a lot worse.During an interview on 4/8/26 at 3:30 p.m., staff member C stated she or staff member B was responsible for completing weekly wound assessments, including wound measurements, evaluation, the wound deterioration or healing, and physician notifications, if needed. Staff member C stated the nursing staff was responsible for monitoring wound dressings and completing dressing changes according to a physician's order. Staff member C stated wound care was documented as completed on the medication administration record (MAR); however, nursing staff were expected to document a wound dressing and status in the resident's medical record progress notes, every shift, and at the time of the wound dressing change. Staff member C stated she was confident wound care was being completed as ordered, as reflected in the medication administration record (MAR); however, documentation of wound dressing observations and wound care was not consistently documented as completed in the nursing progress notes.Review of resident #4's physician orders, dated 3/31/26, showed: Right ankle wound: Change dressing every 3 days. Monitor every shift. Change dressing as needed if saturated.Stage 2 pressure injury to right heel: Change dressing every 3 days. Monitor every shift. Change as needed if saturated.Top of foot wound: Change dressing every 3 days. Monitor every shift. Change dressing as needed if saturated. [sic]Review of resident #4's nursing progress notes from 4/1/26 to 4/8/26 showed one comprehensive wound assessment documented by staff member C on 4/2/26. There were two additional nursing progress note entries during this period, which included: 4/2/26 at 2:45 p.m., . Dressing change done by ADON and is charted, and 4/5/26 at 6:49 p.m., The pt. had his dressings changed with improvement noted to his bilat lower extremities. [sic] Resident #4's nursing progress notes showed a total of two entries referencing the resident's wounds over seven days, during which 14 opportunities existed to document the wounds or wound dressing statuses. Review of a professional wound management resource located online at https://www.woundsource.com/blog/documentation-in-wound-care, accessed on 4/13/26, showed, Clinicians must provide adequate and accurate documentation of all relevant wound characteristics, interventions, and responses.Review of a facility document titled Documentation in Medical Record, revised February 2026, showed: Policy Explanation and Compliance Guidelines: . 1. Licensed staff . shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

Based on observation, interview, and record review, the facility failed to revise a care plan to reflect a resident's current care needs for 1 (#1) of 13 sampled residents. Findings include:During an observation on 4/7/26 at 12:30 p.m., resident #1 was sitting in her wheelchair at the dining table. The resident was noted to have heel protectors on her feet.During an interview on 4/8/26 at 11:44 a.m., staff member C stated resident #1 had a pressure wound on her left heel. Staff member C stated resident care plans were updated weekly, and she was not sure why resident #1's care plan had not been revised for the pressure wound. Review of resident #1's physician progress note, dated 4/3/26, showed resident #1 had an Unstageable pressure ulcer on the left heel, as well as a Stage II pressure ulcer on her coccyx.Review of resident #1's current care plan, reviewed on 4/8/26, did not reflect that the resident had developed pressure wounds on her left heel and coccyx area, or the use of heel protectors.

Based on interview and record review, the facility failed to accurately complete multiple comprehensive Minimum Data Set (MDS) assessments for the resident's Pre-admission Screening and Resident Review (PASRR), for 1 (#12) of 13 sampled residents. Findings include:During an interview on 4/8/26 at 12:22 p.m., staff member F stated resident #12's PASRR Level One was completed on 1/3/23, and a PASRR Level Two was completed on 1/27/23. Staff member F stated that when she completed section A of the resident's MDS submission on 1/21/25 and 1/12/26, she overlooked adding PASRR information because the system pre-populated the resident's demographic information.Review of resident #12's electronic medical record showed the resident was admitted to the facility on [DATE] with a diagnosis of Anxiety, Depression, Schizoaffective Disorder, and Cerebral Palsy. A Level One PASRR was completed on 1/3/23, and the resident qualified for a Level Two screening, which was completed on 1/27/23, with recommended services received on 2/1/23. Staff member F stated resident #12 did not have any disruption in service due to the incorrect coding on the resident's comprehensive assessments submitted on 1/21/25 and 1/12/26.Review of resident #12's MDS assessment dated [DATE] and 1/12/26, with an Assessment Reference Date of 1/6/25 and 1/5/26, section A, showed the facility documented the resident was not considered to have serious mental illness and or intellectual disability or a related condition, using the State PASRR evaluation process, due to how the MDS was coded.

Based on interviews and record reviews, a facility staff member failed to transfer a resident properly while using a mechanical lift and ensure that two staff members were assisting. The resident fell from the lift and sustained a fracture, a head injury, and passed away at the hospital. Documentation reflected that the fall contributed to the resident's death, for 1 (#1) of 7 sampled residents. Findings include: On [DATE] at 11:35 a.m., the facility Administrator, Assistant Administrator/Business Office Manager, and the Director of Nursing were notified of an Immediate Jeopardy (IJ) situation, which involved resident #1 related to a fall with major injuries. The IJ pertained to F689 - Free of Accident Hazards/Supervision/Devices. The Severity and Scope of the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy, lowered to G.On [DATE] at 11:40 a.m., the facility provided an acceptable plan to remove the immediacy for the residents residing in the facility who are at continued risk of harm due to the failed practices related to mechanical lift use. The surveyor verified the removal of immediacy onsite through the use of observations, interviews, and record reviews, on [DATE]. Review of resident #1's care plan, dated [DATE], showed the resident #1 needed total assistance when transferring from surface to surface. The care plan directed the staff to use a Hoyer (full body mechanical) lift with two staff members. Review of resident #1's nursing note, dated [DATE] at 6:44 p.m., showed resident #1 was seen lying on her right side, with the right side of her face on the floor, and a large amount of blood was observed on the floor around the resident. The certified nurse assistant reported the resident fell from the Hoyer (full body ) mechanical lift. Emergency medical services were on the scene at approximately 6:15 p.m. Resident #1 was transported to a local hospital for further assessment and care. Review of the hospital emergency department report, dated [DATE] at 1:01 a.m., showed the resident sustained:-Subdural hematoma, acute-C2 cervical fracture.-Fall in her home (the facility).-Forehead laceration. Review of resident #1's Montana Certificate of Death, dated [DATE], showed resident #1 died on [DATE] at 6:10 a.m., which was three days after the fall with significant injuries. The Montana certificate of death listed the causes of death as:- a subdural hematoma- fall from a Hoyer lift. During an interview on [DATE] at 2:01 p.m., NF1 said she had been working at the facility for about a month before resident #1's fall. NF1 said she did not receive orientation on the mechanical lifts and their use of them and did not complete a return demonstration to verify her knowledge for the use of the mechanical lifts. NF1 said the CNA who trained her to the facility told her to use the mechanical lifts by herself, as this was the practice at this facility. NFI said she had been working as a caregiver for over seven years, and she knew there should be two staff when using lifts, although this did not occur at the time of resident #1's fall. NF1 said she was transferring resident #1 at the end of her shift, and she was tired. NF1 said she was transferring resident #1 from her chair to the bed, and the resident fell out of the lift during the transfer. NF1 said she did not know exactly how the resident #1 fell out of the lift, and said she was not sure how one strap became unhooked from the sling, but the other three straps were still connected to the lift. NF1 said she informed management that the CNAs were using the mechanical lifts alone, training new staff on that practice, and were not using the required two people.During an interview on [DATE] at 2:32 p.m., staff member H said she responded to resident #1's room to assist with patient care after #1's fall from the lift. Staff member H said the front left sling strap was not hooked on the bar of the mechanical lift. Staff member H said that when she had used the mechanical lifts in the past, she had caught the straps popping off the hooks many times. Staff member H said she had been using the lifts independently for a long time at the facility.During an interview on [DATE] at 3:02 p.m., staff member S said he saw resident #1 in the hospital the second day she was there. Staff member S said resident #1 had a subdural hematoma and fractures of the Cervical spine at level C1-C2. Staff member S said the fractures of C1-C2 were unstable, but there was no spinal cord involvement and no spinal cord dissection. Staff member S said he did not complete the death certificate, but the cause of death would likely be from subdural hematoma, closed head injury, and concussion. Staff member S said the cause of death was definitely related to the fall from the lift.During an interview on [DATE] at 2:17 p.m., staff member E said she watched the hallway camera video of the fall which occurred on [DATE] at approximately 6:00 p.m. Staff member E said she saw NF1 stick her head out of the door (of #1's room). Staff member E, and another staff member went into resident #1's room, and she could see one of the shoulder straps was not connected to the lift. During an interview on [DATE] at 2:40 p.m., staff member F said she was the nurse on duty at the time resident #1 fell and was injured. Staff member F said she could tell resident #1 was hurt; most of the damage was on her right side, which she was lying on. Resident #1's eye socket was swollen, and she was bleeding from a laceration on her forehead. The staff did not move her, and the ambulance arrived quickly. Staff member F said NF1 had transferred resident #1 by herself with the mechanical lift. Staff member F said some of the CNAs said staff member C allowed the staff to transfer residents using the mechanical lifts by themselves without a 2nd person to assist for safety.

Based on interviews and record review, the facility staff failed to protect 1 (#1) of 8 residents sampled for neglect of care by the staff when safe lifting practices were not employed during resident transfers with a mechanical lift, and the facility policies were not followed. Findings include:During an interview on [DATE] at 2:01 p.m., NF1 said, “I had been a [position title] for seven years, and I never used mechanical lifts by myself before coming here. I knew I should have a second person to assist because I was trained and have always had two people for lifts. NF1 said she was trained at this facility by CNAs and was told that this facility only used one person to transfer residents with a mechanical lift. During an interview on [DATE] at 2:00 p.m., staff member H said the staff have been completing mechanical lifts without a second person in attendance. Staff member H said this had been going on for over a year and was probably longer. During an interview on [DATE] at 2:33 p.m., staff member C said that when the census went down, the administration and the board made the facility decrease the staff hours. Staff member C said this caused a change in the staffing level, and then there was one certified nurse assistant in the front (assigned to care outside of the dementia unit), and one certified nurse assistant on the secured dementia unit. Staff member C said the staff could not always find two staff members to help during that time. Staff member C said she could not remember the exact time, but said it was between March and July of 2025. Review of resident #1's care plan, dated [DATE], showed that resident #1 was totally dependent upon two staff members for transferring her from surface to surface. The care plan directed the staff to use a Hoyer mechanical lift and two staff members we directed to assist during the lift. Review of resident #1's nursing note, dated [DATE] at 6:44 p.m., showed resident #1 was seen lying on her right side, with the right side of her face on the floor, and a large amount of blood was observed on the floor around the resident. The certified nurse assistant reported the resident fell from the Hoyer (full body ) mechanical lift. Emergency medical services were on the scene at approximately 6:15 p.m. Resident #1 was transported to a local hospital for further assessment and care. Review of the hospital emergency department report, dated [DATE] at 1:01 a.m., showed the resident sustained: -Subdural hematoma, acute. -C2 cervical fracture - Fall in her home (the facility) -Forehead laceration. Review of resident #1's Montana Certificate of Death, dated [DATE], showed resident #1 died on [DATE] at 6:10 a.m., which was three days after the fall with significant injuries. The Montana certificate of death listed the causes of death as: - a subdural hematoma - fall from a Hoyer lift.

Based on interviews and record review the facility failed to ensure the facility was administered in a manner that allowed resident #1 to be provide individualized care related to mechanical lifts and falls and failed to promote the well-being and prevent physical harm, pain and death for 1 (#1) of 10 sampled residents. Findings include: Review of resident #1's care plan dated 8/5/22 showed the resident #1 needed total assistance when transferring from surface to surface. The care plan directed the staff to use a Hoyer lift with two staff members. The care plan failed to identify the size sling to be used for resident #1. Review of resident #1's nurses note dated 9/10/25 at 6:44 p.m., showed resident #1 was seen lying on her right side with the right side of her face on the floor and a large amount of blood noted on the floor around the resident. The certified nurse assistant reported the resident fell from the Hoyer lift. Emergency medical services were on the scene at approximately 6:15. Resident #1 was transported to a local hospital. During an interview 9/23/25 at 2:40 p.m., staff member F said she was the nurse on duty at the time resident #1 fell and was injured. Staff member F said she could tell resident #1 was hurt. Staff member F said the certified nurse assistant transferred resident #1 by herself. Staff member F said some of the certified nurse assistants told her staff member C was aware the certified nurse assistants were doing independent lifts and staff member C allowed the staff to transfer residents using the mechanical lifts by themselves with no help. During an interview of 9/22/25 at 2:01 p.m., NF1 said she was trained and oriented by the other certified nurse assistants. NF1 said the other certified nurse assistants trained her to only have one staff member present during the mechanical lift transfers. During an interview on 9/22/25 at 2:48 p.m., staff member D said the certified nurse aides use the mechanical lifts independently. Staff member D said the management was aware the lifts were being used by one person, and the policy was not being followed. During an interview on 9/23/25 at 2:00 p.m. staff member H said the staff have been doing mechanical lifts without a second person in attendance. Staff member H said the practice of not having two staff member help with lifts had been going on for over a year and probably longer.During an interview on 9/23/25 at 2:33 p.m., staff member C said when the census went down, the administration and the board made the facility decrease staff hours. Staff member C said this caused a change in the staffing level to include one certified nurse assistant in the front and one certified nurse assistant on the locked dementia unit. Staff member C said the staff could not always find two staff to help during that time. Staff member C said she could not remember the exact time and said between March and July of 2025.

Based on interview and record review, the facility failed to ensure licensed nurses and certified nurse assistants received training on the procedure and safety requirements for using mechanical lifts for fifteen (D, E, F, G, H, I, J, K, L, M, N, P, Q, R, NF1) of sixteen sampled staff members. The deficient practice increased the risk of harm for the seven residents in the facility still utilizing a mechanical lift. The facility reported a census of 30. Findings include: During an interview on 9/22/25 at 2:01 p.m., NF1 said she started her job at the facility about a month ago. NF1 said the Director of Nursing did not complete any training with her prior to working directly with residents. NF1 said upon hire she signed some paperwork and then trained directly with a certified nurse assistant during orientation. NF1 said during orientation the CNAs who trained her said a resident who required the use of a mechanical lift did not require two staff to assist, and NF1 could perform the task independently. NF1 said the other certified nurse assistants said they also complete the lift transfers independently. During an interview on 9/22/25 at 2:32 p.m., staff member H said she did not receive training or complete a competencies evaluation related to mechanical lifts and their use of them for transferring residents, prior to 9/11/25, which was after resident #1 fell from the mechanical lift and sustained major injuries. Staff member H said her last mechanical lift competency was completed years ago, which was when she completed her state exam for the certification. During an interview on 9/22/25 at 2:55 p.m., staff member C said nursing staff competencies related to mechanical lift education were completed in May 2025, which was when nursing staff were required to perform a return demonstration of the mechanical lift use.Review of staff education, specifically related to mechanical lifts and their use, showed only staff member O received the mechanical lift training on 5/30/25. Staff member C provided one mechanical lift competency form for staff member O. Staff member C could not produce any more mechanical lift competency training documents for the rest of the licensed or certified nursing staff, and or the two management staff, who retained their CNA certification. Review of resident #1's nursing progress note, dated 9/10/25 at 6:44 p.m., showed, . Upon arrival to the room, resident seen lying on her right side with right side of face on floor and large amount of blood noted on the floor around the resident. CNA reported resident fell from the hoyer lift in a staff witnessed fall. [sic]

Based on interviews and record review the facility failed to ensure services were provided according to professional standards related to safe use of mechanical lifts for 1 (#1) of 8 sampled residents. Review of resident #1's care plan, dated 8/5/22, showed that resident #1 was totally dependent upon two staff members for transferring her from surface to surface. The care plan directed the staff to use a Hoyer fully body mechanical lift. During an interview on 9/22/25 at 2:01 p.m., NF1 had not used a mechanical lift by themself before working at the facility, and stated, I knew I should have a second person because I was trained and have always had two people for lifts. During an interview on 9/22/25 at 2:32 p.m., staff member H said she was taught to use two people when using a mechanical lift to transfer people. Staff member H said she had used the lift by herself. Staff member H said she was aware that only using one person for transferring residents with a mechanical lift was not the right way to provide the care. Staff member H said it upset her when the staffing was changed to having only one CNA in each hall. Staff member H said the residents had to get taken care of, so We had to do what we could to get the residents taken care of, and that included using the mechanical lifts by ourselves. During an interview on 9/23/25 at 10:39 a.m., staff member L said he had training on the lifts in the past. Staff member L said he had been using lifts for a long time, so he knows how to use them. Staff member L said it was never 100% for getting two staff to help. Staff member L said most of the time he had two staff doing the lifts, but sometimes the facility is short-staffed and two staff are not always available.

Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status or meal safety for those who consumed food prepared and served by the facility. Findings include: During the initial tour of the kitchen, on 3/10/25 at 11:50 a.m., no documentation of advanced training for the dietary manager was posted. During an interview on 3/13/25 at 9:47 a.m., with staff members A, B, C, and N, staff member N stated one of the issues the facility continued to review monthly had to do with staff member M's lack of certification as a dietary manager. Staff member N stated she received weekly email reports from staff member M about progress on completing the dietary manager certification. Staff member N stated staff member M worked full-time and was still not certified in the role. Staff member N stated this process was ongoing since the last plan of correction was started after last year's survey process, which was on 2/29/24. During an interview on 3/13/25 at 11:07 a.m., staff member M said she did not have the CDM certificate, but she was enrolled in an online program titled, Certified Dietary Manager/Certified Food Protection Professional, and was only on the third lesson. She did not identify when she would have the course completed. 51111 Review of a facility document titled, Facility Assessment For [Facility Name], dated 8/8/2024, showed: . Food and Nutrition Services . having a Dietary Manager who is working on her CDM who has a vast knowledge and experience of food and nutrition .

Based on interview and record review, the facility failed to maintain medical records which were accurately documented, dated, labeled, and completed in their entirety, for 5 (#s 4, 14, 18, 20 and 23) of 16 sampled residents. Findings include: 1. The following incomplete records were located in resident #4's medical records: a. A review of resident #4's hard-copy POLST form and alternate medical records, dated 3/17/20, showed: - In the section for the resident's full name, date of birth, and sex, the form had been altered by blocking out information with white out. Resident #4's name had been added to the form in the area which had been altered with white out. - In the mandatory section, where there should be a medical provider signature, the date, the time, and the providers phone number, was incomplete. The POLST form would be invalid due to the altered and missing information. b. Resident #4's staff assessment of daily and activity preference, completed on 3/12/25, was incomplete. c. Resident #4's consent for Zoloft and Zyprexa was incomplete. The observation information included the creator, the date of the observation, the date recorded, completion date, and who completed the form was incomplete. The consent was obtained by verbal consent on 12/13/24 and had not been signed by the POA by 3/13/25. 2. The following records were found to be incomplete for resident #23: - Resident #23 had an elopement evaluation with an observation date of 2/23/25. The form was incomplete until 3/10/25, the first day of the survey. - Resident #23 had an elopement assessment initiated on 2/27/25 at 6:15 p.m., and the date the record was completed was 3/10/25. During an interview on 3/11/25 at 10:19 a.m., staff member B said completing assessments later than the observation date would not be the normal practice. Staff member B said the assessments should be completed at the time of the observation. Staff member B said the elopement assessments for resident #23, dated 2/23/25 and 2/27/25, were completed on 3/10/25. 3. Resident #20 had an elopement evaluation which had an observation date on 1/3/25 that was not completed until 1/17/25. 51111 4. Review of resident #18's POLST form, dated 6/20/24, showed the form was left blank in the required fields of: the signature of provider, provider printed name, date and time signed by provider, and provider phone number. During an interview on 3/13/25 at 10:43 a.m. with staff members A, B, C and N, staff member C stated admission forms, including advance directives and POLSTs should be filled out completely. A request was made for a facility POLST policy on 3/12/25, and no specific POLST document was received by the end of the survey. 5. Review of resident #14's care plan showed a short term goal associated with the mood state that included, Target Date: 04/12/2025 kkk [sic] and the associated approaches for the goals showed, Approach Start Date: 01/22/2025 [Male name] loves [staff member C] [sic] and Approach Start Date: 01/22/2025 [Male name] loves [staff member B] [sic] During an interview on 3/13/25 at 10:59 a.m., staff member A stated the information in resident #14's care plan was something she had never seen in a medical record before. Staff member A stated she would check on how the information was added in to the medical record, and stated, Hopefully it's not because of a virus. It's weird though because that's staff member B's husband's name, and the other name is staff member C's husband's name. Staff member A returned to provide information on the documentation seen on the care plan. Staff member A stated staff member N added the information in to the care plan as a way to have staff members B and C notice the care plans needed updated. The information did not pertain to the resident's care or needs. Review of a facility policy titled, Confidentiality of Personal and Medical Records, revised 7/11/2024, showed: . [Facility Name] staff should exercise caution . in using medical record information for documentation purposes .

Based on observation, interview, and record review, the facility failed to timely identify elopement risks, and implement sufficient preventative interventions for residents with elopement(s), for 2 (#s 20 and 23) residents of 2 sampled for elopements who lived on the secure unit. There continued to be elopement hazards, and it was identified necessary staff were not aware of how to identify an elopement, staff failed to use interventions to prevent elopements, and one resident had repeated elopements and was at high risk of eloping. The overall elopement system was not adequate to ensure resident safety. Findings include: A review of the State Operations Manual, Appendix PP, F689 - Accidents and Hazards shows: A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Facility policies that clearly define the mechanisms and procedures for assessing or identifying, monitoring and managing residents at risk for elopement can help to minimize the risk of a resident leaving a safe area without the facility's awareness and/or appropriate supervision . 1. Review of resident #23's current MDS, dated [DATE], showed resident #23 had a BIMS of 4, reflecting severe cognitive impairment. Review of resident #23's nursing progress notes, dated 2/16/25, showed resident #23 had opened a dining room window and climbed out of the window. Resident #23 had obtained a shovel, and when found, he was already shoveling snow in the courtyard. Resident #23 was wearing a jacket, a baseball hat, and medical gloves. Resident #23 refused to return to the facility until he was finished shoveling and staff remained with him. The facility did not assess the resident for injuries following this elopement. Review of resident #23's nurses notes, dated, 2/23/25 at 1:37 p.m., showed, CNA alerted this nurse 10 minutes ago that resident had crawled through his window and was headed toward the facility garage. Resident #23 was returned to the facility by staff, and had no injury. Review of resident #23's nursing note, dated 2/27/25, showed the CNA alerted the nurse at 10:50 a.m., that resident #23's window was open, and he was missing. All staff were notified, and a search was started. Resident #23 was located behind the nursing home, at the clinic, unharmed. Review of resident #23's elopement evaluation, with an observation date of 2/23/25 at 8:14 p.m., was completed on 3/10/25 at 5:15 p.m., by staff member B. Review of resident #23's elopement evaluation, with an observation date of 2/27/25, was also not completed until 3/10/25. The assessments were not completed until all three elopements occurred. No other elopement assessments were located in the resident's medical record. During an interview on 3/10/25 at 2:39 p.m., NF1 said the [Clinic Name] called him and alerted him about the resident being at the clinic, and the clinic was trying to figure out where he belonged. NF1 said that was the only elopement he was aware of for resident #23. NF1 said he was not aware of what the facility was doing to prevent any more elopements for the resident. Resident #23 was at the clinic long enough for him to give his phone number to the clinic staff. Review of resident #23's baseline care plan showed elopements were not initially identified as a problem, and there were no interventions to prevent elopements. The baseline care plan was to be completed within the required 48 hours of the resident's admission, which would have been by 2/14/25. Interventions for elopements were implemented after the second elopement on 2/23/25. The care plan directed the staff to do a window audit to ensure the windows were secured. Although this intervention for the window security was implemented, resident #23 climbed out the window again on 2/27/25. Review of resident #23's care plan approach, dated 2/27/25 showed, the facility initiated an Apple air tag to be placed for monitoring the resident, however resident #23 had removed the tag, so it was not beneficial at the time of resident #23's third elopement. During an observation on 3/10/25 at 1:20 p.m., the secure unit's sitting room window was observed to have a Velcro device attached to it. The device would prevent the window from opening to far, in an attempt to prevent elopements. This same device, was attached to a different window, and it was removed by resident #23, and then he eloped out the window on three occasions. The sitting room was not observed 100% of the time, so it created a risk for this resident if he removed the device in an attempt to elope. During an interview on 3/10/25 at 2:57 p.m., staff member F said resident #23 went out the dining room window, the one that had the air conditioner in it, and he got into the courtyard. Staff member F said no stops were put on the windows in the dining room because it wasn't identified as a potential problem. Staff member F said following resident #23's first elopement, he went around and put in child proof stoppers on the windows where the exit was to the non-secured courtyard. Staff member F said the next time resident #23 eloped, staff assumed he took off the stop, because the stops were only secured by Velcro. After that incident, the facility bought new locks that clamped onto the side of the windows, and a tool was needed to get the stops off the window. The TV room and some of the courtyard windows were not secured yet because the facility was waiting on the order of the devices to arrive. The devices initially received were too small and did not fit the windows. Staff member F stated he monitors the windows every day, but it had not been done yet that day. Staff member F stated if resident #23, took the stops off once, he could do it again. Based on observations on 3/10/25 3:10 p.m., staff member F and this surveyor were able to open the windows to a level of 16 inches on the secure unit for rooms [ROOM NUMBER]. The Velcro closure was screwed into the window incorrectly in room [ROOM NUMBER], and the other windows had the Velcro stops removed. During an interview on 3/10/25 at 3:17 p.m., staff member H said resident #23 had gone into a different resident's room, shut the door, and went through the window. Staff member H said resident #23 went out the window twice during one of her shifts. He was found in the courtyard both times, but one time he was back around the courtyard by the back door. Staff member H said it was snowing the day he eloped through the window, but staff member H was unable to remember when the elopement occurred, and said it was maybe two weeks ago. During an interview on 3/10/25 at 3:30 p.m., staff member G said resident #23 is on 15-minute observations for monitoring his location, which was implemented after the 2/27/25 elopement, which was his third one. Staff member G said due to only one staff person caring for the ten residents on the secured unit, resident #23 is left unsupervised for longer periods of time, therefore, the 15-minute checks were not always timely. Review of resident #23's nursing progress notes, did not show any documentation of the times resident #23 left through the window twice in one day. During an interview on 3/11/25 at 10:19 a.m., staff members A, B, and C did not identify the resident breaking through a window screen and crawling out the window in attempt to leave the facility as an elopement. The staff said he was still on the property and in a courtyard, so they did not think of this as an elopement. The three staff members (A, B, and C) were unable to identify if climbing through a window was authorization to leave and if supervision was necessary. Review of the facility policy titled, Elopement and Wandering Residents, dated 9/3/24, showed the definition of elopement as, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The policy showed a systematic approach to monitoring and managing residents at risk for elopement, to include the identification and assessment of risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness. The policy showed residents were to be assessed for risk of elopement on admission and throughout their stay. The policy included a procedure for post-elopement that included having the nurse complete a physical assessment and documentation of the assessment. The policy included details for how the social services designee will re-assess the resident and make referrals for counseling or consults; and, documentation in the medical record will include findings from nursing and social service assessments, physician and family notification, care plan discussion, and consultant notes. Review of resident #23's IDT progress notes did not include any social services notes to reflect a social services re-assessment was completed after the elopements, or the need for referrals for counseling. During and interview on 3/12/25 3:50 p.m., staff member D said the first time resident #23 eloped, the CNA was on the unit, and staff member D was on the main hall. The CNA saw resident #23 walking toward the garage, so resident #23 was out just a few minutes. Staff member D said the second time resident #23 eloped, the CNA and staff member D had both just checked on him, and within a minute or two of the CNA and staff member D checking on him, he got out the window. Resident #23 was probably gone 15 minutes or more the second time. 2. Review of resident #20's elopement assessment showed an observation date of 1/3/25, however it was not completed until 1/17/25, 14 days after his admission. The assessment identified the resident as being at risk for eloping. Review of resident #20's baseline care plan failed to identify elopement as a problem. Resident #20's care plan did not include the risk of elopement until 1/14/25, and the interventions were minimal, to include, resident #20 resides on a secure unit and the staff will attempt to redirect resident and distract him when upset and wanting to leave. During an observation on 3/10/25 at 1:17 p.m., resident #20 was observed standing at the exit door, pushing on the door handle. The resident stood at the door for 3-4 minutes, then turned around, and began pacing up and down the hall several times. There were no staff observed attempting to redirect the resident from the door or engage him in to intervene in the behavior. During an observation on 3/11/25 at 4:14 p.m., resident #20 was wandering up and down the hallway of the secure unit, which he did several times. Resident #20 came to the exit door of the unit, and pushed against the door that had wallpaper the resembled a library. Resident #20 walked from the door into the TV room, located right next to the exit door, and pushed up against the unsecured window. Resident #20 then sat in a recliner, located next to the window, and stared out of the TV room window. During an observation on 3/12/25 at 12:30 p.m., resident #20 was observed going out the secured unit door into the main area of the facility. Staff member K and M observed the resident exiting the door, stopped him, and returned him to the secure unit. Staff members K and M turned the resident around and allowed him to continue pacing in the hall. No staff were observed to follow the care plan interventions identified and implemented for the prevention of elopements, or try to engage the resident when he was exit seeking. 51111 During an observation on 3/12/25 at 4:10 p.m., resident #20 was in the TV room of the secure unit, sitting in the recliner next to the unsecured window. No other residents or staff were in the room.

Based on observation, interview, and record review, the facility failed to develop and implement individualized comprehensive care plans for 2 (#s 12 and 24) of 16 sampled residents. Findings include: Review of resident #12's comprehensive care plan, with a problem dated 4/12/23, showed the resident was an elopement risk. The care plan did not show the resident lived on the secure unit. The interventions on the care plan failed to identify what approaches should be used to prevent elopements. Resident #12 was observed in the secured unit every day of the survey. During an interview on 3/11/25 at 2:59 p.m., staff member G said resident #24, sometimes listens and will come out to the dining room. Other than that, she sits in her room and cries. Staff member G said he was unaware of what activities the resident prefers. Review of resident #24's current comprehensive care plan showed resident #24 should be encouraged to attend activities. The care plan was not individualized to identify the type of activities resident #24 was interested in. The care plan failed to identify the problem of resident #24's frequent crying and did not direct staff in how to help the resident during episodes of tearfulness. During an observation on 3/12/25 at 12:10 p.m., resident #24 was sitting at the dining room table with her lunch meal in front of her. Resident #24 was talking about what her family had done to her and asking why they abandoned her. Resident #24 did not eat any food or drink any fluids. Staff member I approached her and encouraged her to eat and tried to engage her by talking about planting flowers. When staff member I did not get a response, staff member I then shrugged her shoulders and walked off as she was unsure of what approaches might be effective to help resident #24. Review of nurse's notes, dated 3/7/25 showed, the resident's [family member] and [family member] (neither POA or guardian) were going to take resident #24 out of the facility against medical advice. The nursing note showed the family member's believed resident #24 was capable of making her own decisions. The notes showed the physician was called, and the physician directed the staff to call the police for kidnapping if those family members took resident #24 out of the facility. Review of resident #24's comprehensive care plan failed to identify family dynamics and the potential for family removing the resident from the facility as a problem. There were no directions for the staff in the event the family tried to take resident #24 out of the facility against medical advice. During an interview on 3/11/25 at 10:19 a.m., staff members B and C said they completed and updated all comprehensive care plans with assistance and oversight by staff member N.

Based on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours after admission to reflect the residents' care needs, for 4 (#s 20, 23, 24, 77) of 16 sampled residents. This increased the risk of staff not providing necessary care and services due to the lack of the baseline care plan. Findings include: During an interview on 3/11/25 at 10:19 a.m., staff members A, B, and C were present. Staff members B and C said the care plans are done by the two of them, as they were the IDT (interdisciplinary team), with help from staff member N. Staff member C said the facility has an MDS nurse, but she does not complete care plans. Staff members B and C said an attempt is made to start the baseline care plan on the day of admission, but sometimes care planning doesn't get completed. Staff members A, B, and C said they knew about the requirement for a baseline care plan. Staff member B said the computer system had a template which could be used to complete care plans. During an interview on 3/11/25 at 2:00 p.m., staff member B said there were two admissions on 2/12/25, and resident #23 was admitted later in the day. Staff member B said it was busy that day, and she had to work later that night. Staff member B said the individual baseline care plan's didn't get started. 1. Review of resident #20's MDS, with an ARD date of 1/10/25, showed, resident #20 was admitted on [DATE]. Resident #20's baseline care plan was initiated 1/7/25, when nutrition concerns were added to the plan. 2. Review of resident #23's baseline care plan, with a review date of 2/26/25, showed, resident #23 was admitted on [DATE]. Psychotropic drug use was initiated on the baseline care plan on 2/12/25, however no interventions for the psychotropic drug were included for the care plan problem area. Resident #23 was at risk for eloping, and the elopement risk was not addressed on the care plan until 2/23/25. 3. Review of resident #24's nursing progress notes, dated 2/14/25, showed the resident was admitted to the secured unit on 2/14/25. The baseline care plan only included the resident's wishes for her advance directives. The only other problem addressed in the first forty-eight hours on the baseline care plan was the risk of skin issues, due to the resident refusing care at times, which was added on 2/16/25. 51111 4. During an observation on 3/10/25 at 3:34 p.m., resident #77 was lying in bed resting on the top of the blanket, with a sneaker on one foot but not on the other. A wheelchair was in resident #77's room next to a wall, not beside the bed and within reach. A record review of the resident's baseline care plan showed no information about the use of a wheelchair or assistance needed for resident #77. During an interview on 3/13/25 at 8:37 a.m., staff member B stated nurses can view a pocket care plan for residents, and staff member B usually starts putting care plan information in for newly admitted residents. Staff member B stated other staff members, including staff members C and N, enter information into resident care plans, and they update the care plans when needed. Review of resident #77's baseline care plan showed the diagnoses of Alzheimer's disease and Disorientation, and a single problem was documented on the baseline care plan, which showed, Start Date: 3/03/2025, Category: Advance Directives Resident Rights-Code Status . I am a DNR . Last Reviewed/Revised: 3/03/2025 by [staff member B]. [sic] Review of resident #77's fall risk assessment, completed on 3/5/25, by staff member B, showed a score of 19, showing the resident was a high fall risk. The fall risk was not included on resident #77's baseline care plan. Review of resident #77's admission elopement evaluation, completed on 3/5/25, by staff member B, showed resident #77 was at risk for eloping, and an elopement care plan should be initiated. There was no information documented or added to the baseline care plan for resident #77's increased elopement risk. Review of resident #77's March 2025 medication administration record showed an admitted [DATE], and a physician order for: .sertraline tablet 50 mg . 1 tab QAM; oral . Monitor for target behaviors of sadness and crying. The information to monitor for behavioral signs and symptoms was not included on resident #77's baseline care plan. A review of #77's baseline care plan showed the risk for falls was not added to the plan until 3/11/25, and this was completed by staff member C. Review of a facility policy titled, Baseline Care Plan, revised 9/29/2022, showed: . The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including . i. Initial goals based on admission orders. ii. Physician orders . The admitting nurse, or supervising nurse on duty shall gather information from the admission physical assessment . b. Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall . ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living . A supervising nurse shall verify within 48 hours that a baseline care plan has been developed .

Based on interview and record review, the facility failed to refer a resident with a newly evident or possible serious mental disorder or related condition for a Level II review, for 1 (#3) of 16 sampled residents. This failure put the resident at risk for not receiving services necessary for mental health. Findings include: Review of resident #3's care plan, last updated on 1/22/25, showed a diagnosis of . unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other bipolar disorder . Review of resident #3's telehealth psychiatric progress notes showed diagnoses of .bipolar affective disorders or recurrent manic episodes, anxiety disorder, insomnia and unspecified dementia without behavioral disturbances . The psychiatric progress notes also showed, 1/27/25 resident #3 was receiving Seroquel due to impulsivity. On 2/17/25, the resident's psychotropic medications were changed due to delusions. Seroquel was changed from twice a day, to just be given at bedtime, but Zyprexa Zydis 12 mg was added at noon. During an interview on 3/11/25 at 10:19 a.m., staff member C said she was responsible to make sure the Level I and Level II were completed. Staff member C said she did not complete resident #3's Level I. Review of resident #3's Level I showed a new Level I was initiated 3/10/25. A completed Level I was requested but was not provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to implement appropriate measures to prevent skin breakdown, to provide consistent care, monitoring, and treatment of pressure ulcers for 1 (#14) of 16 sampled residents, resulting in the development of one Unstageable pressure ulcer on the right ankle and one Stage Two pressure ulcer on the right buttock. The deficient practice had the potential to cause worsening of wounds and infection for the resident. Findings include: During an observation on 2/27/24 at 12:01 p.m., resident #14 was observed sitting in his Geri Chair (special wheelchair) with no pressure relieving cushion in place. During observations of resident #14's bed, on 2/27/24 at 2:40 p.m. and 2/28/24 at 11:23 a.m., a pressure reducing mattress was observed on the bed. During a wound care observation on 2/28/24 at 2:28 p.m., two surveyors observed a Stage Two pressure ulcer on resident #14's right buttock. During an interview on 2/28/24 at 11:23 a.m., staff member I stated the mattress on resident #14's bed was a regular mattress not an air mattress. During an interview on 2/28/24, at 11:30 a.m., staff member G stated the mattress on resident #14's bed was not an air mattress, but there was an air mattress available. Staff member G stated the DON usually requested an air mattress as needed, but the mattress had not been put on the bed. Review of resident #14's Admission MDS, with an ARD of 9/7/23, showed resident #14 was admitted to the facility with no pressure ulcers. Review of resident #14's nursing progress notes, from 8/31/23 to 1/3/24, showed the first wound note was documented on 1/3/24 as a new, Unstageable wound on resident #14's right ankle. Review of resident #14's medical record showed the last nutrition assessment completed was on 12/11/23, prior to the development of any pressure ulcers. Review of resident #14's medical record showed the physician's order, dated 1/3/24, as Cleanse R (right) ankle with NS (normal saline) pat dry and cover with optifoam (padded wound dressing). Change Q 3 Days (every three days) and PRN (as needed). [sic] Review of resident #14's nursing progress note, dated 1/12/24, showed, Resident's optifoam to right ankle was saturated with blood. Removed optifoam, cleansed wound with soap and water and patted dry. Left OTA (open to air) for a few hours. Record review of resident #14's nursing progress note, dated 2/11/24, showed, This nurse cleansed area to R (right) ankle, applied TAO (triple antibiotic ointment), and covered with dressing, no s/s (signs or symptoms) of infection at this time. Review of resident #14's nursing progress note, dated 2/17/24, showed, This nurse cleanse, pat dry and applied TAO to R ankle, covered with optifoam dressing, minimal drainage noted, no slough present at this time, white matter is present, redness around the wound continues, no s/s (signs and symptoms) of infection at this time. [sic] Review of resident #14's nursing progress note, dated 2/18/24, showed, Resident continues to have open area to R ankle, cleanse, pat dry, applied [NAME] mixed with collagen and covered with optifoam, no s/s of infection at this time. Record review of resident #14's nursing progress note, dated 2/26/24, showed, Res has an Unstageable pressure ulcer on R ankle that measures 2 cm x 2 cm. There is white slough present and reddened area around the open wound. Cleansed with NS patted dry painted with iodine and covered with optifoam. [sic] Review of facility document in resident #14's medical record showed the initial ankle pressure ulcer measurement was documented as 1.8 cm x 1.3 cm on 1/3/24. The Wound Management Detail Report, dated 2/19/24, showed resident #14's wound has has gotten larger and the overall condition of the wound has deteriorated. The documentation showed the wound as measuring 2 (cm) x 2 (cm) with a moderated amount of purulent (opaque, milky, sometimes green) drainage that was declining in wound health. There no documentation to show the physician had been contacted and informed of the deterioration of the wound or the need to re-evaluate the current treatment for effectiveness. Review of nursing progress note, dated 2/14/24, stated, Resident has an open area to right buttock, cleanse, pat dry, applied TAO, and covered with duoderm dressing, no s/s of infection at this time. Review of resident #14's nursing progress note, dated 2/18/24, stated, Resident has open area to L buttocks, cleanse, pat dry, applied [NAME] mixed with collagen covered with optifoam, no s/s of infection at this time. Review of resident #14's medical record showed a five-day delay in treatment, as the buttock pressure ulcer developed on 2/14/2024 and the physician order was not received until 2/19/24. The physician directed the staff to change the duoderm every three days. There was no other treatment or wound care directions for the pressure ulcer on the residents buttock. Review of resident #14's nursing progress note, dated 2/20/24, showed, Resident has an open area to L buttocks, applied [NAME] mixed with collagen and left open to air d/t maceration, no s/s of infection at this time. Review of resident #14's care plan was updated on 2/20/24, which showed a bed air mattress, and a RoHo wheelchair cushion. No interventions were put into place until 2/28/24. From the date of order on 2/20/24 until 2/28/24 when the cushions and mattress was placed was a delay of eight days. Review of resident #14's nursing progress note, dated 2/22/24 showed, Resident dressing to buttock was soiled. Dressing removed area cleansed with soap and water, skin prep to surrounding skin. Skin intact surrounding wound. Some granulation some blood to center of wound, Optifoam applied per DON. [sic] Review of resident #14's medical record showed the last nutrition assessment completed was on 12/11/23, prior to the development of any pressure ulcers. Review of resident #14's medical record showed a physician order, dated 2/20/24, for Juven nutritional supplement three times daily. During an interview on 2/29/24 at 8:12 a.m., staff member M stated the nutrition assessments had not been re-evaluated after the development of the two pressure ulcers, and stated, What the resident is receiving should be sufficient to meet his needs.

Based on interview and record review, the facility failed to identify an injury of unknown origin as potential abuse or neglect, for 1 (#10) of 11 sampled residents. This failure resulted in potential abuse not being investigated and had the potential to allow unidentified abuse to continue. Findings include: During an interview on 12/8/20 at 3:07 p.m., staff member A stated she was not aware of any injury of unknown source identified for resident #10 on 10/4/20. Staff member A stated if she had been notified, she would have reported and investigated the injury as potential abuse. During an interview on 12/9/20 at 10:23 a.m., staff member E stated she did not remember anything related to resident #10's injury on 10/4/20. Staff member E stated when abnormal skin findings are identified, they are documented in the medical record and reported to staff member A. Staff member E did not remember notifying staff member A. A review of resident #10's nursing progress note, dated 10/4/20 at 6:40 a.m., showed, .a dark purple bruise on resident's R buttock, approximately 9cm x 5cm., and .passed on to day shift nurse. The nursing progress note did not indicate notification of staff member A. A review of resident #10's nursing progress note, dated 10/4/20 at 12:55 p.m., showed, .has dark bruise to right buttock. The nursing progress note did not indicate notification of staff member A. A review of the facility's Policy on Detecting, Preventing and Reporting Abuse, Neglect, Mistreatment of [REDACTED]., including injuries of unknown source, . are reported as required by law. The Facility shall thoroughly investigate and document investigations of instances involving ., including injuries of unknown source and will work to prevent further potential abuse while the investigation is in progress.

Based on interview and record review, the facility failed to monitor, assess, and provide the treatment and services needed to prevent a hospitalization for 1 (#32) of 19 sampled residents. Findings include: During an interview on 2/6/20 at 9:17 a.m., staff member B stated resident #32 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff member B stated resident #32 would be sick and then get better. Staff member B stated, There did not seem to be a reason to notify the physician because the bile would not be a red flag, as the resident was not eating. She said there was no written policy on when to notify the physician. Staff member B stated the staff were monitoring the resident's vitals. A review of the resident's record showed: Review of resident #32's Nursing Progress Note, dated 12/22/19, showed, Resident threw up this afternoon. Resident stated that her stomach was cramping and that she needed to have a bowel movement and she vasovagaled on the toilet. Review of resident #32's Nursing Progress Note, dated 12/23/19, showed the resident had a loose stool and felt nauseous. Review of resident #32's Nursing Progress Notes showed no documented notes from 1/13/20 to 1/21/20. Review of resident #32's Nursing Progress Note, dated 1/21/20, showed the resident had complaints of nausea and requested a clear liquid diet. Review of resident #32's Nursing Progress Note, dated 1/22/20, showed the resident had a small emesis of bile and undigested food. Her vital signs were stable. Review of resident #32's Nursing Progress Note, dated 1/22/20 at 9:00 p.m., showed the resident had two emesis which were bile/brown in color. She refused all her HS medications. Review of resident #32's Nursing Progress Note, dated 1/23/20, showed she was dry heaving and complained of nausea. No nursing assessment or interventions were documented. Bowel sounds were not checked. Review of resident #32's Nursing Progress Note, dated 1/24/20, showed the resident was very weak, and was incontinent of, very strong smelling urine, and she had a small emesis of bile and phlegm. No intervention was documented for the urine odor or the continued emesis. The physician was not notified of the resident's change in condition. Review of resident #32's Nursing Progress Notes showed no documentation on 1/25/20. Review of resident #32's Nursing Progress Note, dated 1/26/20, showed the resident was observed with a distended, tender abdomen, with no bowel sounds present. Continued emesis with no bowel movement noted for 5 days. The emergency room was called and notified of the resident's condition and of transport. Review of resident #32's Nursing Progress Notes, dated 1/26/20, showed the resident had been diagnosed with a bowel obstruction, and passed away at the hospital. During a phone interview on 2/6/20 at 11:03 a.m., NF2 stated she had not been notified of any of resident #32's symptoms or decline in condition. She stated the information was all new to her, and the facility staff should have notified her. Review of resident #32's Vitals Report for bowel movements showed no bowel movements charted between 1/8/20 and 1/13/20, and no bowel movements documented between 1/13/20 and 1/19/20. The last documentation was on 1/25/20, as no bowel movement. During an interview on 2/6/20 at 1:05 p.m., staff member A stated the night shift runs a bowel movement report each night and passes it on to the day shift nursing staff. The facility has standing doctor orders to provide milk of magnesia if no bowel movement for two days, and a suppository if no bowel movement for three days. Review of resident #32's Nursing Progress Notes, did not document the lack of bowel movements or interventions for the resident's constipation until 1/26/20, when it showed no bowel movements for five days. During an interview on 2/6/20 at 1:54 p.m., staff member G stated the aides chart bowel movements at the end of their shift. She stated she would notify the nurse if a resident was constipated. She said she remembered that resident #32 was sick and the staff was pushing fluids. During an interview on 2/6/20 at 11:03 a.m., staff member NF2 stated she could not give a professional opinion on whether the outcome for resident #32 could have been improved with facility-provided interventions, and the physician's involvement.

Based on observation, interview, and record review, the facility failed to provide new interventions to prevent the severe weight loss for 1 (#5) and monitor food intake and preferences for 1 (#20) resulting in weight loss, of 19 sampled residents. Findings include: During an observation and interview on 2/4/20 at 10:03 a.m., resident #5 was being assisted with her brunch meal. The sandwich filling was ground ham. Staff member L said the resident does not eat well. The resident was not able to answer questions. The resident ate 25 percent of the meal. Review of resident #5's Vitals Report for weights, showed a weight of 125.1 pounds on 8/2/19, and a weight of 102.4 pounds on 2/4/20, a severe weight loss of 18 percent in six months. Review of resident #5's care plan for Nutritional Status, dated 10/10/18, with a goal date of 10/9/19, showed, I will maintain a healthy weight. The weight loss was not identified. The most current intervention, dated 12/10/19, showed, My staff has noticed that most of the time I have been pocketing my food. My staff has tried different meat textures but pocketing still occurs. My staff will encourage me to take small bites and to swallow my food. My staff will set up a swallow evaluation with OT. No other weight loss preventative measures were included in the care plan. The facility did not provide documentation of the OT evaluation, or evidence of a trial texture change. Review of resident #5's Nutrition Progress Note, dated 11/17/19, showed the resident had noted weight loss over time. Recent intake greater than 50 percent at most meals, supplements in place and encouraged for stability. Note decrease at NM (sic) today not eating and holding food. Continue to track trends and treatment with IDT support and recommendations. Monitor with current care plan. No root cause or new interventions were identified related to the severe weight loss. Review of resident #5's Annual Nutrition Assessment, dated 1/26/20, showed, weight loss noted and reviewed with the IDT on 12/10/19 when we started supplements and weekly weights. Family and provider aware of weight loss. Weight has stabilized from mid December. Continue with current diet and enhancements to stabilize weight. Remains at pocketing food risk but stable. Encourage at meals. During an interview on 2/4/20 at 2:10 p.m., staff member A stated she would provide physician notification of the weight loss. She stated she knew she discussed it with the family. Staff member A stated the current information may have not gotten to the care plan, and the care plan dates were not correct. She said the diet had just been changed to mechanical soft, and the resident was having trouble swallowing. Review of resident #5's physician note for notification of the weight loss, dated 2/4/20, during the survey, showed Resident to be on Mechanical Soft diet to help prevent aspiration. Swallowing evaluation may be done if family desires, but provider does not recommend due to failure to thrive. During a phone interview on 2/6/20 at 12:49 p.m., staff member E stated he was aware of resident #5's weight loss and had initiated supplements three times per day. Staff member E stated he comes to the facility quarterly and visits with the residents. Weight changes are communicated to him by staff member D through Email. Review of resident #5's Care Area Assessment for nutrition, dated 1/7/20, showed, Resident is on a supplement. It did not identify the weight loss, or the root cause for the weight loss. The facility failed to identify and provide interventions, other than a supplement, to prevent resident #5's continued severe weight loss, starting in August, 2019. 2. During an interview on 2/4/20 at 9:30 a.m., resident #20 stated she had lost some weight since admission and did not like the food. During an observation and interview on 2/4/20 at 4:05 p.m., resident #20 stated the tomatoes in the tortellini dish looked like raw meat and she did not like the meal. Resident #20 ate the bread slice, and some carrots. She covered the pasta on the plate with her napkin and had a full fruit cup in front of her. Resident #20 ate less than 25 percent of her meal. During an observation on 2/4/20 at 4:13 p.m., resident #20 was sitting at the table waiting for staff to come pick up her plate. The staff member in the dining room did not offer a substitution to resident #20. Resident #20 then stood up and left the table. During an interview 2/5/20 at 8:08 a.m., staff member K stated resident #20 does not come to the continental breakfast. During an interview on 2/5/20 at 10:37 a.m., staff member A stated she did not remember resident #20 being on weekly weights. Staff member A stated she had noticed resident #20 had continued to lose weight, and she was beginning to wonder if there was a communication problem between the registered dietician, and the dietary manager. During an interview on 2/5/20 at 10:43 a.m., staff member A stated she did not know how the facility was ensuring an alternative was being offered to resident #20 if the resident had a poor meal intake. During an interview on 2/6/20 at 8:54 a.m., resident #20 stated the staff does not offer anything on the continental breakfast to the resident in her room. During an interview on 2/6/20 at 9:59 a.m., staff member A stated the registered dietician comes quarterly to the facility, he monitored weights from a far, and communicated by email with the facility. Staff member A stated the dietary manager would text message him if the facility had a concern. Staff member A stated the facility had implemented menus which included a five-meal plan which are dietician approved menus through the company. The registered dietician on staff did not look over the menus. During an interview on 2/6/20 at 12:47 p.m., staff member E stated resident #20 had anxiety which affected her appetite. Staff member E stated the staff should have been encouraging the resident to eat the five times a day during the meal times and offer her snacks to help with the resident's weight loss. Review of resident #20's weights showed that on 8/28/19, at admission, she weighed 133.7 lbs., and on 1/1/20 she weighed 123.9 lbs., which showed a 7.33% weight loss. Weights were not completed weekly per the care plan, and were completed monthly from 8/28/19, to her most recent weight on 1/1/20. Review of resident #20's nutritional assessments, showed the following: - On 10/17/19, resident #20 weighed 133 lbs., ate 50-75% of her meals, had no weight loss. The assessment summary showed, Noted diarrhea followed from admit. Immodium available as trends followed and medication reviewed. Appetite meeting needs of ~1786kcals and mls, 60gpro. No oral or abd pain.[sic] The nutrition interventions and concerns showed, Regular diet as appropriate as we follow adaptation and any needed changes. Continue with current CP. - On 12/1/19, showed resident #20 weighed 128.2 (November 2019), meal intake was 25-75%, goal of 75% for 3 meals met was checked no, under supplements as needed for refused or poorly consumed meals as she accepts, no medication changes, no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary of the assessment showed, Remains at increased risk as she recovers from recent PNA/[CONDITION(S)]. Meals and fluids encouraged to maximize po and met est needs of ~1745 ml and kcals, 58gpro. No oral or abd pain reported. Follow overall status and needed changes. [sic] The nutrition intervention and concern section, showed, CP reviewed, offer snacks and supplements PRN. If appetite doesn't improve or weight loss continues as she recovers from recent illness, consider additional diet enhancements. No new diet enhancements were added as resident #20 continued to lose weight. Review of resident #20's food intake, for the five meal a day plan, showed the following: -No food intake documented for 12/2/19, 12/3/19, 12/5/19 to 12/11/19, 12/13/19, 12/14/19,12/16/19, 12/17/19, 12/21/19 to 12/26/19, 12/28/19 to 1/2/20, 1/3/20 to 1/5/20, 1/10/20,1/11/20,1/12/20,1/14/20, 1/16/20, 1/17/20, and 1/26/20 to 2/3/20. -Resident #20 had 13 out of 175 meals documented from 1/1/20 to 2/4/20. -Resident #20 had 10 out of 155 meals documented from 12/1/19 to 12/31/19. A request for resident #20's physician notification of weight loss was made to the facility on [DATE]. No documentation was provided by the facility. Review of resident #20's care plan, dated 9/5/19, showed a problem for nutritional status, a goal that the resident will maintain a healthy weight, and an approach of, I receive a regular diet per provider order. My staff will weigh me weekly per the facility weight policy. No nutritional intervention or food preferences were identified on the care plan.

On 7/21/16 at 2:45 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 1 of 14 sampled and supplemental residents related to investigation and protection in a situation of abuse under F226 with a scope and severity of a J. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to remove the immediacy on 7/22/16 at 7:50 a.m. The deficient practice remained at the scope and severity of G once the immediacy was removed. A summary of the facility's plan to remove the immediate jeopardy was as follows: 1. The nurse named in the allegation will no longer be employed at the facility. 2. The resident and her family were notified of the termination. 3. A new policy for investigating abuse was initiated. Based on observation, interview and record review, the facility failed to thoroughly investigate an incident of reported abuse, and failed to protect a resident from further abuse for 1 (#5) of 14 sampled and supplemental residents. Findings include: A review of the Reporting Form dated 6/27/16, submitted by staff member A, showed the facility received a report alleging abuse from resident #5 on 6/25/16, against staff member M. The incident report showed Resident said a traveling nurse had entered her room when she was in bed, touched her breasts unfastened her attends (sic) looked at her peri area, and did not attach her attends correctly, that she wet the bed. The resident was unsure who the staff member was or when this occurred. A review of the Five Day Investigation Results Report dated, 7/1/16, showed, During my investigation I learned that a nurse had gone into the resident's room to perform a skin check on (resident #5). I explained to (resident #5) that the nurse was performing a skin assessment when she was lying in bed. This resident has had skin inspections done before but usually during her shower, so I explained that some nurses prefer to do skin inspections while the person is in the bed. (Resident #5) understood this. I spoke with {the} nurse to ensure that she explains what she is doing to the resident and that they understood. A review of a hand written, undated chronological account of events, provided by staff member A, showed Resident (#5) brought concern to staff member M on 6/25/16. On 6/27/16 resident (#5) came to me and told me that a staff (traveling) had touched her breasts and removed her attends (sic) and looked at her peri area and they did not attach her attend correctly and she wet the bed. Resident (#5) was unable to tell me who the staff member was or when the incident happened and she has not been working since. Staff member A reviewed the work schedule and identified a number of traveling staff to interview, including staff member M. Staff member A spoke with resident #5 on 6/27/16 and 6/28/16 in an attempt to determine the identity of the nurse. On 6/29/16 staff member A again asked resident #5 who the staff member was, and the resident pointed to staff member M. Staff member A interviewed staff member M, who stated she had completed a skin check on resident #5 while she was in bed. Staff member M stated she had told resident #5 to put her call light on when she was in bed. Staff member A then spoke with resident #5, and explained that staff member M was doing a skin check just like other nurses have done. Staff member A stated that I have done skin checks like (staff member M). Resident #5 was upset and stated No you have not. Staff member A reassured resident #5 and the investigation was concluded. A requests for copies of statements gathered during the investigation reflected a lack of documentation of statements. During an interview on 7/20/16 at 11:30 a.m., resident #5 stated, she was at the nurses' station wearing her pajamas, when staff member M said, I have to feel you all over. The resident and staff member discussed using the call light to notify the nurse when the resident was in bed. Resident #5 stated, The nurse came in and took my diaper off and felt my boobs. I felt weird, like I was being sexually abused. She (staff member M) felt down here (gesturing toward her genitals), I really felt sexually abused. She (staff member M) didn't get my diaper back up. I don't know who else she did that to. Another night she came in again and wanted to do the same thing, and I told her to get out. Resident #5 stated she reported the abuse to an aide the next morning because, I felt like I had been molested. When asked if she had been told the results of an investigation of the incident, resident #5 stated she never heard anything more about the incident. She also stated it would be a waste of effort to bring it up again as, they don't believe me anyway. Resident #5 stated the incident had left her feeling nervous and hurt her ability to trust anyone. During an observation on 7/20/16 at 12:10 p.m., resident #5 was visibly upset and tearful, and stated I feel like it was ignored. She was shaking, her face was red and she was trembling. During an interview on 7/21/16 at 8:30 a.m., resident #5 cried as she relayed an inability to sleep the night before due to fear and uncertainty regarding the discussion of the incident yesterday. She was concerned about retaliation. Her demeanor was sad and uncertain. During an interview on 7/21/16 at 10:15 a.m., staff member M stated there was nothing unusual about the skin assessment she performed on resident #5. Staff member M stated the resident never made any comments to her after her report of abuse. Staff member M stated she was told an investigation of abuse was being conducted. Staff member M does not recall being interviewed regarding the incident. Staff member M was later told by staff member B the incident had been investigated and nothing was found. During an interview on 7/21/16 at 9:40 a.m., staff member A stated she had no further documentation of the investigation. Staff member A also stated she was aware staff member M had continued to work with resident #5. Staff member A stated she had instructed staff member M to have a CNA accompany her when performing skin assessments on resident #5. During an interview on 7/21/16 at 9:50 a.m., staff member D stated she is at times involved in investigating incidents, but not always. Social Services was not involved in this investigation. Staff member D was unsure of what criteria might be used to determine her involvement. Staff member D was under the assumption the issue had been resolved. Staff member D had never talked with resident #5 regarding the incident until the previous day, 7/20/16, when she had noted the resident's distress. During an interview on 7/21/16 at 10:00 a.m., a family member of resident #5 stated she had been told about the incident by the resident, who was visibly upset. The family member was told by staff member A that they had looked into the allegations and knew what had happened and assured her the facility would take care of the situation. The family member stated both she and the resident had been upset by the incident. The subject had come up a number of times and she knew the incident scared resident #5 a lot, and it had harmed her ability to feel safe. The family member wondered why the assessment would be carried out at night in resident #5's bed. A review of a Weekly Skin Integrity Review log showed resident #5 had skin assessments completed by staff member M on 6/1/16, 6/14/16, 6/17/16, and the day of the alleged incident 6/22/16. Staff member M continued skin assessments on 6/29/16, 7/6/16 and 7/14/16. The 7/14/16 assessment includes a note by staff member M stating Done by CNA, resident refused this staff member to assess. A review of the Handout for Abuse Policy provided by the facility stated: - The administrator will be responsible for investigating all reports of abuse or suspected abuse. -The staff will report any suspicion of abuse to their supervisor, and continue to report until the administrator or designee is informed, regardless of the day or time. -Employees who are being investigating will be suspended from work pending an objective investigation. A review of the Wibaux County Nursing Home Reporting Resident Abuse document dated April 2016, showed: -The DON must complete a Resident Abuse Form and obtain a written, signed, and dated statement from the person reporting the incident. -A complete copy of the Resident Abuse Form and written statements from witnesses, if any, must be provided to the administrator within 24 hours of the occurrence of such incident.

On 7/21/16 2:45 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 1 of 10 sampled residents related to weight loss under F325 with a scope and severity of a J. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to remove the immediacy on 7/22/16 at 7:50 a.m. The deficient practice remained at the scope and severity of G once the immediacy was removed. A summary of the facility's plan to remove the immediate jeopardy was as follows: 1. Residents were assessed by an interdisciplinary staff and diets were updated and supplements were added where needed. 2. Physicians and families were notified. 3. Weekly meetings will be conducted to monitor and adjust as needed. Based on record reviews, interviews, and observations, the facility failed to assess, intervene, or prevent severe weight loss for 1 (#2) of 10 sampled residents. The facility also failed to assess, intervene, or prevent a weight gain for 3 (#s 8, 12, and 13) of 14 sampled and supplemental residents. Findings include: 1. Resident #2 had a severe weight loss of 18.5% in 30 days. Review of the facility's weight records for May, June, and July showed resident #2 weighed 123 pounds in May, 121 pounds in June, and 102 pounds in July. This was a weight loss of 19 pounds or 15.7% in 30 days. Any weight loss greater than 5% in 30 days is considered a severe weight loss. A reweigh for resident #2 was requested on 7/20/16 at 11:00 a.m. This information was provided on 7/20/16 at 3:25 p.m. Resident #2's new weight was 98.6 pounds which indicated a severe weight loss of 18.5% in 30 days. Review of resident #2's initial nutrition assessment, completed on 3/21/16, showed the resident's ideal body weight to be 121 pounds. Resident #2's weight was documented as 125 pounds at the time of that assessment. A quarterly nutrition assessment was done on 6/8/16 and resident #2's weight was documented as 121 pounds, and the dietician noted the resident's weight to be stable. During an observation on 7/20/16 at 8:15 a.m., resident #2 was in bed. The head of her bed was raised at a 45 degree angle. Her upper body and head were leaning off to the right side of the bed. A tray of food was on a bedside table next to the resident. The food on the tray appeared to be untouched. Resident #2 appeared to be asleep. At 8:19 a.m., staff member H entered the resident's room and approached resident #2. Staff member H spoke to the resident and the resident did not respond verbally or physically. Staff member H was observed to place a piece of quiche in resident #2's mouth. Resident #2 was not observed to chew or swallow the food in her mouth. Resident #2 appeared to be asleep, her eyes were closed and she did not verbally or physically acknowledge staff member H. During a continued observation on 7/20/16 at 8:31 a.m., staff member H was bent over resident #2, who was lying at about a 45 degree angle in her bed. Resident #2 had her eyes closed and her head was hanging slightly toward her right side. Staff member H poured juice into the residents' mouth. Resident #2 was chewing and food was seen inside her mouth. Staff member H was encouraging resident #2 to swallow before she went back to sleep. The resident continued to move the food around in her mouth, but did not respond verbally. Staff member H attempted to pour water into the resident's mouth, which was closed, and the water fell on to her shirt and clothing protector. Staff member H again told the resident she needed to swallow what was in her mouth before she went back to sleep. Staff member H poured more juice into the resident's mouth. The resident continued to move food around in her mouth. Resident #2 began to cough and sputter, and said, no. The resident continued, for 10 seconds, to cough and move the food around in her mouth. Staff member H picked up the food tray and left the room. Staff member H returned and offered the resident more juice. While the resident continued to chew and had not opened her eyes, she asked, is that all there will be? Staff member H replied, yes. Staff member H cleaned off the resident's table and left the room. Resident #2 remained unmoving in her bed, her mouth agape, and began to snore. During an interview on 7/20/16 at 8:40 a.m., staff member H was asked about the food remaining in the residents' mouth, she stated Oh, I can go get it out. It was requested the administrator be called to check on the resident. During an observation on 7/20/16 at 8:44 a.m., staff member A donned gloves and used a swab to remove food from resident #2's mouth. A piece of food was also removed and wrapped in the glove as it was being thrown in the trash. During a review of the dietary intake record for resident #2, it showed the resident had consumed 26-50% of her breakfast. Based on the observation of resident #2's breakfast tray when it was removed from the room by staff member H, and the food staff member A removed from resident #2's mouth; the resident appeared to have consumed 5% of her breakfast. Review of resident #2's admission MDS, with an ARD of 3/22/16, section G, showed the resident required supervision, with a 1 person assist for eating. A review of resident #2's significant change MDS, with an ARD of 6/20/16, section G, showed resident #2 required limited assistance of 1 staff. During an interview on 7/20/16 at 8:20 a.m., staff member H said resident #2 spent most of her time in bed and most of her meals were fed to her while she was in bed. Staff member H thought resident #2 would be put on comfort measures the next time the doctor saw her. Staff member H said the resident's overall condition had really declined in the last month. During an interview on 7/21/16 at 10:30 a.m., staff member H said resident #2 needed more assistance with eating for at least the last month. Staff member H said this had been reported to the charge nurse and documented in the resident's record. During a review of resident #2's nursing progress notes, it was documented on 7/2/16 by a nurse that a CNA mentioned that this resident needs to sit at a feeder table for assistance or doesn't eat much at meals. During a review of resident #2's current care plan, dated 6/23/16, showed the resident had a potential for weight loss related to poor meal intake. The goal was stated as, Resident will maintain a healthy weight. And the approach was, Resident will receive a heath (sic) supplement with meals. The current care plan did not address the resident's need for assistance to eat. During an interview on 7/21/16 at 7:15 a.m., staff member A said the facility does not have a team that oversees and monitors weight loss and/or weight gain concerns of the residents. Staff member A stated resident #2's physician was notified of her severe weight loss on 7/20/16 at 6:10 p.m. Staff member A stated resident #2's physician had ordered an evaluation by the OT (occupational therapist) at the time of that notification. The physician notification and the occupational therapy assessment occurred after a request was made for resident #2's current weight on 7/20/16 at 11:00 a.m. During a record review, an occupational therapy evaluation was documented in resident #2's record that on 7/20/16 at 7:35 p.m., resident #2 was evaluated by the occupational therapist for diet textures, thickened liquids, and positioning while eating. The recommendations of the occupational therapist were for a pureed diet, nectar thick liquids, and for the patient to be placed in a Broda/Geri-chair during all meals. Prior to this evaluation, the resident was receiving a regular diet as documented on resident #2's initial dietary assessment dated [DATE]. The positioning of resident #2, while eating, was not addressed until 7/20/16 when the occupational therapist completed his evaluation. During an interview on 7/21/16 at 7:15 a.m., staff members A and B said resident #2 was now having a puree diet, thickened liquids, and was to sit in a Broda chair for all meals per the OT's recommendations. During an observation on 7/21/16 at 12:03 p.m., resident #2 was sitting up in a Broda chair in the dining area of the memory care unit. On the table in front of resident #2 was a plate of pureed foods. Resident #2 noticed the flowers on the dining table and she commented on how pretty they were. Staff member H started to feed resident #2 and assist her with her fluids that were on the table. Staff member H got a smaller glass from the cupboard and poured some thickened fluid in the smaller glass. Staff member H gave the smaller glass to resident #2 and resident #2 drank from the glass without assistance. Staff member H continued to feed resident #2 and assist her with fluid intake. Resident #2 consumed about 75% of the pureed foods on her plate. Staff member H then offered resident #2 a 4 ounce container of ice cream. Resident #2 ate all the ice cream with staff member H feeding it to her. Staff member H asked resident #2 if she wanted another ice cream, and resident #2 indicated she did. Resident #2 did not have a Mighty Shake on her tray, which the registered dietician had said to continue with all of resident #2's meals. During an interview on 7/21/16 at 12:25 p.m., staff member H said she poured the juice into a smaller glass so resident #2 could manage it herself. Staff member H said she told the kitchen to hold the Mighty Shake until after resident #2 had completed her meal intake. Staff member H said she wanted to make sure resident #2 ate most of her meal before she got her Mighty Shake. Staff member H said resident #2 would get the Mighty Shake with her snack that afternoon. During an interview on 7/20/16 at 11:25 a.m., staff member C said she did not calculate the percentage of weight loss or weight gain for any resident, unless she was doing section K of an MDS for a resident. Staff member C said she did not calculate weight loss or weight gain for 30, 60, or 90 days. Staff member C said the registered dietician visited the facility monthly and they would discuss resident weight loss or weight gain at that time. Staff member C said if she had a weight or dietary concern regarding a resident, she would make a note of the concern and place the note in a binder that she and the dietician would review on the monthly dietician visit. During an interview on 7/21/16 at 10:50 a.m., contracted staff member AA said the facility had not notified her of resident #2's weight loss concerns until 7/20/16. Contracted staff member AA said she would do visits on an as needed basis, especially in the case of a severe weight loss. Contracted staff member AA said she would have addressed resident #2's weight loss and put interventions into place if the facility would have notified her. She was at the facility to assess the weight concerns for residents #2, #4, #8, #12, and #13. During a review of the new dietary assessment, done by the registered dietician on 7/21/16, showed the resident had a 22% weight loss in 30 days, according to the dietician's calculations. This new dietary assessment also showed the resident was to continue receiving a Mighty Shake TID with meals and was also to receive Juven BID. During an interview on 7/21/16 at 3:00 p.m., staff member A said the facility did not consistently record or monitor the amount of the supplements consumed by the residents. 2. Resident #8 had a weight gain of 12% in 3 months. Review of the admission dietary assessment for resident #8 showed her initial weight was 150 pounds. The facility's weight records showed resident #8 weighed 150 for May 2016, 162 pounds for June 2016, and 168 pounds for July 2016. Resident #8 had a weight gain of 18 pounds or 12% in 90 days. During a record review, the initial dietary assessment, dated 4/22/16, showed the dietician noted resident #8 was to receive a regular diet with no supplements, and her ideal body weight was 125 pounds. During a review of resident #8's care plan, dated 4/19/16, a nutritional care plan was not included in the care plan document. Resident #8's care plan did not address her 12% weight gain. During an interview on 7/21/16 at 7:15 a.m., staff member A said the facility had not notified resident #8's physician of her 18 pound weight gain. During an interview on 7/21/16 at 11:25 a.m., contracted staff member AA said the facility had not notified her of a 18 pound weight gain for resident #8. Contracted staff member AA said she would be doing a new dietary assessment for resident #8 to address her 18 pound weight gain. During an interview on 7/21/16 at 4:00 p.m., resident #8's physician said the facility had not notified him of resident #8's weight gain. During a review of nursing notes from 6/1/2016 to 7/20/16 showed the facility failed to contact the physician of resident #8's 12% weight gain. 3. Resident #12 had a weight gain of 9.4% in 3 months. Review of the facility's weight records for May, June, and July showed resident #12 weighed 159 pounds for May, 165 pounds for June, and 174 pounds for July. This was a weight gain of 15 pounds or 9.4% in 90 days. During an interview on 7/21/16 at 7:15 a.m., staff members A, B, and C said resident #12 had terrible dietary habits. Staff member C said resident #12 drinks beer and eats cookies all day long and then cannot eat his meals. Staff member C said she had spoken repeatedly to resident #12 about this and resident #12 continued to do as he wanted. During an interview on 7/21/16 at 11:25 a.m., contracted staff member AA said the facility had not notified her of a 15 pound weight gain for resident #12. Contracted staff member AA said she was not aware of resident #12's consumption of beer and cookies to the extent of resident #12 weight increasing 15 pounds in 3 months. Contracted staff member said she would be doing a new dietary assessment for resident #12 to address his food preferences and his 15 pound weight gain. During dining observations on 7/19/16, 7/20/16, and 7/21/16, resident #12 was observed to be in the dining room for all meals. Resident #12 had an electric wheelchair and was not dependent on staff pushing him into the dining room. Resident #12 was observed to be sitting at a table for all meals served during those observation periods. Resident #12 was observed with food in front of him, and he appeared to be eating during those observation periods. During a record review, nursing notes from 6/1/16 to 7/20/16 showed the facility failed to contact resident #12's physician about the resident's 15 pound weight gain. Resident #12's record did not show any educational attempts were made by staff member C regarding his beer and cookie intake and it could affect his weight and health. Review of resident #12's nutritional care plan, dated 6/9/16, did not show resident #12 preferred to drink beer and eat cookies more than he preferred to eat food provided by the facility at meal times. The nutritional care did not address resident #12's weight gain of 15 pounds. 5. Resident #13 had a weight gain of 9.4% in 3 months. Review of the facility's weight records for May, June, and July showed resident #12 weighed 127 pounds for May, 133 pounds for June, and 139 pounds for July. This was a weight gain of 12 pounds or 9.4% in 90 days. During an interview on 7/21/16 at 7:15 a.m., staff members A and B said resident #13 was not a big eater at the time of her admission. Staff member A said resident #13 needed assistance to eat and once nursing staff started to feed her, the resident started eating more. Staff member B said resident #13's dietary intake had increased to such an extent that she would get mad if staff weren't feeding her fast enough. During a record review, nursing notes from 6/1/16 to 7/21/16 did not show the physician had been notified of resident #13's weight gain. During a review of resident #13's nutritional care plan, dated 4/27/16, showed the resident had impaired swallowing related to her dementia. The approach, dated 7/20/16 at 7:34 p.m., showed the resident was to sit at the assist table and my staff assists me to eat. I open my mouth and want more food as soon as I have swallowed my first bite. If I don't like something I will spit it out at my staff. The nutritional care plan did not address resident #13's weight gain of 12 pounds. During an interview on 7/20/16 at 11:25 a.m., staff C stated the only time she calculated weight loss or weight gain for was for reporting in Section K of the MDS (minimum data set). Staff member C stated she did not calculate weight loss or weight gain on a 30, 60, or 90 day basis. During an interview on 7/21/16 at 7:15 a.m., staff members A, B, and C stated the physicians, PA (physician assistant), and NP (nurse practitioner) were not provided with comparison weights for residents they were rounding on. Staff members A, B, and C acknowledged the medical providers would not know if a resident had a weight loss or weight gain unless a nursing staff member brought it to the provider's attention. Staff member A stated no physicians had been notified of weight loss or weight gain for any residents at the facility. During an interview on 7/21/16 at 10:50 a.m., contracted staff member AA stated she visits the facility once a month and meets with staff member C. Contracted staff member AA stated she and staff member C do dietary assessments, update diet plans, and address weight concerns together. Contracted staff member AA said she comes to the facility on a PRN basis when she is requested by the physicians or the facility. She said if the facility would have notified her of the weight losses and/or weight gains for residents #2, #4, #8, #12, and #13 she would have come to the facility and done new dietary assessments and addressed those weight concerns. Review of the facility's policy titled Weight Assessment and Intervention showed, 1. The nursing staff will measure resident weights on admission. Unless ordered by PCP (sic) to be more frequently, weights will be measured monthly thereafter. and 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietician in writing. Verbal notification must be confirmed in writing. The analysis section of this policy showed 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: .

Based on interview and record review, the facility failed to inform the physician of the formation of a pressure ulcer for 1 (#2) of 10 sampled residents. The facility failed to notify the physician of severe weight loss for 2 (#'s 2 and 4) of 10 sampled residents. Findings include: Pressure Ulcer 1. Review of resident #2's progress notes showed on 7/16/16 at 11:44 a.m., the resident was noted to have a Slight opening to resident's coccyx above crack. Area is reddened and measures 1 cm x 0.2 cm. Area cleansed and Allyvn (sic) dressing placed on. During an interview on 7/21/16 at 7:15 a.m., staff member K stated she did not call the physician and notify him of resident #2's coccyx wound. Staff member K stated; It was a hectic day and I guess I forgot. Staff member K also said she did not get an order from the physician to treat the wound. Weight Loss 1. Resident #2 had a severe weight loss of 18.5% in 30 days. Review of the facility's weight records for May, June, and July showed resident #2 weighed 123 pounds in May, 121 pounds in June, and 102 pounds in July. This was a weight loss of 19 pounds or 15.7% in 30 days. Any weight loss greater than 5% in 30 days is considered a severe weight loss. A reweigh for resident #2 was requested on 7/20/16 at 11:00 a.m. This information was provided on 7/20/16 at 3:25 p.m. Resident #2's new weight was 98.6 pounds which indicated a severe weight loss of 18.5% in 30 days. Review of nursing notes from June 1, 2016 to July 20, 2016 showed the physician was not notified of resident #2's severe weight loss. During an interview on 7/19/16 at 8:00 a.m., staff member C said she does not inform the registered dietician or physician when a resident has a significant or severe weight loss or weight gain. Staff member C said the nurses should notify the physician of any significant or severe weight loss or weight gain. During an interview on 7/21/16 at 4:00 p.m., resident #2's physician stated he was aware the resident's dietary intake was down but he had not been aware of her weight change from 121 pounds in June to 98.6 pounds in July until the facility notified him on the evening of 7/20/16. 2. Resident # 4 had a weight loss of 11.6% in 90 days. Review of the facility's weight records for May, June, and July showed resident #4 weighed 163 pounds in May, 180 pounds in June and 144 pounds in July. This was a weight loss of 19 pounds or 11.6% in 90 days. Review of nursing notes from May 1, 2016 to July 21, 2016 showed the physician was not notified for resident #4's 11.6% weight loss. During an interview on 7/21/16 at 7:15 a.m., staff members A, and B said resident #4 had a lot of [MEDICAL CONDITION] in May and June, and the provider added [MEDICATION NAME] on 6/2/16 in an attempt to decrease resident #4's [MEDICAL CONDITION]. Staff member A said the provider had not been notified of the 36 pound weight loss, in 30 days, for resident #4. During an interview on 7/21/16 at 5:45 p.m., staff member A said resident #4's provider had been notified of her weight loss. Staff member A said the provider decreased resident #4's [MEDICATION NAME] from 40 mg twice a day to [MEDICATION NAME] 40 mg once a day. During an interview on 7/21/16 at 7:10 a.m., staff member A said the physician had not been notified of the severe weight losses for residents #2, and #4. Review of the facility's policy titled Weight Assessment and Intervention states under Weight Assessment; 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietician in writing. During an interview on 7/20/16 at 11:25 a.m., contracted staff member AA said the facility had not notified her regarding the weight losses experienced by resident #2 and resident #4.

Based on observation, interview and record review, the facility failed to accurately assess a resident and implement a care plan to promote the healing and prevent further deterioration of a resident's heel ulcer. It failed to evaluate and revise care interventions to prevent the spread of infection of this wound. This occurred for 1 resident (#1) of 10 sampled. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial survey tour of the facility on 7/19/16 at 7:20 a.m., staff member K stated that lab results for a culture and sensitivity of resident #1's left heel ulcer had been received during the prior shift and that it was positive [MEDICAL CONDITION]. Resident #1 was asleep in bed with her lower legs elevated. Both legs showed clean dry dressings to both the right and left heels. No foul odor was noted. During a family interview on 7/19/16 at 1:30 p.m., resident #1's family member said she had previously been notified of the development of an ulcer on the resident's right heel by the facility. She had also been told by the facility staff that the right heel had almost completely healed. During a visit to the facility on [DATE], resident #1 had complained to her family member that her heel pain had increased in severity. The family member looked at the resident's right heel and found it almost completely healed. She then looked at the resident's left heel. It was swollen, red, and warm on the resident's left heel and part of the sole of the foot. She said she was very alarmed when she saw it. She said she had not been aware there was any wound on the resident's left leg or foot until her observation of the resident's left heel on 7/9/16. A review of the MARs for resident #1 showed that Tylenol #3 had been administered to the resident for left heel pain relief at least once a day or more between 7/1/16 and 7/19/16. A record review of Weekly Skin Integrity Review forms for Resident #1, dated 3/15/15 through 7/11/16, showed the following recordings as signed by nursing staff: 5/21/16 Left heel 1/2 x 1/2 cms black area with redness. 5/24/16 Left heel 1/2 x 1/2 cm black area with redness, tender to touch 5/30/16 Left heel 1/2 cm x 1/2 cm area with redness 6/6/16 Diabetic ulcer left heel 6/13/16 Charted in computer 6/20/16 Diabetic ulcer left heel 6/2716 Diabetic ulcer to left heel 7/4/16 Diabetic ulcer left heel. No drainage 7/6/16 Open areas right leg above ankle. 2 smaller open areas on side of foot. 7/11/16 Diabetic ulcer left heel, right leg above ankle, 2 on side of foot From 3/15/15 through 8/27/15, the records were checked to show skin intact. There were references made to a small open area to right lateral heel made on 8/13/15, 8/27/15, and 9/17/15. On 9/15/15 it was again reported that Resident #1's skin was intact and remained so until the entry of 5/21/16 as listed above. No further entries were found to be made after 7/11/16. A record review of a Wound Care Flow Sheet for Resident #1 showed the following measurements and descriptions of the resident's diabetic ulcer of the left heel as recorded by 3 different nursing staff members: 5/24/16 diabetic ulcer left heel 6/3/16 1 cm x 2.8 cm diabetic ulcer outer left heel 6/27/16 1 cm x 3 cm diabetic ulcer lateral left heel 6/30/16 1.5 cm x 3 cm diabetic ulcer left heel lateral A record review of lab results, dated 7/16/16, of a culture and gram stain of resident #1's left heel wound as sent to the facility by a community clinic showed that the culture had grown 3 [MEDICAL CONDITION]. The document showed that it had been sent to the facility from the clinic on 7/19/16 at 10:23 p.m. A review of physician orders [REDACTED].#1 was ordered to receive [MEDICATION NAME] 100 mg BID x 3 weeks on 7/18/16. Prior to this, Resident #1 had been ordered on [DATE] to receive Keflex 500 mg BID x 7 days for infection. A record review of a progress note, dated 7/18/16 which documented Provider BB's debridement of resident #1's wound on the left lateral heel showed 2/3 of the thickness of the eschar was able to be removed of 80% of the total wound area. Depth continues to be unknown due to no granulation tissue present at this time. The wound was described as a pressure type wound of 5.3 (cms) in length and 3.4 (cms) in width with small, serous exudate with odor absent. The procedure was performed by a wound care specialist contracted outside the facility. A record review of medical Provider #CC's progress notes, as performed on 7/18/16 with an encounter date of 7/12/16, showed a [DIAGNOSES REDACTED]. A record review of the MDSs, as completed for resident #1 in 2016, showed that an MDS had been completed for a Significant Change in her assessment on 6/1/16. During an observation on 7/19/16 at 1:35 p.m., wound evaluation of Resident #1 right and left foot ulcers was done. The right foot showed a healed skin tear on the lower ankle with a 1 cm x 1 cm dried brown scab with no drainage. The left foot showed a 4-5 cms x 3-4 cms oval ulcer of 1 cm depth on the top of the foot near the ankle without drainage or odor. The left heel had a 5 cms x 5 cms area on the heel pad of black torn skin with blackness under the pad callous which was approximately 1/3 of the sole of the foot. During a wound evaluation of resident #1's left heel ulcer on 7/18/16 at 1:40 p.m., the resident's primary medical provider also evaluated the resident's wounds. She said she thought the ulcer on top of the resident's left foot was due to the resident wearing protective heel covers whose Velcro straps had been too tightly wrapped. She was heard to verbally instruct staff member K to make sure to keep the resident's legs elevated as much as possible. During intermittent observations on 7/19/16 through 7/22/16, resident #1 was not seen ambulatory. She always had her lower legs elevated, except when she was sitting in a wheelchair for meals where she had her feet supported off the floor by the wheelchair. A record review of the resident's care plan showed on 4/8/16 the resident had the potential for skin breakdown/incontinence R/T limited mobility and diabetes mellitus and incontinence exhibited by long periods of time in bed sleeping. It also showed that the resident's skin was intact. The care plan did not show that any additions or revisions had been made under the category of pressure sores since 4/8/16. The care plan did not document the resident'[MEDICAL CONDITION] infection or contain interventions to prevent the spread of the infection.

Based on medical record review, facility policy and procedure review, staff interviews, and observations, the facility failed to provide oral hygiene that maintained the mouth in a clean and intact condition for residents who were unable to carry out activities of daily living on their own for 4 residents (#s 6, 11, 13, and 15) of 16 sampled and supplemental residents. Findings included: 1. Resident #11 was admitted to the facility on [DATE] with: Alzheimer's, anxiety, benign [DIAGNOSES REDACTED] positional [MEDICAL CONDITION], and constipation. ADL tracking forms for a.m. and p.m. for the month of March 2014 listed the resident as total dependence for ADLs. The resident's care plan conference sheet dated 3/12/14 contained documentation that resident #11 required assistance with bathing, grooming, and dressing. An entry in the resident's record read that the resident was transferred on 3/18/14 to a local emergency room via ambulance at 10:20 a.m. The admitting paperwork from the hospital listed the resident's Diagnoses: [REDACTED]. A nursing note from the hospital dated 3/18/14 read, "oral care performed due to pt (patient) having very dry mucous membranes. It is noted that pt has bridge in mouth that was very difficult to remove. After removal and evaluation of the mouth it is noted with significant purulent? drainage and crusting to roof of mouth and bidge (sic) appliance. (Redacted), FNP notified and culter (sic) obtained for oral cavity and taken to lab." The physician's note dated 3/18/14 read, "Mouth and Throat: Mucous membranes are dry. Her mouth contains a large amount of purulent mucus." A lab summary from the hospital dated 3/18/14 for an oral cavity swab was obtained for review. The swab culture included: [MEDICAL CONDITION], abundant yeast, and GPC. Five interviews with the facility direct care staff were conducted. -An interview was conducted with staff member E, a CNA, on 3/25/14 at 10:20 a.m. This staff member said that when doing oral cares, dentures were taken out, brushed, and that the mouth was swabbed out. Staff member E said that she did not perform cares for resident #11 except for helping with transfers; however, staff member E said the resident was completely dependent on ADL care. -An interview was conducted with staff member F, a CNA, on 3/25/14 at 11:20 a.m. This staff member said that when doing oral care, teeth were brushed and that you swabbed the mouths of the residents that could not spit. If a resident had dentures they were removed and cleaned. Staff member F said that the resident #11 did not like having oral care and would hit at them when doing cares. The staff member also said that oral care would usually get done, but when resident #11 had her mind made up, facility staff could not return and complete oral care. -An interview with staff member D, a CNA, was conducted on 3/25/14 at 2:45p.m. She stated that for residents who were dependent on care, a toothette swab was used, and if they have them, dentures are brushed every a.m. when the resident woke up. This staff member concurred that resident #11 was dependent on staff for ADL cares. -An interview with staff member G, a CNA, was conducted on 3/25/14 at 4:27 p.m. This staff member performed oral care for residents when they were ready for bed, and noted that many of the dependent residents did not like toothbrushes so sponges would be used. Staff member G also said resident #11's care would be "done as best it could." The resident clenched her teeth and shook her head. Staff member G would soak a sponge and sometimes be able to get some into the resident's mouth, but care was often refused by resident #11. -An interview was conducted on 3/26/14 at 9:10 a.m. with staff member C, a CNA. She stated she would use swabs and mouthwash in a cup for residents with no teeth. If the resident was able to help with care then the staff member had the resident rinse their mouth four times. For residents that wore dentures, this staff member said that mouthwash on a swab was used in the resident's mouth prior to dentures being placed in their mouth. The staff member also mentioned that resident #11 was completely dependent for ADL cares, that the resident's partial was difficult to remove, and that the resident had been having what appeared to this staff member to be thrush for six months. Staff member C had brought this to the attention of the charge nurse and said the physician was aware. The nursing staff mentioned that when cares were refused, they were reported to the charge nurse and documented. The Mood/Behavior monitoring sheet dated 3/3/14-3/11/14 was reviewed for resident #11. There were no notations of the resident exhibiting the behavior for: "Physical behavioral symptoms directed toward others (e.g., hitting, kicking, grabbing, etc.)," "Verbal behavioral symptoms directed toward others (e.g. threatening others, cursing at others, etc.)" nor, "rejected evaluation or care that is necessary to achieve resident's goals for health and well-being." Nurse's notes were reviewed in the resident's chart from November 2013-March 2014. There was one mention of the resident refusing cares during that time, which occurred on 12/30/13. Resident #11's care plan for "Cognitive deficit and decline in ability to perform ADLs" dated 3/12/14 read, "3. EXPLAIN ALL CARE & TX's 4. If (resident #11) refuses cares, allow a span of time and then return to offer cares again or have a different staff member offer to assist her." An interview was conducted on 3/26/14 at 1:30 p.m. with staff members A, the administrator, and B, the DON. Staff member A said that she was aware that resident #11 refused cares as she had worked the floor as a CNA. She also said that resident #11 would refuse oral cares. Facility staff would try to re-approach the resident when cares were refused, but sometimes the resident's oral care would not be completed so that the resident did not become too agitated. An interview with hospital emergency room staff was conducted on 3/27/14 at 11:45 a.m. The interviewee confirmed that the partial was hard to remove, that it was covered in pus and a green substance, and that it took at least 20 swabs to clean the pus out of the resident's mouth. Further, there was no resistance to oral cares provided and the resident's anxiety decreased after having oral care performed. A policy and procedure for oral hygiene was requested from the facility. A fax from the facility regarding oral hygiene was received by the state agency on 3/28/14 . The information contained a cover sheet with the heading "Montana Nursing Assistant Candidate Handbook." Pages 16 and 17 were included, and on page 16 under Denture Care & Oral Mouthcare #14 read, "Cleans and rinses resident's mouth. Brushes gums/tongue with toothbrush and toothpaste and rinses thoroughly with water OR mouthwash. Wipes residue from resident's face." 2. Resident #6 was admitted to the facility on [DATE] with: Alzheimer's dementia, arthritis, anxiety disorder, [MEDICAL CONDITION], [MEDICATION NAME] degeneration and generalized weakness. According to her most recent quarterly MDS with an ARD of 1/6/14, resident #6 was moderately impaired in daily decision making and required total assist for ADLs, which included personal hygiene and oral cares. On 3/26/14 at 7:41 a.m., staff member C, a CNA, entered resident #6's room for a.m. cares. The resident was sleeping when the staff member and the surveyor entered the resident's room. Staff member C brushed and rinsed the resident's top denture which was located in a denture cup, in the bathroom. The resident's face was washed with a washcloth, and then the resident was asked by staff member C if her top denture could be placed in her mouth. The resident complied. There was no offer for the resident's mouth to be cleaned, rinsed, have the gums/tongue brushed with a toothbrush and toothpaste, or have a sponge/swab to clean the gums. 3. Morning care was observed for resident #15 on 3/26/14 at 7:25 a.m. Staff member H, a CNA, performed the care for resident #15. At 7:25 a.m., the surveyor accompanied staff member H into resident #15's room. Resident #15 was sleeping upon entering his room. Staff member H changed resident #15's incontinence brief, dressed him, used a lift to transfer him to his wheel chair, and put in his dentures. Prior to putting in resident #15's dentures, staff member H did not perform oral care. At 7:45 a.m., staff member H stated, "I should have done oral care for (resident #15's name)." 4. Morning care was observed for resident #13 on 3/26/14 at 7:45 a.m. Staff member H performed the care for resident #13. Resident #13 was sleeping upon entering her room. Staff member H put lotion on resident #13's legs and performed ROM on her arms. Staff member H dressed resident #13. Another staff member came and assisted staff member H to transfer resident #13 to her wheel chair. Staff member H washed resident #13's face, and then she was going to take resident #13 down to the dining room. The surveyor asked staff member H about when she usually performed oral care and staff member H performed oral care at that time. Staff member H did not perform oral care until the surveyor questioned her about it. ? Purulent: Containing, consisting of, or being pus. "Purulent." Merriam-Webster. Merriam-Webster, n.d. Web. 31 Mar. 2014.