**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, review of the State Survey Long-Term Care Reporting Portal and interviews, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 6 of 8 residents (#4, #18, #20, 26, 46 and #56) reviewed for abuse and neglect. These deficient practices resulted in residents being subjected to neglect, abuse, and ongoing verbal abuse with the potential for physical and/or psychosocial harm. Findings include: -Residents #4, #20, #26, and #46 experienced mental and psychosocial harm when they were verbally abused by Resident #61. - Resident #56 experienced neglect when she did not receive wound care for a pressure ulcer. - Resident #18 experience physical harm from the facility staff during cares. The facility's Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property Policy, dated 8/22, stated a resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy defined verbal and mental abuse as oral, written, or gestured language that includes disparaging and derogatory terms to the resident or their families or within their hearing distance regardless of their age, ability to comprehend or disability, that would demean or humiliate, resulting in pain or mental anguish. Mental abuse can be verbal or non-verbal. It includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. 1. Facility and resident records documented multiple incidents of Resident #61's verbal abuse of Residents #4, #20, #26, and #46, and incidents of verbal and physical aggression which residents witnessed resulting in mental and psychosocial harm, as follows: - Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and chronic hypertensive kidney disease. A quarterly MDS assessment dated [DATE] documented Resident #4 was cognitively intact. - Resident #20 was admitted to the facility on [DATE] with multiple diagnoses including multiple sclerosis, Todd's paralysis, aphasia, and mixed receptive-expressive language disorder. A quarterly MDS assessment dated [DATE], documented Resident #20 was severely cognitively impaired. - Resident #26 was admitted to the facility on [DATE] with multiple diagnoses including anemia, fracture of the femur, osteoporosis, and unspecified dementia. An Annual MDS assessment, updated 8/14/24, documented Resident #26 was severely cognitively impaired. - Resident #46 was admitted to the facility on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia, pulmonary embolism, diabetes, and congestive heart failure. A Quarterly MDS assessment, dated 7/9/24, documented Resident #46 was cognitively intact. a. An I&A report dated 8/12/24, documented Resident #61 became agitated, he yelled and cursed at Resident #20. Resident #26 witnessed this and told Resident #61 he needed to stop yelling and cursing at Resident #20. Resident #61 then began yelling at Resident #26. A physician's assessment, dated 8/14/24, recommended that referrals be made for Resident #61 to an autism specialist for evaluation and to a neurologist or geriatric specialist for further evaluation for management of Resident #61's dementia. No documentation was found in Resident #61's records that he was referred to an autism specialist, a neurologist or geriatric specialist. A nursing progress note for Resident #61, dated 8/17/24, documented Resident #61 was yelling outside of Resident #4's room and was verbally aggressive towards Resident #26, cussing and yelling at her. Resident #34 walked by and told Resident #61 to stop talking to her like that. Resident #61 and Resident #34 began yelling and cussing at each other before being separated by staff. An I&A report, dated 8/17/24, documented Resident #34 left the nurses office because Resident #61 was yelling indiscriminately [at Resident #26] and was speaking aggressively, so Resident #34 told Resident #61 to stop speaking to people that way. Resident #34 stated, Resident #61 then became aggressive towards him, spitting in his face, saying the F-word and F-your family repeatedly using the F-word and putting his middle finger in Resident #34's face. Resident #34 returned to his room, called the police, and made a report. The report documented the facility could not identify why Resident #61 was verbally aggressive towards Resident #26. Resident #61 was moved to a different hall with police assistance. Seventeen residents were assessed if they felt safe in the facility and if they were fearful of any residents. Resident #3, #20, #26, and #30 stated they were fearful of Resident #61. The report further documented Resident #61 was moved to another room. The report concluded Resident #61 has many triggers which influence his aggression and behaviors, directly related to his Autism and OCD diagnoses. The facility is working to place Resident #61 in a different environment as he would benefit from placement in a smaller setting that manages behaviors. The facility did educate staff on Resident #61's triggers, and indicated they would update his care plan as new triggers were identified. A Social Services progress note, dated 8/23/24 at 5:36 PM, documented a new unidentified resident in the facility (stated she was fearful of Resident #61 because he kept coming into her room and he had threatened her. The resident reported Resident #61 yelled and cursed at her several times, and that Resident #61 was angry at her because she was staying in his previous room. The resident told the SSD that if she was not able to move to a different area of the building, she would have her daughter take her home. The resident reported she has called her daughter several times and told her daughter she did not feel safe in the facility. Grievances reviewed for August 2024 did not show documentation of this interview. No I&A report was found regarding this incident. A nursing progress note for Resident #61, dated 9/7/24 at 3:19 PM, documented Resident #61 was standing over Resident #26 who was sitting in her wheelchair in the entrance of her room. Resident #61 screamed and yelled profanity to Resident #26. When asked, Resident #61 stated Resident #26 told him to stop entering her room. An I&A report dated 9/7/24, documented Resident #26 stopped Resident #61 from entering her room, stating, Why are you entering my room, do not come into my room. Resident #61 then yelled and screamed at Resident # 26, Fuck you lady, go fuck yourself, who the fuck to you think you are? It stated Resident #26 has poor short-term memory and does not remember the previous incidents with Resident #61. The report concluded Resident #26 will redirect or scold Resident #61 when he raises his voice, triggering Resident #61's negative responses to her. As Resident #26 does not remember the interaction, she did not show signs or symptoms of psychosocial harm. A SBAR note, dated 9/13/24 at 4:20 PM, documented a nurse reported Resident #61 had frequent outburst of cursing and yelling at residents and staff. The note documented, Today Resident #61 stated I am going to slit all of your cock sucking mother fucking throat, I am going to take a knife and slit all your throats. I am going to just shoot this mother fucking place up and kill y all. The SBAR documented Resident #61's primary provider recommended Resident #61 be sent to the ER for psych evaluation and should not return to the facility at this time. A hospital progress note for Resident #61, dated 9/13/24, documented, The staff at the facility where [Resident #61] resides has said [Resident #61's] behavior has been escalating and he becomes loud and makes threats and frightens the other residents. [Resident #61] has not been physically aggressive. However, due to the nature of his [Resident #61's] statements that he was going to kill kitchen staff [Resident #61] will not be accepted back to the facility at this point. Resident #61 was diagnosed to have aggressive behavior due to dementia. b. Facility residents were interviewed about abuse and neglect, as follows: During an interview on 10/08/24 at 11:39 AM, Resident #4 was asked if she felt safe in the facility, and if the staff and residents were treating her well. She stated, I don't feel safe with [Resident #61]. He came into my room, yelling at me, and I spoke back to him. He left. I see him around the facility, and I don't make eye contact. I look down or towards the wall. During an interview on 10/08/24 at 10:23 AM, Resident #46 was asked about if she felt safe in the facility, and if the staff and residents were treating her well. She stated, Resident #61 used to live across the hall from me and would wander into my room. I didn't feel safe. I know he doesn't like women. They moved him, and it's been better, but I still don't know if I should fear him as I can't move, and [staff] don't come very quickly when I press the call light. I also think about what I have nearby to pick up and defend myself if he does come back. c. A Resident Council Meeting was conducted on 10/8/24 at 2:30 PM. During the Resident Council meeting Resident's #4, #17, #18, #25, #30, #34, #36, and #49 voiced concerns regarding Resident #61, as follows: All eight residents in attendance stated Resident #61 makes their life in the facility uncomfortable and were fearful of him. When asked if they felt safe in the facility, all residents at the Resident Council Meeting listed above, turned their head to the surveyor, with large eyes and expressions of fear shaking their head and stating out loud, NO! The residents in attendance stated Resident #61 made them feel as they needed to adjust their behavior to include looking down and away if they were passing him in the hallway. Resident #17 and #34 stated they felt the need to step in between female staff or residents to keep everyone safe. Resident #34 stated he was unhappy calling the police didn't get a respectful response as the facility is labeled the [name of the facility] loonies. During an interview on 10/11/24 at 1:31 PM, with the Administrator, he was asked what the facility was doing regarding the behavior of Resident #61 and ensuring the safety of the facility residents. The Administrator stated, We have had to send Resident #61 to the hospital to get psych evaluations. No one was available to see him here as our facility is not set up for these types of evaluations. The Administrator stated the facility had been working to get Resident #61 placed into an appropriate facility to care for his specific diagnoses. Staff have been educated on Resident #61's specific triggers, and how to redirect him. 2. Physical abuse by CNA #2 directed at Resident #20: An I&A report dated 3/17/24, documented CNA #2 swatted Resident #20's bottom. CNA #2 was terminated. The I&A documented CNA #2's background check was not completed prior to her working in the facility. On 10/10/24 at 10:04 AM, the Administrator stated background checks are received prior to placing employees on the floor with the residents. On 10/11/24 at 2:30 PM, the Administrator clarified the facility uses a service which provide preliminary approval based on background check that does not include fingerprinting. Finger printing must be completed within the first month. CNA #2 had not been working at the facility long enough to get her fingerprints taken or assessed before she was terminated. On 10/11/24 at 11:54 AM, the DON stated she has been employed for two weeks and she was not familiar with this complaint. She will be looking into the case to see what happened. The DON stated, in her experience, nursing staff are not allowed to work with residents without having a clear background check prior to employment. 3. Resident #56 did not receive wound treatment for her pressure ulcer. Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease. The resident was on Hospice care upon admission and discharged to a Hospice Facility on 09/17/24. Review of Resident #56's admission MDS dated [DATE], documented Resident #56 was cognitively intact. Review of Resident #56's Health Status Note dated 08/25/24 documented Resident had approximately a five-centimeter (cm) diameter, non-blanchable pressure ulcer with multiple two-millimeter openings on her coccyx area. A staff member from the Hospice agency stated that she was sending a nurse to assess the resident's coccyx area for an air mattress. Review of Resident #56's record did not include an order for treatment of her wound. Also Resident also did not include a care plan for her wound. During an interview on 10/10/24 at 2:52 PM, the ADON stated, Resident #56's did have a wound and [the facility's] our wound care physician was not following her care. She said the resident was a hospice patient, and they were responsible for providing wound care orders and treatments. She confirmed there were no orders, skin assessments, or a care plan for Resident #56, or one from the Hospice Agency. During an interview on 10/10/24 at 2:53 PM, the Administrator stated, I didn't know what occurred regarding this resident until last week, when the daughter came in to pick up her belongings after she passed away at the hospice house. Yes, we are still the primary caregivers, but they took care of the wound. Ultimately her daily care is our responsibility. Their hospice doctor writes their orders for their patients. The service agreement we have with Hospice of North Idaho transferred over with the sale of the building. I have reached out to them for an /updated agreement. During an interview on 10/11/24 at 1:30 PM, the DON stated, If the resident is admitted to this facility, then we are the primary caregivers and responsible for them. I don't know why or how this occurred since I only arrived last week. However, since learning about this resident, I met with the RN of our current hospice resident, and we have come to an agreement that she must see myself or the unit manager prior to leaving so that we can coordinate care and we're always on the same page. The DON confirmed there was no collaboration with the Hospice Agency that was providing care to Resident #56 while she was a resident at the facility. She said she only knew the Hospice nurse came weekly to see the resident. She further said, this shouldn't have happened and won't happen again. Review of Service Agreement between Hospice of [name of hospice agency] and [name of facility] signed 06/10/19 revealed: 4.2 Facility Services: a) The Facility will comply with all applicable state and/or federal regulations when providing care to residents who have elected Hospice. Basic services will include the following . iii) Nursing services as required by Idaho Department of Health and Welfare Rules, IDAPA 16, Title 03, Chapter 02, Rules and Minimum Standards for Skilled Nursing and Intermediate Care Facilities . vi) Supervision of Facility staff providing services under the Hospice Plan of Care established by the Hospice team . vii) Services provided will be consistent with the services provided to the resident before hospice care . b) Ensure that each Hospice resident receives treatments, medications and diet as prescribed, and is kept clean, comfortable and well groomed . e) Allow, members of the IDT, as identified in the Plan of Care to attend, counsel, treat and serve Hospice residents . k) Except as otherwise provided herein, the services of the facility provided pursuant to the terms of this Agreement shall be made available to hospice residents 24 hours a day, 7 days a week. During this term or any succeeding terms of this Agreement, the Facility will hold itself (including a sufficient number of its personnel, as determined by the Facility and the Hospice as having the requisite skills) available to finish, and shall furnish the services and facilities contracted for herein. 4. Physical abuse directed by Resident #130 to Resident #18. Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including left hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following stroke and diabetes. a. A review of an investigative summary report uploaded to the State's Long-Term Care Reporting Portal, dated 5/28/24, documented [Resident #18] reported to a staff that [Resident #130] tried to block her from going out to the smoking area. She stated [Resident #130]would not move, and they had an argument. [Resident #18] stated [Resident #130] reached over and slaped her to each side of her face. The investigation report documented [Resident #18] was noted to have a scratch, approximately 6.2 x 0.4 on the left side of her face. There was also one small superficial open area at the top of the scratch closer to her ear. [Resident #130 was interviewed and stated [Resident #18] was blocking the exit to the smoking area and had an argument. [Resident #130] stated she pushed [Resident #18's] wheelchair out of the way but did not touch any part of [Resident #18]. The investigation report documented [Resident #130] had a large brace on her hand and wrist that could have easily caused a scratch if there was contact made with [Resident #18's] face. Activities and nursing staff were interviewed and all report stated that prior to the incident [Resident #18] did not have a scratch on her face. The facility's investigation report concluded that it was suspected [Resident #130] slapped [Resident #18]. The report documented the facility had taken measures to ensure that contact between the two residents was limited and any activities would be supervised by staff. Both residents agreed to a set schedule for smoking. [Resident #18] would smoke during the even hours and [Resident #130] would smoke during the odd hours. On 10/11/24 at 11:43 AM, the Administrator together with the ADON stated he was the facility's abuse coordinator and stated all suspected residents' abuse/neglect are to be reported and investigated. The ADON stated Resident #130 denied slapping Resident #18, but later on she acknowledged that she did slap Resident #18. The ADON stated the two residents were put on different smoking schedules. 5. Physical abuse by CNA #3 directred at Resident #18. A review of an investigative summary report uploaded to the State's Long-Term Care Reporting Portal, dated 2/27/24, documented [Resident #18] was fearful of a CNA #3. [Resident #18] was interviewed on 2/26/24, [Resident #18] stated a staff came to wake her up and pushed her bad hip. She reported the staff seemed upset that she had diarrhea and needed to be cleaned up. [Resident #18] stated CNA #3 told her if she could go out to smoke, she could get up to go to the bathroom. [Resident #18] reported CNA #3 grabbed her right wrist and left ankle and flipped her onto her back forcefully. She stated CNA #3 was very angry and aggressive towards her. [Resident #18] stated she asked CNA #3 to stop and to leave her alone multiple times but, CNA #3 did not stop holding her down. [Resident #18] complained of right wrist injury from the incident. She was found to have 3.5 cm x 3.5 cm reddened area on the top surface of her wrist. On the palm side of her wrist were three small circular bruises each measuring 1.25 cm x 1.5 cm. [Resident #18] stated she was afraid of CNA #3 and does not want her to ever take care of her or be near her. The facility's investigation report concluded the allegation of abuse by CNA #3 to [Resident #18] was substantiated due to the presence of physical bruising and redness on her wrist which were not present prior to the cares provided by CNA #3. The facility's investigation report, documented CNA #3 was terminated from her employment via phone conversation on 2/26/24 at 12:34 PM. On 10/11/24 at 11:48 AM, the Administrator stated because of the bruises sustained by Resident #18 during cares, CNA #3 was terminated from her employment. The Administrator also stated the facility had a float pool of staff and hire them at corporate level with long-term contracts, usually 13 weeks, to better care for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the State Long-Term Care Reporting Portal, review of facility policies, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This affected 1 of 6 residents (Resident #1) reviewed for medication administration. Resident #1 was harmed when she did not receive 13 doses of short-acting insulin for 4 consecutive days and required hospitalization for emergency treatment for hyperglycemia. Findings include: The facility's Physician's Orders policy, revised on [DATE], documented a nurse will confirm accuracy of orders by leaving new or changed orders in the queue for a second licensed nurse to verify. The second nurse will review the orders for transcriptions errors and errors of omission. The facility's procedure for managing hospital discharge orders documented, The center will obtain the appropriate physician's orders for the resident's immediate care at the time the resident is admitted . This allows the center to be prepared to manage the clinical needs of the resident and allows for efficient utilization of clinical and financial resources across the care continuum. These procedures were not followed. A State Portal incident #32860 documented a facility-reported incident related to medication errors. The report documented a resident was hospitalized for hyperglycemia after the facility staff failed to administer her short-acting insulin for 4 days. The report documented the facility initiated a self-imposed plan of correction including the development of new policies and procedures to prevent additional occurrences and staff education related to the new policies and procedures. Resident #1 was admitted on [DATE] with multiple diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood efficiently), type 1 diabetes, and chronic kidney disease. Resident #1 was admitted to the facility on the evening of [DATE] from a local hospital. Her transfer orders included 5 units of Lantus (a long-acting insulin) to be given at bedtime, and 1-5 units of Lispro (a short-acting insulin) to be given before meals and at bedtime (4 times per day) according to a blood sugar sliding scale. Resident #1's MAR documented she had received 9 units of Lispro, as ordered, at bedtime on [DATE] and 4 units of Lispro, as ordered, before her breakfast on [DATE]. The MAR documented the Lispro order expired on [DATE] at 9:27 AM and Resident #1 did not receive any further doses of Lispro from [DATE] to [DATE], when she was hospitalized . Resident #1's nurse progress notes, dated [DATE], signed by a facility LPN, documented the facility had transported Resident #1 to her nephrology appointment where she experienced blood-tinged vomitting and became difficult to arouse. She was transported to the hospital ED for assessment and treatment. Resident #1's emergency department provider notes, dated [DATE], signed by the hospital physician, documented Resident #1 was diagnosed with DKA (diabetic ketoacidosis is a serious complication of diabetes that develops when the body does not have enough insulin). In an interview on [DATE], beginning at 10:25 AM, the facility's Regional Director of Clinical Operations, Resident #1's Portal incident and medical record were reviewed in her presence. She confirmed Resident #1 should have received 3 additional doses of Lispro on [DATE], 4 doses on [DATE], 4 doses on [DATE], and 2 doses of Lispro before breakfast and lunch on [DATE], yet the doses were not administered. When asked why the doses were not given, she stated Resident #1's Lispro order had been changed and renewed on [DATE], and the new order was not activated in the electronic medication record by the facility nurses, leaving the order as pending. She stated the nurses, when interviewed, stated they were not familiar with the procedure to check for and activate pending medication order changes and felt they were too busy to notice the medication changes.