Rim Country Health & Retirement Community

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to develop and implement policies and procedures for the documentation and reporting of alleged violations involving abuse for one resident (#23). The deficient practice resulted in allegations of abuse not being reported, not investigated and residents not protected from further abuse.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to complete notifications involving abuse for two residents (# 15 and #23). The deficient practice resulted in allegations of abuse not being reported, not investigated and residents not protected from further abuse.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to develop and implement policies and procedures for the documentation and reporting of alleged violations involving abuse for one resident (#23). The deficient practice resulted in allegations of abuse not being reported, not investigated and residents not protected from further abuse.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to complete notifications involving abuse for two residents (# 15 and #23). The deficient practice resulted in allegations of abuse not being reported, not investigated and residents not protected from further abuse.

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Based on clinical record review, staff and caregiver interviews, and policy and procedures, the facility failed to ensure resident was free from a condition or situation that may cause physical injury by failing to ensure medications for one resident (#10) were securely stored in accordance with professional standards. Findings include: Resident #10 was admitted on February 5, 2025, with diagnoses of essential hypertension, adult failure to thrive, atherosclerotic heart disease, anxiety disorder, and major depressive disorder. The nursing note dated February 6, 2025 at 8:00 a.m. revealed that the resident was found unresponsive and unknown medications were found with resident. Per the documentation, the resident was sent to the local emergency department (ED) for further evaluation. Further review of the clinical record revealed no additional documentation regarding this incident. During an initial interview with the Director of Nursing (staff #124) conducted on February 11, 2025 at approximately 2:55 p.m., the DON stated that the resident was admitted to the facility on February 5, 2025 at approximately 8:00 p.m.; and, was later found unresponsive with empty medication bottles with the resident on February 6, 2025 at approximately 6:10 a.m. The DON further stated that the resident's family reported giving the box of resident's medications to the nurse; and that, the resident's family had seen the registered nurse (RN/staff #19) put the bottles of medications in the medication cart. The DON also said that the other medications of the resident were destroyed. An interview was conducted on February 12, 2025 at approximately 9:45 am with a licensed practical nurse (LPN/staff #48) who stated that he arrived for his shift that day at approximately 6:00 a.m. and received a report from previous nurse (RN/staff #19) who was concerned about a "small turquoise box of medications that were missing" that belonged to the resident; and that, the medications were not immediately located or secured. The LPN stated he was then asked by a certified nursing assistant (CNA/staff #31) to come to the room of resident #10. He stated that he found resident #10 unresponsive, had a labored breathing and had a very low BP (blood pressure). The LPN said that the resident also had a blue box between her legs with medication bottles in it and one of the medication bottles was clonazepam (anti-anxiety) was opened and laying on top. The LPN stated he attempted to arouse the resident using a sternal rub with no response from the resident and then called the nurse manager and 911. Further, he stated that when the resident's bedding was pulled back in preparation for paramedics, there were three (3) additional empty medication bottles found on the resident's bed. He stated that one bottle was for Isosorbide (vasodilator), second bottle was for Plavix (platelet inhibitor) and he could not recall what the third bottle was for. He stated that the paramedics arrived and began treatmen

Based on documentation, interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#21) did not abuse another resident (#32). Findings include: -Resident #32 was admitted on November 22, 2022 with diagnosis that included unspecified dementia with unspecified severity and without behavioral disturbance, psychotic disturbance, mood disturbance, schizoaffective disorder, Alzheimer's disease and anxiety. A review of the annual MDS (minimum data set) dated December 6, 2024 revealed a BIMS (brief interview of mental status) score of 01, indicating severe cognitive impairment. The MDS further revealed no noted potential indicators of psychosis, but did note physical behaviors 1-3 days and wandering 4-6 days within a week. The care plan revealed that resident #32 uses psychotropic medications for behavior management, schizoaffective disorder, anxiety and dementia with behaviors. Furthermore, the care plan indicated that resident #32 was a wanderer, at risk for impaired thought processes and has the potential to be unable to avoid a physical confrontation with a fellow resident due to dementia. -Resident #21 was admitted on March 24, 2023 with diagnosis that included senile degeneration of the brain, Alzheimer's disease, dementia of unspecified severity with psychotic disturbance and other mixed anxiety disorder. A review of the quarterly MDS dated October 2, 2024 revealed a BIMS score of 03, indicating severe cognitive impairment. The MDS further revealed that the resident had no noted potential indicators of psychosis and that verbal behaviors were present 1-3 days per week. A review of the physician orders revealed that the resident was prescribed lorazepam (Psychotropic medication) and quetiapine fumarate (Psychotropic medication). The care plan for resident #21 revealed that the resident uses psychotropic medications, is at risk for impaired thought processes, has the potential to demonstrate verbally abusive behaviors and has demonstrated the physical behavior of slapping another resident (noted posted incident). A review of the progress notes dated December 12, 2024 at 1:52 P.M. revealed that a nurse was standing at the nurse's station when she heard yelling from the dining room. It was noted that a resident who was sitting in front of the nurse's station stated that "that lady just slapped that man across the face." It was noted that the nurse ran over to separate the residents and asked the resident if she had slapped the gentleman, to which it was noted that she replied "I did slap him but don't ask me why I can't remember." No injuries were noted in the progress notes. Review of the electronic health record revealed no evidence of prior physical resident to resident altercations. A review of the facility 5-day investigation revealed that on December 11, 2024 at 8:35 P.M. resident #21 was in the dining room in the secured behavioral unit with fellow resident #32. It was noted that resident #32 was propel

Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #2 was free from abuse from resident #1. The deficient practice could result in residents experiencing emotional and mental trauma from abuse. Findings include: -Regarding Resident #1: Resident #1 was admitted to the facility on July 24, 2024 with diagnoses of acquired absence of left leg below the knee, dementia, and aphasia. Review of a discharge Minimum Data Set (MDS) assessment dated November 13, 2024 revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 10 which indicated the resident was moderately cognitively impaired. The care plan was revised on November 11, 2024 included that the resident has potential for physical behaviors towards staff and other residents due to poor impulse control. Interventions included addressing the resident's trigger of loud noises, intervening and redirecting when inappropriate behaviors are observed and notifying the provider when the resident appears to be a danger to others. There was no evidence that this focus area was in the resident's care plan prior to November 11, 2024. A nurse's note, dated November 11, 2024, revealed a late entry note. The note indicated that at 8:50 AM a Certified Nursing Assistant (CNA) called for help and the nurse was informed that resident #1 had punched another resident in the head twice behind the right ear. The note also indicated that both residents were in their wheelchair and were then separated. A review of a hospital's health and progress notes revealed resident #1 was taken to the emergency room due to his aggression towards another resident and for a possible urinary tract infection. The note also indicated resident #2 stated he was "forced to leave" and "to put it frankly there was a bitch walking up and down the hallway that was waking me up". Regarding Resident #2: Resident #2 was admitted to the facility on January 30, 2023 with diagnoses of Major Depressive Disorder, trochanteric bursitis in the right hip, anxiety disorder, and difficulty walking. Review of the quarterly MDS assessment, dated October 27, 2024, revealed a BIMS score of 03 which indicated the resident was cognitively impaired. A care plan, last revised on October 23, 3034, revealed resident #2's risk of having impaired thought processes. Interventions included keeping the resident's routine consistent and reporting any changes related to cognitive function to the provider. A nurse's note, created on November 15, 2024 but effective on November 11, 2024, indicated a full head to toe assessment was completed after the incident; there were no injuries noted and vital signs were within normal limits. An interview was conducted with resident #1 on November 20, 2024 at 9:58 AM. Resident #1 explained that he was upset that resident #2 had hit him on his back and then he had gotten upset and hit her. He was not able to identify who resident

Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #1's care plan was updated to accurately reflect the resident's care. The deficient practice could result in residents not getting the appropriate care they need. Findings include: Resident #1 was admitted to the facility on July 24, 2024 with diagnoses of acquired absence of left leg below the knee, dementia, and aphasia. A nurses' note, dated October 18, 2024 at 5:34 AM indicated resident #1 had raised his hand toward the nurse when the nurse refused to leave his morning medications on his table. No physical contact was made. A nurses' note dated, October 30, 2024 at 6:30 PM, revealed resident #1 had punched a Certified Nursing Assistant (CNA), on the front of the upper thigh, who was attempting to redirect him out of another resident's room. The note indicated the punch resulted in a large bruise which was 6 centimeters round on the CNA's thigh. A nurse's note, dated November 11, 2024, revealed a late entry note. The note indicated that at 8:50 AM resident #1 had punched another resident in the head. The care plan was revised on November 11, 2024 included that the resident has potential for physical behaviors towards staff and other residents due to poor impulse control. Interventions included addressing the resident's trigger of loud noises, intervening and redirecting when inappropriate behaviors are observed and notifying the provider when the resident appears to be a danger to others. There was no evidence that this focus area was in the resident's care plan prior to November 11, 2024. Review of a discharge Minimum Data Set (MDS) assessment dated November 13, 2024 revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 10 which indicated the resident was moderately cognitively impaired. A care plan note, dated November 22, 2024 at 9:00 AM indicated the resident's care plan was updated to reflect the recent physical behavior. An interview was conducted with resident #1 on November 20, 2024 at 9:58 AM. Resident #1 explained that he was upset that another resident had hit him on his back and then he had gotten upset and hit her. An interview was conducted on November 20, 2024 at 12:47 PM with the Director of Nursing (DON/staff #44). Staff #44 explained that resident #1 had hit and struck another resident on the side of the head, twice. She indicated that after the incident she spoke with the resident about the facility's zero tolerance for violence. Staff #44 had also explained that prior to the resident-to-resident altercation, resident #1 had hit one of her CNAs "so hard that she couldn't walk that day". Staff #44 explained that the facility had accepted the resident knowing he had a history of physical behaviors at his previous placement because the plan was for the resident to be onsite for two weeks. After two weeks, the resident's daughter had planned to move the resident

Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #2 was free from abuse from resident #1. Findings include: -Regarding Resident #1: Resident #1 was admitted to the facility on July 24, 2024 with diagnoses of acquired absence of left leg below the knee, dementia, and aphasia. Review of a discharge Minimum Data Set (MDS) assessment dated November 13, 2024 revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 10 which indicated the resident was moderately cognitively impaired. The care plan was revised on November 11, 2024 included that the resident has potential for physical behaviors towards staff and other residents due to poor impulse control. Interventions included addressing the resident's trigger of loud noises, intervening and redirecting when inappropriate behaviors are observed and notifying the provider when the resident appears to be a danger to others. There was no evidence that this focus area was in the resident's care plan prior to November 11, 2024. A nurse's note, dated November 11, 2024, revealed a late entry note. The note indicated that at 8:50 AM a Certified Nursing Assistant (CNA) called for help and the nurse was informed that resident #1 had punched another resident in the head twice behind the right ear. The note also indicated that both residents were in their wheelchair and were then separated. A review of a hospital's health and progress notes revealed resident #1 was taken to the emergency room due to his aggression towards another resident and for a possible urinary tract infection. The note also indicated resident #2 stated he was "forced to leave" and "to put it frankly there was a bitch walking up and down the hallway that was waking me up". Regarding Resident #2: Resident #2 was admitted to the facility on January 30, 2023 with diagnoses of Major Depressive Disorder, trochanteric bursitis in the right hip, anxiety disorder, and difficulty walking. Review of the quarterly MDS assessment, dated October 27, 2024, revealed a BIMS score of 03 which indicated the resident was cognitively impaired. A care plan, last revised on October 23, 3034, revealed resident #2's risk of having impaired thought processes. Interventions included keeping the resident's routine consistent and reporting any changes related to cognitive function to the provider. A nurse's note, created on November 15, 2024 but effective on November 11, 2024, indicated a full head to toe assessment was completed after the incident; there were no injuries noted and vital signs were within normal limits. An interview was conducted with resident #1 on November 20, 2024 at 9:58 AM. Resident #1 explained that he was upset that resident #2 had hit him on his back and then he had gotten upset and hit her. He was not able to identify who resident #2 was. An interview was conducted with a Registered Nurse (RN/staff #65) on November 20, 2024 at 10:2

Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #1's care plan was updated to accurately reflect the resident's care. Findings include: Resident #1 was admitted to the facility on July 24, 2024 with diagnoses of acquired absence of left leg below the knee, dementia, and aphasia. A nurses' note, dated October 18, 2024 at 5:34 AM indicated resident #1 had raised his hand toward the nurse when the nurse refused to leave his morning medications on his table. No physical contact was made. A nurses' note dated, October 30, 2024 at 6:30 PM, revealed resident #1 had punched a Certified Nursing Assistant (CNA), on the front of the upper thigh, who was attempting to redirect him out of another resident's room. The note indicated the punch resulted in a large bruise which was 6 centimeters round on the CNA's thigh. A nurse's note, dated November 11, 2024, revealed a late entry note. The note indicated that at 8:50 AM resident #1 had punched another resident in the head. The care plan was revised on November 11, 2024 included that the resident has potential for physical behaviors towards staff and other residents due to poor impulse control. Interventions included addressing the resident's trigger of loud noises, intervening and redirecting when inappropriate behaviors are observed and notifying the provider when the resident appears to be a danger to others. There was no evidence that this focus area was in the resident's care plan prior to November 11, 2024. Review of a discharge Minimum Data Set (MDS) assessment dated November 13, 2024 revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 10 which indicated the resident was moderately cognitively impaired. A care plan note, dated November 22, 2024 at 9:00 AM indicated the resident's care plan was updated to reflect the recent physical behavior. An interview was conducted with resident #1 on November 20, 2024 at 9:58 AM. Resident #1 explained that he was upset that another resident had hit him on his back and then he had gotten upset and hit her. An interview was conducted on November 20, 2024 at 12:47 PM with the Director of Nursing (DON/staff #44). Staff #44 explained that resident #1 had hit and struck another resident on the side of the head, twice. She indicated that after the incident she spoke with the resident about the facility's zero tolerance for violence. Staff #44 had also explained that prior to the resident-to-resident altercation, resident #1 had hit one of her CNAs "so hard that she couldn't walk that day". Staff #44 explained that the facility had accepted the resident knowing he had a history of physical behaviors at his previous placement because the plan was for the resident to be onsite for two weeks. After two weeks, the resident's daughter had planned to move the resident closer to her. However, the transfer did not happen as planned. Staff #44 indicated that care

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#9) were free from physical abuse resulting in injury by other residents (resident #23). Findings include: -Resident #9 was admitted to the facility on May 4, 2024, with diagnosis that include Dementia, Psychotic disturbances, anxiety, and Alzheimer's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated August 14, 2024, revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had mild cognitive impairment. A behavioral care plan revised April 7, 2023 revealed the resident is at risk for impaired thought processes related to vascular dementia, with a noted intervention of keeping the resident's routine consistent in order to decrease confusion when able. However, review of the care plan revealed no care plan measures addressing verbal or physical aggression showed by the resident. -Resident #23 was admitted to the facility on May 1, 2010 with diagnoses that include Paranoid personality disorder, and other schizoaffective disorders, and a history of lobotomy. Review of the Quarterly Minimum Data Set (MDS) assessment dated July 27, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 08 which indicated the resident had moderate cognitive impairment. A behavioral care-plan initiated May 1, 2012, revealed the resident is at risk for mood swings and behaviors related to a history of a lobotomy as evidenced by verbally abusive behaviors, with noted interventions of when the resident becomes agitated, intervene before agitation escalates, and guide the resident away from sources of distress. Review of information received from the SA complaint tracking system revealed that on October 1, 2024, a complaint was received that revealed on October 1, 2024 at 6:25 p.m. on the secured memory and behavioral unit there was a resident to resident altercation after the evening meal in the dining room between resident #9 and resident #23. It further revealed that resident #23 grabbed resident #9 by her right arm when resident #9 was attempting to pass resident #23 to leave the dining room. Resident #9 then turned around and smacked resident #23 in her face with an open left hand. It continues that staff verbally intervened while approaching the residents asking them to separate. Resident #9 then pushed resident #23 causing resident #23 to lose her balance falling backwards and hitting the back of her head on the floor. Resident #23 was later sent to the ER for diagnostics. A review of progress notes for resident #23 revealed no documentation related to the above incident. A review of progress notes for resident #9 dated October 2, 2024 at 3:01 a.m. revealed that resident #9 returned from the ER after having a CT of the head and cervical spine, and that the resident's daughter was present with the resident at the hospital. An interview was conduc