Every finding on record at Ashley Medical Center Nursing Home

Based on observation and staff interview, the facility failed to provide access to a personal phone for 1 of 1 sampled resident (Resident #13). Failure to place a resident's personal phone within reach limits the residents' ability to communicate with friends and family and may result in loneliness.Findings include: Review of the facility admission packet occurred on 07/02/25. This packet contained A Guide to Your Rights as a Resident of a Nursing Facility in North Dakota. Page 16 of this document stated, You have the right to safe, clean and comfortable surroundings, allowing you to keep your personal belongings to the extent space permits. The facility must provide you with reasonable accommodation for your personal needs and preferences.Observations of Resident #13 occurred on 07/01/25 at 10:25 a.m., 11:50 a.m., 1:25 p.m., and 07/02/25 at 11:00 a.m. The resident was in her recliner, wheelchair, or bed and the personal phone on the windowsill behind the resident's recliner. A sign on the wall stated, Please put phone on table daily. Replace on jack [charger] PM Bedtime. Thank you. On 07/02/25 at 11:00 a.m., Resident #13 stated, I would like the phone where I can reach it.During an interview on 07/02/25 at 1:05 p.m. two administrative staff members (#1 and #2) confirmed the resident has the right to access her phone.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents (Resident #11 and #13). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan, and the care provided to the residents. Findings include:SECTION E: BehaviorThe Long-Term Care Facility RAI User's Manual, revised October 2024, pages E-1 to E-2 stated, . E0100: Potential Indicators of Psychosis . Hallucinations . Delusions . Review the resident's medical record for the 7-day look-back period. Coding Instructions . Code based on behaviors observed and/or thoughts expressed in the last 7 days rather than the presence of a medical diagnosis.Review of the medical record for Resident #13 occurred on all days of survey. The review of the quarterly MDS, dated [DATE], showed staff coded delusions. Review of the medical record for the seven-day look-back period failed to identify Resident #13 experienced delusions.SECTION N: MedicationsThe Long-Term Care Facility RAI User's Manual, revised October 2024, pages N-1 to N-4 stated, . N0300: Injections: . Coding Instructions . Record the number of days during the 7-day look-back period . that the resident received any type of medication, antigen, vaccine, etc., by injection.- Review of Resident #11's medical record occurred on all days of survey. A significant change MDS, dated [DATE], showed facility staff coded section N0300 indicating Resident #11 received an injection one time during the seven-day look back period. The medical record failed to identify the resident received an injection. During an interview on 07/02/25 at 10:44 a.m., an administrative staff member (#2) confirmed the MDSs were coded incorrectly for Resident #11 and Resident #13.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the resident's current status for 1 of 2 sampled residents (Resident #3) reviewed for anticoagulation (blood thinner) therapy. Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.Findings include:Review of the facility policy titled [NAME] Medical Center Baseline Care Plan and Care Plan Policy occurred on 07/02/25. This policy, dated January 2019, stated, . The development, implementation, and maintenance of a resident's comprehensive plan of care is an interdisciplinary process. Care Plans are to be reviewed within 7 days of MDS [Minimum Data Set] completion every 3 months unless otherwise specified by goal time frames.Review of Resident #3's medical record occurred on all days of survey. A physician's order included Coumadin (an anticoagulant) daily. The admission MDS dated [DATE], identified an anticoagulant use.Resident #3's current care plan lacked problem, goals, or interventions for anticoagulation therapy.During an interview on 07/02/25 at 11:49 a.m., an administrative nurse (#1) confirmed staff failed to revise Resident #3's care plan.

Based on observation, record review, review of the facility policies, and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 3 sampled residents (Resident #12) observed during gait belt transfer and 1 of 4 sampled residents (Resident #19) observed during a mechanical stand lift transfer. Failure to use a gait belt or ensure proper use of a stand lift during transfers placed residents at risk for injury. Findings include: Review of the policy titled Gait Belt Policy occurred on 06/04/24. This undated policy stated, . The belt should be placed near the waist unless previous diagnosis exist. Make sure the belt is snug on the user. Additional tightenings [sic] may be appropriate when the patient stands up. Hold onto the belt with the hand or hands under the belt . Observations on 06/03/24 at 5:00 p.m. showed a certified nurse aide (CNA) (#2) assisted Resident #12 with a transfer from the wheelchair to the bed. The CNA (#2) placed a gait belt loosely around the resident's chest and proceeded to transfer the resident. During the transfer the resident had difficulty standing and turning. The gait belt slid up under the resident's arms and provided no support to the resident during the transfer. The CNA (#2) failed to place the gait belt at the resident's waist and failed to tighten the gait belt prior to transfer or when standing the resident. Observation on 06/04/24 at 1:25 p.m. showed a CNA (#3) assisted Resident #12 from the wheelchair to the bed. The CNA placed a gait belt loosely around the resident's waist and proceeded to transfer the resident. The resident had difficulty standing and turning. The resident's chair alarm sounded and a nurse (#4) entered the room and assisted with the transfer. During the transfer, the gait belt slid up under resident's arms and provided no support to the resident. The CNA (#3) failed to tighten the gait belt prior to transfer and the CNA (#3) and nurse (#4) failed to tighten and readjust the gait belt during the transfer. During an interview on 06/05/24 at 2:41 p.m., and administrative nurse (#5) confirmed staff are expected to place the gait belt around the resident's waist, make it snug, and readjust as needed. Review of Resident #19's care plan identified, . Assist [Resident #19] with transfers for safety, provide varied level of assist as needed usually Medi-lift [mechanical sit to stand lift] for transfers, at times he does not comprehend to safely participate in transfers with Medi-lift, use Hoyer Lift [full body mechanical lift]. Observations on 06/03/24 at 3:36 p.m., showed a CNA (#6) assisted Resident #19 to stand with a sit to stand lift from the recliner. After the CNA had the resident in a standing position, the CNA pulled down the resident's pants and removed the brief. The CNA left the resident unattended and obtained supplies. The resident let go of the handles on the lift and began to fidget and move around which caused the lift to move as the brakes were not locked in place. The CNA reminded the resident multiple times to hold onto the lift handles but the resident did not until the CNA completed all cares. The CNA then put the resident's hands on the lift handles, moved the stand lift over to the wheelchair, and lowered the resident into the wheelchair. The CNA failed to lock the wheels of the sit to stand lift and failed to ensure Resident #19 held onto the lift handles. 46477

Based on observation, review of resident record, review of facility policy, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 1 sampled resident (Resident #26) observed during insulin administration. Failure to obtain a new medication label from the pharmacy for an insulin pen or affix a label noting change in the directions, may result in residents receiving an incorrect dose of insulin. Findings include: Review of the facility policy Medication Administration and Safe Handling Policy/Procedure occurred on 06/05/24. This undated policy stated, . The correct label should be on the medication from [name of pharmacy]. If the dose changes, [name of pharmacy] will be contacted for a new label, and the nurse will put a Change of Directions sticker on the medication to refer to the order until a new label comes. Observation on 06/03/24 at 11:48 a.m. showed a nurse (#1) removed a Novolog insulin pen from the top drawer of the medication cart to prepare for administration. The current label included the resident's name and directions for administration. The label instructions stated to administer 8 units in the morning, 14 units at lunch and 16 units in the evening. Review of Resident #26's current physician orders identified to administer 15 units at 8:00 a.m., 15 units at 11:30 a.m. and 16 units at 5:30 p.m. The nurse (#1) confirmed the label affixed to the insulin pen as incorrect and a new label should have been ordered.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed enhanced barrier precautions for 1 of 2 sampled resident (Resident #20) observed during cares. Failure to follow infection control practices related to enhanced barrier precautions may result in the spread of infections within the facility. Findings include: Review of the facility policy titled Enhanced Barrier precautions occurred on 06/05/24. This policy, dated 04/29/24, stated . when implementing Enhanced Barrier Precautions it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use . disinfect lifts between each resident and adhere to recommended infection control prevention practices . Observation on 06/04/24 at 2:00 p.m. showed two certified nurse aides (CNAs) (#6 and #8) entered Resident #20's room. Signage identified enhanced barrier precautions. The CNAs donned gloves and gowns and assisted Resident #20 to bed using a full body lift. The CNAs removed the resident's soiled brief and provided incontinence cares. Without removing the soiled gloves and donning clean gloves, the CNAs, applied a clean brief, adjusted the residents clothing, bedding, catheter, and lift. The CNAs (#6 and #8) then removed their gloves, and exited the room with the lift. The CNAs failed to disinfect the lift after use and perform hand hygiene after leaving the room. During an interview on 06/04/24 3:27 p.m., an administrative nurse (#5) stated she expects staff to sanitize all mechanical lifts between residents.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 2 supplemental residents (Resident #9 and #10) observed during personal cares. Failure to follow infection control practices regarding hand hygiene has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Policy for Hand Hygiene occurred on 05/10/23. This undated policy stated, . Hand hygiene is required in the following situations. Before and after assisting a resident with personal cares . After removing gloves . - Observation on 05/08/23 at 4:15 p.m. showed two certified nurse aides (CNAs) (#2 and #3) donned gloves and checked Resident #10's brief. The CNA (#3) cleansed the rectal area of stool using a wet wipe and removed her gloves. Without performing hand hygiene, the CNA (#3) donned clean gloves and assisted in applying a clean brief, adjusted the resident's clothing, raised the head of bed, provided the resident a drink of water, gave the resident her rosary, moved the bedside table, removed her gloves, and exited the room without performing hand hygiene. The CNA (#3) failed to perform hand hygiene between glove changes and before exiting the room. - Observation on 05/08/23 at 4:52 p.m. showed two CNAs (#1 and #2) changing Resident #9 in bed. Both CNAs performed hand hygiene, donned gloves, and repositioned Resident #9 to remove the incontinent product. One CNA (#1) provided perineal cares and applied a new incontinent product while the other CNA (#2) positioned the resident. Both CNAs removed their soiled gloves following perineal care. One CNA (#1) failed to perform hand hygiene upon exiting the resident's room. During an interview on 05/10/23 at 4:40 p.m., two administrative nurses (#4 and #5) confirmed they expected staff to perform hand hygiene between glove change and before exiting the resident's room. 47896

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the medical record for 5 of 12 sampled residents (Resident #9, #10, #11, #13 and #18) accurately reflected the resident's code level directive. Failure to ensure the resident or the resident's legal representative signed the code level directive has the potential to inaccurately reflect the resident's wishes for life-sustaining services. Findings include: Review of the facility policy titled Provider Statement/Code Level Directive occurred on 12/14/21. This policy, revised 07/14/16, stated, . The provider statement identifies if the resident is capable, or incapable of making decisions independently. If the admitting provider is unable to determine this at the time of admission, it will be reviewed within one month. - Review of Resident #9's medical record occurred on all days of survey. The Provider Statement for Code Level Directive dated, 12/09/20, identified the resident as incapable of making medical decisions, and the code level directive stated, NO CODE. The code level directive lacked a signature from the resident's representative. - Review of Resident #10's medical record occurred all days of survey. The Provider Statement for Code Level Directive, dated 04/19/21, identified the resident as capable of making medical decisions, and the code level status stated, NO CODE. The code level directive lacked the resident's signature. - Review of Resident #11's medical record occurred on all days of survey. The Provider Statement for Code Level Directive, dated 06/15/20, identified the provider was unable to determine if the resident could make medical decisions and to review in one month, and the code level status stated, NO CODE. The code level directive lacked a signature from the resident's representative, and the medical record failed to show documentation the provider reviewed the resident's ability to make medical decisions. During an interview on 12/14/21 at 2:10 p.m., an administrative nurse (#1) confirmed she was unable to find the provider's review of Resident #11's decision making ability and confirmed staff should have obtained a resident representative's signature. - Review of Resident #13's medical record occurred all days of survey. The Provider Statement for Code Level Directive, dated 07/23/21, identified the resident as capable of making medical decisions, and the code level status stated, CODE. The code level directive lacked the resident's signature. - Review of Resident #18's medical record occurred all days of survey. The Provider Statement for Code Level Directive, dated 05/31/19, identified the provider was unable to determine if the resident could make medical decisions, and the code level status stated, CODE. The code level directive lacked a signature from the resident or the resident's representative, and the medical record failed to show documentation the provider reviewed the resident's ability to make medical decisions. During an interview on 12/14/21 at 4:44 p.m., an administrative nurse (#1) confirmed staff should obtain the resident's or their legal representative's signature for all Code Level Directive forms.

Based on observation, review of facility policy, resident interviews, review of resident council meeting minutes, and meal test tray, the facility failed to serve foods at palatable temperatures for 1 of 1 meal observed (noon meal 12/14/21). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Food Holding Temperatures occurred on 12/14/21. This form, dated 1998-1999, stated, . Serve/Hold: Hot Foods - above 140 degrees Fahrenheit (F) . check temperature of item every 30 minutes . Cold Foods - at 41 degrees F or below . Review of the 09/02/21 Resident Council meeting minutes occurred on 12/13/21. The meeting minutes stated, Food is not always brought up early enough at noon and not warm enough for some residents. - During an interview on 12/13/21 at 2:20 p.m., Resident A stated, Food is often served cold or lukewarm. - During an interview on 12/13/21 at 3:02 p.m., Resident B stated, The food is terrible, it is too cold. - During an interview on 12/13/21 at 3:16 p.m., Resident C stated, The soup isn't warm enough. On 12/14/21, at 12:16 p.m., the survey team received a test tray. Food temperatures taken showed roast turkey at 123.5 degrees F, gravy at 123 degrees F, mashed potatoes at 132 degrees F, stuffing at 129.7 degrees F, corn at 128 degrees F, cranberry sauce at 64.2 degrees F, chocolate cream pie at 63.5 degrees F, and juice at 58.7 degrees F. During an interview on 12/14/21 at 4:35 p.m., a dietary staff member (#9) stated he expects staff to serve hot foods at 140 degrees F or higher and confirmed he failed to complete audits or follow-up on cold food temperatures since the September Resident Council meeting.

Based on review of facility policy and staff interview, the facility failed to include all elements required for 1 of 1 facility policy reviewed for resident and staff refusal of [CONDITION(S)]-CoV-2 (COVID-19) testing. Failure to have a process in place for testing refusal may lead to a lack of further required interventions. Findings include: Review of the facility policy titled Testing Residents and Healthcare Personnel for [CONDITION(S)]-Cov-2 occurred on 12/15/21. This undated policy lacked a procedure for staff and residents who refused COVID-19 testing. During an interview on 12/15/21 at 9:10 a.m., an administrative staff member (#1) confirmed the facility failed to have a procedure established for staff and/or residents who refused COVID-19 testing.

Based on observation, review of facility policy, and staff interview, the facility failed to provide care for 2 of 7 sampled residents (Residents #10 and #15) observed during assistance with activities of daily living (ADL), in a manner and environment that maintained, enhanced, and respected each resident's dignity and individuality. Failure to provide cares in a respectful manner does not preserve the residents' personal dignity or enhance their quality of life. Findings include: Review of the policy titled, Personal & Privacy Rights occurred on 12/15/21. This undated policy, stated, . The facility staff must treat you courteously, fairly, and with dignity. Observations showed the following: * 12/13/21 at 1:18 p.m., a certified nurse aide (CNA) (#4) entered Resident #15's room, called the resident's name twice, crouched down, looked him in the face, and said, Hello, are you in there? A second CNA (#3) entered the room to assist with a transfer and a brief change. During the brief change, the CNA (#3) pulled up the front of the brief to secure the adhesive tabs and stated, The gems are in, lock it up! * 12/13/21 at 3:30 p.m., a CNA (#4) assisted Resident #10 with a transfer. During the transfer, and in front of Resiudent #10, the CNA (#4) stated, I don't know which one of you [surveyors] has [a different resident] but he is very needy he is by the book that way. During an interview on 12/15/21 at 8:35 a.m., an administrative nurse (#5) agreed the CNAs failed to speak to the residents courteously and with dignity, she she expects staff to refrain from speaking about other residents while providing cares.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's legal representative signed a vaccine consent for 1 of 6 sampled residents (#10), identified as incapable of making medical decisions. Failure to ensure the resident's legal representative gives consent has the potential for the resident to receive unwanted treatment. Findings include: Review of the facility policy titled Provider Statement/Code Level Directive occurred on 12/14/21. This policy, revised 07/14/16, stated, . The provider statement identifies if the resident is capable, or incapable of making decisions independently. Review of the facility policy titled Advanced Directive Policy occurred on 12/14/21. This undated policy stated, . In the event that a patient or resident . is unable to make or communicate responsible decisions about his/her health care, the following persons, are authorized to make health care decisions for the individual . a court appointed guardian who is authorized to make healthcare decisions or a court appointed custodian of the patient . Review of Resident #10's medical record occurred on all days of survey. The Provider Statement dated, 02/04/20, identified the resident as incapable of making medical decisions. Review of the vaccine consent form showed staff obtained the resident's signature instead of the required legal representative's signature, failed to date the consent form, and administered the vaccine on 01/06/21. During an interview on 12/14/21 at 4:44 p.m., an administrative nurse (#1) confirmed that staff use the Provider Statement form to identify who should sign consent forms and staff should have obtained Resident #10's legal representative's signature for consent of the vaccination.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 1 of 2 sampled residents (Resident #18) reviewed for Preadmission Screening and Resident Review (PASRR). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs, and has the potential to affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2019, pages A-21-23 stated, A1500: Preadmission Screening and Resident Review (PASRR) . Review the PASRR report provided by the State if Level II screening was required . Coding Instructions . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Review of Resident #18's medical record occurred all days of survey. A PASRR Level II screening, dated 06/05/19, stated, . is within compliance with inclusion criteria for PASRR population because of her primary mental health history of [CONDITION(S)]. An annual MDS dated [DATE] identified section A1500 coded NO indicating Resident #18 did not have a PASRR Level II screening which determined a serious mental illness. During an interview on 12/14/21 at 2:30 p.m., an administrative nurse (#8) agreed staff failed to correctly code section A1500 of the MDS.

Based on record review and staff interview, the facility failed to ensure an accurate Pre-Admission Screening and Resident Review (PASARR) for 1 of 2 sampled residents (Resident #13), who triggered for PASARR services. Failure to complete a change in status assessment with a new serious mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of Resident #13's medical record occurred on all days of survey. On 07/28/21, a physician newly identified a [CONDITION(S)], which required the completion of a PASARR. Facility staff failed to complete a change in status assessment with a new diagnosis. During an interview on 12/14/21 at 5:50 p.m., a social services staff member (#6) and a social services director (#5) confirmed staff should have completed a new PASARR with the [CONDITION(S)] diagnosis.

Based on observation, record review, and staff interview, the facility failed to provide care and services to ensure proper skin care for 1 of 1 sampled resident (Resident #15) with a skin infection. Failure to initiate skin assessments for residents with an identified skin condition has the potential to cause adverse health effects and continued physical discomfort. Findings include: Review of the facility guideline titled Wound/Ulcer Assessment occurred on 12/15/21. This guideline, dated 06/29/18, stated, . enter your treatment order and do a wound/ulcer assessment x [times] 3 days and then weekly until healed. Review of Resident #15's medical record occurred on all days of survey and identified the resident has a tinea rash (fungal infection of the skin). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Vaseline to groin prn [as needed] for redness or irritation . and order, dated 12/09/21, stated, . [MEDICATION(S)] [anti-fungal medication] 0 UNIT/GM [gram] Apply to groin topically two times a day for [MEDICATION(S)]/rash for 10 Days apply to bilateral thigh/scrotum rash, also retract foreskin and apply around entire head of penis . Observation on 12/13/21 at 1:18 p.m. showed two certified nurse aids (CNAs) (#3 and #4) performed perineal cares for Resident #15. The resident's scrotum, penis, and bilateral groin appeared red, moist, macerated, and scaly in appearance; and extended outward to both thighs/inner legs. The resident groaned and tightened his legs together when the CNA (#3) cleansed area with moistened wipes and applied Vaseline to both groin areas. Review of Resident #15's progress notes showed the following: * 10/27/21 at 3:37 a.m., Note was sent to clinic regarding groin that is red and sore looking - would like to use Vaseline prn for redness . * 12/09/21 at 4:00 p.m., Provider Visit . Staff has noticed a rash on the bilateral upper groin and scrotum. They have been using vasoline [sic]. It was noted that there was some blood from the penis as well. Patient with signiifcant [sic] dementia . Tinea rash to bilateral upper groin and both lateral sides of scrotum. Foreskin retracted and tip of penis with some excoriation wo [without] active bleeding. During an interview on 12/14/21 at 4:44 p.m., an administrative nurse (#1) stated the nursing staff failed to follow the policy to complete the wound assessment for three days and then weekly until healed.

Based on observation, review of facility document, and staff interview, the facility failed to discard expired medications in 2 of 2 medication storage areas (medication cart and medication room). Failure to discard expired medication increases the risk of residents receiving outdated medications with reduced efficacy. Findings include: Review of the facility document titled Medications with Shortened Expiration Dating Once Opened occurred on 12/14/21. This undated document, identified Novolog ([MEDICATION(S)]) insulin vial should be discarded 28 days after opened. Observation of the medication cart occurred on 12/14/21 at 2:43 p.m. with a licensed nurse (#2) and showed a bottle of [MEDICATION(S)] ([MEDICATION(S)]) expired on 11/05/21. Observation of the medication room occurred on 12/14/21 at 3:15 p.m. with a licensed nurse (#2) and showed an undated open vial of [MEDICATION(S)] insulin located in the medication refrigerator. The licensed nurse (#2) confirmed the expired bottle of [MEDICATION(S)] and undated vial of insulin should be discarded. During an interview on 12/14/21 at 3:56 p.m., an administrative nurse (#1) confirmed staff should discard the undated insulin vial and expired [MEDICATION(S)] medication.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received foods served in the appropriate consistency for 1 of 6 sampled residents (Resident #5) with an altered diet. Failure to serve diets consistent with the physician's order may result in coughing, choking, and/or the development of aspiration pneumonia. Findings include: Review of the facility policy titled Consistency-Altered Diets occurred on 12/14/21. This policy, dated 2011, stated, . Level 1 Dysphagia (difficulty swallowing) Pureed: Pureed homogenous, cohesive, pudding-like food that is in the form of an easy to swallow bolus; Moist, pudding-like consistency without particles . Review of Resident #5's medical record occurred on all days of survey. A provider's order, dated 11/22/21, identified on a pureed diet. Observations showed staff served Resident #5 the following items: * 12/14/21 at 8:22 a.m.: round banana slices and unaltered scrambled eggs; resident had 2 episodes of coughing during breakfast. * 12/14/21 at 12:12 p.m.: chocolate cream pie with sprinkles and an intact crust During an interview on 12/15/21 on 8:12 a.m., a dietary manager (#9) agreed the observed foods served to Resident #5 did not meet the ordered diet texture.

Based on record review, review of the facility's policy, and staff interview, the facility failed to ensure a regimen free of unnecessary medications for 1 of 2 sampled residents (Resident #8) and 1 resident discharged from the facility (Resident #10) who received an antibiotic. Failure to discontinue the antibiotic or include documentation regarding the clinical justification for continued use of the antibiotic placed Resident #8 and #10 at risk of experiencing adverse effects related to it's continued use. Review of the facility policy titled Urinary Catheters and Indications for Urinalyses (UA) and Urine Cultures (UC) occurred on 10/20/20. This policy, dated 09/15/16, stated, . Urinalyses and Urine Cultures: The RN should notify the physician and obtain a urinalysis, and, if indicated, a urine culture in the following situations . A patient has symptoms of UTI (urinary tract infection) and the following conditions are present . new flank or suprapubic pain or tenderness . change in character of urine . worsening of mental or functional status . patient has a fever of unknown origin . - Review of Resident #10's medical record occurred on all days of survey and identified a history of UTIs. The infection portion of the care plan, revised 01/09/20, identified the following; antibiotic as ordered, observe culture report once received, follow up UA on completion of antibiotic . and monitor the resident's symptoms of UTI. The progress notes identified the following: * 04/08/20, . Patient seen in NH (nursing home) rounds for readmission visit. * 04/14/20, New orders received to straight cath. for UA. New orders received [MEDICATION NAME](an antibiotic) 250 mg. (milligrams) PO (orally) BID (twice daily) for 10 days. * 04/17/20, . To continue [MEDICATION NAME] final urine culture received. The urine culture microbiology report, dated 04/20/20, identified the resident had a yeast infection. The facility failed to discontinue [MEDICATION NAME] being informed of the yeast infection. The record further identified the resident was resistant [MEDICATION NAME] her previous culture/susceptibility report. During an interview on the afternoon of 10/20/20, an administrative nurse (#3) provided a copy of Resident #10's lab reports. The administrative nurse (#3) reported Resident #10 completed her course [MEDICATION NAME] 04/24/20 and acknowledged the medication hadn't been stopped and probably should have been. - Review of Resident #8's medical record occurred on all days of survey and identified a history of UTIs. The care needs portion of the care plan identified the following; . independent with toileting as she desires. The progress notes identified the following: * 06/25/20, . Resident states that she still has pain and discomfort on her left lower back area near her kidney . * 06/26/20, . Resident was up earlier and stated that she had pain again on left lower back area . Resident state that she does not having (sic) any burning with urination or urgency. She also stated that she does not feel that her urine has a strong odor . Bactrim DS (antibiotic) Tablet 800-160 mg ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth two times a day for UTI for 7 days . UA . * 06/30/20, . Patient being seen today for follow up for UTI. Patient notes pain is better with UTI treatment. Does have urination frequency, but improving . The UA report identified the sample was contaminated. The facility failed to call the provider for orders to repeat the UA and/or discontinue the antibiotic. During an interview on the afternoon of 10/20/20, an administrative nurse (#3) provided a copy of Resident #8's lab reports. The administrative nurse (#3) reported Resident #8 completed her course of Bactrim DS on 07/03/20 and acknowledged the 06/26/20 sample was contaminated, the nurse should have called the provider, and the provider should have called for a cath.

Based on record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17), the facility failed to ensure resubmission of a required Minimum Data Set (MDS) assessment for 1 of 1 supplemental resident (Resident #1) whose MDS was rejected for submission. Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual, page 5-5 stated, . Fatal Record Errors result in rejection of individual records by the QIES (Quality Improvement Evaluation System) ASAP (Assessment Submission and Processing) system. The provider is informed of Fatal Record Errors on the Final Validation Report. Rejected records must be corrected and resubmitted. Review of Resident #1's MDSs occurred on 03/03/20. The facility completed a quarterly MDS, dated [DATE], and QIES ASAP informed the facility of a fatal error for this MDS on the Final Validation Report. Review of the Center for Medicare and Medicaid Services (CMS) MDS reports for Resident #1 identified an annual MDS, dated [DATE], as the last accepted MDS by QIES ASAP. During an interview on 03/04/20 at 10:06 a.m., an administrative nurse (#1) confirmed the facility had received a fatal error report on the validation report for Resident #1 and had not resubmitted the CMS quarterly MDS.

Based on record review and staff interview, the facility failed to provide a bed-hold notice upon transfer to the hospital for 1 of 3 sampled residents (Resident #13). Failure to provide the facility's bed-hold policy does not allow residents or their legal representatives to make informed choices regarding their readmission rights. Findings include: Review of Resident #13's medical record occurred on all days of survey and identified the facility transferred the resident to the hospital on [DATE]. The medical record lacked evidence the facility staff provided Resident #13 and/or their legal representative written notice of the bed-hold policy upon transfer to the hospital. During an interview on the morning of 02/12/19, a administrative nurse (#1) confirmed the facility failed to provide the bed-hold notices.

PAIN 1. Based on record review, review of facility policy, staff interview, and information received from the complainant, the facility failed to provide the necessary care and services to maintain overall well-being for 1 of 1 sampled resident (Resident #1) who sustained a bruise of unknown origin with swelling to the area, complained of pain, and thirteen days later diagnosed with [REDACTED]. Findings include: Review of Resident #1's medical record occurred on 06/20/17. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set, dated dated [DATE], identified rarely/never for ability to understand or be understood by others, unclear speech, severely impaired vision, severely impaired for daily decisions, extensive assist with bed mobility, transfer, dressing, eating, and personal hygiene, and daily pain assessed from resident's expression. Review of the progress notes identified the following: * 12/28/16 at 8:27 a.m. - [MEDICATION NAME] 220 milligram (mg) as needed (PRN) crushed and put in pudding for arm pain (First time arm pain identified) * 12/28/16 10:28 a.m. - Provider Visit . I saw this resident, (Resident Name) . had no falls or hospitalization s in the past 60 days. is non verbal, staff deny any changes or concerns with patient. Review of Systems: Negative . Resident and nurse had no further questions or concerns. * 12/28/16 2:16 p.m. - (Family) phoned . with concern of resident's condition. Informed son did grimace with pain this am (morning) when sleeve to shirt applied to right arm [MEDICATION NAME] at breakfast with relief. Also unformed (sic) son that resident seen today by FNP (family nurse practitioner) for 60 day check-up. (Provider did not address this pain) * 12/28/16 at 5:59 p.m. - [MEDICATION NAME] 220 mg for right shoulder pain. Noted as effective at 6:31 p.m. (No documentation on how the shoulder pain was identified or the pain level.) * 12/29/16 at 8:29 a.m. - [MEDICATION NAME] 220 mg for arm pain. Noted as effective at 9:30 a.m. (No documentation on how the shoulder pain was identified or the pain level.) * 12/29/16 at 11:09 a.m. - Communication with FNP regarding resident's complaint of pain and an order received [MEDICATION NAME] mg daily in the am for pain control * 12/29/16 at 11:58 p.m. - Residents right wrist noted to be swollen with light tannish bruising visible. [MEDICATION NAME] at HS (hour of sleep) with relief. (No documentation regarding the investigation of the swelling/bruising or communication to the provider) * 01/03/17 at 2:58 a.m. - Weekly Progress Note Received [MEDICATION NAME] (times) 4 for pain to right wrist with some relief. * 01/07/17 1:00 p.m. - Resident weak today and transferred with medi-lift and assist of 2. * 01/11/17 3:35 p.m. - . FNP here to see resident regarding swelling and pain to Rt. (right) lower forearm/wrist area over a period of time. Noted to have more pain with touch today per CNA (certified nursing assistant) staff. * 01/11/17 5:25 p.m. - FNP here to see resident again, results from Rt. wrist x-ray received at this time. Noted to have Rt. wrist fracture at this time. Rt. wrist splint in place for 6 weeks. * 01/11/17 6:19 p.m. - Provider note . Staff called reporting swollen right wrist . Swollen for about 2 weeks. Resident unable to say what happened. Has advanced dementia. Right wrist tender to palpation. C/o (complains of) pain with rotation of wrist. Appears slightly swollen. Fx (fracture) right wrist. * 01/17/17 at 3:00 p.m. - (Family) here and inquired abt (about) resident's condition. Informed resident seemed to have pain to right wrist for abt 2 weeks and FNP saw her and ordered x-ray to right wrist and showed fx to wrist. During an interview on the afternoon of 06/20/17, an administrative nurse (#1) confirmed staff failed to complete an investigation of Resident #1's initial and continued pain, bruising, and swelling, before the [DIAGNOSES REDACTED]. Failure to investigate Resident #1's pain and bruise/injury of unknown origin in a timely manner resulted in the resident's continued pain during the thirteen days before the x-ray and [DIAGNOSES REDACTED]. BEHAVIORS 2. Based on record review, review of facility policy, and information received from the complainant, the facility failed to provide the necessary care and services to maintain overall well-being for 1 of 2 closed records (Resident #6) reviewed with a [DIAGNOSES REDACTED]. Failure to monitor behaviors, provide non-pharmacological interventions, and consider the administration of a physician prescribed antianxiety medication ([MEDICATION NAME]), may have resulted in Resident #6's increased behaviors and resulted in an increase of [MEDICATION NAME], an antipsychotic medication. Findings include: Review of the facility policy titled [MEDICAL CONDITION] Medication Monitoring System occurred on 06/20/17. This policy, dated November 2013, stated, . The resident's mood/behaviors will be documented daily by CNA (certified nursing assistant) on CNA Flowsheet. The nurse will also document any changes in mood/behavior in nurses notes or Weekly Progress Notes. Review of Resident #6's medical record occurred on June 20, 2017 and identified an admission date of [DATE]. [DIAGNOSES REDACTED]. Medications on admission included [MEDICATION NAME] 0.25 milligrams (mg) twice a day (increased to 0.5 mg twice a day on 03/24/17), and [MEDICATION NAME] 0.5 mg every 6 hours as needed (PRN). Resident #6's care plan stated, (name) has history of delusions, anxiety, upsetting dreams. 5-22-17 May have [MEDICATION NAME] prn for anxiety . Interventions: [MEDICATION NAME] prn for anxiety, agitation, restlessness . Even though the provider ordered [MEDICATION NAME] PRN on the resident's admission to the facility, the facility failed to included the antianxiety medication on her care plan until 05/22/17. Review of Resident #6's progress notes identified the following: * 03/18/17 (Saturday) at 12:08 a.m. - Resident is waking up very confused. Resident said that people were stealing money and jewelry from the cart. She was wondering if her kids and her were safe. Resident was redirected and assured that she was safe. Will continue to monitor. * 03/21/17 (Tuesday) at 12:28 p.m. - Faxed Dr. (name) with concerns regarding resident's hallucinations and delusions after discussing cares with staff. Reported that resident had rough weekend and was frequently crying stating that her spouse was 'throwing her babies out the window' or 'cheating with hooker.' Resident had these hallucinations in hospital as well. Awaiting correspondence back from Dr. (name). A note to the provider, faxed 03/24/17 (Friday) at 3:45 p.m., stated, This resident was just seen as a new patient of yours. She has been continuing to have hallucinations/delusions. Was reported by staff to LSW (licensed social worker) that over the weekend resident became very upset, crying and accusing spouse of being with another woman and stating that he was with 'hookers' and 'throwing my babies out the window.' She also stated she was walking down the hall (resident unable to walk as she has undergone amputation) and a man was following her and exposed himself to her. Her current [MEDICAL CONDITION] medications are: . [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg BID (twice a day) (and) PRN [MEDICATION NAME] 0.5 mg every 6 hours as needed. The provider responded on 03/24/17 and stated, increase [MEDICATION NAME] to 0.5 mg BID. The facility failed to locate and provide the CNA flowsheets for the weekend of March 17-19, 2017, additional nurses' notes which showed Resident #6's increased behaviors, and the non-pharmacological interventions attempted to alleviate the behaviors. Review of Resident #6's March 2017 Medication Administration Record [REDACTED]. The facility failed to administer the medication even though the progress notes and the faxed note to the provider identified increased behaviors. Facility staff failed to document Resident #6's behaviors and identify interventions provided/attempted to alleviate the behaviors, provide non-pharmacological interventions, and consider the administration of [MEDICATION NAME]. These failures resulted to the increase of [MEDICATION NAME], an antipsychotic medication.

Based on observation, record review, review of facility policy and procedure, review of professional literature, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #1) received the care and services necessary to attain the highest degree of safety possible while being fed in his room. Failure to ensure a resident with a known risk of aspiration was alert and positioned properly prior to administering medications and/or providing food/liquid resulted in the resident aspirating. Findings include: The facility policy titled "Nursing Swallow Screen," revised January 2012, stated, "Prerequisite to proceed with Swallow Screen: Able to have head of bed at 90 degrees, Patient is awake (and) alert . . . If any of the above conditions are not met, patient NPO (nothing per mouth) - refer to Speech Language Pathologist (SLP). . . . Poor swallow: No attempt to swallow . . . Delayed swallow, Coughing or choking, Drooling, Wet or gurgly voice . . . If ANY item marked "Yes," patient NPO - immediate referral to SLP. Nancy B. Swigert, "The Source for Dysphagia: Third Edition", LinguiSystems, Inc, 2007, pages 15, 47, 125, 128 and the educational handouts identified, ". . . Signs of oral phase dysphagia include pocketing of food in the cheeks (Observed January 7-8, 2014 during medication administration and while being fed), losing food or liquid out the front of the mouth (Observed January 7-8, 2014 during medication administration and while being fed) . . . Signs of pharyngeal dysphagia are coughing or choking during a meal (Observed 01/08/14 while being fed), . . . Wet (vocal) quality may be related to poor management of secretions (Observed January 7-8, 2014 during cares, during medication administration and while being fed), . . . During the oral intake of medicines, foods and/or liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in a bed or in a chair. . . . Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue (Observed January 7-8, 2014 during cares, during medication administration and while being fed), . . . Controlling the bolus (bite) size is important . . . As long as the bolus size is controlled to a small amount . . . the bolus can rest in the valleculae and pyriforms (parts of the throat) without aspiration during a delayed swallowing response (Observed January 7-8, 2014 during medication administration and while being fed) . . . It's . . . difficult . . . to determine if pneumonia is due to aspiration unless the pneumonia developed soon after an observable episode of aspiration . . ." Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognitive skills, no swallowing issues, no nutritional approaches needed, and limited assistance of one person required for eating. Resident #1's current care plan identified, "02/16/13 Focus: Self care deficit . . . Approaches: . . . Feeding assist as needd (sic) May need total assist. Set up asst (assistance) to actual assist. . . . 07/05/13 Focus: . . . Difficulty swallowing . . . Approaches: Monitor (Resident #1) for s/s (signs/symptoms) of aspiration with intake, SOB (shortness of breath), gurgly voice, coughing, (increased) temp (temperature), emesis p (after) intake, Notify MD (medical doctor)/FNP (family nurse practitioner) of any concerns of aspiration, To be upright for all oral intake, supervise (at) mealtimes has nectar thick liquids, To have 1:1 supervision with eating/drinking." The bedside swallowing evaluation, dated 08/13/13, identified, ". . . coughing (with) meals, frequent pneumonia . . . Mechanical Soft . . . Ground meats . . . No mixed or two consistency foods . . . Slow rate, Small amount, 1 tsp. (teaspoon) size . . . Nectar thick liquids . . . Small sip . . . Chin neutral . . . Sitting up 60 min (minutes) after meal . . . Medications crushed in pureed . . . nursing to supervise . . . Assist patient with meal . . . Recommend modified [MEDICATION NAME] swallow study . . ." The modified [MEDICATION NAME] swallow study had not been completed due to the resident's power of attorney's concern the resident could not tolerate a long trip. A nurse's note, dated 01/07/14, identified at 1:35 p.m., "CNA (certified nursing assistant) stated res (resident) started coughing (and) choking on his lunch (and) then became very lethargic. Res taken from dining room (and) put to bed" . . . at 2:15 p.m., "(doctor) . . . up to see res . . . f/u (follow-up) in 1-2 days. . . ." A physician progress notes [REDACTED]. . . At lunch today, the patient reportedly choked and has been lethargic and sleeping since. . . . There is audible upper respiratory rattling with respirations. . . . Slight crackles in the lungs bilaterally. . . . Choking incident with possible aspiration . . . He will be monitored for signs of aspiration pneumonia including fever and difficulty breathing." Observation on 01/07/14 at 2:30 p.m. showed a nurse (#1) raise the head of Resident #1's bed to an approximate 45 degree angle (placing Resident #1 at an increased risk of premature loss of food/liquid over the back of his tongue) as he laid with his head tilted back, eyes closed, and mouth open. The nurse placed a pain pill on the tip of Resident #1's tongue and cued him to swallow. When he made no effort to swallow the pill, the nurse (#1) cued him again as she spooned three teaspoons of thickened water into his mouth. The pill slipped between Resident #1's right cheek and teeth (pocketed) (an indication Resident #1 had poor oral skills), and he drooled (an indication Resident #1 did not swallow his secretions) and presented a wet, gurgly vocal quality (an indication Resident #1 did not swallow his secretion and secretions had entered his airway). He gagged when the nurse (#1) used the spoon to retrieve the pill from his cheek, and whispered, "No more." The resident's POA, who sat in a chair at the end of his bed, asked, "Can't it (the pill) be crushed next time?" Resident #1 laid in bed with his head tilted back, eyes closed, mouth open, and drool running down his chin and the pill again resting on the tip of his tongue. The nurse (#1) continued to cue Resident #1 to swallow as she spooned four heaping teaspoons of pudding (placing Resident #1 at an increased risk of aspirating during a delayed swallowing response) followed by six teaspoons of thickened water into his mouth. Resident #1 continued drooling and presented a wet, gurgly vocal quality. The pill eventually disolved in the resident's mouth. The nurse's notes identified the following: * 01/07/14 at 8:00 p.m., "Lethargic, refused supper and snack. . . . T (temperature) 99.9 degrees . . . Tylenol po (orally) were given . . . for elevated temperature. . . ." * 01/08/14 at 8:30 a.m., "Res not very alert eating poorly gags easily . . . Had lg (large) amount of thick green phlegm" . . . at 9:00 a.m., "Res not running a temp is in bed resting (doctor) up to see res at this time orders received . . ." Observation on 01/08/14 at 9:35 a.m. showed the resident's physician discussing medication options with a medical student. The nurse (#1) stated, "We've been crushing his meds (medications) lately, so we'd prefer crushed or liquid form." She failed to inform the physician of the signs/symptoms of aspiration she observed while administering Resident #1's pain medication. A physician progress notes [REDACTED]. He ate poorly for breakfast. . . . Patient is awake but does not respond to questions. He makes an upper respiratory rattling sound with respirations. Some crackles in lungs bilaterally. Choking incident with possible aspiration. . . . [MEDICATION NAME] 300 mg (milligrams) every 8 hours for 7 days and [MEDICATION NAME] 1 g (gram) im (intramuscular) every 24 hours for 7 days for possible aspiration pneumonia. . . ." A nurse's note, dated 01/08/14 at 11:45 a.m., identified, "Res kept in room for lunch refused meal would not swallow." This conflicts with the observation at 12:10 p.m. when a CNA fed him his noon meal. Observations showed the following: * 01/08/14 at 10:50 a.m., two CNAs (#2 and #3) provided Resident #1's toileting cares. Following cares, one of the CNAs (#2) offered him two sips of thickened water via straw as he lay in bed, with the head of his bed only raised to an approximate 10 degree angle. Resident #1 presented with a wet, gurgly vocal quality that could be heard at the nurses' station (across the hall from his room) for approximately one hour later. * 01/08/14 at 12:10 p.m., a CNA (#2) raised the head of Resident #1's bed to an approximate 55 degree angle. Resident #1 coughed (an indication Resident #1 had poor vocal fold closure and secretions had entered his airway) after the CNA (#2) cued him to sip thickened juice through a straw. He laid in bed with his head tilted back, eyes closed, and mouth open. The CNA (#2) then spooned a teaspoon of thickened juice into Resident #1's mouth as he lay in bed with his head tilted back, eyes closed, and mouth open. Resident #1 did not respond when the CNA (#2) cued him to swallow, instead he drooled, pocketed some of the juice between his cheek and teeth, coughed, and presented a wet, gurgly vocal quality. The CNA (#2) spooned two more teaspoons of thickened juice into his mouth. Resident #1 demonstrated a two-to-three second delayed swallow (an indication Resident #1 had difficulty eliciting a swallow) and coughed. The CNA (#2) then spooned a teaspoon of mashed potatoes into Resident #1's mouth. He gagged and made a slight chewing motion, with his mouth open and potatoes visible on the roof of his mouth. The CNA (#2) spooned two teaspoons of thickened juice into Resident #1's mouth, and he coughed immediately following the second teaspoon. The surveyor informed the CNA (#2) she should stop feeding the resident as potatoes continued to be visible on the roof of his mouth. The CNA (#2) turned to Resident #1 and asked him if he "wanted more," to which the resident whispered "No." The CNA (#2) then spooned two teaspoons of thickened juice into Resident #1's mouth as he lay in bed with his head tilted back, eyes closed, and mouth open. He demonstrated a two-to-three second delayed swallow followed by a deep cough, and presented a wet, gurgly vocal quality. The surveyor informed an administrative nurse (#4) of Resident #1's signs/symptoms of dysphagia and/or aspiration (pocketing, drooling, delayed swallow reflex, coughing, and wet vocal quality) when the CNA (#2) continued feeding the resident. * 01/08/14 at 1:30 p.m., an unidentified Certified Medication Assistant (CMA) raised the head of Resident #1's bed to an approximate 55 degree angle as he laid with his head tilted back, eyes closed, and mouth open. The CMA placed a crushed pain pill on the tip of his tongue and cued him to swallow. She stated, "He's asleep. Yeah, it's (the crushed pill) sitting right there." The pill had slipped between Resident #1's cheek and teeth (pocketed), and he gagged when the CMA used a spoon to retrieve the crushed pill from his cheek. She stated, "Most of it's back out. He's not pocketing it anymore. He's sleeping. He's really out of it." The observations during survey demonstrated facility staff were unaware of the proper techniques for feeding Resident #1. The care and services provided placed Resident #1 at an increased risk aspiration, and caused him to take food/liquids into his airway, causing him harm. The nurse's notes identified the following: * 01/08/14 at 1:30 p.m., "[MEDICATION NAME] . . . crushed given to res res had problems swallowing med" . . . at 2:00 p.m., "Res resting eyes closed easy respirations" . . . at 2:30 p.m., "Staff discussion regarding swallowing, will modify diet and provide liquids to resident that are thickened and not food if resident unable to d/t (due to) (increased) secretions in throat (and) mouth, staff cont. (continue) to monitor temp (and) lung sounds." * 01/08/14 at 9:00 p.m., "Took sips of thickened liquids. T - 97.5 degrees . . ." During an interview the morning of 01/09/14, an administrative nurse (#4) reported staff have received education regarding the signs/symptoms of aspiration. She also confirmed staff are to ensure residents are alert and awake and positioned properly prior to any feeding attempts. The facility failed to 1) ensure Resident #1 was awake and alert prior to administering medications and prior to feeding him, 2) position Resident #1 as close to 90 degrees as possible prior to administering medications and prior to feeding him, 3) control the size of the bolus (bite), offering teaspoon sized bites of food, 4) crush Resident #1's medications per previous bedside swallowing evaluation recommendations, 5) recognize Resident #1's signs/symptoms of dysphagia and/or aspiration (drooling, pocketing, delayed swallow, coughing, wet, gurgly vocal quality), 6) notify the physician of Resident #1's continuing signs/symptoms of aspiration during medication administration and while being fed, and 7) reassess Resident #1's swallow. Failure to implement the above interventions resulted in the resident continuing to aspirate during medication pass and meals.