Based on interview and record review, the facility failed to notify the State Ombudsman Office when a resident was transferred to the hospital and failed to provide the resident with contact information for the State Ombudsmans Office for 3 (#s 13, 127, and 177) of 20 sampled residents. This deficient practice left the residents without an advocate related to the transfers in the event there were concerns. Findings include: During an interview on 5/5/25 at 2:56 p.m., NF1 stated, I am concerned the facility is not notifying the Ombudsman Office when they transfer someone to the hospital or when a resident is discharged . This is leaving them without an advocate during that time. During an interview on 5/7/25 at 1:25 p.m., staff member G stated we did not let the ombudsman know resident #177 was discharged because the facility was not aware the local hospital sent him to a larger hospital. During an interview on 5/8/25 at 8:07 a.m., NF1 stated, I am not notified when someone is transferred or discharged from the facility. During an interview on 5/8/25 at 8:45 a.m., staff member G stated, The director of nursing or the charge nurse will fill out the transfer/discharge notice when someone leaves for the hospital. The form also includes the bed hold notice. They print it off and send it with the residents when they leave. I was not aware the form had to include contact information for the State Ombudsman Office. I only notify the ombudsman when we do an incident report in Bounds. I was unaware I had to notify the ombudsman when someone transferred or discharged . Review of resident #13's Transfer/Bed Hold Notice showed he was transferred to the hospital on 5/4/25 and on 5/6/25. The transfer notices did not contain contact information for the State Ombudsman Office. Review of resident #127's Transfer/Bed Hold Notice's showed she was transferred to the hospital on 1/10/25, 1/20/25, and 3/2/25. The transfer/discharge notices did not contain contact information for the State Ombudsman Office. Review of resident #177's Transfer/Bed Hold Notice showed he was transferred to the hospital on 3/4/25. The transfer/discharge notice did not contain contact information for the State Ombudsman Office. A request was made for documentation of notification of transfer/discharge to the State Ombudsman Office. The facility did not provide any further documentation prior to the end of the survey period. Review of a facility document titled, Transfer or Discharge, Facility Initiated, dated October 2022, showed: . Notice of Transfer or Discharge (Emergent or Therapeutic Leave) . 4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements).

4. Hand Hygiene During an observation on 5/5/25 at 3:08 p.m., staff member D removed the soiled bandage from resident #22's left hip. Staff member D removed (doffed) her dirty gloves, donned new gloves, but did not sanitize her hands before donning the new gloves. Staff member D cleansed resident #22's wound, doffed her gloves, donned new gloves, but did not sanitize her hands before donning new gloves. During an interview on 5/5/25 at 3:29 p.m., staff member D stated she should have sanitized her hands between glove changes. She stated she was upset with herself and was nervous, as she was the wound care nurse and knew the process. Review of the facility's policy titled, Standard Precautions, last revised 12/07, showed: - . 1. Hand hygiene - a. Hand hygiene refers to handwashing with soap (anti-microbial or non antimicrobial) OR using alcohol-based hand rubs (gels, foams, rinses) that do not require access to water, and - . d. Wash hands after removing gloves. References: Centers for Disease Control and Prevention. (2024, March 5). C. diff: Facts for Clinicians. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html 3. Transmission Based Precautions During an observation and interview on 5/6/25 at 8:32 a.m., staff member I entered resident #178's room to deliver her breakfast. A biohazard sticker, a sign that showed droplet/contact precautions, and a sign that showed EBP required were observed on the door of resident #178's room. A box of masks were observed on the handrail outside of the room. The door to the room was halfway open. Staff member I was observed with no mask, gown, or gloves and walked up to the sink and began washing her hands before exiting the room. The door to the room was left open when she walked out. Staff member I stated she thought it was ok to leave the door open. Staff member I stated, All of the PPE is in the room on the back of the bathroom door. The resident has C. diff and is on droplet precautions. We (staff) should be wearing gowns, gloves, and masks, which we put on after we enter the room. During an interview on 5/6/25 at 8:41 a.m., staff member D stated, Resident #178 is positive for C. diff and should be on contact precautions. The resident's door should be closed, and the staff should use the PPE on the inside of the room. Based on observation, interview, and record review, the facility failed to ensure the infection preventionist was properly trained; failed to ensure the safety measures were in place to prevent the growth of a waterborne illness (such as Legionella); failed to identify appropriate Transmission-Based Precautions for a resident with Clostridioides difficile (C. diff) for 1 (#178); and staff member D failed to adhere to proper infection control practices related to not performing hand hygiene between doffing and donning gloves, while performing wound care for 1 (#22) of 20 sampled residents. These deficient practices had the potential to affect all residents in the facility increasing the risk for infections overall. Findings include: 1. Infection Prevention During an interview on 5/7/25 at 2:29 p.m., staff member E stated they did not feel they had received the proper education that was required for their position. Staff member E stated hand hygiene audits were completed weekly, but they did not keep record of these audits. Staff member E stated PPE audits were completed weekly as well, but they were not able to show documentation by the end of the survey. Staff member E stated they were unsure how often mandatory education was completed concerning infection control. They stated they were unsure what PPE precautions were needed for a resident with a Coronavirus-19 infection. Staff member E stated they did not have a sheet or a quick system in which they could refer to when trying to figure out which precautions were needed for specific infections. Staff member E stated they relied heavily on the public county health nurse for all of those types of questions. Staff member E stated they were unsure which diseases were reportable to the state, but would communicate with the public health nurse for this information as well. Staff member E stated a gown, gloves, and a mask were the required PPE for a C. diff infection. Staff member E stated alcohol was better than handwashing for a resident who had C. diff. The CDC refers to the C. diff spores as being very difficult to kill (Centers for Disease Control and Prevention, 2024). The CDC website also showed, Washing your hands with soap and water is the best way to prevent the spread of C. diff from person to person (Centers for Disease Control and Prevention, 2024). Review of a facility document titled, Monitoring Compliance with Infection Control, revised 8/2019, showed: . 2. Monitoring includes regular surveillance of adherence to hand hygiene practices and availability of hand hygiene supplies, and the availability of personal protective equipment and its appropriate use. Review of a facility document titled, Reporting Communicable Diseases, revised 7/2014, showed: . 1. All reportable infectious diseases (residents' or employees') must be reported to the Infection Preventionist as soon as a definite diagnosis is made or strongly suspected. 2. Legionella During an interview on 5/7/25 at 10:22 a.m., staff member H stated the [local entity] checked the water. Staff member H stated they did not keep a log of flushing toilets, but stated staff member E would maybe know more information regarding this topic. Staff member H stated they did complete a test for Legionella by swab testing the countertop in the kitchen. During an interview on 5/7/25 at 2:29 p.m., staff member E stated, Are we supposed to do that?, when referring to records and the weekly flushing requirement to prevent the growth of Legionella. Review of a facility policy, titled Legionella Water Management Program, revised 9/2022, showed: Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. .e. Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; . h. A system to monitor control limits and the effectiveness of control measures; . j. Documentation of the program.

Based on interview and record review, a resident was acting out aggressively, and the staff restrained the resident for a Period of Imminent Danger to the Safety and Well being of others, and failed to ensure the required steps were taken to address the emergency restraint immediately after it occurred, or for future events in which a restraint may have been needed for this resident, for 1 (#2) of 1 sampled resident. Findings include: A review of a facility-reported incident, dated 11/11/24, revealed the following: On 11/13/24, at approximately 4:30 p.m., a personal care attendant (PCA) reported to the administrator-in-training that she had sustained an injury on 11/11/24, while assisting the charge nurse and other staff in physically restraining resident #2. During the investigation staff reported on 11/11/24, around 10:00 a.m., the charge nurse directed staff to physically restrain resident #2, due to the resident exhibiting physical aggression toward staff, and other residents. This restraint was implemented to allow the charge nurse to administer an intramuscular injection of an antipsychotic medication. The charge nurse instructed staff to continue restraining the resident for an additional fifteen minutes after the injection to allow the medication to take effect. After fifteen minutes, the charge nurse directed three staff members who were physically restraining resident #2 to resume their other assigned duties, leaving the PCA and security staff member to continue restraining resident #2 for a total of one hour until the resident fell asleep. Steps were not taken to ensure future restraint use was addressed for the resident and his behaviors. During an interview on 12/3/24 at 12:03 p.m., staff member E stated, on 11/11/24, resident #2 had attempted to hit, kick, and spit at staff and other residents in the facility. Staff member E stated the charge nurse requested staff member E to physically restrain resident #2, by holding her hand under the resident's left ankle while the nurse administered an intramuscular injection in the residents left arm. Staff member E stated the charge nurse requested resident #2 be physically restrained by staff for an additional fifteen minutes for the medication to take effect. Staff member E stated she did not hold the residents left leg down continuously but did restrain the resident at times by holding his left ankle when resident #2 attempted to kick at staff. The staff failed to ensure the least restrictive restraint was used, and verify with the nurse it was safe to continue restraining the resident throughout the hour period. During an interview on 12/3/24 at 2:20 p.m., staff member G stated on 11/11/24 she was summoned by the charge nurse to assist in physically restraining resident #2's right lower leg, while the charge nurse administered an intramuscular medication to the resident. Staff member G stated resident #2 had been physically aggressive to staff and residents on the morning of 11/11/24, by attempting to hit, kick, and spit. Staff member G stated after the charge nurse administered the medication, she left the resident's room and continued her other assigned duties. The nurse did not verify with the staff the least restrictive method of restraint was to be used. During an interview on 12/4/24 at 2:51 p.m., staff member J stated, on 11/11/24, resident #2 was destructive and swung at and punched staff. Staff member J stated the charge nurse asked him and another staff member to hold resident #2 down, while she administered an intramuscular medication. Staff member J stated he held resident #2's wrist, off and on, when the resident was trying to hit staff. Staff member J stated when resident #2 would calm down he would let go of the resident's wrist and try to talk to the resident. Staff member J stated resident #2 attempted to get out of bed, and the charge nurse instructed him not to allow the resident to get out of bed because he was a fall risk. Staff member J stated, I was just kind of confining him to an area but not being forceful. The Appendix PP, of the State Operations Manual, addressing restraints, shows: . the order from the practitioner and supporting documentation for the use of a restraint must be obtained either during the application of the restraint, or immediately after the restraint has been applied. The failure to immediately obtain an order is viewed as the application of restraint without an order and supporting documentation . If application of a restraint occurs, the facility must: - Determine that a physical restraint is a measure of last resort to protect the safety of the resident or others; - Provide ongoing direct monitoring and assessment of the resident's condition during use of the restraint; - Provide assessment by the staff and practitioner to address other interventions that may address the symptoms or cause of the situation (e.g., identification of an infection process or delirium, presence of pain); - Ensure that the resident and other residents are protected until the resident's behavioral symptoms have subsided, or until the resident is transferred to another setting; - Discontinue the use of the restraint as soon as the imminent danger ends; and - Immediately notify the resident representative of the symptoms and temporary intervention implemented. Documentation must reflect what the resident was doing and what happened that presented the imminent danger, interventions that were attempted, response to those interventions, whether the resident was transferred to another setting for evaluation, whether the use of a physical restraint was ordered by the practitioner, and the medical symptom(s) and cause(s) that were identified. The steps identified as required in the Appendix PP, under F604 - Restraints, were not followed by the facility for the emergent restraint use for resident #2, or to address future potential episodes of imminent danger.

Based on observation, interview, and record review, the facility failed to update a resident's individualized care plan for personal preferences related to communication and the provision of ADL care from male staff who had the ability to speak the resident's native language. When male staff assisted the resident, and used the resident's native language when communicating, the resident would exhibit less agitation and aggression, for 1 (#2) of 7 sampled residents. Findings include: During an observation and interview on 12/3/24 at 2:45 p.m. resident #2 was observed sitting in his wheelchair speaking his native language with staff member H. Resident #2 appeared happy, smiling at times, and responsive during the interaction. Resident #2 stated he preferred male staff who spoke his Crow language to care for him stating, white people are okay. During an interview on 12/3/24 at 2:55 p.m., staff member H stated resident #2 preferred male staff to care for him who speak his native Crow language. Staff member H stated resident #2 was less aggressive and more compliant with daily care with male Crow-speaking staff. Staff member H stated resident #2's preferences should be reflected on his current care plan and was not sure why it was not listed under the care plan's interventions. During an interview on 12/4/24 at 12:08 p.m., staff member B stated resident behaviors were discussed each morning at stand up (the facility's daily meeting) and if updates were needed to a resident care plan, it would be assigned to herself or staff member D. Staff member B stated the morning meeting is how they determined resident #2 responded better with a male staff who spoke his native language. Staff member B stated the missing interventions on resident #2's care plan was an oversight, and they (the facility staff) were getting better at developing individualized resident care plans. Review of resident #2's care plan, with a revision date of 11/18/24, failed to show the resident preferred male staff who spoke his native language, during the provision of ADL, as it would decrease the resident's agitation and aggressive behavior towards others.

Based on interview and record review, facility failed to ensure all nursing staff working with a resident who exhibited aggressive behaviors towards others, was educated to the extent necessary and competent to provide services for the resident's needs to be met for behaviors and use of restraints; and to ensure restraint use was utilized properly for resident safety, in the event of an emergency situation; and failed to ensure all staff working with the resident when a restraint was applied had necessary training for physicial restraint use, for 1 (#2) of 7 sampled residents. The deficient practice resulted in a resident being physically restrained for up to one hour without nursing oversight. Findings include: A review of a facility-reported incident, dated 11/11/24, showed the following information: On 11/13/24, at approximately 4:30 p.m., a personal care attendant (PCA) reported to the administrator-in-training that she had sustained an injury on 11/11/24, while assisting the charge nurse and other staff in physically restraining resident #2. During the facility's investigation, staff reported on 11/11/24, around 10:00 a.m., the charge nurse directed staff to physically restrain resident #2, due to the resident exhibiting physical aggression toward staff and other residents. The restraint was implemented to allow the charge nurse to administer an intramuscular antipsychotic injection. The charge nurse instructed staff to continue restraining the resident for an additional 15 minutes after the injection to allow the medication to take effect. After 15 minutes, the charge nurse directed three staff members who were physically restraining resident #2, to resume their other assigned duties, leaving the PCA and a security staff member to continue restraining resident #2 for a total of one hour until the resident fell asleep. During an interview on 12/3/24 at 2:59 p.m., NF2 stated resident #2 had become aggressive with staff and residents at approximately 9:00 a.m. on 11/11/24. NF2 stated nursing staff had tried to redirect the resident, but interventions failed. NF2 stated she contacted the medical provider and received an order for the resident to have intramuscular antipsychotic injection to help with his aggressive behaviors. NF2 stated she gave resident #2 the injection at around 10:00 a.m., and requested staff physically restrain resident #2 for fifteen minutes until the medication would take effect. NF2 stated she returned to resident #2's room after fifteen minutes, and the resident was still aggressive and agitated. NF2 stated she had a male staff member stay with resident #2, and continue to physically restrain him for safety. NF2 stated she did not reassess or document the resident's condition every 15 minutes after her initial assessment. Review of resident #2's electronic medical record failed to show resident #2 was re-assessed at any time by nursing staff during the one hour period of physical restraint on 11/11/24. During an interview on 12/4/24 at 12:08 p.m., staff member B stated the nurse involved in the restraint incident was a brand-new graduate who had just passed her nursing boards. She stated after the incident management had reviewed the Haldol usage and interviewed other nurses about resident #2, and she believed it was the new nurse who was having the most difficulty. Staff member B stated there should be an assessment before resident #2 received the injection, a justification with exactly what he was doing, what interventions weren't working, and then the Haldol. Staff member B stated when giving the intramuscular shots the practice should be not holding him for any longer than it takes, just long enough to make sure he doesn't hit or kick, and then letting him go. During an interview on 12/4/24 at 2:51 p.m., staff member J stated on 11/11/24 resident #2 was destructive and swung at and punched staff. Staff member J stated the charge nurse asked him and another staff member to hold resident #2 down while she administered an intramuscular medication. Staff member J stated he held resident #2's wrist off and on when the resident was trying to hit staff. Staff member J stated when resident #2 would calm down he would let go of the resident's wrist and try to talk to the resident. Staff member J stated he did not receive any training from the facility on how to restrain a resident, and it was the first time he had any physical contact with a resident. Staff member J said prior to the incident on 11/11/24, he would call a CNA if a resident needed help. Staff member J stated he knew he was not to provide any hands-on care. Staff member J stated he was doing what he was told to do by the facility supervisor at the time. Review of staff member J's personnel file failed to show documentation of training or education regarding resident care or restraint use. During an interview on 12/4/24 at 3:00 p.m., Staff member C stated the aides would sometimes ask the nurse to get the resident a shot for behaviors, but it was up to the nurse to evaluate if it was appropriate not to just give it.

Based on observation, interview, and record review, the facility failed to prevent resident abuse in the form of a physical altercation with a staff member for 1 (#2) of 4 residents sampled. Findings include: Review of resident #2's nursing progress notes, dated 7/22/24, showed, Resident and her assigned one on one CNA in the door way to the dining room. CNA has residents hands behind her back pulling on her in an aggressive manner. Holler for CNA and security to help. CNA pulled resident to the floor with her hands still behind her back . [sic] During an interview on 7/29/24 at 1:20 p.m., staff member A stated when the staff to resident altercation had been reported to her, she came to the facility to review the security footage and began investigating the incident. Staff member N was removed from the shift, and later terminated. Staff member A stated through interviews the facility learned staff member N was easily angered and had been a bully. During an observation on 7/29/24 at 2:45 p.m., the security camera footage, dated 7/22/24, showed resident #2 walking into the dining room with her walker. Staff member N was the assigned 1:1 following the resident at a distance. Resident #2 turned and left the dining room, aggressively pushing her walker towards staff member N. Staff member N grabbed the resident by her arms, turned her around with her arms behind her back, and pulled her to the ground, despite other staff coming to help de-escalate the situation.

Based on interview and record review, the facility failed to assess for the root cause or triggers of behavioral outbursts for 1 (#2); and failed to provide the behavioral health services outlined in a PASRR Level II for 1 (#4) of 4 sampled residents. Findings include: 1. Review of resident #2's nursing progress notes, dated 6/29/24 - 7/30/24, showed the resident had been assigned a 1:1 sitter after a pattern of agitation and aggression towards other residents and staff including: - 6/29/24 Assaulting another resident and being sent to [Clinic Name 2] emergently for a psychiatric evaluation. - 7/1/24 Pacing and agitation resulting in a phone call to the physician for a one-time medication order. - 7/2/24 Cursing and yelling at her 1:1. - 7/11/24 Kicking at another resident seated in her recliner. - 7/22/24 Charging and punching her 1:1. During an interview on 7/30/24 at 9:11 a.m., staff member A stated there were no root cause assessments done to identify trends or triggers related to resident #2's incidents. Staff member A stated it did not appear anyone was looking at the documentation on the 1:1 sitter sheet to determine if there were patterns associated with resident #2's behaviors. During an interview on 7/30/24 at 10:00 a.m., staff member J stated the facility had been told by [outside behavioral health clinic 2] to not send a referral to have resident #2 seen, but to send her through the E.R during a crisis. Staff member J stated this was difficult because the drive to this clinic was an hour, and the resident was calm by the time she arrived at the clinic. Staff member J stated the facility had sent out many referrals and requests for new placements with every place declining to take resident #2, due to her behaviors. 2. Review of resident #4's PASRR Level II, dated 6/2/22, showed the resident had a history of schizophrenia and institutionalization that required the specialized services of Outpatient Mental Health. Review of resident #4's EMR failed to show any documentation the resident was receiving or refusing any form of outpatient mental health services. During an interview on 7/30/24 at 12:00 p.m., staff member B stated it was a near weekly conversation with [outside clinic 1] to have the residents at the facility seen for behavioral health services. Staff member B stated [outside clinic 1] was the only provider in the area, and had been difficult to work with. During the exit conference on 7/30/24 at 1:00 p.m., staff member A stated the intention was to send the requested behavioral health documentation to the State Survey Agency. No documentation was received.

Based on interview and record review, the facility failed to ensure prn psychotropic drugs were limited to 14 days or had documented rationale for extended prn usage; and failed to ensure prn anti-psychotic drugs were limited to 14 days and not renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for 1 (#2) of 4 sampled residents. Findings include: Review of resident #2's MAR, dated July 2024, showed the resident had prn orders for: 1. Ativan 1mg give 1 tablet by mouth every 8 hours as needed for agitation. There was a start date of 7/1/24. The resident had received this dose seven times for the month of July. There was no physician documentation detailing the resident's need for continued prn dosing of this medication. There was no stop date listed. 2. Olanzapine 2.5mg give 2.5mg by mouth every 6 hours as needed for depression. There was a start date of 7/1/24. The resident had received this dose twice for the month of July. There was no physician documentation of an evaluation to extend the prn dosage period of this medication. There was no stop date listed. During an interview on 7/30/24 at 12:00 p.m., staff member B stated the physician was at the facility once per month, otherwise available by phone. They did not have an onsite physician who could re-evaluate residents after the 14-day prn period for antipsychotics was met. Staff member B stated pharmacy did the monthly reviews to catch stop dates, but had not yet done the reviews for the month of July 2024.

Based on interviews and record review, the facility failed to review and update the facility assessment to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population for residents with behavioral health needs. This practice had the potential to affect residents with behavioral health needs admitted to the facility. Findings include: During an interview on 7/29/24 at 3:58 p.m., staff member H stated resident #2 required a one-to-one sitter related to behaviors. Staff member H stated the facility was waiting for a psychological evaluation to be done. Staff member H stated staff member J was responsible for setting up the psychological evaluations. Staff member H stated, [Resident #2] deserves to be in a place that is more equipped to take care of behavior patients. I'm afraid to say it, but if we don't get her somewhere, it's (staff to resident abuse) going to happen again. We are not equipped to care for her. During an interview on 7/30/24 at 9:06 a.m., staff member J stated, We are not equipped to take care of [resident #2]. I don't know why the facility assessment says we can take behavior patients, we really shouldn't. I'm new and didn't know anything about facility assessments until yesterday when it was requested (by surveyors). During an interview on 7/30/24 at 10:26 a.m., staff member E stated there were seven residents with aggressive behaviors on the unit that she was aware of. Staff member E reported the following behaviors included: hitting, kicking, pinching, yelling, throwing things, and cussing. Staff member E stated, They (CNAs) really don't have the skills to care for these behaviors. I don't even know how I would handle some of them in the moment. Review of the facility provided, Facility Assessment, dated 12/13/22, reflected: -Part 2: Services and Care We Offer Based on our Residents' Needs -Mental health and behavior: manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide behavioral health training for staff; consistent with the needs of the residents in the facility for 2 (#s 2 and 3) of 4 sampled residents. Findings include: During an observation and interview on 7/29/24 at 1:17 p.m., resident #2 was lying in bed diagonally, watching the television. Staff member C was sitting in a chair next to resident #2's bed looking at a personal cell phone. Staff member C stated she was the sitter for resident #2. Staff member C stated she was to document every 15 minutes what resident #2 was doing, and follow her if she left her room. Staff member C stated she was not aware of any behaviors resident #2 had in the past, and no one told her what she should do if resident #2 had behaviors. Staff member C stated she, . would try to go find the Director of Nursing if something happened. Staff member C stated she had not been trained on how to handle behaviors. During an interview on 7/29/24 at 1:25 p.m., staff member D stated she did not know about the care plan or the interventions for resident #2's behaviors. During an interview on 7/29/24 at 1:32 p.m., staff member E stated resident #2 was very fast and strong. Staff member E stated resident #2 had a sitter, and all the sitters could do was stay with her. Staff member E stated the facility had medication for resident #2's behaviors, and the only trigger she was aware of was if someone sat in her favorite chair in the common area. Staff member E stated she did not know if resident #2 had other triggers and stated resident #2 frequently had behaviors for no reason. Staff member E stated resident #2 had frequent outbursts of aggressive behavior toward staff and residents. Staff member E did not know what the care plan interventions were other than a sitter and medication. Staff member E stated, Truthfully, I don't know what I'd do when she gets aggressive, attacking people. Staff member C stated she had not been trained on how to handle behaviors. During an interview on 7/29/24 at 1:41 p.m., staff member F stated resident #2 was quick. Staff member F stated, I usually tell her, 'Don't do that' and try to get her back in her room. Staff member F stated she had not had training on managing behaviors specifically, and did not know what interventions were on resident #2's care plan. During an interview on 7/29/24 at 3:27 p.m., staff member G stated if a resident were to become aggressive toward her, she would yell for a nurse, and they would take care of it. We (staff) were told not to fight back, just go get a nurse. During an interview on 7/29/24 at 3:58 p.m., staff member H stated resident #2 required a one-to-one sitter related to behaviors. Staff member H stated, [Resident #2] deserves to be in a place that is more equipped to take care of behavior patients. I'm afraid to say it, but if we don't get her somewhere, it's (staff to resident abuse) going to happen again. We are not equipped to care for her. Staff member H stated the staff at the facility were not trained to care for the residents behaviors. Staff member H stated he had told staff to call for him when the behaviors occur so he could help them, but if he was not available the only thing the staff could do was to use the call light for a nurse to come help. During an observation and interview on 7/30/24 at 8:15 a.m., resident #2 finished her breakfast in the dining room and immediately returned to her room. Staff member I was following resident #2 to her room and left a trainee in the room with her while staff member I remained in the hallway. Staff member I stated resident #2 did not like her, and would become angry if she entered her room so she was staying back and allowing the trainee to stay with her. Staff member I stated she did not know what the care plan stated for the resident's behaviors or interventions. Staff member I stated the only trigger she knows of is resident #2 did not like her. Staff member I stated she completed the 15-minute checks form, and returned them to the nurse on duty. Staff member C stated she had not been trained on how to handle behaviors. During an interview on 7/30/24 at 8:18 a.m., staff member E stated she did not know where the 15-minute check forms were going, and they were probably filed away somewhere. Staff member E stated she had not reviewed the 15-minute check forms in the three weeks she had been at the facility. During an interview on 7/30/24 at 9:06 a.m., staff member J stated, The behaviors have been a learning process. We took [resident #2] back from [hospital name] because they said her behaviors were better. [Resident #2's] behaviors came right back when she returned, and we are not equipped to handle it (behaviors). Staff member J stated, We should review the 15-minute checks, but we haven't so I don't think anyone really looks at them. Staff member J stated none of the CNAs like being the sitter for the residents with behaviors, and she had to have a meeting to tell all CNAs they were to take turns, and all share the sitter time. During an interview on 7/30/24 at 10:26 a.m., staff member E stated there were seven residents with aggressive behaviors on the unit that she was aware of. Staff member E reported the residents on the unit exhibited behaviors which included: hitting, kicking, pinching, yelling, throwing things, and cussing. Staff member E stated, They (CNAs) really don't have the skills to care for these behaviors. I don't even know how I would handle some of them in the moment. During an interview on 7/30/24 at 10:44 a.m., staff member N stated resident #3 hits, kicks, cusses, and yells when staff try to change his brief. Staff member N stated, We just hope for the best, and get it done. It's hard and all they (management) say is we have to do it (check and change). During an interview on 7/30/24 at 11:37 a.m., staff member K stated, I feel burned out with all this aggressiveness. I don't even want to come in. I try to get someone to cover. During an interview on 7/30/24 at 11:38 a.m., staff member L stated she felt overwhelmed at times by the behaviors. Staff member L stated most days the staff dealt with more behaviors than ADL cares. Staff member L stated she had not received training on managing aggressive behaviors. Review of resident #2's Care Plan, updated 7/1/24, reflected: -I have the potential to be a safety risk to self and others due to my paranoid like schizophrenia and aggressive history of unprovoked behaviors towards others. - I would benefit from clinical medical management in a geriatric psych setting. Review of resident #2's CNA [NAME], dated 4/15/24, reflected: -Provide 1:1 staff to resident monitoring when resident is up out of bed and in common areas by keeping resident in line of sight. -Redirect to her room if resident appears agitated or aggressive or vocalizes threatening statements. -Attempt non-pharmacologic interventions when resident exhibits behaviors such as agitation, pacing, wandering, disorganized thoughts. Encourage walking, offer emotional support, allow her to watch a movie, provide a snack and/or fluids, sit with her, provide a calm, quiet environment with decreased stimuli. There was no documented indications of triggers. Review of resident #2's Nursing Progress notes, dated 6/29/24 - 7/30/24, showed the resident had a pattern of agitation, cursing, and kicking at other residents and staff. There was no identification of triggers or attempts to determine the root cause the behaviors. Review of resident #3's Care Plan, revision date of 12/31/24, reflected: -New Behavior Potentially Causing Harm to self of others (Episodic). Resident was in physical altercation with another resident causing harm to other resident on 11/30/23. -If Resident poses a potential threat to injure self or others notify provider - If safe, allow Resident personal space - If wandering or pacing, initiate visual supervision during acute episode - Minimize environmental stimuli - Monitor Resident for signs / symptoms of agitation - Provide verbal feedback to Resident regarding behavior - Utilize diversion techniques as needed Review of resident #3's Progress Notes, dated 7/16/24, reflected: Social services were asked to assist with the resident having aggressive behaviors when nursing staff is trying to change his pants and underwear, which the resident soiled. The resident began to be combative and swinging at CNAs and DON. The resident was transferred from the commons couch to wheelchair while still combative. Staff was able to get the resident to his room, where he tried to hit and bite staff. Staff eventually changed the resident and the resident calmed down.

Based on interview and record review, the facility failed to revise and update a care plan for 1 resident (#26) of 17 sampled residents. Findings include: Review of resident #26's electronic medical record, dated 12/29/23, showed the resident had a chronic non-pressure ulcer of the right lower extremity. The physican order, dated 1/4/24, showed the right lower leg was to be cleaned with normal saline and patted dry, then staff were to apply Gentamicin ointment on the wound, and ABD pads and wrap with Kerlix, and cover with Tubi grip. Resident #26's care plan failed to show interventions related to any wound care treatment to resident #26's right lower extremity. Review of resident #26's nursing progress note, dated 1/31/24, showed the resident was seen in the emergency room due to excess fluid retention. The emergency room physician instructed the facility to weigh resident #26 daily. The facility failed to update the resident's care plan interventions to include daily weights. During an interview on 4/23/24 at 1:49 p.m., staff member D stated care plan conferences were not completed after the last Director of Nursing resigned and left the facility. The care plan meetings and updates for March and April 2024 were not completed. She stated staff are trying to get caught up with the care plan updates and also with conducting care plan meetings. During an interview on 4/24/24 at 10:58 a.m., staff member A stated care plans are updated by staff in the facility when necessary.

Based on interview and record review, the facility failed to ensure the nurse competencies and skills set was sufficient to provide services for resident care, which included wound care services, for 1 (#26) of 2 sampled residents with wounds. Findings include: Review of resident #26's electronic medical record showed an admission diagnoses of diabetes Type 2 with other skin ulcer, and non-pressure chronic ulcer of other part of right lower leg. The physician admission order, dated 12/29/23, included an order for Gentamicin Sulfate ointment to be applied to the affected area once a day. Resident #26's physician order did not show which skin wound was to be treated. Review of resident #26's treatment record for December 2023, showed there were initials showing the wound treatment was not completed on 12/29/23, 12/30/23, and 12/31/23. Resident #26's medical record failed to show why the treatments were not completed. Review of resident #26's medical records from 12/29/23 through 12/31/23, failed to show a medical provider was contacted to obtain or clarify wound care orders. Review of resident #26's late entry nursing progress note, dated 1/1/24, at 10:00 a.m., showed, Clarified orders with charge nurse regarding dates of wound changes, written orders hard to read and understand. Review of resident #26's progress note, dated 1/1/24 at 2:02 p.m., showed, Resident has a prescriber written order for RLE venous stasis ulcer/wound. The wound is be changed every day. The order is to remove previous dressing, apply Gentamicin, collagen powder, apply ABD pad, wrap kerlix guaze to keep dressing in place, then put a tubigrip over entire dressing. Will continue to monitor for excess drainage and infection. [sic] Resident #26's physician orders and treatment record s failed to show the order was transcribed onto the treatment record for the right lower leg wound treatment that was to be started on 1/1/24. Review of resident #26's nursing progress note, dated 1/1/24, showed Gentamicin antibiotic ointment had not been received from the pharmacy and was not available to be administered. During an interview on 4/24/24 at 3:36 p.m., staff member D said resident #26's admission orders did not include the complete wound treatment because the admitting physician was not the doctor that routinely took care of resident #26's wounds. Staff member D said, she was aware prior to admission resident #26 was treated by a wound clinic, and was unable to make contact with the wound clinic on 12/29/23. Staff member D said the wound clinic was closed for the weekend, and the holiday, and could not be reached for order clarification until Monday 1/1/24.

Based on interview and record review, the facility failed to accurately code a significant weight loss on the MDS, for 1 (#15) of 1 sampled resident. Findings include: Review of resident #15's Quarterly MDS, with an ARD of 2/25/23, section K, showed the resident's Weight (in pounds) was 37 lbs.; and, the section for the Loss of 5% or more in the last month or loss of 10% or more in the last 6 months . was marked with a response of no meaning the resident did not have a loss of weight. Review of resident #15's monthly weights in the electronic medical record, accessed on 4/25/23, showed: - On 2/20/23 resident #15 weighed 137 lbs. - Six months prior, on 8/22/22, resident #15 weighed 153.6 lbs. This represented a 12% weight loss. During an interview on 4/25/23 at 3:53 p.m., staff member B stated she followed the PCC triggers, in the vitals and weight loss section for percentage of weight loss/gain changes, and it wasn't showing next to the recorded 137 lbs. She stated she shouldn't trust the computer so much and would submit a correction of the MDS.

3. A review of resident #7's medical record, showed a Health Status Note dated 6/28/22, that showed, . charge nurse informed of residents positive urine drug screen and informed that resident verbally consented to random drug screen until further notice and nephrologists and other care team to be informed. MD aware will follow necessary protocol based on recommendation of state and administrator. [sic] During an interview on 4/27/23 at 10:47 a.m., staff member B reported the Facility Reported Incident in question occurred during the time of her transition to a new role. The Facility Reported Incident investigation was handled by the previous employee. Staff member B reported the facility's current process would be to discuss all new Facility Reported Incidents during the Stand Up manager's meeting. Resident #7's care record and care plan, on 4/27/23, showed no entry or update to reflect the incident, the resident's drug use and his associated behavior, risks of drug use, recommendations for random urine drug screens, or how resident drug use would be handled by the facility in the future. Based on interview and record review, the facility failed to update care plan interventions after resident to resident interactions, falls, and suspected drug use, for three (#s 7, 10, and 70) of three sampled residents. This deficient practice did not keep all staff informed of resident care needs related to continued resident behaviors and falls. Findings include: 1. Review of resident #10's nursing progress notes, dated 10/24/22, showed, .at lunch she made statements of aggression toward another resident almost hitting them in the face and asking, 'do you want to fight?' . [sic] Review of a Facility Reported Incident, dated 12/2/22, showed resident #10 tried to hit another resident who was seated at a table with her in the common area. The other resident took some papers in front of resident #10, which led to resident #10 trying to stab the other resident with a pencil. They were immediately separated by staff. Review of resident #10's nursing progress notes, for the month of December 2022, showed a lack of nursing progress notes related to the Facility Reported Incident. There was no notation of the incident noted anywhere in the resident's medical record. Review of resident #10's care plan, with a review date of 3/13/23, showed a lack of interventions related to the resident's aggressive behavior towards other residents. During an interview on 4/27/23 at 10:27 a.m., staff member B stated anyone could add interventions to resident care plans. She stated resident concerns were discussed each morning at stand up (the facility's daily managers meeting) and if an update was needed it would be assigned to the applicable department. 2. Review of resident #70's fall worksheets, dated 9/22/22, 9/25/22, and 11/30/22, showed #70 had three falls. Each fall had a root cause analysis completed, and several different fall risk factors and interventions, were identified. One common factor in each fall was that resident #70 had been bathed and put to bed early, tried to get himself back up, and had fallen. Review of resident #70's care plan, with a review date of 3/13/23, showed a lack of interventions related to this specific identified fall risk. During an interview on 4/27/23 at 10:52 a.m., staff members A and E stated the missing interventions were an oversight, and they (the facility) were getting better at developing care plans.

Based on interview and record review, the facility failed to intervene and use identified interventions for a resident who was a fall risk, to prevent recurring falls, for 1 (#70) of three sampled residents. Findings include: Review of resident #70's Post Fall Huddle Form, dated 9/22/22, showed: - The resident had an unwitnessed fall in his room on 9/22/22 at 8:30 p.m. - Having a bath later in the evening 10:30 -11 p.m. was documented as an intervention to prevent further falls. - New staff not familiar with resident bedtime schedule/routine was listed in the fall description. - The resident sustained a minor laceration to his forehead and was placed on neuro protocol. Review of resident #70's Post Fall Huddle Form, dated 9/25/22, showed: - The resident had an unwitnessed fall in his room on 9/25/22 at 10:15 p.m. - Resident bathed too early and placed in bed was listed as the contributing error. - The laceration to the resident's forehead from the previous fall was reopened. Review of resident #70's Post Fall Huddle Form, dated 11/30/22, showed: - The resident had an unwitnessed fall in his room on 11/30/22 at 5:55 p.m. - Putting resident to bed too early was listed as the contributing error. - The resident did not sustain any injuries. During an interview on 4/27/23 at 10:52 a.m., staff member A stated the night shift staff was aware of resident #70's bedtime routine, they just needed to get better about the care plan updates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident medical record documentation was dated appropriately for physician visit notes for 1 (#70) of 1 sampled resident. Findings include: Review of resident #70's most recent medical visit, dated 4/8/23, showed he was seen by NF2. No questions or concerns was listed in the resident's history, and the physical assessment showed his abdomen was, soft & nontender. Review of resident #70's Hospital Progress notes, dated 4/9/23, showed the resident had been hospitalized since his admission on [DATE] with a small bowel obstruction. The resident was not at the facility on 4/8/23. During an interview on 4/26/23 at 12:55 p.m., staff member B stated, 4/8/23 was the date resident #70 would be due for a physician visit, following the CMS regulation for frequency of physician visits. During an interview on 4/26/23 at 2:03 p.m., NF2 explained the date discrepancy and stated he had visited the resident the week prior and had been late getting his note in to the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of the facility document titled, 24 Hour Shift Report, showed the resident names, room numbers, and CPR or DNR status under the resident names. During an interview on [DATE] at 3:48 p.m., staff member A stated the facility document titled, 24 Hour Shift Report was not part of the medical record, but was something the staff developed to give shift report with. Resident #17 was listed on the 24 Hour Shift Report as a code status of CPR. Review of Resident #17's medical record included a completed Montana POLST form indicating No CPR. The POLST form was signed and dated by the resident on [DATE], and signed and dated by the healthcare provider, on [DATE]. Resident #17's medical record also included a code status of No CPR on resident's EHR dashboard. The resident's No CPR status was noted as reconfirmed with the resident on [DATE]. The resident's code status was accurately reflected in the medical record, but was inaccurately reflected on the 24 Hour Shift Report. During an interview on [DATE] at 3:10 p.m., staff member H reported if she needed to determine a resident's resuscitation status (CPR or DNR), she would look at the 24 Hour Shift Report. 2. During an interview on [DATE] at 3:00 p.m., staff member I stated the residents' code status on the dashboard, was generated by a physician order, and it was the same as the 24 Hour Shift Report the Nurse and CNAs used during their scheduled shift. Staff member I said the 24 Hour Shift Report sheet was not generated by the electronic medical record, but was created by a staff member. Staff member I said that she was not aware of who created or updated the 24 Hour Shift Report sheet used by the nursing department. Review of resident #9's code status, documented on the 24 Hour Shift Report sheet, and on residents #9's dashboard in the electronic medical record, showed the resident's code status was Cardiopulmonary Resuscitation (CPR). Review of resident #9's Montana Provider Orders for Life-Sustaining Treatment (POLST), dated and signed [DATE], by the resident and provider, showed the resident's code status was Do Not Resuscitate (DNR). Resident #9's medical record and the facility's 24 Hour Shift Report was not consistent with the resident's signed POLST form.Based on interview and record review, the facility failed to ensure residents' records displayed the correct code status, correct physician orders, and correct staff notification of code statuses for three (#s 9, 10, and 17) of eighteen sampled residents. Findings include: 1. Review of the facility document titled, 24 Hour Shift Report, showed a list of the residents, their room numbers, and their CPR or DNR statuses. During an interview on [DATE] at 3:13 p.m., staff member A stated the resident code status, on the resident dashboard in the facility's electronic medical record (PCC), were the same as those on the report sheet the CNAs used. Review of resident #10's document, Montana Provider Orders for Life-Sustaining Treatment (POLST), dated and signed [DATE], showed the resident was a code status of DNR. Review of resident #10's code status, documented on the 24 Hour Shift Report, and on the resident dashboard in PCC, showed she was incorrectly identified as a code status of CPR.

Based on interview and record review, the facility failed to have an RN working at least eight hours per twenty-four hour period, seven days per week. This deficient practice had the potential to affect all residents who received skilled nursing services. Findings include: Record review of the October, November, and December 2022 schedules, for licensed nursing, showed the following dates did not have eight hours of RN coverage documented in a twenty-four hour period: - 10/22/22, 10/23/22, 10/29/22, 10/30/22, - 11/5/22, 11/6/22, 11/12/22, 11/13/22, 11/19/22, 11/20/22, 11/26/22, 11/27/22, - 12/4/22, 12/11/22, 12/17/22, 12/18/22. During an interview with staff member D, on 4/27/23 at 9:21 a.m., the facility staffing schedule and [NAME] PBJ report were reviewed and discussed, for the period of October to December, 2022. Staff member D stated there were no RN hours within a twenty-four hour period on the weekend dates, as noted in the prior paragraph. During an interview on 4/27/23 at 11:13 a.m., staff member A reported facility administration had addressed prior staffing deficiencies, and in the current year they have had RN coverage, for eight hours every day. The facility had not applied for an RN Nursing Waiver.