Kalispell Rehabilitation and Nursing LLC

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical well-being for 1 (#1) of 8 sampled residents. The facility failed to administer an anticoagulant medication as ordered, resulting in the omission of 27 doses of Eliquis (Apixaban), increasing the risk for complications including stroke and blood clots; and failed to implement physician-ordered medication hold instructions before a scheduled vascular procedure, resulting in the cancellation and rescheduling of the resident's fistula surgery on two separate occasions and causing the resident frustration. These failures delayed medically necessary treatment.

Inspectors wroteBased on interview and record review, the facility failed to effectively and systematically identify, assess, implement, monitor, and modify interventions timely after the identification of facility-acquired pressure injuries, which resulted in the progression of bilateral heel pressure injuries, including the development of an additional pressure injury to the plantar aspect of the left heel for 1 (#2) of 3 sampled residents for pressure injuries. The facility actions being taken for the wound(s) were not sufficient to meet the resident's needs related to wound care and the prevention of wounds.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to promptly identify, evaluate, and implement interventions to address clinically significant weight loss and nutritional declines for 3 (#s 2, 7, and 5) of 3 sampled for weight loss; and failed to timely notify the resident representative of severe weight loss for 1 (#2) resulting in delayed intervention for a resident who experienced the severe 19.2 pound weight loss (14.0%) within approximately 30 days and met criteria for severe malnutrition for #2. This failure also resulted in delayed implementation and evaluation of nutritional interventions after resident #7 experienced progressive, clinically significant weight loss, which was severe, and subsequently met criteria for severe malnutrition; [...]

Inspectors wroteBased on interview and record review, the facility failed to reposition and facilitate ambulation for 1 (#98) and this deficient practice resulted in the development of an avoidable Stage III pressure ulcer; and the facility failed to provide necessary positioning and repositioning for skin protection and the prevention of wound development, for 3 (#s 2, 71, and 73) of 38 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to frequently encourage and facilitate ambulation for 1 (#98) of 38 sampled residents, and this contributed to resident #98 losing mobility and becoming bed-bound and developing a Stage III pressure wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to failed to ensure proper PPE was worn, clean technique was followed, a catheter bag was emptied timely, and catheter perineal care was completed correctly for an indwelling Foley catheter for 1 (#2), and the resident had multiple urinary tract infections in the prior year; and the facility failed to provide a physician ordered catheter change(s), failed to provide proper daily site assessments and a dressing change(s), and failed to empty the catheter drainage bag timely for a resident with a Suprapubic indwelling catheter, for 1 (#15). These deficient practices increased the risk of negative urinary outcomes for all residents receiving catheter services, out of 5 sampled residents for catheter use and care.

Inspectors wroteBased on interview and record review, the facility failed to employ a certified dietary manager or a full-time dietician to serve as the director of food and nutrition services. The deficient practice had the potential to affect all residents who received meals and nutritional services from the facility. The deficient practice increased the risk for food quality/safety concerns; resulted in inadequate oversight of food service operations; increased the potential for weight loss; resulted in residents eating less and feeling hungry (see F804.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable food (including appetizing food visually, taste wise, and with preferences) for 10 (#s 2, 8, 26, 27, 36, 50, 73, 74, 79 and 101) of 38 sampled residents. This deficient practice resulted in residents eating less, feeling hungry, a potential in weight loss, and resident #74 requesting to be discharged .

Inspectors wroteBased on observation and interview, the facility failed to store food in a safe, sanitary manner; failed to maintain cooler temperatures within a safe range; and failed to maintain cleanliness of the kitchen and food preparation/storage areas. The deficient practices caused increased risk for foodborne illness for all residents receiving food from the dietary department.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment, by not maintaining clean resident rooms and resident bathrooms, for 6 (#s 3, 7, 24, 35, 57, and 80) of 41 sampled residents; and failed to keep the community bathing/shower room on the A and B hall clean.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the required enhanced barrier precaution (EBP) signage posted for residents who required EBP for cares for 2 (#s 15 and 82); failed to ensure staff adhered to EBP protocols for personal protective equipment (PPE) while providing catheter care for a Suprapubic catheter for 1 (#15); failed to ensure proper perineal care was completed, clean technique used, and enhanced barrier precautions were followed when emptying a foley catheter bag for 1 (#2); and failed to ensure hand sanitizer was available to prevent the spread of infection for 4 (#s 54, 71, 73, and 74) of 38 sampled residents. These deficient practices increased the risk of facility acquired UTI's, and the transmission of microorganisms from resident to resident.

Inspectors wroteBased on interview and record review, the facility failed to honor a POA's (Power of Attorney) wishes with regard to treatment for 1 (#84) of 41 sampled residents. This deficient practice resulted in the POA not being informed of resident #84's condition or treatment, the resident continuing to receive a psychotropic medication without the POA's knowledge for approximately six months, and the resident receiving the psychotropic medication for approximately two months after the POA requested it to be stopped.

Inspectors wroteBased on interview and record review, the facility failed to consult and receive a representative's permission to order and administer a psychotropic medication for a resident on the memory care unit, for 1 (#84) of 41 residents. This deficient practice resulted in the resident representative not being informed in advance or being allowed to make treatment decisions for the resident's care.

Inspectors wroteBased on interview and record review the facility failed to schedule timely care conferences with the POA (Power of Attorney) for a resident who resides on the memory care unit, for 1 (#84) of 41 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to submit an initial incident report for an allegation of neglect to the State Survey Agency, for 1 (#11) of 38 sampled residents. The resident did not receive the necessary care and services related to a nephrostomy tube and the tube being dislodged during care, which was later identified to be an accident.

Inspectors wroteBased on interview and record review, the facility failed to identify and investigate an allegation of potential neglect of care for 1 (#11) of 38 sampled residents. The allegation was later found to be an accident, but the reporting timeline was not met for an allegation of neglect, and the investigation was not immediately initiated for neglect of care, in an attempt to rule out neglect of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safe interventions for swallowing medications and food for 1 (#73) of 38 sampled residents. This deficient practice resulted in resident #73 feeling rushed when taking his medications, coughing on the medications, and potentially vomiting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to independently carry out activities of daily living (ADL) for self-grooming and showering was provided a regular shower and the removal of female facial hair for 1 (#6) of 4 sampled residents for ADL services.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services (including preferences, goals, and standards of care) to meet the resident's physical, mental, and psychosocial needs for 1 (#74) of 38 sampled residents. This deficient practice resulted in resident #74 feeling uncared for, crying about the food (or lack of) served to her, NF5 upset about the care provided to resident #74, and resident #74 requesting to be discharged from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with necessary respiratory care and services in accordance with professional standards of practice and physician orders and failed to ensure a portable oxygen tank was replaced when the metered volume was empty for 1 (#6) of 4 residents sampled for oxygen therapy. This deficient practice increased the risk of negative outcomes related to hypercapnia (a condition characterized by abnormally high levels of carbon dioxide in the blood, typically caused by hypoventilation, chronic lung diseases, like COPD, or breathing issues resulting in confusion, fatigue, and shortness of breath).

Inspectors wroteBased on interview and record review, the facility failed to ensure staff had the competencies and skills to provide care for 1 (#11) of 38 sampled residents. The deficient practice caused the resident concerns for safety and had potential to cause the resident infection, harm, pain and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to have an updated written agreement with a hospice, which was signed by an authorized representative of both the hospice and the facility, before hospice care was furnished at the facility to ensure coordination and communication of care was provided as ordered for 2 (#s 29 and 65) of 3 residents sampled for hospice services. This deficient practice increased the risk to any resident receiving hospice services.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide enough supervision and monitoring of a resident who had a history of falls with injury. The resident resided on the memory care unit, had dementia, and significant cognitive deficits, which hindered her ability to comprehend safety awareness. The resident wandered consistently and had altercations with other residents, and although supervision was in place, it did not meet the resident's safety needs related to her behavior and falls. The resident sustained two major injuries, one was from a known fall, and one was an unknown injury, suspected to be from a fall. The resident's care plan, although it had interventions in place, was not adequate to meet her safety, supervision, and oversight needs related to accidents and hazards, for 1 (#15) of 24 sampled residents. [...]

Inspectors wroteBased on interviews and record reviews, the facility and staff failed to provide the supervision and oversight for a resident residing on the memory care unit, who had dementia, poor safety awareness, displayed aggressive behavior towards others, and would wander continuously. On one occasion, the resident went into a room of a fellow resident, was pushed, had a fall, and fractured her hip, as staff were not available and present to stop her from going into the room, for 1 (#15) of 3 residents sampled on the memory care unit; and, this affected 1 (#20) when resident #15 went into her room and punched her in the chest while sleeping, which made the resident afraid. Although the facility did attempt to identify and implement interventions for the resident and her behaviors, they were not adequate to meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to address the lack of housekeeping services and concerns with missing laundry, which had been complained about in the resident council for several months, but the issues were ongoing. This failure affected any resident who did not have their concerns addressed or whose room/area they were in was not maintained by housekeeping.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean environment for the residents and failed to ensure the laundry for the residents was managed and returned to them in a timely manner; including not providing the labeled clothing to the correct resident(s), which resulted in an altercation between 2 (#s 1 and 2) of 24 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to report allegations and findings of abuse timely to the State Survey Agency, for 3 (#s 10, 11, and 21) of 24 sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a care plan contained dementia-related interventions, other than nonspecific redirection strategies, for a resident who displayed aggressive behaviors, wandering, had frequent falls, pain, and was an elopement risk, for 1 (#15); and the lack of activities affected 2 others (#s 19 and 20) of 24 sampled residents. This deficient practice resulted in the staff lacking clear guidance on how to effectively meet a resident's needs, placing the resident at risk for inconsistent and unsafe care and unmet psychosocial needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an ongoing program of daily, individualized or group activities, and meaningful engagement consistent with the cognitive needs and interests of residents with dementia residing on the secure memory care unit. to include for 3 (#s 15, 19, and 20) residents, for those sampled on the secure unit.

Inspectors wroteBased on interview and record review, the facility failed to accurately identify wandering behaviors on the MDS Resident Assessments for 1 (#15) of 24 sampled residents. This failure limited the facility's ability to implement appropriate care planned interventions to prevent foreseeable harm to a resident with dementia and a known behavior of wandering daily.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's call lights were answered timely for 6 (#s 10, 12, 26, 29, 30, 32) of 40 sampled and supplemental residents, leading residents to feel their pain was not adequately managed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure transmission-based precautions were accurate and followed; failed to ensure documentation and notification of Covid tracing in residents was completed; and failed to have a system in place to prevent and monitor water borne illnesses. These infection control failures could affect any resident at the facility, to include 8 (#s 1, 6, 10, 20, 27, 31, 32, and 280) of 40 sampled and supplemental residents; and the failure to have a waterborne pathogen program in place which could affect any resident residing at the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a clean environment in resident showers; and failed to exercise reasonable care of resident clothing and other personal resident items from loss or theft, and failed to utilize a grievance process to address lost/missing items, for 4 (#s 5, 33, 67 and 69) of 25 sampled residents.

Inspectors wroteBased on observation, interview, and record review ,the facility failed to maintain an affective grievance program to address resident concerns, specifically related to ongoing problems with lost resident belongings. This deficient practice increased the risk of a negative outcome for all residents who had concerns with grievances or lost items not elevated to a grievance level by management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was adequate staff supervision on the memory care unit for 3 (#s 22, 45, and 62); failed to identify, implement, and provide sufficient interventions for a resident who eloped, for 1 (#276) ; and failed to ensure 2 (#s 2 and 28) were properly positioned when eating food for 40 sampled and supplemental residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain was routinely assessed and treated according to professional standards for 3 (#s 10, 29, and 30), especially concerning pain management for a resident with advanced dementia for 1 (#14); and failed to failed to properly follow physician orders regarding pain monitoring documentation for 1 (#10) of 25 sampled and supplemental residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on referrals for dental care for 5 (#s 3, 5, 6, 48, 280) of 40 sampled and supplemental residents.

Inspectors wroteBased on observations, interviews, and record review, the facility dietary department and staff failed to serve food timely, and follow the posted meal times, and food was often served late which resulted in cold food, for 5 (#s 6, 10, 28, 35, and 41) of 40 sampled and supplemental residents; and 3 (#s 29, 48, 49) of 25 sampled and supplemental residents stated they disliked the food.

Inspectors wroteBased on interview and record review the facility failed to refer resident #62 for a PASARR Level II when the diagnosis of Post Traumatic Stress Disorder was added for 1 (#62) of 25 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to include on a resident's baseline care plan that the resident received enteral tube feedings, for 1 (#281) of 25 sampled residents. This deficient practice increased the risk of the resident not receiving proper tube feedings, or receiving food items, and the resident was NPO.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received the required assistance at meals, for 1 (#5); and failed to ensure a resident received assistance with toileting and dressing for 1 (#58) of 25 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to ensure hospice referrals were completed timely for 2 (#s 14 and 29) of 3 residents sampled for hospice concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received services for the treatment of post traumatic stress disorder, for 1 (#62) of 25 sampled residents.

Inspectors wroteBased on interview and record review, facility nursing staff failed to administer two medications during the evening medication administration time, that were ordered to be given two times a day for 1 (#76) of 25 sampled residents. This resulted in a 6.4 percent medication error rate. This deficient practice had the potential to adversely affect the resident who was taking an antibiotic two times a day for pneumonia, and Potassium Chloride two times a day for encephalopathy.

Inspectors wroteBased on observations and record review, the facility failed to follow the posted menu for two meals of the three observed meals, which could affect any resident wishing to utilize the posted menu's.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the physician ordered therapeutic diet was followed for 3 (#s 12, 48, 280) of 40 sampled and supplemental residents.

Inspectors wroteBased on observation, interview, and record review, the facility licensed staff member failed to provide necessary services, medically neglecting a resident's care needs, after a significant medication error occurred due to the staff member failing to follow the facility procedures for medication administration, resulting in an Immediate Jeopardy level significant medication error, for 1 (#1) resident of 3 sampled residents for medication errors. The resident had a significant decline in health, was unresponsive, had to be given Narcan, and was sent to the ER and had a hospital stay due to the failures identified.

Inspectors wroteBased on interview and record review the facility failed to keep 2 (#s 1 and 3) residents free from significant medication errors, of 3 sampled residents for medication errors. This deficiency resulted in an Immediate Jeopardy level deficiency for 1 (#1) resident, and interventions included medication, emergency medical care, and hospitalization, and the deficiency had the potential to cause life threatening side effects for resident #3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect 1 (#1) resident from neglect of medical care by a staff member, when the licensed staff member provided incorrect medications, which was a significant medication error, then failed to properly monitor the resident after the error, and the resident then had a decrease in cognition and change in vital signs. When the decline was identified, the resident had to be given additional medication and was sent to the emergency room and had a hospital stay; the facility also failed to protect two (#s 5 and 7) residents on the memory care unit from having sexual contact without having prior assessment for their ability to consent to sexual contact; and, failed to protect 1 (#10) resident from a resident to resident abuse event which resulted in a resident fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect 2 (#s 9 and 10) residents from accidents and hazards. Resident #9 sustained eight falls within 17 days, she was sent to the hospital for five of the falls, and had significant injuries for two of the falls. Resident #10 was pushed by another resident and fell to the floor, putting her at risk for injury, due to her wandering, of 11 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to maintain clinical records in accordance with professional standards and practices for 13 (#s 1, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) of 13 sampled residents. This deficiency had the potential to affect the resident's safety from sexual abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and report an incident of suspected medical neglect of care by a staff member, for 1 (#1); and failed to identify and report an incident of inappropriate sexual contact, involving 2 (#s 5 and 7) to the State Survey Agency, of 11 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully investigate an incident involving a significant medication error when medical neglect occurred after the error, for 1 (#1) resident; failed to fully investigate an incident involving sexual contact between 2 (#s 5 and 7) residents who were not assessed to ensure it was consensual contact, and ensure other residents were protected, which allowed ongoing sexual behaviors to go unaddressed as needed. This negatively affected a resident (#6), who would then not leave her room or go to the dining room due the male's approaches and comments to her, of 4 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide clean resident rooms for 12 (#s 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 13, and 14) of 14 sampled residents. This deficient practice had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide a structured activities program, to meet each residents' individual preferences and needs in the secured, memory care unit. This deficient practice had the potential to affect all residents residing in the secured care unit.

Inspectors wroteBased on observation, interview, and record review, staff member M failed to provide services which met professional standards of quality by not priming an insulin pen prior to the administration of insulin for 1 (#6) of 14 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services for a dependent resident for 1 (#9) of 14 sampled residents. This deficient practice caused the resident to feel unsafe, dirty, and embarrassed.

Inspectors wroteBased on observation, interview, and record review, staff member M failed to perform proper hand hygiene when entering/exiting a resident's room, during blood glucose monitoring, during insulin administration, and during administration of eye drops for 1 (#6) of 14 sampled residents; failed to utilize a protective barrier during blood glucose monitoring; and failed to clean a glucose monitoring device (glucometer) after use. This deficient practice had the potential to increase the risk of bloodborne pathogens spread to other residents using the same glucometer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the floors and rooms were clean for 10 (#s 1, 2, 3, 4, 6, 7, 9, 10, 12, and 15) of 14 sampled residents for a clean environment. This deficient practice caused resident #3 to feel discouraged and frustrated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care planned fall interventions for 1 (#4) of 2 sampled residents for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent a fall for 1 (#4) of 2 sampled residents for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's preference of sleeping in a recliner instead of a bed, for 1 (#53) of 1 sampled resident, which caused concern for the resident related to her safety and comfort.

Inspectors wroteBased on interview and record review, a facility staff member neglected to communicate a resident's pain concerns to the nurse on more than one occasion, and over a 1 to 2 hour time span; and, during an interaction the staff member verbally mistreated the resident, and used a hand gesture to slap in the resident's face being mean and disrespectful, for 1 (#333) of 1 sampled resident.

Inspectors wroteBased on interview and record review, facility nursing staff failed to follow a provider order for donning and doffing anti-embolism stockings, 1 (#53) of 1 sampled resident

Inspectors wroteBased on observation and interview, facility dietary staff failed to ensure dry food storage was in line with identified safe food handling guidelines, and failed to have processes in place to identify and maintain a clean environment in the kitchen, as evidenced by the lack of a cleaning schedule, and unsanitary conditions in the kitchen. This deficient practice had the potential to affect all residents receiving food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to provide and submit complete and accurate Payroll Based Journal information for all required data for Fiscal Year 2023.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, sanitary environment in the laundry facility. This deficient practice had the potential to affect residents requiring laundry services; and failed to ensure a residents soiled bed sheet was replaced for 1 (#227) of 35 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely submission of resident MDSs for 7 (#s 16, 63, 64, 73, 223, 225, and 227) of 35 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assisted with transfers in a timely manner for 3 (#s 2, 66, and 227) of 35 sampled residents. This deficient practice resulted in resident #2 feeling scared and delayed care for others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide enough staff to assist residents with ADL needs and tasks, and complete MDSs, resulting in long resident wait times and incompletion of assistance and tasks for 6 (#s 2, 37, 39, 66, 223, and 227), causing resident #66 to be scared; and late MDS submissions for 7 (#s 16, 63, 64, 73, 223, 225, and 227) of 35 sampled residents.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to honor bathing preferences for 2 (#s 39 and 40) residents, who felt it was important due to skin concerns and comfort, of 35 sampled residents.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to notify the physician of a change in a resident's increased depression for 1 (#53); and failed to notify the physician of a missed antibiotic for 1 (#53) of 35 sampled residents.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement a comprehensive, personalized care plan for 1 (#53) of 35 sampled residents.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to revise a care plan with focus, goals, and interventions for increased depression for 1 (#53) of 35 sampled residents.

Inspectors wroteBased on interview and record review, facility staff failed to maintain professional standards due to failure to follow ¹physician orders for 1 (#53) of 35 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete root cause analysis was completed post fall for 1 (#65) of 35 sampled residents. This deficient practice could negatively affect a resident and hinder efforts for fall prevention in the future, if appropriate interventions related to root causes of falls were not identified, and addressed.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to identify and address behavioral health service needs for 1 (#53) of 35 sampled residents.

Inspectors wroteBased on interview and record review, the facility staff failed to provide dental services for 1 (#64) of 35 sampled residents, resulting in a delay of treatment for the resident.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, homelike environment in good repair for the residents on the memory care unit, and for the residents who used the main dining room.

Inspectors wroteBased on interview and record review the facility failed to provide an environment safe from accidents and hazards, and anticipate and assess the residents needs related to fall prevention, for 1 (#4) of 4 sampled residents, and the resident had a history of falls with significant injury. This deficiency resulted in resident #4 having an unwitnessed fall, with a significant injury, resulting in the resident requiring an additional hospital visit and surgery.

Inspectors wroteBased on interview and record review the facility failed to allow 1 resident (#1) of 2 sampled residents to refuse a recommended medical treatment by having her sign a behavioral contract stating she would go to counseling services she had previously refused to attend.

Inspectors wroteBased on interview and record review the facility failed to allow 1 resident (#1) of 2 sampled residents to voice grievances without fear of reprisal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to anticipate the risk and protect one resident (#2) of 1 sampled resident from sexual abuse by another resident (#3) causing #2 to yell out and appear frightened, and the facility failed to protect one resident (#1) of 1 sampled resident from intimidation by staff, causing the resident emotional distress to include slapping herself in the face.