Every finding on record at Avantara Mountain View

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to protect the residents' right ro be free of misappropriation of property by one of one certified nurse aide (CNA)/qualified medication aide (QMA) (D) who agreed to cash one of one sampled resident's (2) scratch tickets in exchange for half of the winning money amount and who took one of one sampled discharged resident's (1) medication for her personal use. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include:1. Review of the provider's 5/21/26 SD DOH FRI revealed that assistant administrator C was notified by human resources director I that on 5/21/26 CNA/QMA D had possibly taken a discharged resident's Mounjaro (an injectable medication for type 2 diabetes that frequently leads to significant weight loss), after registered nurse (RN) G reported the incident to human resources. CNA/QMA D was immediately interviewed and admitted that she took resident 1's Mounjaro medication. She stated that she asked RN E to administer the injection for her. CNA/QMA D and RN E were suspended on 5/21/26 pending investigation. CNA/QMA D's employment with the facility was terminated on 5/22/26 and RN E returned to work after completing education on medication disposal and abuse and neglect on 5/23/26. 2. Review of the provider's 6/19/26 SD DOH FRI revealed that on 6/19/26 resident 2 had told licensed social worker (LSW) H that she had offered CNA/QMA D half of her lottery scratch ticket winnings if CNA/QMA D would go cash them out at a gas station. Resident 2 had won $50 and offered CNA/QMA D $25. Resident 2 could not remember the exact date of the incident. CNA/QMA D's employment with the facility was terminated on 5/22/26, so no disciplinary action could be taken. All residents with a BIMS of 10 or higher were interviewed to determine if there had been any other misappropriation of property, and all of those sampled residents stated no. 3. Observation and interview on 7/1/26 at 4:07 p.m. with resident 2 in her room revealed that she liked to purchase lottery scratch tickets. She had made an arrangement with CNA/QMA D to turn in her scratch tickets when she won money, and in exchange, resident 2 would give CNA/QMA D half of her winnings for gas money and time. She remembered winning $50 and offered to give CNA/QMA D $25. Resident 2 was educated on the facility's policy that the staff were not allowed to accept money from the residents. There was a $25 voucher on her bedside table that indicated the facility had reimbursed her, along with a copy of the facility's gift policy. 4. Review of resident 2's electronic medical record (EMR) indicated that she admitted to the facility on [DATE]. She had a 4/3/26 Brief Interview of Mental Status (BIMS) assessment score of 15, which indicated that her cognition was intact. There were no notes in her EMR regarding the reported incident on 6/19/26. 5. Review of resident 1's EMR indicated that she admitted to the facility on [DATE] and was discharged on 5/12/26. She had a 4/17/26 physician's order for 10 milligrams of Mounjaro to be administered per injection every Friday. 6. Interview on 7/2/26 at 8:55 a.m. with licensed practical nurse (LPN) F revealed that unused medication was expected to be returned to the pharmacy or destroyed by two nurses. There was a list of medications in the medication room for the staff members to determine which medications were eligible to be sent back to the pharmacy. Only nurses and qualified medication aides had access to the medication room. She indicated that the staff members recently had to complete education on the facility's gift policy, destruction of medications, and the facility's abuse and neglect policy. When a resident discharged from the facility, all the resident's medications were expected to be collected, counted, and either returned to the pharmacy or destroyed. 7. Interview on 7/2/26 at 9:14 a.m. with RN E revealed that CNA/QMA D asked her to administer the Mounjaro injection to her. The Mounjaro injection syringe did not have a label on it that indicated who that syringe belonged to. RN E asked CNA/QMA D to confirm what dose of medication she was on, and the dose she stated matched the dose in the syringe. RN E did administer the Mounjaro injection to CNA/QMA D. She would not have administered the medication if she had known that CNA/QMA D took the syringe from a discharged resident's medication supply. 8. The provider's actions that were implemented to mitigate the likelihood of the deficient practice from reoccurring were verified on 7/2/26. Review of the investigation notes regarding CNA/QMA D taking resident 1's injectable medication revealed that all residents taking injectable medications were audited and no missing medication was found. The facility also performed medication disposition audits of five discharged residents and all of those medications were counted, and either returned to the pharmacy or destroyed. Those audits were completed weekly for four weeks, and no further missing medications found. The incident will be brought to the next Quality Assurance and Performance Improvement (QAPI) meeting for further review by the interdisciplinary team. In addition, a sample of ten staff members were interviewed by nursing management regarding if they had ever witnessed any misappropriation of discharged residents' medications and all reported that they did not. Those same ten staff members were then asked about the process for destroying or returning medications and all ten were able to state the facility's process correctly. All staff members with access to the resident's medications completed education on the return or disposal of discharged residents medications. 9. Review of the investigation notes regarding CNA/QMA D accepting money from resident 2 revealed that ten residents with a BIMS score of 10 or higher were interviewed by the facility's management team. All ten residents stated that they had no concerns about the safety of their money in the facility and that the staff did not ask for or receive any money from them. All staff members were required to complete education regarding the facility's gift policy and the employee handbook that they were not allowed to accept any cash or gifts from the residents. 10. Review of the provider's undated Disposal of Medications Policy revealed that medications left in the facility after a resident's discharge were to be determined by nursing staff if they qualified to be returned to the pharmacy. If the medication did not qualify to be returned to the pharmacy, that medication as to be removed from the current medication supply for prompt disposition. Regular medications (considered non-controlled medications), shall be destroyed by the nursing care center [authorized facility staff] in the presence of a pharmacist or nurse, and one other witness. 11. Review of the provider's May 2025 Abuse and Neglect Policy revealed that financial abuse included diversion of a resident's medication for personal use or gain. 12. Review of the provider's August 2024 Gift Policy revealed that the employees were not allowed to accept any cash, tips, gratuities, personal checks, gift cards, etc., that could not be shared with other staff members. 13. Review of the provider's March 2025 Employee Handbook revealed that it is strictly prohibited to accept any gifts, tips, or gratuities from any resident, resident family member, or vendor, and acceptance of gifts, tips, or gratuities will result in immediate termination of employment. Based on the above information, noncompliance at F602 occurred on 5/21/26, and based on the provider's corrective action plans that were initiated on 5/22/26 and implemented for the deficient practice confirmed on 7/2/26, the noncompliance is considered past noncompliance.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review the provider failed to ensure a resident received the necessary behavioral health services to treat a diagnosed serious mental illness and to identify and implement interventions and effective communication processes with other healthcare entities to mitigate the resident's risk for self-harm for one of one sampled resident (2) with diagnosed mental health illness who attempted suicide with a call light cord.Findings include:1. Review of the provider's 5/4/26 SD DOH FRI revealed on 5/4/26 at 7:15 a.m. director of nursing (DON) B was notified by registered nurse (RN) G that on 5/3/26 at approximately 3:00 a.m. certified nursing assistant (CNA) Q notified RN G that resident 2 had a call light cord wrapped loosely around his neck. CNA Q notified RN G immediately and they removed the call light cord from around resident 2's neck and put it around the enabler bar (bar/bars attached to the bed).RN G reported the call light cord was not tight around resident 2's neck, and it did not leave marks on his neck after it was removed. When resident 2 was asked what had happened, he stared at RN G and CNA Q and said nothing. When RN G left the room, she instructed CNA Q to check on resident 2 every 15 to 30 minutes and notify her of any abnormal behaviors.RN G stated she had gotten busy and forgot to notify the on-call nurse or resident 2's provider about that incident. Resident 2's provider was notified of the call light cord having been wrapped around resident 2's neck on 5/4/26 at 7:30 a.m., and he advised that resident 2 be sent to the emergency department (ED) for evaluation and treatment of his mental health. Resident 2's family was notified that he had a call light wrapped around his neck on 5/4/26 and agreed to resident 2 being transferred to the ED. At 9:00 a.m. the ambulance transported resident 2 to the ED.Resident 2 did not have a history of harming himself. He did not behave differently than normal during the day shift on 5/3/26, after the call light cord was found around his neck. Resident 2 would not answer any questions related to the call light cord being around his neck. The oncoming day shift nurse on 5/3/26 was not notified that resident 2 was found with the call light cord around his neck during the night. 2. Review of resident 2's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His diagnoses include depression, vascular dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbance, and adjustment disorder with depressed mood (an emotional or behavioral reaction to a stressful life event).He had 1/2/26 physician's orders for fluoxetine (an antidepressant medication) 20 milligrams (mg) to be administered one time a day for depression, trazadone (an antidepressant medication) 50 mg to be administered at bedtime for insomnia (the inability to sleep), and Wellbutrin XL (an antidepressant medication) 150 mg one time a day for depression.His 5/14/26 care plan indicated he was seeing counseling for inappropriate behaviors towards the staff and sexually inappropriate behaviors. The interventions identified in the care plan related to resident 2's depression were to monitor, document, and report to the physician signs and symptoms of depression; Encourage him to talk about his feelings and deficits; and monitor and report to the nurse, to notify the physician as needed for symptoms of depression such as sadness, irritability, anger, never being satisfied, crying, shame, worthlessness, guilt, suicidal ideations, a negative mood, slowed movements, agitation, disrupted sleep, if he does not enjoy his usual activities, changes in his cognition, and attention seeking.Resident 2's behavioral health counseling notes indicated he was referred to a counseling service for depression symptoms, grief/loss, a history of traumas, adjustment disorder, anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and depression. On 10/23/25 and 2/12/26 it was documented that he voiced passive [expressing a wish to die without a plan to commit suicide] suicidal ideations [thoughts of suicide] during his PHQ9 [a screening tool to measure the severity of depression].On 2/12/26, 3/5/26, 3/19/26, and 4/16/26, resident 2 had moderate blunted affect (reduced ability to express emotions), was moderately depressed, and had moderate emotional withdrawal with symptoms of anger, helplessness, anxiety, irritability, and negative thinking.A 10/23/25 progress note written by social service assistant I stated, SS [social service] F/U [follow-up] with [the] resident's counselor after [his] session today, as [the] resident is not very happy with the situation he is in right now. [The] Resident does not have any plans to harm himself but is having a hard time seeing the bright side of anything. SSD [Social Service Director] to F/U with [the] resident next week, along with [the] resident to continue name redacted counseling sessions.There was no documentation in resident 2's EMR that the recommended SSD follow up the following week was completed. Resident 2's ED documentation indicated a 3/12/26 evaluation for abdominal pain included that resident 2, made statements expressing suicidal intent if [he] returned to the nursing facility, specifically stating he would hang himself with a call light cord. Psychiatry was consulted for further evaluation. On psychiatric assessment, [the] patient denied active suicidal ideation, intent, or plan, and attributed prior statements to frustration with [his] current living situation.Psychiatry determined there is no indication for inpatient psychiatric admission at this time.His 3/12/26 psychiatry evaluation indicated he answered yes to Have you wished you were dead or wished you could go to sleep and not wake up?, and Have you actually had any thoughts of killing yourself? His suicide risk assessment was determined to be low due to his denial of suicidal ideations, plan, and intent. The safety plan was completed with the RN in the ED and stated including patient instruction to contact 988 [suicide hotline], 911, or return to an emergency department if suicidal.A 3/13/26 progress note indicated resident 2 returned to the facility from the ED at 1:25 a.m. The report received from the ED was that resident 2 had a urinary tract infection, but there was no documentation in that report of his suicidal ideations while he was in the ED. His 3/12/26 after visit summary from the ED included information related to the 988 hotline but it did not include information related to resident 2's suicidal ideations or psychiatry evaluation.On 5/4/26 resident 2's physician was notified at 7:36 a.m., and resident 2's representative was notified at 7:45 a.m., that resident 2 had attempted suicide by wrapping the call light cord around his neck. On 5/4/26 at 9:05 a.m., resident 2 was transferred to the ED for Apparent suicide attempt.A 5/5/26 progress note by DON B indicated that resident 2 was sent to the ED due to a suicide attempt on 5/3/26 at approximately 3:00 a.m. There were no other progress notes related to the suicide attempt in resident 2's EMR. There was no skin assessment documented after resident 2's suicide attempt by wrapping a call light cord around his neck. 3. Interview on 5/12/26 at 5:00 p.m. with CNA Q revealed she had found resident 2 with his call light cord wrapped two times around his neck on 5/3/26 during her 11:30 p.m. resident rounds. She removed the call light cord from around resident 2's neck, tied the call light cord to the bed frame so resident 2 could use the call light but would not have access to the call light cord, and notified RN G of what she found. The call light cord was wrapped tightly enough around resident 2's neck that it left a red mark on his neck. When she asked resident 2 what happened he looked at her and did not say anything.RN G told CNA Q to check on resident 2 every 15 to 30 minutes to ensure his safety. CNA Q checked on resident 2 every 15 to 30 minutes for the rest of her shift, but did not document those checks. Resident 2 did not act out of ordinary before or after he wrapped the call light cord around his neck, except that he went to bed before 9:00 p.m., one hour earlier than he normally did. CNA Q reported to the on-coming shift staff that resident 2 was found with the call light cord around his neck. 4. Interview on 5/13/26 at 10:40 a.m. with RN G revealed that she was told by CNA Q that she found resident 2 with a call light cord around his neck, but CAN Q did not tell her that resident 2 had wrapped the call light cord around his neck. She told CNA Q to check on resident 2 every 15 to 30 minutes and let her know if anything else happened. She did not go into resident 2's room after she was notified of the call light being on resident 2's neck to assess him for injuries.CNA Q did not follow up with her during the night, and by morning she had forgotten about it and did not pass what happened on to the oncoming shift. RN G did not notify on-call management, resident 2's physician, or his representative after she was told about the call light cord around his neck.RN G called DON B on 5/4/26 after RN G completed her night shift and was at home because that was when she recalled resident 2 had a call light cord wrapped around his neck on 5/3/26. 5. Interview on 5/13/26 at 11:24 a.m. with social service director (SSD) Y revealed resident 2 was seeing the same counseling service since 2023. Social service assistant I was responsible for reviewing all the residents' counseling notes. SSD Y was not aware that resident 2 made passive suicidal ideations during his counseling on session 2/12/26. She expected to have been notified immediately of those statements so she could follow up immediately with the resident's physician, and notify their representative. She acknowledged that not being notified immediately was a missed opportunity to address resident 2's suicidal ideations before he attempted suicide. 6. Interview on 5/13/26 at 1:10 p.m. with CNA O revealed she worked the day shift on 5/3/26. She received a report from CNA Q, who informed her that resident 2 had wrapped the call light cord around his neck during the night. The day nurse did not talk to her about resident 2's suicide attempt and CNA O thought resident 2 was more irritable during her day shift on 5/3/26. 7. Review of the provider's video camera footage from 11:00 p.m. on 5/2/26 through 6:10 a.m. on 5/3/26 revealed that on 5/3/26 at 1:27 a.m. CNA N and Q entered resident 2's room and exited at 1:39 p.m. At 1:41 a.m. CNA Q was at the nurses' station talking with RN G and CNA Q was gesturing towards her neck. After CNA Q left the nurses station RN G wrote something on a piece of paper.CNA Q entered resident 2's room at 2:29 a.m., 3:19 a.m., 3:51 a.m. and 5:22 a.m. She walked by resident 2's room at 5:05 a.m. and 5:19 a.m. At 6:07 a.m. she was walking in the hallway talking with CNA O. RN G did not enter resident 2's room between 1:41 a.m. and 6:10 a.m. 8. Interview and review of resident 2's EMR on 5/13/26 at 4:51 p.m. with social services assistant I revealed she was aware resident 2 had suicidal ideations in the past, told the DON of his suicidal comments, and that he was cleared by a physician. She did not know when that had happened, but she stated he was on every 15-minute checks and his physician was notified. Social services assistant I stated the events involving resident 2 that day were not documented in resident 2's EMR and she was unable to recall when it had happened. 9. Interview on 5/14/26 at 9:00 a.m. with physician D revealed he was resident 2's physician. His partner was on call the day resident 2 attempted suicide, but he was aware that resident 2 was transferred to the ED due to a suicide attempt. Physician D checked resident 2's chart that morning (5/14/26) and found resident 2 had also expressed suicidal ideations while he was in the ED for his catheter (on 3/12/26).Physician D expected he, or one of his partners, would be immediately notified if a resident had suicidal ideations or made a suicide attempt. He expected that after resident 2's suicide attempt the nurse would have assessed resident 2, notified management staff, notified the on-call physician, and notified resident 2's representative.Physician D did not review residents 2' counseling notes. He expected the counselor to alert himself or the nursing staff if a resident reported suicidal ideations. He thought that the ED did the right thing by having resident 2 consult with psychiatry but there should have been communication between the ED and the facility when resident 2 returned to the facility so the staff were aware of resident 2's suicidal ideations and could initiate interventions and monitoring of resident 2. 10. Interview and review of resident 2's EMR on 5/14/26 at 10:15 a.m. with DON B revealed she expected the staff to notify herself or the on-call manager immediately after a resident threatened or attempted suicide.DON B stated she was notified of resident 2's suicide attempt on 5/4/26 at 7:15 a.m. by RN G who told her that he had his call light cord around his neck on 5/3/26 at approximately 3:00 a.m., which was 28 hours before DON B was notified. DON B expected RN G to notify the on-call manager immediately after resident 2 was found with the call light cord around his neck as well as resident 2's physician and representative. She was not aware of resident 2's suicidal ideations on 10/23/25, 2/12/26, or 3/12/26.DON B did not watch the 5/3/26 video camera footage. She was told by RN G that she went into resident 2's room and assessed his skin after he attempted suicide. She did not know CNA Q was the person who removed the call light cord from resident 2's neck and that she saw a red mark on his neck when she removed it. RN G told DON B that the call light cord was loose around resident 2's neck.She was not aware resident 2 expressed suicidal ideations to the counselor and expected the counselor would have notified the management staff of those thoughts. She was not aware resident 2 had been evaluated by a psychiatrist in the ED due to suicidal ideations and that she expected the ED to inform the nursing staff of that. There was nothing in resident 2's EMR related to his suicidal ideations.The provider received the after-visit summary from resident 2's ED visit on 3/12/26 but did not get the ED progress notes. They had access to retrieve them from the hospital's electronic system, but that was something that the provider did not routinely do. She acknowledged that if they had known about resident 2's suicidal ideations expressed to his counselor and during his 3/12/26 ED visit, interventions could have been initiated to prevent resident 2 from attempting suicide.The provider had not developed a plan for resident 2's return after his hospitalization for his suicidal attempt. The plan was upon resident 2's return to the facility the provider would go through resident 2's room to look for items resident 2 could harm himself with. The plan was to replace his call light cord with a bell that he could ring when he needed assistance from the staff.DON B verified there were no progress notes in resident 2's EMR related to his suicidal ideations on 10/23/25 other than social services assistant I's follow up note or documentation of resident 2's 15-to-30-minute checks after his suicide attempt on 5/3/26. She expected resident 2's care plan to include interventions to help him with his suicidal ideations and it did not. 11. Review of the provider's 11/18/25 Suicide Threats/Suicide Precautions policy revealed, Staff should report any resident threats of suicide or comments of 'wanting to die' immediately to the Nurse Supervisor/Charge Nurse. The Nurse Supervisor/Charge Nurse should immediately assess the situation and notify the Charge Nurse/Supervisor and /or Director of Nursing Services of such threats. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse should notify the resident's Attending Physician and resident representative. Provide 1:1 supervision and remove all equipment from [the] room that could be used and/or cause harm (sharps, cords, belts, etc.). 1:1 [one to one] supervision will continue until the resident is transferred or deemed to be not a threat to themselves or others by the physician or mental health professional. If a resident has attempted suicide: a. provide any emergency care and call 911. b. Notify VPO [vice president of operations] and RNC [regional nurse consultant] immediately.d. A suicide attempt is not a reportable event under Federal, South Dakota guidelines, however, each case should be discussed with VPO and RNC as it occurs as some situations may be reported (i.e., care plan not followed, previous threats not addressed, etc.). e. Any suicide attempt which results in any injury to the resident shall be reported to the DOH. 12. Review of the provider's 11/18/25 Notification of Change of Condition policy revealed The facility must promptly inform the resident; consult with the resident's medical provider; and notify, consistent with his or her authority, the resident representative(s) when: .A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in wither life-threatening conditions or clinical complications).

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to report incidents to the SD DOH within the required time frame, for one of one sampled resident (3) who reported to registered nurse (RN) E that his wound was caused by his bed frame, one of one sampled resident (4) who was allegedly abused by certified nursing assistant (CNA) M and was not reported until two weeks later by CNA P, one of one sampled resident (5) who was involved in a relationship with one of one licensed practical nurse (LPN) (J), and one of one sampled resident (2) who attempted suicide. Findings include:1. Review of the provider's 1/19/26 SD DOH FRI revealed that CNA P reported to director of nursing (DON) B that CNA M was verbally rude and physically rough while providing care to resident 4. The incident had occurred two weeks prior, and CNA P was unable to remember the exact date the incident happened. CNA M was suspended pending investigation, and CNA P was immediately re-educated on reporting abuse or neglect immediately. CNA P indicated that when CNA M was rough with resident 4, it was not to the level of physical pain or abuse. Resident 4 was admitted to the hospital on [DATE] for chronic medical issues unrelated to the incident and was readmitted to the facility on [DATE]. A skin assessment was performed by the nursing staff upon readmission to the facility and no skin alterations were found on that assessment. Resident 4 denied any negative verbal or physical interactions from the staff and that she felt safe in the facility. 2. Interview on 5/13/26 at 1:15 p.m. with CNA P revealed that after the incident between resident 4 and CNA M, she had a busy rest of the shift and had forgotten about the incident. She had remembered the incident later and confirmed that she should have reported it earlier. She was expected to report any allegations of abuse to management immediately. 3. Interview on 5/14/26 at 10:15 a.m. with DON B revealed that the expectation from all staff was to immediately report any suspicions of abuse so an investigation and report can be completed on time. 4. Review of the provider's 2/2/26 SD DOH FRI revealed that resident 3 was admitted to the hospital from [DATE] through 2/10/26 for an infected diabetic ulcer (a slow healing, open wound that often develops on the foot due to complications from diabetes) to his left outer foot. He required surgical amputation of his left fifth toe on 1/31/26 and was discharged from the hospital back to the facility on 2/10/26. Wound care nurse (WCN)/registered nurse (RN) E indicated that resident 3 had told her on 1/26/26 that the cause of this wound was from scraping his foot against the metal frame of his bed. This was not discovered until the facility conducted a chart review of resident 3 on 2/2/26 and submitted the FRI to the SD DOH. 5. Review of resident 3's electronic medical record (EMR) revealed that the left outer foot wound was discovered on 1/22/26 when the nursing staff documented that resident 3 had a blister in the area. The nurse's note indicated that resident 3's wound might [have] happened while putting on shoes and the wound may have rubbed against [the] shoe. WCN/RN E assessed his wound on 1/27/26 and confirmed that resident 3 reported that he thought his wound came from hitting the metal frame of his bed and not from his shoes. 6. Interview on 5/14/26 at 9:56 a.m. with WCN/RN E revealed that resident 3 reported to her that his wound was caused by facility equipment. She honestly didn't even think about needing to report it and treated it [the wound] as usual. She was suspended and reinstated after completing education regarding reporting any injury that was suspected to be caused by medical equipment. 7. Interview on 5/14/26 at 10:15 a.m. with DON B revealed she expected any injury to a resident that was caused by medical equipment to be reported to management immediately. She considered the facility beds to be medical equipment. 8. Review of the provider's 2/25/26 SD DOH FRI revealed on 2/25/26 at 5:30 p.m. DON B was notified by certified medication aide (CMA) X that CNA L had witnessed LPN J lying in bed with resident 5. Resident 5 was admitted to the facility on [DATE] following a motor vehicle accident. He had multiple broken bones and was there to receive therapy before he returned home. Resident 5 had a Brief Interview of Mental Status (BIMS) assessment score of 14, which indicated his cognition was intact, and he was his own responsible party. LPN J reported she and resident 5 were in a relationship in the past, but had taken a break before resident 5 was admitted to the facility. LPN J admitted she was visiting resident 5 when she was off duty and had lain with resident 5 in his bed. Resident 5 declined to be interviewed but did state he was not forced to do anything by LPN J. During staff interviews, 12 of 25 staff members interviewed had witnessed LPN J lying with resident 5 in his bed, flirty behaviors between them, or had heard from other staff members that something was going on between LPN J and resident 5. When LPN J was lying with resident 5 in his bed, she was off duty. Two staff members had witnessed resident 5 sitting at the nurses' station talking with LPN J, and rubbing her feet. When the staff were asked why they did not report the relationship, they stated it was because they were uncomfortable with the situation and resident 5 was consenting to it. LPN J did not disclose the relationship to the provider after resident 5 was admitted to the facility. She stated during her interview she spent time with resident 5 during off-work hours. Video camera footage on 2/25/26 at 6:24 p.m. revealed LPN J was wheeling resident 5 into the small dining room, she kissed him on the forehead, hugged him, and then resident 5 reached under LPN J's sweater and was rubbing her buttocks. 9. Review of resident 5's EMR revealed he was admitted to the facility on [DATE] following a motor vehicle accident. During the motor vehicle accident, he suffered multiple broken bones and needed therapy before he could return home. His 1/9/26 BIMS assessment score was 14, which indicated his cognition was intact. He was discharged from the facility with LPN J on 3/5/26. At the time of discharge, LPN J was listed as his emergency contact. 10. Interview on 5/12/26 at 5:12 p.m. with CNA L revealed she had knocked and entered resident 5's room and witnessed LPN J on top of resident 5 in his bed grinding on him. She closed the door and did not go back into the room. She reported to RN G that she saw LPN J in resident 5's room, but did not go into detail about what she saw because there were multiple other staff members with RN G. CNA L did not know what day she had seen that happen. A few days after CNA L saw LPN J and resident 5 together in his room, she witnessed resident 5 rubbing LPN J's legs, and LPN J told him to stop because she was working. CNA L was told by other staff members that they had witnessed inappropriate touching and kissing between LPN J and resident 5, but did not report it. 11. Interview on 5/13/26 at 10:30 a.m. with CNA K revealed she was hired on 2/19/26. When she first started her training, she was told there was a nurse who was in a relationship with resident 5. On CNA K's first or second day of training, she witnessed LPN J lying in bed with resident 5. She did not report what she had heard or witnessed to a nurse or the management staff. 12. Interview on 5/13/26 at 10:30 a.m. with RN G revealed she was told by CNA L, in front of other CNAs, that she had witnessed LPN J in resident 5's room, but CNA L did not say what she saw she just made a face, made a squeak noise, and walked away. RN G did not ask CNA L any questions and CNA L did not come back to talk with RN G later. RN G stated she did not follow up with CNA L about what she had seen and did not report anything to the management staff. 13. Review of the provider's 5/4/26 SD DOH FRI revealed on 5/4/26 at 7:15 a.m. DON B was notified by RN G that on 5/3/26 at approximately 3:00 a.m. CNA Q notified RN G that resident 2 had a call light cord wrapped loosely around his neck. CNA Q notified RN G immediately and they removed the call light cord from around resident 2's neck and put it around the enabler bar (bar/bars attached to the bed). RN G reported the call light cord was not tight around resident 2's neck and, it did not leave marks on his neck after it was removed. When resident 2 was asked what had happened, he stared at RN G and CNA Q and said nothing. When RN G left the room, she instructed CNA Q to check on resident 2 every 15 to 30 minutes and notify her of any abnormal behaviors. RN G stated she had gotten busy and forgot to notify the on-call nurse or resident 2's provider about that incident. Resident 2's provider was notified of the call light cord having been wrapped around resident 2's neck on 5/4/26 at 7:30 a.m., and he advised that resident 2 be sent to the emergency department (ED) for evaluation and treatment of his mental health. Resident 2's family was notified that he had a call light cord wrapped around his neck on 5/4/26 and agreed to transfer resident 2 to the ED. At 9:00 a.m. the ambulance transported resident 2 to the ED. Resident 2 did not have a history of harming himself. He did not behave differently than normal during the day shift on 5/3/26, after the call light cord was found around his neck. Resident 2 would not answer any questions related to the call light cord being around his neck. The oncoming day shift nurse on 5/3/26 was not notified that resident 2 was found with the call light cord around his neck during the night. 14. Review of resident 2's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. There was a progress note that was entered on 5/5/26 at 2:55 p.m. by DON B that resident 2 was sent to the ED due to a suicide attempt on 5/3/26 at approximately 3:00 a.m. There were no other progress notes related to the suicide attempt in resident 2's EMR. His 5/14/26 care plan indicated he was seeing counseling for inappropriate behaviors towards the staff and sexually inappropriate behaviors. The interventions identified in the care plan related to resident 2's depression were to monitor, document, and report to the physician signs and symptoms of depression; Encourage him to talk about his feelings and deficits; and monitor and report to the nurse, to notify the physician as needed for symptoms of depression such as sadness, irritability, anger, never being satisfied, crying, shame, worthlessness, guilt, suicidal ideations, a negative mood, slowed movements, agitation, disrupted sleep, if he does not enjoy his usual activities, changes in his cognition, and attention seeking. His care plan did not include that he had expressed suicidal ideations, interventions related to his expression of suicidal ideations to keep him safe, or preventative interventions related to his mood or depression. Resident 2's behavioral health counseling notes indicated that on 10/23/25 and 2/12/26 it was documented that he voiced passive [expressing a wish to die without a plan to commit suicide] suicidal ideations [thoughts of suicide] during his PHQ9 [a screening tool to measure the severity of depression]. On 3/12/26 during his evaluation in the ED for abdominal pain, resident 2, expressed suicidal ideations, stating he will harm himself if discharged back to the nursing facility. He reports intent to strangle himself using items such as a call light cord. 15. Interview on 5/12/26 at 5:00 p.m. with CNA Q revealed she had found resident 2 with his call light cord wrapped two times around his neck on 5/3/26 during her 11:30 p.m. resident rounds. She removed the call light cord from around resident 2's neck and immediately notified RN G of what she found. The call light cord was wrapped tightly enough around resident 2's neck that it left a red mark on his neck. 16. Interview on 5/13/26 at 10:40 a.m. with RN G revealed that she was told by CNA Q that she found resident 2 with a call light cord around his neck, but CAN Q did not tell her that resident 2 had wrapped the call light cord around his neck. She told CNA Q to check on resident 2 every 15 to 30 minutes and let her know if anything else happened. She did not go into resident 2's room after she was notified of the call light being on resident 2's neck to assess him for injuries. CNA Q did not follow up with her during the night, and by morning she had forgotten about it and did not pass what happened on to the oncoming shift. RN G did not notify on-call management, resident 2's physician, or his representative after she was told about the call light cord around his neck. RN G called DON B on 5/4/26 after RN G completed her night shift and was at home because that was when she recalled resident 2 had a call light cord wrapped around his neck on 5/3/26. 17. Review of the provider's video camera footage from 11:00 p.m. on 5/2/26 through 6:00 a.m. on 5/3/26 revealed on 5/3/26 at 1:27 a.m. CNA N and Q entered resident 2's room and exited at 1:39 p.m. At 1:41 a.m. CNA Q was at the nurses' station talking with RN G and CNA Q was gesturing towards her neck. After CNA Q left the nurses station RN G wrote something down on a piece of paper. 18. Interview on 5/14/26 at 10:15 a.m. with DON B revealed she expected the staff to notify herself or the on-call manager as soon as they suspected potential sexual abuse or exploitation and if a resident threatened or attempted suicide. DON B was notified of LPN J's relationship with resident 5 after a CNA called her and reported it on 2/25/26. She expected the staff to have notified her of the relationship between resident 5 and LPN J immediately after they heard about it or witnessed it, even if they were aware of their previous relationship. She believed the relationship was started shortly after resident 5 was admitted to the facility on [DATE]. DON B was notified of resident 2's suicide attempt on 5/4/26 at 7:15 a.m. by RN G who told her that he had his call light cord around his neck on 5/3/26 at approximately 3:00 a.m., which was 28 hours before DON B was notified. DON B expected RN G would have notified the on-call manager immediately after resident 2 was found with the call light cord around his neck. She was not aware of resident 2's suicidal ideations on 10/23/25, 2/12/26, or 3/12/26. 19. Review of the provider's 5/14/25 Abuse and Neglect policy revealed, Sexual abuse includes but is not limited to harassment, coercion, disparaging remarks, or sexual assault. Examples: implied or actual contact between a caregiver and resident of sexual nature. All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to your state agency immediately (within 2 hours) after the initial allegation is received. 20. Review of the provider's 11/18/25 Suicide Threats/Suicide Precautions policy revealed, If a resident has attempted suicide: a. provide any emergency care and call 911. b. Notify VPO [vice president of operations] and RNC [regional nurse consultant] immediately.d. A suicide attempt is not a reportable event under Federal, South Dakota guidelines, however, each case should be discussed with VPO and RNC as it occurs as some situations may be reported (i.e., care plan not followed, previous threats not addressed, etc.). e. Any suicide attempt which results in any injury to the resident shall be reported to the DOH.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, employee record review, and policy review, the provider failed to protect the resident's right to dignity and respect when one of one certified nursing assistant (CNA) U used her phone to record a video in the shower room while one of one CNA (S) verbally abused one of one resident (1) who was taking a shower. Findings included:1.Review of the provider's 5/7/26 submitted SD DOH FRI report regarding resident 1 revealed on 5/7/26 at 3:40 p.m. restorative/rehab aide V notified director of nursing (DON) B and administrator A that she heard that on 4/9/26 CNA U had taken a Snapchat video of a conversation between CNA S and resident 1. The Snapchat video reportedly showed CNA S speaking to resident 1 in a tone of voice that appeared annoyed. Resident 1 was interviewed by DON B and infection preventionist/licensed practical nurse (LPN) W and she stated she had no concerns. CNA U was suspended due to violating the facility's cell phone use, photography, and video policies. CNA S was suspended pending the facility's investigation related to allegations of verbal abuse. 2. Review of resident 1's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities), anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability) and depression. Her Brief Interview of Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact. 3. Interview on 5/13/26 at 2:25 p.m. with resident 1 revealed she remembered being in the shower room and being spoken to rudely by a staff member. Resident 1 reported she did not want to take a shower and was grabbing the grab bars and attempted to stand up, but the staff member, whose identity she could not recall, told her to stop, then grabbed her hands and pulled them off the grab bars. She recalled that she begged the staff member to stop. Resident 1 stated she does not recall any Snapchat video being taken. Resident 1 stated she has not seen the staff member since the incident and has not experienced further problems during showers. 4. Phone interview on 5/13/26 at 2:35 p.m. with restorative/rehab aide V revealed she recalled hearing that CNA U took a Snapchat video of CNA S in the shower room talking rudely to resident 1. Restorative/rehab aide V heard CNA U and CNA S laughing and making jokes about the Snapchat video. She never seen the video herself but notified DON B and administrator A of what she had heard. 5. Review of CNA S's personnel file revealed her professional certification was current, and her pre-employment background checks identified no areas of concern. She had signed her acknowledgement of the employee handbook on 10/22/24, which included the use of cell phones, photographs, and videos. She was current on abuse prevention and training, resident rights training, and HIPPA (Health Insurance Portability and Accountability Act) fundamental training. CNA S had a prior verbal warning and suspension on 2/3/26 due to taking a picture of a resident on CNA S's personal cell phone and posting it on social media. 6. Review of CNA U's personnel file revealed her professional certification was current, and her pre-employment background checks identified no areas of concern. She had signed her acknowledgement of the employee handbook on 10/22/24, which included the use of cell phones, photographs and videos. She was current on the abuse prevention and training, resident rights training, and HIPPA fundamental training. CNA U had received no disciplinary action from the facility. 7. CNA S was not available for an interview during the time of the survey. 8. CNA U was not available for an interview during the time of the survey. 9. Interview on 5/13/26 at 4:00 p.m. with administrator A and DON B revealed all staff was re-educated regarding the employee handbook policies addressing cell phone use, photographs, and videos in the workplace. The staff were re-educated on the Abuse and Neglect policy as well as the reporting requirements. Audits had not begun, they would be focused on observing whether the staff were using personal phones while on duty and to monitor staff communication with the residents. 10. Review of the provider's undated Resident Rights admission Agreement revealed: 28. The Resident has the right to be free from verbal abuse 11. Review of the provider's revised 11/18/25 Resident Dignity and Privacy policy revealed that It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as, care for each resident in a manner and in an environment, that maintains resident privacy.

Based on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the provider failed to ensure a physician's antibiotic medication order was accurately entered into the resident's electronic medical record (EMR) by one of one registered nurse (RN) (H) for one of one sampled resident (3) who did not receive his antibiotic until a day after it was prescribed and needed his left foot's fifth toe amputated due to an infection. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the 2/2/26 SD DOH FRI revealed that resident 3's had a left foot wound that was assessed by his physician on 1/26/26. The nursing staff received orders for an oral (pill) antibiotic, an intramuscular (IM; use of a needle to inject the medication into a muscle) antibiotic, and for the staff to outline the area of redness to his left foot for monitoring purposes. The oral antibiotic order was entered by registered nurse (RN) H to be administered on 1/26/26. The IM antibiotic was entered by RN H to start on 1/27/26, which was incorrect as the physician's order indicated it was to be administered on 1/26/26. Resident 3 was admitted to the hospital from [DATE] through 2/10/26 for surgical intervention of an infected diabetic ulcer (a slow healing, open wound that often develops on the foot due to complications from diabetes) to his left outer foot. His left foot's 5th toe was amputated on 1/31/26. 2. Review of resident 3's EMR confirmed that his physician ordered an IM antibiotic to be given once daily on 1/26/26 and 1/27/26 for increased suspicion of an infection to his left foot. 3. Interview on 5/14/26 at 8:18 a.m. with RN H revealed she printed resident 3's antibiotic orders from his physician and entered them into resident 3's EMR. She knew both antibiotics were ordered to be given on 1/26/26. When she came back to work the next day, she realized that resident 3 did not receive the IM antibiotic. She did not double-check the order date when entering resident 3's antibiotic order and he missed his first dose of IM antibiotics on 1/26/26. The facility had her do education on double-checking all entered physician's orders for accuracy. 4. Interview on 5/14/26 at 9:00 a.m. with physician D revealed that he expected physician orders to be entered correctly and medications to be given to the resident according to that physician's order. 5. Interview on 5/14/26 at 10:15 a.m. with director of nursing (DON) B revealed that she expected physician's orders to be entered into the resident's EMR as written by the physician. 6. Review of the provider's investigation of that incident revealed that they educated RN H and placed a corrective action in her personnel file. All nursing staff completed education regarding entering accurate physician's orders in the resident's EMRs. The facility brought this incident to their 2/3/26 Quality Assurance and Performance Improvement (QAPI) meeting and audits were performed on all new physicians' orders in the previous 30 days. That audit did not find any further incorrect entries of physician's orders. 7. Review of the provider's January 2018 Medication Orders policy revealed that the seven elements to receive a complete physician's order for a medication must include: the name of the medication, the strength of the medication, the dose and dosage form, the time or frequency of administration, the route of administration, the duration of therapy, and a diagnosis for intended use. 8. Based on the above information, non-compliance at F658 occurred on 1/26/26, and based on the provider's implemented corrective actions on for the deficient practice confirmed on 5/14/26, the compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to identify and implement specific care approaches that addressed the mental and psychosocial needs of one of one sampled resident (3) with diagnosed post-traumatic stress disorder, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event (PTSD) and one of one sampled resident (2) who had experienced a traumatic event to mitigate trauma triggers and prevent re-traumatization.Findings include: 1. Review of the provider's 5/4/26 SD DOH FRI revealed on 5/4/26 at 7:15 a.m. director of nursing (DON) B was notified by registered nurse (RN) G that on 5/3/26 at approximately 3:00 a.m. certified nursing assistant (CNA) Q notified RN G that resident 2 had a call light cord wrapped loosely around his neck. CNA Q notified RN G immediately and they removed the call light cord from around resident 2's neck and put it around the enabler bar (bar/bars attached to the bed). RN G reported the call light cord was not tight around resident 2's neck, and it did not leave marks on his neck after it was removed. When resident 2 was asked what had happened, he stared at RN G and CNA Q and said nothing. When RN G left the room, she instructed CNA Q to check on resident 2 every 15 to 30 minutes and notify her of any abnormal behaviors. RN G stated she had gotten busy and forgot to notify the on-call nurse or resident 2's provider about that incident. Resident 2's provider was notified of the call light cord having been wrapped around resident 2's neck on 5/4/26 at 7:30 a.m., and he advised that resident 2 be sent to the emergency department (ED) for evaluation and treatment of his mental health. Resident 2's family was notified that he had a call light wrapped around his neck on 5/4/26 and agreed to resident 2 being transferred to the ED. At 9:00 a.m. the ambulance transported resident 2 to the ED. Resident 2 did not have a history of harming himself. He did not behave differently than normal during the day shift on 5/3/26, after the call light cord was found around his neck. Resident 2 would not answer any questions related to the call light cord being around his neck. The oncoming day shift nurse on 5/3/26 was not notified that resident 2 was found with the call light cord around his neck during the night. 2. Review of resident 2's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His diagnoses include depression, vascular dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbance, and adjustment disorder with depressed mood (an emotional or behavioral reaction to a stressful life event). He had 1/2/26 physician's orders for fluoxetine (an antidepressant medication) 20 milligrams (mg) to be administered one time a day for depression, trazadone (an antidepressant medication) 50 mg to be administered at bedtime for insomnia (the inability to sleep), and Wellbutrin XL (an antidepressant medication) 150 mg one time a day for depression. His 5/14/26 care plan indicated he was seeing counseling for inappropriate behaviors towards the staff and sexually inappropriate behaviors. The interventions identified in the care plan related to resident 2's depression were to monitor, document, and report to the physician signs and symptoms of depression; Encourage him to talk about his feelings and deficits; and monitor and report to the nurse, to notify the physician as needed for symptoms of depression such as sadness, irritability, anger, never being satisfied, crying, shame, worthlessness, guilt, suicidal ideations, a negative mood, slowed movements, agitation, disrupted sleep, if he does not enjoy his usual activities, changes in his cognition, and attention seeking. Resident 2's behavioral health counseling notes indicated he was referred to a counseling service for depression symptoms, grief/loss, a history of traumas, adjustment disorder, anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and depression. On 10/23/25 and 2/12/26 it was documented that he voiced passive [expressing a wish to die without a plan to commit suicide] suicidal ideations [thoughts of suicide] during his PHQ9 [a screening tool to measure the severity of depression].On 2/12/26, 3/5/26, 3/19/26, and 4/16/26, resident 2 had moderate blunted affect (reduced ability to express emotions), was moderately depressed, and had moderate emotional withdrawal with symptoms of anger, helplessness, anxiety, irritability, and negative thinking. 3. Interview and review of resident 2's EMR on 5/13/26 at 11:24 a.m. with social services director (SSD) Y revealed resident 2 was seeing the same counseling service since 2023. Social services assistant I was responsible for reviewing all the residents' counseling notes and completing each resident's trauma informed care assessment on their admission to the facility and quarterly. SSD Y verified a trauma informed care assessment was not completed on resident 2. She was not aware resident 2 was referred to counseling services for past traumas. She was aware resident 2 was in a motor vehicle crash in the 1980's but stated he denied having any trauma. He normalized everything and was not open to sharing his feelings and experiences. She could have reached out to his counselor to find out more information about his past traumas and any triggers he may have had. When a resident had a history of a traumatic experience, SSD Y or social services assistant I attempted to gather information about the trauma and any triggers related to that trauma. They documented that information in the resident's care plan in an attempt to avoid retriggering a resident's past trauma. SSD Y verified resident 2 did not have a past trauma identified on his care plan or any known or potential triggers he may have had. 4. Interview and review of resident 2's EMR on 5/13/26 at 4:51 p.m. with social services assistant I revealed she was not aware that one of the reasons resident 2 was seeing a counselor was because of a past traumatic experience. Social services assistant I could reach out to the counselor for more information if a resident was known to have a past trauma, but did not disclose the trauma or did not want to talk about it. She stated a history of trauma could be added to a resident's care plan even if they did not disclose the trauma or potential triggers to that trauma. 5. Interview on 5/14/26 at 9:00 a.m. with physician D revealed he was resident 2's physician. Resident 2 was in a motor vehicle crash in the 1980's, which resulted with him becoming a paraplegic (partial or complete paralysis of the lower half of the body, including both legs). 6. Interview on 5/14/26 at 10:15 a.m. with DON B revealed the trauma informed care assessments were completed by the social services staff. She expected a resident who was identified as having past trauma would have that identified on their care plan as well as any potential triggers to avoid the retraumatization of that resident. 7. Interview on 5/13/26 at 2:55 p.m. with resident 3 in his room revealed that he had served in the Korean War. He denied having any triggers or PTSD from the war but stated that he had trauma from losing his wife of 71 years the previous year. He stated that he had been working through this with a therapist. 8. Review of resident 3's EMR revealed he admitted to the facility on [DATE]. He had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that he had severe cognitive impairment. His diagnoses included depression, anxiety, insomnia, and cognitive communication deficit (difficulty with communication from an underlying impairment in thinking process). His 5/21/25 care plan indicated that he demonstrated significant mood distress related to his diagnosis of depression and difficulty adjusting to loss and change in role or status. The interventions identified in the care plan related to his depression were to discuss any fears or issues regarding health or other subjects. Staff were to monitor, document, and report any signs or symptoms of depression including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive complaints, and tearfulness. Resident 3 went to his first counselling session on 4/16/26. The reason for referral section included issues with trauma. Resident 3 was screened for trauma and had a positive screening with current associated emotional symptoms. A short-term goal of counselling included examine the relationship between emotions and triggers during his next sessions. 9. Interview on 5/13/26 at 11:26 a.m. with SSA I revealed that she was expected to check when a resident's counselling notes were completed, review those notes, then upload them to the resident's EMR. 10. Review of the provider's 11/18/25 Mental Health Adjustment Difficulties Related to Trauma, PTSD, or Other Mental Health Issues policy revealed that all residents were to be assessed to determine if services were needed. Based off that assessment, the resident's care plan should address the individualized emotional and psychosocial needs of the resident.

Based on observation, record review, interview, and policy review, the provider failed to ensure the staff followed professional standards of practice to ensure:*The resident's physician was notified that one of two sampled residents (31) with physician's orders for dialysis treatments refused four of those treatments from 12/5/25 through 12/31/25.*One of one observed certified medication aide (CMA) (L) administered medications according to the physician's order to ensure the full dose was given for one of one sampled resident (34) with orders for lactulose laxative medication.*One of one sampled resident's (57) insulin was administered according to the physician's order by one of one licensed practical nurse (LPN) (I).*Documentation supported that one of one sampled resident's (86) WanderGuard (a wearable door alarming device) was checked each shift to ensure it was on the resident's ankle and functioning, according to his physician's order and the provider's policy.*One of one sampled resident's (5) gastric tube was checked for placement according to the physician's order and the provider's policy for one of one sampled resident (5) with a tube for receiving nutritional formula, medication, and hydration. Findings include:1. Review of resident 31's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included: End-stage renal disease, chronic kidney disease stage 5, renal dialysis, type 2 diabetes, and edema. *Her physician's orders included a 6/4/25 order for dialysis treatments on Monday, Wednesday, and Friday. *Her 12/5/25, 12/12/25, 12/19/25, and 12/24/25 nurse progress notes indicated she had refused to go to those dialysis treatments. There was no indication that her physician had been notified of those refusals. *Her dialysis assessment forms for her dialysis treatment dates of 12/5/25, 12/12/25, 12/18/25, 12/23/25, and 12/31/25 were initiated but not completed. There was no indication that her physician had been notified of her refusal to attend her dialysis treatments on those assessment forms. 2. On 1/5/26, resident 31 was at dialysis and not available for an interview. 3. Interview and record review on 01/06/2026 at 11:09 a.m. with infection preventionist/LPN K regarding dialysis treatments revealed: *She was aware that resident 31 was to receive dialysis treatments. *When a resident refuses dialysis the nurse should document that in a progress note, and notify the physician. *She was unable to find documentation that resident 31's physician was notified of her dialysis treatment refusals on the above dates. 4. Interview and review of resident 31's EMR on 1/6/26 at 2:24 p.m. with director of nursing (DON) C revealed: *When a resident refused to attend their dialysis treatment, she expected that the resident's physician would be notified and documented by the nurse. *Confirmed there was no documentation in resident 31's EMR that supported that resident 31's physician was notified of her dialysis treatment refusals on 12/5/25, 12/12/25, 12/19/25, and 12/24/25. 5. Review of the provider's 2/20/24 Dialysis Management policy revealed it did not include the process for when a resident refused their ordered dialysis treatments. 6. Interview on 1/6/26 at 2:14 p.m. with regional nurse consultant (RNC) B and DON C regarding dialysis revealed the provider did not have a dialysis refusal policy. 7. Review of the provider's 11/18/25 Notification of Change of Condition policy revealed: *The facility will provide care to residents and provide notification of resident change in status. *The facility must promptly inform the resident; consult with the resident's medical provider; and notify, consistent with his or her authority, the resident representative(s) when:: *A need to alter treatment significantly . *Continued resident refusal of ordered treatments or procedures (at least three consecutive refusals). 8. Observation and interview on 1/4/26 at 11:40 a.m. with certified medication aide (CMA) L in resident 34's room revealed CMA L administered the resident's eye drops. She then reminded the resident to drink the clear liquid inside the plastic cup that was on the resident's bedside table. CMA L stated there was lactulose (a laxative medication) in that cup. CMA L stated she left the lactulose on the resident's bedside table during a medication pass earlier that morning and planned to check back later to verify that the resident took the lactulose. 9. Review of resident 34's January 2026 medication administration record (MAR) revealed the resident's lactulose was documented as having been administered at 8:00 a.m. on 1/4/26. 10. Interview on 1/5/26 at 2:45 p.m. with CMA L regarding the above observation revealed she documented resident 34's lactulose was administered even though she knew the resident had not yet taken that medication. MAR documentation was not expected to occur until after she had confirmed a medication was taken by the resident. 11. Observation on 1/5/26 at 4:50 p.m. of CMA M preparing resident 66's medications for administration revealed she mixed the resident's MiriLAX (a laxative medication) powder with water inside a drinking cup. She crushed the resident's pills and mixed them with apple sauce inside a medication cup. CMA M had resident 66 take sips of the MiriLAX in between swallowing spoonfuls of the crushed medications. The resident ingested all of the crushed medications, and CMA M returned the cup with remaining MiriLAX in it to the medication cart. She marked that cup with the resident's initials, then documented on the resident's MAR that both the MiriLAX and the crushed medications were administered. CMA M explained she would continue to periodically offer sips of the MiriLAX to the resident until the MiriLAX was gone. This was her usual practice for administering the resident's MiriLAX. CMA M stated that she was not expected to document a medication administration on the MAR without confirming a medication was taken by the resident. 12. Observation and interview on 1/6/26 at 8:35 a.m. with LPN I revealed she had checked resident 57's blood sugar level, and the amount of Humalog (insulin) she would then administer to the resident was contingent upon that blood sugar level. 13. Review of resident 57's 11/25/25 Humalog insulin order with LPN I revealed the resident was to be administered two units of Humalog based on the resident's 181 blood sugar reading. The order indicated that insulin was to be administered before meals and at bedtime. The resident also had an order to receive 18 units of scheduled [NAME] (insulin). That insulin was to be administered in the morning and at bedtime. 14. LPN I entered resident 57's room with insulin administration supplies and prepared to administer the resident's insulin. She inserted the needle on the Humalog insulin pen into the resident's left lower abdomen, and then pressed the injection button for less than two seconds before removing it from the resident's abdomen. She inserted the needle on the Lantus insulin pen into the resident's lower right abdomen, and then pressed the injection button for less than three seconds before removing it from the resident's abdomen. LPN I stated she had not pressed the injection buttons of either insulin pen for an appropriate amount of time before removing them from resident 57's abdomen. She stated that the injection time should have been ten seconds. That compromised the full dose of both of the insulins from being delivered. LPN I confirmed she had not followed the physician's order to administer resident 57's Humalog before breakfast. That was a medication error. She knew that Humalog was a rapid-acting insulin that worked quickly to manage the expected rise in blood sugar that occurred after eating. 15. Review of the provider's September 2018 Medication Administration General Guidelines policy revealed, 20. The resident is always observed after administration to ensure that the dose was completely ingested. Review of the provider's revised 11/18/25 Following Physician's Orders policy revealed, 9. All physician orders should be followed as written. Review of the provider's revised 2/20/24 Medication Error policy revealed the purpose of that policy was To ensure medication errors are identified to prevent adverse resident effects. That policy included a Medication Error Report. Section 4 of that report identified classifications of medication errors that included Wrong Time: not given at scheduled time or interval. Review of the provider's May 2016 Medication Administration Subcutaneous Insulin policy revealed Keep the injection button pressed all the way. Slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered. 16. Review of resident 86's EMR revealed he was admitted to the facility on [DATE] from a hospital. His 12/2/25 Elopement Risk Evaluation indicated he was not at risk for elopement (leaving the facility without staff knowledge). There was no documentation in the progress notes from 12/2/25 through 12/27/25 regarding resident 86 having attempted to elope or having eloped during that time. His 12/3/25 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated his cognition was moderately impaired. A 12/28/25 progress note indicated that on 12/28/25 at about 4:00 p.m., resident 86 was not in his second-floor room. A subsequent second-floor, facility-wide, and grounds search was completed and was not successful in locating the resident. At 4:30 p.m., a code green (Elopement Alert) was called. Management staff, the resident's contact persons, power of attorney, and emergency services (911) were also notified of the elopement. At about 4:56 p.m., staff called the nearby motel where resident 86 previously lived. The resident had checked back into the same room at the motel. The resident's daughter picked the resident up from the motel and returned him to the facility. After returning to the facility on [DATE], a skin evaluation was completed for resident 86. No new skin issues were identified. A WanderGuard (a wearable door alarm device) was placed on the resident's left ankle. Resident 86's Elopement Risk Evaluation and care plan were updated on 12/28/25 to reflect his elopement. A 12/28/25 physician's order instructed: WanderGuard placed to left ankle due to [the resident's] elopement risk. Ensure placement every shift. 17. Observation on 1/5/26 at 9:20 a.m. of resident 86 revealed he was lying in his bed and did not awaken after his name was called. He was wearing a WanderGuard on his left ankle. 18. Interview on 1/5/26 at 9:30 a.m. with CMA N and registered nurse (RN) O revealed that the nursing staff were responsible for visually confirming the WanderGuard was on resident 86's ankle each shift. That WanderGuard was also to be checked to ensure a red light was flashing on the device, which indicated it was properly functioning. Review of resident 86's December 2025 and January 2026 MARs and continued interview with RN O revealed there was no documentation on those MARs to support that, since 12/28/25, the WanderGuard had been checked to ensure it was on the resident's ankle and functioning. RN O did not know why there was no daily documentation to support that the 12/28/25 physician's order had been followed. 19. Interview on 1/6/26 at 1:30 p.m. with DON C and review of resident 86's December 2025 and January 2026 MARs revealed that she confirmed there was no documentation to support that, each shift, the nursing staff had confirmed resident 86's WanderGuard was on his ankle and properly functioning, but there should have been. 20. Review of the provider's revised 11/18/25 Wanderguards/Door Signaling Devices policy revealed, 6. Placement verification and testing of each Wanderguard or signaling device will be completed daily and recorded on the MAR or TAR. Replacement will be completed as necessary. 21. Review of resident 5's EMR revealed: *He had a G-tube (a tube surgically placed through the abdomen into the stomach to deliver medications, fluids, or nutritional formula). *He had provider's order to check PEG-tube placement prior to water flushes/feeding and medication administrations. *The instructions for this order were to check residual and placement by attaching a 60ml piston syringe to gastric tube and gently pulling back 10ml. Aspirate [remove] 5-10ml of gastric content and use pH strips to confirm pH of 1.5 to 5.5. Stop procedure and call MD [doctor] if outside these parameters. If no gastric content appears, the tube may be against the lining of the stomach or may be obstructed. 22. Observation on 1/6/26 at 10:28 a.m. with LPN I revealed: *She had a clean syringe on a clean paper towel on the arm of resident 5's chair. *She pulled 10ml (milliliter) of air into the syringe and attached it to the valve on resident 5's G-tube. *She placed her stethoscope on his stomach, pushed the air into his G-tube, and listened for the air in his stomach. *She reported that the G-tube was in the correct location. *She removed the syringe, attached the resident's nutritional formula to the G-tube, and administered the formula. 23. Interview on 1/6/26 at 2:12 p.m. with DON C revealed she would expect nursing staff to listen for placement of a G-tube with a stethoscope as well as check the pH level of the gastric content per policy. 24. Interview on 1/6/26 at 3:38 p.m. with administrator A revealed: *She would expect staff to follow the physician's orders when administering formula through a feeding tube. *She expected staff to follow the provider's policy for administering formula and medication through a feeding tube. 25. Review of the provider's 11/18/25 Enteral Feeding (Tube Feeding) policy revealed: *The nurse would check for residual and placement by attaching a sixty milliliter [ml] piston syringe to gastric tube and gently pulling back about 10 ml. If resistance is met as stomach contents are aspirated, stop procedure and notify MD [provider]. *If no resistance, aspirate five to ten ml of gastric contents. The appearance of gastric content implies that the tube is patent and in the stomach. Use pH strips to confirm that aspirate is at a pH of 1.5 to 5.5. If outside of these parameters, stop procedure and notify MD.

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, record review, and policy review, the provider failed to ensure residents received quality of care for:One of one sampled resident (18) who was not repositioned and provided continence care for approximately nine hours by two of two certified nursing assistants (CNA) (U and V) between 7/18/25 and 7/19/25. One of one sampled resident (64) whose care plan was not followed by one of one CNA (S) on 12/7/25.One of one sampled resident (23) who was not provided timely continence care by one of one CNA (P) on 1/1/26.This citation is considered past non-compliance after review of the corrective actions the provider implemented following those incidents.Findings include: 1. Review of the provider's 7/22/25 FRI revealed that resident 18 was not repositioned or provided continence care for approximately nine hours between 8:30 p.m. on 7/18/25 and 5:41 a.m. on 7/19/25. This was confirmed after the provider reviewed their 7/18/25 and 7/19/25 camera footage. The root cause of the incident, per the provider's investigation, was that staff assignment sheets had not been updated by the nurse to reflect that CNA U and CNA V had split the 7/18/25 overnight shift. There was also no hand-off communication between those two CNAs when one CNA was finished working the split shift and the second CNA started working the split shift. Interview on 1/4/26 at 3:15 p.m. with CNA W, CNA X, and CNA Y revealed that staff assignment sheets were kept on a clipboard at the nurses' station for CNAs to know their shift assignments. If there was a shift split between two CNAs, that was reflected on the assignment sheet. Huddles [meetings to update staff about residents' care needs or changes] occurred between the CNAs and the nursing staff at the start of shift and as needed throughout the shift to keep the CNAs informed of changing resident needs. Outgoing and incoming CNAs also completed walking rounds [resident status updates that occurred while walking door to door by residents' rooms]. At the start of the shift, the outgoing (going off duty) CNA shared a brief report with the incoming (coming on duty) CNA regarding each resident they had cared for during the shift. Review of the 1/4/26 assignment sheet with CNA X revealed there were separate assignment sheets for the first and second floors. The sheets identified the nursing, CNA, and qualified medication aides assigned to work the day, evening, and night shifts that day. Each scheduled CNA was assigned specific resident room numbers that they were responsible for during their shift. Interview on 1/4/26 at 3:30 p.m. with licensed practical nurse (LPN) I revealed that the assignment sheets were made up by a nurse manager at least one day in advance. It was the responsibility of the floor nurse to notify the on-call nurse of any staffing changes. The on-call nurse had a copy of the current assignment sheet and worked with the floor nurse to make any necessary changes to the assignment sheet. It was the floor nurses' responsibility to update the assignment sheet with any staffing changes and communicate those changes to the floor staff. Review of the provider's 7/22/25 SD DOH FRI report regarding resident 18 and interview on 1/6/26 at 2:45 p.m. with director of nursing (DON) C and administrator A revealed the following post-incident follow-up was completed and verified while on-site:CNA U and CNA V were suspended from work pending the outcome of the incident investigation. Both CNAs received disciplinary action related to the 7/22/25 incident.Education was provided for CNA U, CNA V, and all other staff regarding the provider's Abuse/Neglect policy.Nurses were educated regarding their responsibility to update staff assignment sheets when CNA work assignments are changed.CNAs were educated regarding the expectation that hand-off communication occurs between the outgoing and oncoming CNAs.Staff were interviewed following the incident regarding their knowledge of abuse/neglect reporting, and the expectation that routine resident checks occurred. Residents were interviewed to determine if they were regularly checked on by staff, as well as their feelings of safety inside the building.Audits were initiated to confirm that routine rounding on residents was occurring and that assignment sheets had been updated when it was indicated.Resident 18's care plan was updated to reflect her and her family's request that she have every four-hour checks related to the resident's preference not to be disturbed during the overnight hours.CNA U returned to work after the completion of the investigation. CNA V is no longer employed by the facility. 2. Review of the provider's 12/15/25 FRI revealed that during the investigation of an unrelated incident, it was identified that CNA S had not followed resident 64's care plan, which indicated that the resident was to receive Cares in Pairs, meaning the presence of two staff was expected when the resident's care was provided. CNA S assisted resident 64 with toileting without another staff person present. There were no adverse consequences that occurred as a result of this failure. The incident occurred on 12/7/25 at 8:30 p.m. Interview on 1/4/26 at 12:10 p.m. with CNA T regarding Cares In Pairs revealed that the term meant the presence of two staff persons was expected when resident care was provided due to reasons such as resident behavioral concerns, staff, or resident safety. There were several places a CNA could look to identify if a resident required Cares in Pairs including their care plan or their electronic medical record (EMR). Observation and interview on 1/6/26 at 10:40 a.m. with resident 64 revealed that two unidentified CNAs assisted her out of bed, into and out of the bathroom. After exiting the bathroom, resident 64 asked, How did they [the CNAs] do? That same question was redirected back to the resident for her response, and she stated the CNAs did well. She indicated she was satisfied with her caregivers. She was treated with dignity and respect by them. Resident 64 had no concerns. She had been directing her own care for two years.Review of resident 64's care plan revealed on 9/13/24, an intervention for Cares in Pairs was initiated related to the resident's history of manipulative behavior, verbal abuse towards staff, recording staff without their knowledge or permission, and making false accusations/statements about staff. Review of the provider's 12/15/25 submitted SD DOH FRI report and interview on 1/6/26 at 2:45 p.m. with director of nursing (DON) C and administrator A revealed the following post-incident follow-up was completed and verified while on-site:CNA S was suspended from work pending an investigation of the 12/7/25 event. She received written discipline and education regarding the expectation that residents' care plans were followed. She returned to work after the investigation was completed. Law enforcement, the resident's power of attorney, and her medical provider were notified of the incident.All staff were educated regarding the expectations for residents who require Cares in Pairs. 3. Review of the provider's 1/2/26 submitted SD DOH FRI report regarding resident 23 and interview on 1/5/26 at 3:45 p.m. with DON C and administrator A revealed: On 1/1/26, certified nursing assistant (CNA) P was assigned to provide resident 23's care. At 6:19 p.m., resident 23 activated her call light. At that same time, CNA P was seen exiting another resident's room. She entered resident 23's room, turned off resident 23's call light, then returned to the room she had just exited.At 6:47 p.m., CNA P exited that room and was approached by an unidentified resident's family member. It appeared that the resident's family member had requested assistance from CNA P for a resident (their relation).At 7:40 p.m. on 1/1/26, resident 23 was heard hollering out from inside her room. CNA Q informed CNA P that resident 23 was hollering. CNA P responded: [Resident 23] always does that, [the resident] just wants her [dinner] tray removed [from her room].CNA R then asked CNA Q to check on resident 23. CNA Q entered resident 23's room and then exited that room at 8:15 p.m. after she had changed resident 23's brief. The resident had a bowel movement that was coming out of her brief. Fecal matter was observed on the resident's bedding that looked like it had been there awhile.Review of CNA P's personnel file revealed her date of hire was 9/22/25. She had completed training related to resident rights, mandatory incident reporting, and abuse/neglect shortly after her hire date. Her background check was reviewed. No significant findings were noted. Interview on 1/5/26 at 2:30 p.m. with resident 23 regarding the 1/1/26 incident revealed that she confirmed having soiled her brief that evening and turning on her call light to have it changed. The resident stated it was one and a half to two hours before a CNA came into her room to change her brief. The resident was not able to recall the names of the staff members she had interacted with on the evening of 1/1/26. Resident 23 stated her incontinence care was usually promptly provided by staff. She felt the 1/1/26 incident was an isolated event. It was resident 23's experience that the staff had treated her with dignity and respect. Interview on 1/6/26 at 2:45 p.m. with DON C and administrator A revealed the following post-incident follow-up was completed and verified while on-site:An assessment of resident 23's skin was completed, and no new skin concerns were identified. CNA P was suspended from work pending the outcome of the provider's investigation into the incident on 1/1/26. On 1/4/26, CNA P text messaged her resignation to the provider. Both CNA Q and CNA R were educated regarding the provider's Abuse/Neglect policy, including the expectation that the on-call nurse be contacted immediately regarding any resident abuse/neglect allegation. Education for all other staff was initiated regarding that same information. A sample of staff persons was interviewed and confirmed their knowledge and understanding of the facility's abuse/neglect policy and the expectations for reporting such allegations. A sample of residents was interviewed regarding how staff interacted with them, how staff had cared for them, and their feelings of safety. There were no negative findings. The social services director was meeting with resident 23 to monitor the resident for potential negative outcomes as a result of the incident. Interview and record review on 1/6/26 at 3:45 p.m. with DON C and administrator A revealed the interviews, education, and audits referenced in the provider's 7/22/25, 12/15/25, and 1/2/26 submitted SD DOH FRIs were completed and documented. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 1/6/26 after record review revealed the facility had followed their quality assurance process, education was initiated for all direct care staff regarding resident abuse and neglect, FRI-related audits were initiated, and observations and interviews confirmed staff understood the expectations for updating and following the staff assignment sheets, implementing Cares in Pairs, and how to identify and report alleged resident abuse and neglect.Based on the above information, non-compliance at F684 occurred on 7/18/25, 12/7/25, and 1/1/26, and based on the provider's implemented corrective actions for the deficient practice confirmed on 1/6/26, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices regarding: *Hand hygiene (handwashing) and glove use by two of two certified nursing assistants (CNA) (D and E) observed assisting one of one sampled resident (2) with transferring, using a full body mechanical lift (a lift and sling used to lift a person's full body). *Hand hygiene and glove use by one of one wound care registered nurse (RN) (F) observed performing a wound dressing change for one of one sampled resident (2). *Hand hygiene and glove use by one of one licensed practical nurse (LPN) (I) observed cleaning a resident's glasses and administering liquid nutritional formula through a feeding tube for one of one sampled resident (5). *Glove use by one of one LPN (I) observed checking one of one sampled resident's (57) blood sugar reading. Findings Include: 1. Review of resident 2's electronic medical record (EMR) revealed he had a wound to his sacrum (the lower back in between the hip bones of the pelvis) and physician's orders to change that wound dressing twice a day. 2. Observation on 1/6/26 at 9:36 a.m. in resident 2's room revealed: *He had a sign on his door for Enhanced Barrier Precautions with the instructions to wear a gown and gloves when providing direct contact care with the resident. *Certified nursing assistant (CNA) D and CNA E arrived at resident 2's doorway with a Hoyer lift (a mechanical lift and sling used to lift a person's full body). *Both CNAs put on gowns and gloves without first performing hand hygiene. They assisted resident 2 with incontinence care. *They both then discarded their gloves and gowns in the trash and performed hand hygiene. 3. Observation on 1/6/26 at 9:45 a.m. of wound care registered nurse (RN) F and wound care RN G in resident 2's room revealed: *They performed hand hygiene and applied gloves and gowns before entering resident 2's room. *Wound care RN G supported resident 2 in position on his side in the bed while wound care RN F performed the dressing change to his wound. Wound care RN F noted that resident 2 did not have a dressing in place to his sacral wound. * Wound care RN F cleaned resident 2's wound, removed her gloves, and discarded them. *She looked around the room and stated, There's no hand sanitizer in here. *She then put on a new pair of gloves without first performing hand hygiene and placed a dressing on the resident's wound. 4. Review of resident 5's EMR revealed he had a G-tube (a soft tube surgically placed through the abdomen into the stomach to administer medications, fluids, or nutrition). 5. Observation on 1/6/26 at 10:28 a.m. of LPN I in resident 5's room revealed: *The supplies to administer nutritional formula and fluids through the resident's feed tube had already been placed on a clean paper towel next to the resident. *She removed the resident's glasses from his face, washed them with a paper towel and water, and placed them back on his face. *With those same gloved hands, she administered the resident's nutritional formula through his G-tube. 6. Observation and interview on 1/6/26 at 8:35 a.m. with LPN I revealed she was preparing to check resident 57's blood sugar (the amount of sugar in the blood). After she performed hand hygiene, she gathered the needed supplies and entered the resident's room. She laid a clean paper towel on top of the resident's over-the-bed table and set some of the supplies on top of the clean paper towel. She placed a clean pair of gloves on top of the resident's bedding without a barrier between the bedding and those gloves. She pricked the resident's finger, placed blood from the resident's finger on a testing strip that measured the resident's blood sugar level, and inserted that strip into the glucometer (blood glucose meter). LPN I agreed that the top of the resident's bedding was not a clean surface, and the gloves she placed directly on top of that bedding would not be considered clean. She should have laid the gloves on top of a clean paper towel or other barrier. 7. Interview on 1/6/26 at 1:43 p.m. with director of nursing (DON) C revealed: *She expected the staff to perform hand hygiene before putting on gloves and before putting on personal protective equipment (PPE) such as gowns. *She agreed that LPN I should have completed hand hygiene and put on new gloves after cleaning resident 5's glasses and before administering his tube feeding through his tube. *Gloves should be left on a clean surface to mitigate the risk of cross-contamination after they are placed on a caregiver's hands. 8. Interview on 1/6/26 at 3:38 p.m. with administrator A revealed she expected all staff to perform hand hygiene per the provider's policy. Review of the provider's 5/15/25 Hand Hygiene policy revealed: *All staff members were to be trained on hand hygiene as part of their initial orientation and regularly educated on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. *All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *Alcohol-based hand rub was the preferred method of hand hygiene: -*Before and after direct contact with residents. -*When entering and leaving a resident care area/room. -*Before donning [putting on] and after removing gloves. -*Before handling clean or soiled dressings, gauze pads, etc. -*Before moving from a contaminated body site to a clean body site during resident care. -*After handling used dressings, contaminated equipment, etc. *The use of gloves does not replace hand hygiene. Hand hygiene must be completed prior to and after removal of gloves.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (34) observed with a medication left at her bedside was evaluated for her ability to safely self-administer that medication. Findings include:1. Observation and interview on 1/4/26 at 11:40 a.m. with certified medication aide (CMA) L in resident 34's room revealed CMA L administered the resident's eye drops. She then reminded the resident to drink the clear liquid inside the plastic cup on the resident's bedside table. CMA L stated there was lactulose (a medication used to treat symptoms associated with severe liver disease) inside that cup. She left the lactulose on the resident's bedside table during a medication pass earlier that morning. CMA L stated that the lactulose was not pleasant tasting, and leaving it at the resident's bedside enabled the resident to take periodic sips of the lactulose throughout the morning rather than having to drink it all at once. 2. Review of resident 34's electronic medical record (EMR) revealed there was a 4/21/20 physician's order for lactulose to be administered three times per week. There was no order for the resident to have that medication left at her bedside or for her to self-administer it. Resident 34 was evaluated on 11/7/25 for her ability to safely self-administer melatonin, a hormone supplement commonly used to help a person sleep. The resident was deemed Not safe to self-administer [melatonin]. Factors that determined her inability to self-administer that medication included dementia or Alzheimer [Alzheimer's disease] that affect their [the resident's] ability to self-administer [the medication] and schizophrenia [a mental illness that causes distorted thinking, perception, and behavior]. There was no medication self-administration evaluation completed for the resident's lactulose. 3. Interview on 1/5/26 at 2:45 p.m. with CMA L revealed she did not know if resident 34 was evaluated or deemed safe to have her lactulose left at the bedside to self-administer. CMA L stated that sometime after 11:40 a.m. on 1/4/26, she observed that the cup that had lactulose in it was empty, and resident 34 verbally confirmed to CMA L that she had consumed it. 4. Interview on 1/6/26 at 1:30 p.m. with director of nursing (DON) C revealed she confirmed resident 34 was not safe to self-administer her own medication. CMA L was expected to observe resident 34 consume the lactulose in its entirety before leaving the resident's room and documenting that the medication had been administered. Review of the provider's January 2020 Self-Administration of Medications policy revealed, Each resident has a right to self-administer medications should they desire, unless this practice is determined unsafe.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff protected the residents' right to privacy and confidentiality of their protected health information in their electronic medical records (EMR) that was displayed and viewable to anyone who passed by. Findings include: 1. Observation on 1/4/2026 at 9:45 a.m. revealed there was a laptop computer on top of the medication cart in front of the first-floor nurses' station. That nurses' station was near the end of a resident living unit hallway. The computer screen displayed a list of residents' full names and photographs, along with other identifying information about them. That screen was viewable to anyone passing by the medication cart. 2. Observation on 1/4/26 at 11:20 a.m. revealed the same medication cart in front of the first-floor nurses' station. The computer screen was opened and displayed resident 2's medication administration record (MAR). Certified medication aide (CMA) L was standing about 10 to 15 feet away from the medication cart, administering resident 2's medications. Resident 2 spat out the medication, and CMA L returned to the medication cart and discarded it. She prepared another dose of the same medication for resident 2. CMA L then closed the computer screen before she returned to administer resident 2's medication for the second time. 3. Observation on 1/4/26 at 11:40 a.m. of CMA L revealed she prepared resident 34's eye drops for administration at the medication cart. She left the computer screen on top of the medication cart open. It displayed the resident's MAR. She then walked down the hall to the resident's room to administer those eye drops. After administering the eye drops, CMA L returned to the medication cart and documented the eye drop administration. She reviewed resident 34's opened MAR and realized the resident had additional scheduled medications to administer. CMA L prepared those medications and then closed the computer screen before she left the medication cart to administer those medications. 4. Observation on 1/5/26 at 1:16 p.m. of the first-floor hallway revealed: *A medication cart with an open computer on the top of that cart. *Resident 88's information was displayed on that open computer screen. *There were no employees in the hallway for approximately three minutes. Licensed practical nurse (LPN) H walked into the hallway with a machine used to check vital signs (measurements of the body's basic functions such as blood pressure, pulse, temperature, and respiration rate). 5. Interview on 1/5/26 at 1:19 p.m. with LPN H revealed: *She agreed that she was the last person to use the computer observed above and did not lock the screen, which left resident 88's personal information displayed on it. -*She acknowledged that the resident information was visible to anyone who would walk by that medication cart. -*She acknowledged that someone would be able to access any information and document in the facility's computer system under her name if she did not lock the computer screen. 6. Interview on 1/6/26 at 3:38 p.m. with administrator A revealed: *She expected staff to always maintain the privacy of any resident's information. *She agreed that documentation could be accessed and/or changed by anyone if the computer screen with the resident's electronic medical record was not locked before the staff member left the computer unattended. Review of the provider's September 2018 Medication Administration General Guidelines policy revealed, 18. Resident's health information needs to remain private. The pages of the MAR [medication administration record] notebook [electronic medical record] containing resident health information must remain closed or covered when not in direct use.

Based on observation, interview, and policy review the provider failed to ensure: *Appropriate whirlpool (WP) tub cleaning by one of one certified nursing assistant (CNA) M in one of two WP tub rooms after bathing residents. *Proper hand hygiene was performed during medication administration by four of four observed staff members (RN N, LPN P, UMA K, RN I) for seven of seven sampled residents (10, 18, 22, 35, 40, 54, and 69) during seven of seven medication administrations observations. Findings included: 1. Observation and interview on 12/11/24 at 10:43 a.m. with CNA M in the WP tub room revealed: *She had been assisting residents with bathing for the past two days. -The regular bath aide had been out sick. *She had been employed with the facility as a CNA since 3/26/23. *She used the following process to clean the WP tub: -She sprayed water into the WP tub while she sprayed WP disinfecting cleaner. -She stated she would scrub the WP tub for 20-30 seconds. -She filled the WP tub with water and scrubbed around the tub chair and the sides of the WP tub for approximately 30 seconds. -She drained the WP tub and then rinsed the WP tub with water. -She opened the back door of the WP tub and dried around the perimeter of the back door of the WP tub with a clean towel. Follow-up interview on 12/11/24 at 10:44 a.m. and review of the posted WP tub cleaning instructions with CNA M revealed: *She had known the instructions were posted on the side of the WP tub. *She was not aware she was to: -Run five gallons of water into the tub and pour 10 ounces of disinfectant into the water. -Run disinfectant through the aerator holes/jets, let the aerator/jets run for at least 20 seconds. While the aerator/jets are running, use a brush or sponge to scrub the tub insides, bottom, and chair. Ensure that all surfaces are wetted by the disinfectant solution. *She was not aware that area was to stand for at least 10 minutes. *She was not aware she was to: -While waiting, wipe all other contact areas such as the outside of the bath, door seals, hand control with a cloth soaked in disinfectant solution. -After 10 minutes of contact or longer, drain the bath of the residual disinfectant solution. -Thoroughly rinse the insides of the tub including the chair with water. Fill the tub with enough water to cover the intake valve and turn on jets/aerator and run for 20 seconds to ensure that the disinfectant is thoroughly rinsed. *She agreed she was not cleaning the tub according to the posted instructions. Interview on 12/11/24 at 11:05 a.m. with director of nursing (DON) D revealed: *CNA M had been assisting with baths for two days. -The regular bath aide had been out sick. *She agreed CNA M had not been cleaning the WP tub according to the posted instructions. 51816 2. Observation and interview on 12/10/24 at 10:57 a.m. with resident (54) while in her room revealed: *She was lying on her right side under a blanket. *She stated she had a skin concern under [her] tummy but the nurses were addressing that. Interview on 12/11/24 at 7:49 a.m. with registered nurse (RN) N revealed she stated: *Resident 54 had a yeast infection in her groin area, under her breasts, and her left underarm area. *They were treating this infection by washing and powdering the areas two times a day. Observation on 12/11/24 at 8:23 a.m. of resident 54's personal care and treatment of her yeast infection while in her room revealed: *RN N washed her hands for about five seconds before putting on gloves and then performed personal care for resident (54) with soap, water and a washcloth. *RN N then put those dirty washcloths on the floor, removed her gloves, and washed her hands again for about five seconds before applying clean gloves. *With those gloved hands RN N dried that area with a towel, removed her gloves, washed her hands for about three seconds with water, and applied clean gloves. *RN N then applied Nystatin powder to the reddened skin in resident 54's groin area. *RN N then removed those gloves, did not wash her hands, applied clean gloves and then washed the resident's left underarm area with soap, water, and a washcloth. *RN N removed her gloves, washed her hands for about three seconds with water, and applied clean gloves then with those gloved hands she dried that area with a towel and applied Nystatin powder to the resident's left underarm area. 3. Observation on 12/10/24 between 10:14 a.m. and 10:20 a.m. of licensed practical nurse (LPN) P revealed she: *Administered oral medications to residents 10, 22 and 40. *Did not perform hand hygiene prior to the preparation of medications for all three of those residents. *Did not perform hand hygiene after she administered the medications to all three of those residents. 4. Observation on 12/11/24 at 4:44 p.m. of unlicensed medication aide K during medication administration revealed: *She did not perform hand hygiene prior to the preparation of medications for residents 35 and 69. *She did not perform hand hygiene after she administered medications to resident 69. 5. Observation on 12/12/24 at 8:40 a.m. of registered nurse (RN) I revealed: *She did not perform hand hygiene prior to putting on gloves. *There was a sign on the door that indicated resident 18 was on contact precautions (use of gloves and gown when providing direct resident care), to whom she administered medications. 6. Interview on 12/12/24 at 12:40 p.m. DON D regarding handwashing during medication administration revealed: *Her expectation was for staff to follow the hand hygiene policy. -This included completing hand sanitizing or washing before entering a resident room, with donning and doffing of personal protective equipment, between dirty and clean areas, and before exiting a resident room. -The hand washing should have been at least 20 seconds each time. -Hand washing competencies were completed with all staff at least once per year. 7. Review of RN N's 11/2/23 and 10/15/24 hand washing competencies revealed there were no concerns regarding her hand hygiene. 8. Review of the February 20, 2024, Hand Hygiene policy revealed: *This facility considers hand hygiene the primary means to prevent the spread of infections. *All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *Vigorously lather hands with soap and rub them together, creating friction to all surfaces. For at least twenty (20) seconds under a moderate stream of running water, at a comfortable temperature. 43844

Based on observation, record review, interview, and policy review, the provider failed to ensure: *One of one sampled resident's (74) prescription Ativan (anti-anxiety medication) was accurately labeled. *Outdated medical supplies had been removed from two of two observed medication storage rooms. *One of one sampled resident (50) had a pharmacy label on his aspart insulin pen. *Two of two sampled residents (18 and 85) opened aspart insulin pens were not available for use after the expiration period. Findings include: 1. Review of the first-floor controlled substance binder revealed: *AnIndividual Resident's Controlled Substance Record page for resident 74's liquid Ativan. -The resident's name and Ativan 2mg [milligrams]/ml[milliliter] was hand-written on it. There was no pharmacy label on that sheet. *That medication was administered as ordered on 11/30/24 and again on 12/8/24. Observation and interview with registered nurse (RN) N on 12/10/24 at 11:50 a.m. in the first-floor medication room revealed: *In the medication refrigerator there was a sealed plastic bag dated 11/30 with resident 74's name on it that contained a bottle of Ativan. -There was no prescription label affixed to that bottle that would have confirmed the identity of the resident that medication was prescribed to, medication dosage information, or the instructions for use. *The 11/30/24 physician's order for that Ativan was 0.5 ml sublingually [under the tongue] every 2 hours as needed for anxiety/restlessness. -Without a label on that medication bottle, the nursing staff were not able to compare it to the physician's order on the resident's medication administration record (MAR) to ensure the medication matched the order before it was administered. 2. Observation on 12/10/24 at 10:25 a.m. in the second floor medication storage room revealed: *Three Ambu (artificial manual breathing unit) bags each in an individually sealed package. -The expiration date on two of those packages was 2/25/22 and the expiration date on the third package was 10/21/22. *One bag of hypodermic safety needles with a use by date of 3/2020. 3. Observation on 12/10/24 at 10:45 a.m. in the first floor medication storage room revealed: *One opened box of BD brand blood collection kits that was 75% full. -The expiration date on that box was 7/31/23. *Two boxes of strap tourniquets. -The manufacturer date on one box was 11/2/19 and the manufacturer date on the second box was 4/21/19. The instructions for use on each box indicated best [used] before 24 months from date of manufacturing. 4. Interview on 12/11/24 at 9:20 a.m. with central supply manager/business office assistant O regarding medical supply management for the medication storage rooms revealed she: *Was responsible for ordering, receiving, and stocking the medical supplies in both medication storage rooms. -Unlicensed medication aide (UMA) L was responsible for checking for and removing outdated medical supplies from those rooms. 5. Interview on 12/11/24 at 1:18 p.m. with UMA L regarding medical supply management revealed: *He checked for and removed outdated stock medications (bulk supply of medications not required to be labeled for an individual's use by the pharmacy) from both medication storage rooms on a regular basis. -That task was not assigned to him to have completed but it was something he had started to do on his own. *He had not been checking for and removing outdated medical supplies at the same time he was checking for and removing outdated stock medications. Review of the provider's September 2018 Medication Storage and Storage of Medication policy revealed: *13. Refrigerated medications should be kept in closed and labeled containers . *14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock . -The policy made no mention regarding the storing and disposal of outdated medical supplies. 51472 6. Observation on 12/12/24 at 11:27 a.m. of residents' insulin pens revealed: *There was a container in a medication cart with resident 50's name on it that had an aspart insulin pen in it. -There was no prescription label affixed to the insulin pen that would have confirmed the identity of whose medication it was, medication dosage information, or the instructions for using that medication. *Resident 18's Novolog insulin pen had an 11/13/24 date written on it. *Resident 85's aspart insulin pen had an 11/8/24 date written on it. Interview on 12/12/24 at 11:27 a.m. with registered nurse (RN) I revealed: *There should be a pharmacy label on all insulin pens. *She could obtain a replacement label from PharMerica. *Insulin pens were to be dated with the date it was opened. *When she was asked what length of time insulin was able to be used after opening, she stated I am sure we have a book. *She was unable to locate the insulin expiration date information. Interview on 12/12/24 at 12:00 p.m. with assistant director of nursing (ADON) E revealed she would have expected: *A pharmacy label to be on all insulin pens. *The staff to date the insulin pens at the time of their first use and to discard the pens after the expiration date. Review of the provider's 7/19 Med-Pass Medication with Shortened Expiration Dates form indicated, Novolog (aspart) insulin expires 28 days after first use or removal from refrigerator, whichever comes first.

Based on interview, record review and policy review the provider failed to ensure three of three sampled residents (26, 33, and 85) who required dialysis treatment were monitored for abnormalities upon returning from their dialysis treatments. Findings include: 1. Observation and interview on 12/10/24 at 2:07 p.m. with resident 26 revealed: *She was seated in her wheelchair in her room. *She stated she had just returned from dialysis and was waiting for a certified nurse aide (CNA) to assist her into her bed. *She stated there was a dialysis port in her right arm. Review of resident 26's electronic medical record (EMR) revealed: *Her admitted was 5/4/19. *Her diagnoses included: end-stage renal disease, dependence on renal dialysis, heart failure, and Type II diabetes. *Her physician's orders included she was to receive dialysis treatments on Tuesdays, Thursdays, and Saturdays. Review of resident 26's Post-Dialysis Evaluation assessment, Section 3 vitals area documentation revealed: *Her 11/23/24 blood pressure (BP), temperature, pulse, and oxygen (O2); her 11/21/24 respiration rate (RR); and her 11/29/24 blood sugar were documented as her post-dialysis vital on 11/30/24. *Her 11/23/24 BP, temperature, pulse, and O2; her 11/21/24 RR were documented as her post-dialysis vitals on 12/2/24. *Her 12/7/24 BP, temperature, pulse, RR, and O2; her 12/9/24 blood sugar (BS) were documented as her post-dialysis vital on 12/10/24. 2. Interview on 12/10/24 at 3:52 p.m. with resident 33 revealed she stated: *She received dialysis on Tuesdays, Thursdays, and Saturdays. *Nurses sometimes check her vital signs when she returned from dialysis, and at other times she would go to dinner without them being taken. Review of resident 33's EMR revealed: *Her date of admission was 2/26/20. *Her 11/6/24 Brief Interview of Mental Status (BIMs) assessment score was a 13, which indicated her cognition was intact. *Her diagnoses included: chronic kidney disease (CKD) Stage 5, other symptoms and signs involving cognitive functions and awareness, dementia, type 2 diabetes with hyperglycemia, and dependence on renal dialysis. *Her physician's orders included she was to receive dialysis treatments on Tuesdays, Thursdays, and Saturdays. Review of resident 33's Post-Dialysis Evaluation assessment, Section 3 vitals area documentation revealed: *Her 11/23/24 BP, temperature, pulse, and O2; her 11/15/24 RR; and her 11/29/24 BS were documented as her post-dialysis vitals on 11/30/24. *Her 11/23/24 BP, temperature, pulse, and O2; her 11/15/24 RR; and her 12/2/24 BS were documented as her post-dialysis vitals on 12/3/24. *Her 12/7/24 BP, temperature, pulse, RR, and O2; her 12/9/24 BS were documented as her post-dialysis vitals on 12/10/24. 3. Review of resident 85's EMR revealed: *His admitted was 11/8/24. *His diagnoses included: end stage renal disease, dependence on renal dialysis, diabetes, heart disease, acute and chronic heart failure, kidney failure, and orthostatic hypotension(low blood pressure when standing from sitting or lying position). *His dialysis schedule was Monday, Wednesday, and Friday. *His care plan included, Report significant changes in pulse, respirations, and BP [blood pressure] immediately. Review of resident 85's Post-Dialysis Evaluation assessment Section 3 vitals documentation revealed: *His 12/5/24 BP, temperature, pulse, RR, and BS; 12/5/24 02 were documented as his post-dialysis vitals on 12/2/24. 4. Interview on 12/12/24 at 10:45 a.m. with unlicensed medication aide (UMA) L and certified nursing assistant (CNA) R revealed: *The nurse or a CNA would obtain a resident's vitals when a resident returned from dialysis. -When the CNA obtained the resident's vitals, they would write the vitals on a piece of paper and give that paper to a nurse. Interview and record review on 12/12/24 at 11:23 a.m. with registered nurse Q revealed the process for completion of a resident's post-dialysis return assessment was: *The resident's vital signs were obtained when the resident returned from dialysis. -A nurse or anyone was able to take the vital signs. -When a CNA obtained resident's vital signs, they write it down and hand it to us. *When reviewing the post-dialysis assessment in Section 3 and the vitals for that section, she confirmed the documented post-dialysis vitals referred to above were not dated the day the residents returned from dialysis and should have been. Interview and record review on 12/12/24 at 12:56 p.m. with director of nursing D regarding the post-dialysis assessment for residents upon their return from dialysis revealed: *She agreed the post-dialysis assessment vitals were sometimes recorded from a previous day and not the day the resident returned from dialysis. *When a new assessment was started the last documented set of vital signs were pre-populated into that assessment. -Whomever was completing the new assessment were to have removed the pre-populated data and enter that day's post-dialysis resident's vitals. *She confirmed the removal of the pre-populated data was not always completed. *She stated, I should have known about this a long time ago. 47780 5. Review of the provider's revised February 2024 Dialysis Management policy revealed: *The facility has designed and implemented processes which strive to ensure the comfort, safety, and appropriate management of hemodialysis residents. The facility will ensure the following; -7. Upon return from Dialysis Center, review information provided on Dialysis communication form. Communicate and address as appropriate. Complete post-dialysis information and record on UDA [user defined assessment] in PCC [Point Click Care].

A. Based on observation, interview, and policy review, the provider failed to adhere to professional standards of care practice and their facility's process for the accountability of controlled (risk for mental or physical dependence) medications by one of one registered nurse (RN) (I) and two of two licensed practical nurses (LPN) (S and P) who had signed the accounting of controlled medications sheet before a physical inventory of those medications with the oncoming nurse had occurred. Findings include: 1. On 12/10/24, review of the second floor east wing Shift Verification Of Controlled Substances Count sheet at 8:22 a.m. and interview at 2:30 p.m. with LPN S revealed: *At each change of shift, the oncoming and offgoing nurses completed and verified an accounting of all the controlled (risk for mental or physical dependence) medications in the medication cart. -Both nurses signed and dated the verification of controlled substances count sheet after the accounting process was completed. *As the 12/10/24 oncoming nurse for the 6:00 a.m. to 6:00 p.m. shift, LPN S and the offgoing nurse counted the controlled medications in the medication cart together and signed the verification sheet. -LPN S then signed the verification sheet as the offgoing nurse for 12/10/24 even though her shift was not scheduled to have ended until 6:00 p.m. and the controlled medication count with the oncoming nurse for the next shift had not been completed. 2. Review of the second floor west wing Shift Verification Of Controlled Substances Count sheet and interview on 12/10/24 at 8:45 a.m. with LPN P revealed: *As the oncoming nurse for the 6:00 a.m. to 6:00 p.m. shift that day she and an offgoing nurse from the overnight shift had signed that sheet that confirmed they had completed the controlled medication count. -LPN P had signed the verification sheet as the offgoing nurse for 12/10/24 even though her shift was not scheduled to have ended until 6:00 p.m. that night. *LPN P knew she was not to have signed that sheet as the offgoing nurse until the end of her shift after the controlled medication count was completed with the oncoming nurse. 3. Review of the first-floor east wing Shift Verification Of Controlled Substances Count sheet and interview on 12/10/24 at 10:40 a.m. with RN I revealed she: *Had signed the verification sheet as the offgoing nurse for 12/10/24 even though her shift was not scheduled to have ended until 6:00 p.m. that night. -Was not to have signed that sheet as the offgoing nurse until the end of her shift after the controlled medication count was completed with the oncoming nurse. Review of the provider's November 2017 Medication Storage and Controlled Medication Storage policy revealed 6. At each shift change or when keys are surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. 51472 B. Based on observation, record review, interview, and policy review the provider failed to accurately document that assessment of the appropriateness and safety of self-administration of medications for one of one sampled resident (59) who self-administered an inhaled medication. Findings include:: *Required assessments and documentation were completed prior to resident 59 self-administering his Ventolin HFA inhaler. *One of two sampled registered nurses (RN) (I) had administered medications prior to documenting that those medications were administered one of one sampled residents (18). Findings include: 1. Observation on 12/10/24 at 11:00 a.m. of resident 59 while in his wheelchair in the hallway revealed he: *Removed a medication inhaler from his shirt pocket. *Inhaled twice from the inhaler. *Returned the inhaler to his shirt pocket. Review of resident 59's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 11/12/24 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated he had moderate cognitive impairment. *His diagnoses included lung cancer, chronic obstructive pulmonary disease (COPD)(a group of lung diseases that block airflow and make it difficult to breathe), and dementia. *On 12/10/24 at 11:30 a.m. a physician order was entered that indicated resident 59 May keep [Ventolin HFA inhaler] at bedside. *On 4/11/24 a Ventolin HFA inhaler order was entered into the physician orders that did not include May keep at bedside in the order. *On 12/10/24 at 11:27 a.m. a Medication Self-Administration Evaluation assessment was completed. -Section four of this assessment was related to disqualifying factors for self-administration. -One of the listed disqualifying factors was Dementia or that affect their ability to self-administer. -There were no previous assessments for self-administration prior to 12/10/24. *His care plan was updated on 12/10/24 to include, May keep Ventolin inhaler at bedside and self-administer. I prefer to keep in my pocket. *There were no documented administrations or self-administrations of the inhaler in resident 59's medication administration record (MAR). 2. Observation and interview on 12/11/24 at 8:17 a.m. with resident 59 revealed: *His inhaler was in his shirt pocket. *He stated that he had been using an inhaler for two to three years. *He stated that he had had the inhaler to take on his own since he was admitted to the facility. *He stated that he was taught how to use the inhaler when he lived in a neighboring state. *When he was asked if staff had talked to him about how and when to use the inhaler since he was admitted , he replied, They might have but I cannot remember. Interview and review of resident 59's EMR on 12/12/24 at 12:00 p.m. with assistant director of nursing (ADON) E revealed: *She had entered the order for May keep at bedside, updated the care plan, and completed the Medication Self-Administration Evaluation on 12/10/24 after she had witnessed resident 59 self-administer his inhaler. *She confirmed resident 59's had a BIMS assessment score of 10 and a diagnosis of dementia. *She confirmed the Medication Self-Administration Evaluation contained a section labeled Disqualifying Factors and one of those disqualifying factors was Dementia or Alzheimer that affect their ability to self-administer. Review of the provider's 11/19/24 Self-Administration of Medications policy revealed: *If the resident has expressed a desire to self-administer, the interdisciplinary team will complete an evaluation of the resident's cognitive, physical and visual ability to carry out this responsibility. The facility may require the drugs to be administered by the nurse until the care planning team has the opportunity to obtain information necessary to make a determination on resident's ability to complete the task. *Evaluations will be completed Quarterly, with change of condition, annually and prn [as needed]. *If the resident is deemed capable to self-administer medications, then the drugs will be stored in a locked box in the resident's room, unless otherwise determined by the interdisciplinary team. *Nursing staff will be responsible for recording self-administration doses in the resident's medication administration record, unless otherwise determined by the interdisciplinary team. 3. Observation on 12/12/24 at 8:40 a.m. of RN I while administering resident 18's medications revealed: *Resident 18 had twelve oral medications and one nasal spray scheduled to be administered. *RN I compared the medication cards to the resident's MAR as she prepared the medications for administration. *She selected the Y [yes] in the MAR as she removed the medications from the cards and bottles. *She signed that she had administered those medications in the MAR. *She then took those medications to resident 18's room and administered the medications. Interview on 12/12/24 at 1:45 p.m. with director of nursing (DON) D revealed she expected medications to be administered to residents prior to staff signing that the medications had been administered. Review of the provider's 9/18 Medication Administration policy revealed The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.

Based on observation, interview, record review, policy review, and manufacturer's recommendation review the provider failed to ensure the following: *A topical pain medication was applied according to the manufacturer's recommendation for three of three sampled residents (18, 20, 22, and 37) by two of two staff members (RN G and UMA K.) *A nasal spray was administered per the physician's order to one of one sampled resident (18) by one of one RN I. *A nebulizer treatment was administered per the physician's order to one of one sampled resident. *A topical powder was applied to one of one sampled resident (54) without a physician's order. Those observations created a medication error rate of 18.75%. 1. Observation and interview on 12/11/24 from 1:00 p.m. through 1:30 p.m. of RN G during medication administration revealed: *She administered diclofenac sodium external gel 1% (for arthritis pain and inflammation) to resident 20's knees. -The order on the medication administration record (MAR) indicated she was to receive four grams. *She identified that there was a measurement device that was to be used to determine the correct dose, but she did not use it. *She dispensed an unknown amount of gel into a medication administration cup. *She administered diclofenac sodium external gel 1% to resident 22's knees. -The order on the MAR indicated that the medication was to be applied to her knee four times a day as directed. -There was no dose included in the medication order. *She did not clarify the dose with the provider prior to administering it. Observation on 12/11/24 at 4:53 p.m. of the medication pass with UMA K revealed: *She administered diclofenac sodium 1% gel to resident 37's lower back. -The order on the MAR indicated four grams were to be administered. *She did not use the measurement device to determine the correct dose. *The measurement device remained secured to the inside of the box the diclofenac was in. *The tube of diclofenac was partially used prior to that administration. Observation and interview on 12/12/24 at 8:40 a.m. of a medication pass with RN I revealed: *She administered Flonase 50mcg (micrograms)/act two sprays in each of resident 18's nostrils. *The order on the MAR was to administer 1 spray in each nostril twice daily. *She indicated that she had given more Flonase than what was ordered to resident 18. Interview on 12/12/24 at 11:11 a.m. with UMA L revealed: *The measuring device that was included in the box with the diclofenac sodium 1% gel was to be used to determine the dose of the gel to be administered. *He agreed the measurement device remained secured to the diclofenac sodium 1% gel box that was pulled from the medication cart. *He agreed the tube in the box was partially empty. *He indicated that some staff members do not use the device when they administer the medication. Interview on 12/12/24 at 1:45 p.m. with director of nursing (DON) D revealed it was her expectation: *That the measurement device in the diclofenac sodium 1% gel be used to determine the dose of the medication prior to administration. *That the correct dose of medication be administered. Review of the manufacturers' 2/22 recommendations for the diclofenac sodium 1% gel revealed: *Under the heading Measuring the correct amount using the dosing card. -The direction for dose measurement was Squeeze gel from the tube equal to the length shown. Review of the provider's 9/18 Medication Administration policy revealed: *Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices. *Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. 47780 2. Observation on 12/11/24 at 7:59 a.m. revealed resident 29's nebulizer medicine cup was sitting on her bedside table and contained a clear liquid. Review of resident 29's MAR revealed her morning nebulizer treatment was documented as administered. Interview on 12/11/24 at 11:20 a.m. with resident 29 revealed she: *Had not received her morning nebulizer treatment. *Stated she had been busy during the morning and when she returned to her room, she could not reach the button to start her nebulizer treatment. Interview on 12/11/24 at 11:32 a.m. with director of nursing (DON) D in resident 29's room revealed: *Resident 29 had told DON D she had not had her morning nebulizer treatment. *DON D confirmed the clear liquid in resident 29's nebulizer medicine cup was her morning nebulizer treatment. Continued interview on 12/11/24 at 11:37 a.m. with DON D revealed: *She confirmed resident 29's morning nebulizer treatment was documented as administered. *Her expectations of staff were to fill the nebulizer medication cup when the resident was ready for the treatment and hand the nebulizer treatment to the resident. After the resident was finished with the nebulizer treatment, the staff were to clean the mask and the medicine cup. 51816 3. Observation and interview on 12/10/24 at 11:56 a.m. with resident 54 while in her room revealed: *She was lying in bed covered with a blanket. *She stated she sleeps a lot in the mornings and is tired. *She stated she had a skin concern under [her] tummy. Interview on 12/11/24 at 7:49 a.m. with RN N regarding resident 54's skin revealed: *She stated resident 54 has a severe yeast infection in her groin area, under her breasts, and her left underarm area. Observation on 12/11/24 at 8:23 a.m. of RN N while providing skin care to resident 54 revealed RN N applied Nystatin powder to resident 54's groin area and left underarm area. Review of resident 54's electronic medical record (EMR) revealed there was no current physician's order for Nystatin powder. Record review, observation, and interview on 12/11/24 at 2:11 p.m. with RN N regarding resident 54's Nystatin powder administration revealed: *She was unable to locate an area in resident 54's EMR to document the administration of the above medication. *The label on the bottle of Nystatin said to Reorder after 12/9/24. -She stated when it gets down to here, while pointing at the bottom quarter of the bottle, I'll reorder it. Interview on 12/11/24 at 2:20 p.m. with RN N revealed she had called resident 54's physician and had received an order for Nystatin powder. Interview on 12/12/24 at 12:36 p.m. with DON D regarding medication administration of Nystatin powder for resident 54 revealed: *Her expectation was for all medications to have a current physician's order prior to administration. *She agreed resident 54's Nystatin powder should not have been administered without a current physician order. 43844

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (68) who received an antibiotic for a potential urinary tract infection (UTI) had met clinical criteria for the use of that antibiotic. Findings include: 1. Review of resident 68's electronic medical record revealed: *Her diagnoses included diabetes, peripheral vascular disease, depression, insomnia, and anorexia. *A 12/4/24 medical provider progress note. Chief complaint: nursing requested to see pt [patient] - mood changes. Nursing note in hucu: [an electronic communication used by facility nursing staff to communicate with the medical provider]. Please add to schedule regarding depression . Intakes are 0-25% and 7 refused meals poss [possibly] d/t [due to] depression. Mirtazapine [an anti-depressant sometimes used as an appetite stimulant] dose increased. *A 12/6/2024 Health Status Note entered at 11:25 a.m.: Bath aid told this nurse to go look at residents floor. Nurse entered room and white milky urine was on floor from resident. Complains of dysuria [pain or discomfort when urinating] and has not been acting like herself. Low appetite. New order obtained to collect UA [urinalysis]. -The resident's last documented vital signs were 11/15/24. There was no description of what not acting like herself had meant. A diminished appetite, weight loss, and mood changes were not new symptoms for the resident. *A 12/6/24 medical provider progress note: Visit Type: Acute. Chief complaint: Nursing requested to see pt - recheck weight and UA order. History of present illness: Nursing note in hucu: Milky urine noted again. Complaints of dysuria. Acting not like herself. -The medical provider ordered: Labs-UA with micro; reflex to culture, can straight cath [a thin, flexible tube used to drain urine from the bladder] if needed, CBC [complete blood count], BMP [basic metabolic panel]. -Start cefdinir [an antibiotic], 300 mg PO [by mouth] BID [twice daily] x 7 days for potential UTI [urinary tract infection]. -Recheck 12/09/24 to review labs. *A Medication Administration Note on 12/6/24 at 11:15 p.m. regarding the physician's order that indicated Unable to obtain (the UA). *A 12/8/24 Infection Note: Resident continues oral antibiotic therapy for UTI, no adverse reaction to medication noted. UA to be collected this evening for C & S. No c/o pain or discomfort. Continue to monitor. *A 12/9/24 provider progress note indicated the resident's UA was not obtained and an antibiotic had already been started for a potential UTI. Will DC [discontinue] UA and continue to monitor. The resident was stable and looked to be improved. Interview on 12/11/24 at 1:20 p.m. with licensed practical nurse (LPN) F regarding documentation of the nurse assessment and reporting of a suspected UTI to the medical provider revealed a progress note such as the 12/6/24 Health Status Note was used. Interview on 12/11/24 at 4:15 p.m. with assistant director of nursing (E) regarding the nurse assessment and communication tool used by nursing staff to report to a medical provider a resident suspected of having a UTI revealed: *An Agency for Healthcare Research and Quality Suspected UTI SBAR (Situation, Background, Assessment, and Recommendation) form was expected to have been completed by the nurse. -A copy of that form was found at the first floor nurses' station but not found at the second floor nurses' station. Interview on 12/11/24 at 1:10 p.m. with infection preventionist (IP)/LPN T regarding resident 68's potential UTI revealed: *There was no documentation to support: -Why the medical provider's order for a UA was unable to have been obtained. -If any other attempts had been made to collect the resident's urine sample. -If the resident's medical provider was notified regarding the inability to have obtained a UA. -A UTI SBAR form was completed by the nurse upon suspecting the resident had a UTI. -The antibiotic ordered and administered to resident 68 for a suspected UTI had met clinical criteria for use without an appropriate clinical assessment completed by a nurse or a UA having been completed. Review of the 12/7/24 McGeer Criteria for Infection assessment and interview on 12/11/24 at 4:30 p.m. with IP/LPN T revealed: *She had completed that assessment. *Both specific signs and symptoms of a UTI and microbiological criteria were required to support a UTI diagnosis according to that assessment. The assessment indicated resident 68 had met both of those criteria. -IP/LPN T had incorrectly documented that microbiological criteria was met. Review of the provider's revised 2/20/24 Antibiotic Stewardship Program policy revealed: *It is our Mission to implement an Antibiotic Stewardship Program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (26 and 51) had their care plans followed, updated, and revised promptly to reflect their current status and care needs. Findings include: 1. Interview on 12/12/24 at 10:46 with unlicensed medication aide L and certified nurse aide (CNA) R regarding resident 26 revealed: *Resident 26 was blind in one eye. *This time of year, is hard on resident 26. -She raised her grandchildren and wants to do things for them that she is not able to do. *Resident 26, at times, gets out of line verbally. -When that happens staff would get the nurse or director of nursing to assist them. -Her personal care was provided with two staff members present. *CNA R stated they find information in the resident's Kardex (an electronic summary of a resident's care needs), and the CNA's trained each other on how to care for the residents. Interview and record review on 12/12/24 at 11:04 a.m. with social service director U regarding resident 26 revealed: *Resident 26 was usually very kind and there are times when she is not so kind to some staff. *After reviewing resident 26's care plan interventions for her behaviors she agreed the non-pharmacological (excludes medications) interventions were not listed. *The process to review and update care plans was an interdisciplinary process (involves more than one) process. -She was responsible for updating the behavior area of the resident's care plans. Interview on 12/12/24 at 11:18 a.m. with registered nurse (RN) Q regarding resident 26's behaviors revealed she stated the interventions included cares in pairs, so two staff go in [to care for resident 26] at all times. Review of resident 26's 12/12/24 care plan revealed: *She had a history of manipulative behaviors and false accusations. *The interventions for her manipulative behaviors and false accusations included Non-pharmacological interventions but there were no specific non-pharmacological interventions listed. 2. Review of resident 51's medical record revealed: *He was admitted on [DATE]. *His diagnoses included vascular dementia and stroke. *His physician orders included: -Eliquis (a blood thinner medication) 5 milligrams (mg) by mouth twice daily for irregular heartrate. -Aspirin 81 mg one time a day. Review of resident 51's 12/11/24 care plan included: *A 2/6/24 revised focus area of I am on Antiplatelet therapy [prevents blood platelets from clumping together into a blood clot]/ASA (aspirin) and Plavix related to Cerebrovascular Disease. -A 6/21/23 intervention to Monitor/document/report to MD [medical doctor] as needed signs/symptoms of antiplatelet complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB [shortness of breath], Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s [vital signs]. Interview on 12/12/24 at 11:17 a.m. with RN Q regarding resident 51's medications revealed: *Eliquis and Plavix were not the same medication. *Eliquis required more labs and blood monitoring than Plavix would. *Resident 51 was prescribed Eliquis and not Plavix, his care plan indicated he was taking Plavix. Interview on 12/12/24 at 12:28 p.m. with director of nursing (DON) D regarding resident 51's medications revealed: *Plavix is an anti-platelet medication. *Resident 51 was taking Eliquis. -Eliquis did not require routine lab work. *The care plan process was for the interdisciplinary team to work together to develop and revise the resident's care plans. -The Minimum Data Set nurse would initiate the resident's care plan related to medications. -Medications were not typically specified on the care plan as medications could change. *Her expectation was for the resident's care plan to be updated as the resident's care and needs changed. Review of the provider's 9/30/24 Care Plan policy revealed: *Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. In doing so, the following considerations are made: -Each resident is an individual. The personal history, habits, likes and dislikes, life patterns and routines, and personality facets must be addressed in addition to medical/diagnosis-based care considerations. -Care planning is constantly in process; it begins the moment the resident is admitted to the facility and doesn't end until discharge or death. *Interventions act as the means to meet the individual's needs. The recipe for care requires active problem solving and creative thinking to attain, and clearly delineates who, what, where, when, and how the individual resident goals are being addressed and met. Assessment tools are used to help formulate the interventions (they are not THE intervention). *Care Plans should be updated between care conferences to reflect current care needs of the individual resident as changes occur. 51816

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, record review, and policy review, the provider failed to ensure one of two facility operated buses had functional straps to safely secure one of one sampled resident's (26) wheelchair while being transported from another location. Failure to ensure the straps were functional and the wheelchair was safely secured potentially placed the resident at risk for harm or injury. This citation is considered past-non-compliance based on a review of the corrective action the provider implemented following the incident. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 26 revealed: *On 10/19/24 at 1:30 p.m. resident 26 was being transported from a dialysis appointment to the facility on one of the provider's buses. -During that transport, the driver of the bus had looked in the rear-view mirror and noted the resident to be tilted backward in her wheelchair. -Upon his assessment of the wheelchair, he noted one of the front clamp straps, that was used to secure the wheelchair, was extended. -It was explained that the tie-down system is supposed to automatically tighten when the strap begins to loosen from normal bumps of the bus. The tie-down had not done that. -The facility initiated a tie-down inspection to be completed daily as a part of the daily bus inspections to ensure proper functioning. The provider implemented actions to ensure the deficient practice does not reoccur was confirmed after review revealed the provider had: *Removed the non-functioning tie-down strap. *Purchased a new strap. *Provided education to the bus drivers regarding the use of the tie-down straps and how to inspect them to ensure they were functioning properly. *Implemented a documented daily inspection process for the buses and functionality of the strap. *Assigned a bus driver to a lead' position to be responsible for communicating any maintenance requirements to the bus driver's supervisor. *Completed audits to ensure the daily inspection forms were being completed. *ensured their audits were presented at the next Quality Assurance meeting. *Followed their quality assurance process. Based on the above information, non-compliance at F689 occurred on 10/19/24, and based on the provider's implemented actions on 10/29/24 for the deficient practice it was confirmed on 12/12/24 the non-compliance is considered past non-compliance.

Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure adequate pain management for one of one sampled resident (1) who inflicted harm to himself that required surgical treatment at a hospital. Failure to assess and provide adequate pain control may have contributed to resident 1's action of self-harm. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the SD DOH FRI regarding resident 1 revealed: *He had inflicted a stab-wound to his abdomen on 5/4/24. *He stated, I do not want to be here, and I am not getting what I want so I stabbed myself with a piece of that picture I broke. *He was transferred to the hospital and had surgery to his self-inflected stab wound to his abdomen. Interview on 5/13/24 at 3:22 p.m. with administrator (ADM) A and director of nursing (DON) B regarding the incident involving resident 1 above revealed: *During the provider's investigation into the incident involving they found non-compliance in the pain management process including: -Pain documentation. -Providing pain medication without documenting it. -Accurate completion of pain assessments. Review of Resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *On 5/4/24 he discharged to the hospital for surgical treatment of his self-inflicted wound. *His 5/1/24 Brief Interview of Mental Status score was a 14, which meant he was cognitively intact. *His 5/1/24 PHQ-9 score was a 00, which meant he had no signs or symptoms of depression. *His diagnosis included: Systemic Inflammatory Response Syndrome of Non Infectious Origin, Cerebral Infarction, Retention of Urine, Rheumatoid Arthritis, Arterial Embolism and Thrombosis of Abdominal Aorta, Contusion of Left Front Wall of Thorax, Obstruction and Reflux Uropathy, and hemorrhoids. *He had physician orders for the following pain medications: aspirin, clopidogrel bisulfate, hydrocortisone acetate rectal suppository, Plaquenil, prednisone, and Tamsulosin. *An order for 625 milligrams (mg) of Tylenol, as needed, every six hours for pain in his back and legs was added on 5/4/24. -There was no documentation that the Tylenol had been administered. Interview on 5/15/24 at 9:16 a.m. with DON B regarding standing orders and resident 1's pain revealed: *Standing orders for pain control were not always put in a resident's EMR when they were admitted . *A standing order for Tylenol for pain control for resident 1 was implemented prior to 5/4/24 by a licensed nurse. -That nurse had not entered the standing order for Tylenol in his electronic medical record (EMR). -The nurse that implemented the order should have entered the standing order into his EMR and documented the Tylenol she had given him. *Their medical director had reviewed their process and changed it to include: -The admitting nurse would enter standing orders for pain upon each resident admission. -On day two of a resident admission, a physician assistant would visit the resident and ask the resident which pain medication worked best for them. --That pain medication would then be ordered for the resident. *Staff were educated on the new process for standing orders on 5/5/24. *The Pain Assessment was updated on 5/1/24. -The previous medication administration (MAR) pain assessment included Pain Assessment: Numeric Scale (0=no pain; 1 to 3 = mild pain; 4-7 = moderate pain; 8-10 severe pain) or PAIN AD [scale to assess pain for people with advanced dementia] every shift. --There was an area to document the pain level and if it was on the day or evening shift. -The current MAR pain assessment included Pain Eval or PAINAD q [every] shift (0=no pain; 1 to 3 = mild pain; 4-6 = moderate pain; 7-9 severe pain; 10 excruciating. Ask if pain is acceptable, if yes, then no further action, if no provide non-harm interventions (cold/warm wash cloth, massage, distractive activities, reposition, etc.) or ordered analgesic medications. If interventions not effective, then notify MD [medical doctor]. --There was an area to document the pain level and if it was the day or evening shift. *She was unable to determine if the nursing staff understood the question on the revised 5/1/24 Pain Assessment and was documenting a resident's pain level correctly. -She provided education on the assessment of pain and documentation of pain after the incident. Review of resident 1's pain level documentation revealed his pain level score using a scale of 1-10 with 10 being excruciating pain revealed: *On 5/1/24 the score was a 5. *On 5/2/24 the score was an 8. *On 5/3/24 at 8:30 a.m. the score was a 0, there was no score recorded for the second (evening/night) shift. *On 5/4/24 at 2023, the score was an 8. *On 5/4/24 at 22:27, and 5/4/24 at 22:53 the score was a 10. *There was no documentation to support any interventions were provided to relieve his pain. Review of resident 1's 5/1/24 MAR revealed there was no documentation of Tylenol given from 5/1/24 through 5/4/24. Review of resident 1's 5/1/24 registered nurse assessment revealed: *He had pain or hurting at anytime in the past 5 days. *His pain was almost constantly and included stomach pain, bruised ribs, and rheumatoid arthritis, and he had no pain with therapy. *He rated his pain as a score of 5 out of 10. Review of resident 1's nurses progress notes revealed: *On 5/1/24 he was having pain at a score of 9 or 10, and He is seeking percocet [Percocet, a pain medication] and that he is leaving this facility is he is not given a Percocet immediately .Resident became frustrated with our policy and procedure and states that he is going to call 911 and possibly discharge asap [as soon as possible] .APAP [an abbreviation referring to acetaminophen, a very common pain-relieving - drug] administered per prescription orders. *On 5/2/24 After speaking with resident and his family, they remembered that the pain medication he takes for his arthritis is prednisone, not Percocet. Prednisone is already scheduled per order. Review of resident 1's 4/30/24 care plan revealed: *A focus that he was at risk for pain. *The goal for this focus, states that level of pain is tolerable or has relief with interventions. *The interventions included: -Evaluate efficacy of pain management. -Notify MD if inadequate pain relief. -Provide analgesic as ordered. -Utilize non-pharmacological intervention [specify e.g. massage, repositioning, distractive activities, cold/warm wash cloth, music, snacks, journaling, other, etc. --The interventions did not specify which of those non-pharmacological interventions worked for him. Interview on 5/15/24 at 10:15 a.m. with certified nursing assistant (CNA) D regarding residents' pain revealed: *When a resident would report they had pain to her, she would: -Notify the nurse. -Offer the resident a warm towel or ice pack. Interview on 5/15/24 at 10:22 a.m. with CNA E regarding residents' pain revealed: *When a resident would report they had pain to her, she would: -Ask where the pain is and the level of pain they are having. -Notify the nurse and provide her this information. -Offer to reposition the resident. Interview on 5/15/24 at 10:30 a.m. with registered nurse (RN) C regarding residents' pain revealed: *She assessed residents for pain, including asking where the pain was and how often the pain occurred. -She then checked their MAR to see what medication the physician might have ordered. -When they did not have an order for pain medication, she would administer the standing order for Tylenol. --When the standing order for Tylenol was not pre-loaded into a residents' MAR she would have to add it. *There had been lots of education on pain recently. *Resident 1 had not volunteered information regarding his health, she had to pull it from him. -She thought he had a flat effect. Review of the provider's 3/23/23 Pain Management Policy revealed: *The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. *'Pain Management' is defined as the process that includes the following: -a. Assessing the potential for pain; -b. Effectively recognizing the presence of pain; -c. Identifying the characteristics of pain; -d. Addressing the underlying causes of pain; -e. Developing and implementing approaches to pain management; -f. Identifying and using specific strategies for different levels and sources of pain; -g. Monitoring for effectiveness of interventions; and -h. Modifying approaches as necessary. *Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: -Rheumatoid arthritis -Constipation *Pain management interventions shall be consistent with the resident's goals for treatment. Such goals will be specifically defined and documented. *Pain management interventions shall reflect the sources, type and severity of pain. *Strategies that may be employed when establishing the medication regimen include: -Combining long-acting medications with PRNs [as needed] for breakthrough pain. *Implement the medication regimen as ordered, carefully documenting the results of the interventions. *Report the following information to the physician or practitioner: -Significant changes in the level of the resident's pain. Review of the provider's 5/18/21 Following Physician Orders policy revealed: *If the order is for a medication or treatment, it should be entered in the MAR/TAR [medication administration record/treatment administration record]. Review of the provider's Standing Orders policy revealed the following: *Only licensed nurses implement standing orders. Professional judgment is used in the initiation and administration of standing orders. *Documentation of the situation requiring the use of standing order is placed in the nursing notes section of the resident's medical record prior to initiation of the order. Interview on 5/15/24 9:57 a.m. DON B regarding a documentation policy revealed: *They used nursing standards which included if something was not documented [it was] not done. *The reference source for nursing standards was The standard of Fundamental of nursing 10th edition [NAME]. Continued interview on 5/15/24 at 11:39 a.m. with DON B revealed: *The provider did not have a policy specific to entering standing orders upon admission. -She stated this was an internal process and no policy was required. The provider implemented systemic changes to ensure the deficient practice does not recur by having: *Provided education for all nursing staff that included: -Assessing a resident for pain, including pain level, location of pain and to do full pain assessment. -Documenting this assessment, give pain meds as ordered and notify the residents physician. -Tylenol was a standing order and must be put into PCC [the electronic medical records system] if not already there, after ensuring no allergy to Tylenol. -If Tylenol did not relieve pain the nurse MUST call the provider and notify them. -All interventions must be documented in the electronic medical record and Progress Notes. --Non-pharmacological interventions need to be attempted and documented. -Pain management policy. -Pain Numeric Rating Scale or PAINAD Order Directions. -Following Physician Orders. -Standing Orders policy and process. *Initiated audits for newly admitted residents to ensure they had pain medication ordered or a standing order for Tylenol entered into their MAR, documentation of PRN (as needed) medication and follow-up completed for those PRN medications. *Initiated a performance improvement project (a concentrated effort to improve care or services in a facility area that needs improvement). *Initiated the above items into their Quality Assurance Program Improvement. Based on the above information, non-compliance at F697 was determined, and based on the provider's implemented corrective actions for the deficient practice, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of four sampled residents (59) who had been identified at risk for pressure ulcers had interventions in place timely to prevent pressure ulcer development. Findings include: 1. Observation on 6/26/22 at 6:30 p.m. of resident 59 revealed he: *Was residing on the COVID-19 unit. *Was sitting in his wheelchair, and had foam boots on both feet. Observation on 6/28/22 at 4:45 p.m. of resident 59's dressing change revealed: *He was on the bed with foam boots on both feet. *He was placed on his left side, dressing changed to his right, and left buttock by wound care/unit manager D. -Wound care/unit manager D cleansed, and measured wound. --She stated wound was getting better with less drainage then previous. *He was placed on his back. *Foam boots were removed, and heels cleansed and measured. -Heels were dry and cracked. -She applied [MEDICATION(S)] to bilateral heels. Interview on 6/28/22 at 4:45 p.m. with wound care/unit manager D regarding wound care and resident 59 revealed: *She had never been a wound care nurse before. *She started training for wound care in March. *She had been on her own since May. *She assessed and measured wounds weekly. *She was unaware that his sensory in the peri area was so low. Review of resident 59's medical record revealed: *He was admitted on [DATE]. *His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *His 5/26/22 Nursing-Admission revealed: -His Braden scale for predicting pressure sore risk indicated he was at risk for developing a pressure ulcer. -He was incontinent of bladder. *He had skin evaluations on 5/26/22, 6/2/22, 6/9/22, 6/16/22. *On 5/26/22 skin was assessed as normal, pale, elastic and sacrum redness. -Interventions listed in care plan were: --To keep skin clean, dry and apply lotion to dry skin. --Turn and reposition every two hours and as needed. *On 5/29/22 in progress notes under health status Excoriation/shearing noted to left buttock. Dressing has been in place but due to incontinence it was removed and barrier cream applied with each brief change. He has been encouraged to off load and reposition frequently. *On 6/1/22 skin/Wound note revealed left buttock was open and measured 2.5 cm (centimeters) x 2 cm. -Fax sent to provider on 6/2/22. *On 6/2/22 Skin evaluation indicating resident has: -Excoriation with opening to left buttock. --No measurements given. -Stage 2 pressure to left heel (2 in length x 3 in width and 0 depth). -Deep tissue injury (blister) to right heel (2.5 length x 4 width x 0 depth). *On 6/2/22 skin/wound note stated that left buttock open area measured 2.5 cm x 2 cm. *On 6/2/22 Minimum data set (MDS) note stated No skin concerns. Has a pressure redistributing mattress on his bed and cushion in his w/c. *On 6/3/22 MDS note revealed: -He is frequently incontinent of bowel and bladder. -New skin concerns with stage 2 PU (pressure ulcer) on Lt (left) heel and DTI (deep tissue injury) on Rt (right) heel. *On 6/3/22 order signed for [MEDICATION(S)] to left buttock, Batadine to right heel, and wound care to evaluate and treat left heel stage 2 wound. Foam heel protectors on at bedtime. *On 6/4/22 recommendations from registered dietitian to have Ensure clear twice a day (BID), 30 ml Prostat BID. *On 6/6/22 resident agreed to wear foam boots at all times, with white socks with one pair of gripper socks on top of white socks. *On 6/9/22 skin evaluation revealed: -Left buttock, red, barrier cream applied, wound care nurse notified. --No measurements given. -Right buttock, red, barrier cream applied, wound care nurse notified. --No measurements given. -Left heel, breakdown, under care of facility wound care nurse, foam boots worn at all times. --No measurements given. -Right heel breakdown, under care of facility wound care nurse, foam boots worn at all times. --No measurements. *On 6/9/22 order entered for: -Foam boots on at all times. -Low air loss mattress due to wound noted to left buttock and bilateral heels. -Med pass 4 ounces in between meals two times a day. -Ensure 237 ml (milliliter) two times a day. *On 6/10/22 task for turn and reposition every two hour had been started. *On 6/10/22 order note revealed: -Wound care to left buttock was to apply Santyl to wound bed, cover with calcium alginate and secure with border foam dressing. -Wound to left buttock had worsened to unstageable pressure sore. -Will continue to follow wounds at the facility with weekly measurements and wound assessments. *On 6/15/22 Skin/Wound note revealed: -Wounds had worsen since last weekly wound assessment. -He had an unstageable on the right buttock. -His left buttock had not improved. -Will be requesting referral for outpatient wound care. *On 6/16/22 skin evaluation revealed: -Coccyx and type was pressure. --No measurements. -Right heel and type is DTI. --No measurements. *On 6/17/22 Order to schedule outpatient wound care. -Outpatient wound care appointment was set for 7/11/22 at 10:00 a.m. *Wound assessments revealed: -On 6/15/22 right buttock was identifed and measured 2.40 x 0.50 x 0.0. --Left buttock was identified on 5/31/22 and measured 7.5 x 3.5 x 0.0. -On 6/23/22 left buttock measured 7 cm x 2 cm x 0 (length x width x depth). -On 6/28/22 left buttock measured 5.5 x 1.5 x 0.5. --Left ischial tuberosity was identified on 6/21/22 and was closed. --Right buttock measured 1.5 x 0.30 x 0.0. --Right heel was identified on 6/2/22. It measured 0.90 x 1.0 x 0.0 --Left heel was identified 6/2/22 and was closed. *Plan of care on 5/26/22 revealed: -That he was at risk for alterations in bladder due to frequent incontinence. --Intervention for incontinence is to apply moisture barrier to the peri area after incontinence episode. --No other interventions in place for incontinence. Interview on 6/29/22 at 11:55 a.m. with director of nursing C regarding evaluating skin of residents revealed: *Upon admission a Braden Scale (an assessment used for predicting pressure ulcer risk) was completed and then again once a week for four weeks. *A resident who had a high score on the Braden scale was reviewed in the morning clinical meeting and interventions were discussed. *Interventions should have been started immediately. *A skin evaluation was completed every seven days for all residents. *When a pressure injury or skin issue was found, the nurse who found the issue should do a wound alteration evaluation and the wound nurse was notified. *The wound nurse would follow up on the issue. Review of provider's updated 4/2021 skin program policy reveals: *A plan of care (POC) will be put into place for resident that are identified with actual skin breakdown or at-risk for skin breakdown. *Nursing personnel will utilize the results of the physical exam and the pressure injury Assessment tools to determine an individualized pressure injury prevention program for each at-risk resident. This will include interventions to: a) Protect the skin against the effects of pressure, friction and shearing, b) Protect skin from moisture, c) Encourage optimal nutrition and fluid intake, d) Educate staff, resident and families, e) Train front-line caregivers, and f) Immediate prevention plan instituted when potential areas are identified. *POC to include: Impaired mobility, Pressure relief, Nutritional status and interventions, Incontinence, Skin condition checks, Treatment, Pain, Infection, Education of resident and family, Possible causes for pressure injury and what interventions have been put into place to prevent. Skin checks to be completed at least weekly by a Licensed Nurse.

Based on observation, interview, record review, job description review, and policy review, the governing body failed to make certain: *The facility was managed in a manner that ensured the safe management and overall well-being for all eight-nine residents in the facility. *Necessary resources were available and being used for staff to provide for and meet the needs of the individual resident(s). Findings include: 1. The following deficiencies were: *Repeated deficiencies from the previous recertification survey on 2/11/16: F280 and F281. *Repeated deficiencies from the complaint survey on 9/28/16: F280, F281, F441, and F514. *Newly cited deficiencies for the current complaint survey: F224, F314, F490, and F520.

Based on observation, interview, record review, and policy review, the provider failed to ensure an effective quality assurance (QA) program had been implemented and followed through for resolution for identified deficiencies and to develop and implement corrective actions for all residents. Findings include: 1. Phone interview on 1/5/17 at 10:20 a.m. with the medical director revealed: *He had just taken on the medical director role at the beginning of December. -That was his first time being a medical director for a nursing facility. *He stated he had not been aware of the survey concerns that had been found the week before. *He had attended the 12/20/16 quality assurance performance improvement (QAPI) meeting and planned to continue to attend monthly. *He confirmed he would like to be involved with improving the quality of care and services for the residents. Interview on 1/5/17 at 3:30 p.m. with the administrator, director of nursing (DON), assistant director of nursing (ADON), and field service care director (FSCD) revealed: *The QAPI committee had monthly meetings. *The QAPI committee consisted of the administrator, DON, ADON, FSCD, medical director, and a respresentative from each department of the facility. *The interdisciplinary department team would meet prior to QAPI and would have reviewed items of concern to be addressed or reviewed. *Had been aware of concerns with pressure injuries and wounds. *They had been working on staff retention, reducing turnover, reducing the amount of temporary staff they needed, and hoping to get more consistent staffing since he had started. -Staff turnover had gone down. *They had ADHOQ meetings which was a subpart of QAPI and at those meetings they: -Reviewed new issues or concerns. -Attempted to fix those concerns prior to the monthly QAPI meeting. -Would have taken those concerns to the monthly QAPI meeting for an action plan if they could not fix the issue. *Other areas reviewed at the QAPI meetings had been the following: -Corporate template. -Casper reports. *They had been aware of conerns with pressure injuries and infection control. -Those issues had not been discussed at length or reviewed at the QAPI meetings. *Infection control: -Reviewed immunizations only during the QAPI meetings. -Had not reviewed any tracking or trending concerns regarding the multi-drug resistant organisms (MDRO) history and concerns in the facility. -Had not identified carbapenem-resistant [MEDICATION NAME] (CRE) as an issue of concern for the QAPI team to review and develop an action plan. *Only the number of pressure ulcers had been reviewed at the QAPI meetings. -Those pressure ulcers had not been identified as an area of concern for developing an action plan. *They agreed they talked a lot about things in QAPI and more needed to have been done to address those areas of concerns for improvement to occur. Review of the provider's August 2014 QAPI Committee Guideline revealed The QAPI committee monitors and sustains Living Center operational performance in clinical and nonclinical systems through self identification and improvement in areas where opportunities for improvement (OFIs) have been identified. Refer to F224, F280, F281, F314, F441, F490, F493, and F514.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being of all eight-nine residents. Findings include: 1. Interviews, observations, record reviews, and policy reviews, throughout the course of the survey revealed the administrator and the director of nursing had not ensured the safe management and overall well-being of the residents. Review of the provider's 10/14/15 job description for the administrator revealed: *To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's business objectives. Serve as a mentor to guide and support all other assigned facilities. *Leads the facility management staff and consultants in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments. Monitors each department's activities, communicates policies, evaluates performance, provides feedback, and assists, observes, coaches and disciplines as needed. *Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; moral of the staff; and ensures resident needs are being addressed. *Ensures consultants and other support resources are appropriately utilized and a high level of interdepartmental teamwork is maintained. *Utilize the quality improvement process in all areas of facility operation. Review of the provider's 4/5/12 job description for the director of nursing (DON) and nurse consultant I revealed: *Plans, coordinates and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to residents. Maintains quality care that is consistent with company and regulatory standards. Assumes responsibilities of daily operations in the absence of the Executive Director. *Oversees the nursing staff for the provision of quality and appropriate resident/patient care that meets or exceeds company and regulatory standards. *Maintains regular and ongoing communications with the living center's Medical Director to identify educational needs for staff and provide quality care and services to meet the needs of the residents. *Manages clinical aspects of state or federal government survey processes. *Attends the weekly 'at risk' meeting and reviews modifications to residents' and patient's plan of care. *Collects, review and analyzes clinical outcome date and determines trends. Brings identified concerns to the QA&A committee for developing appropriate plans of action. Review of the provider's 8/1/13 Field Services Clinical Director job description revealed: *Acts as a resource to provide clinical assistance and education within assigned area of responsibility. Collaborate with Team Members in identifications of clinical priorities in assigned area and development of strategy. *Assist with managing urgent high risk events. *Assist LivingCenter leadership to turn around serious regulatory issues. *Assist in implementation of new clinical trainings or programs. *Assist with resources for training when new clinical complexities present for admission. *Participates in education and implementation of new company initiatives including new evidence-based practices. *Supports development of Quality Assessment Performance Improvement (QAPI) process. *Respond with urgency and communication when identified care issues are noted. *Regularly communicate to Team Members on matters related to compliance, patient liability, adverse events, and regulatory issues. Interview on 12/29/16 at 9:30 a.m. with the DON regarding resident care concerns revealed: *She felt things starting declining in October when they had a large number of admissions and discharges of residents. *There were a lot of staff let go around that time due to budget cuts. *She stated she only had three weeks of training, and then all the corporate resources were sent to help another facility in town. *She had a traveling DON with her from February 2016 to around May 2016 to assist her but did not feel she had been prepared for all the areas her role encompassed. *She confirmed certified nursing assistants (CNA) had not received report from the nurses at the change of shift. -There was a problem with communication between the CNAs and the nurses. -She expected the nurse to inform the CNAs of resident changes that occurred during the shift. -She expected the CNAs to inform the nurse of resident changes they had noticed during their shift as well. *Related to the resident infections she stated: -The department of health (DOH) had staff come in to conduct staff education recently on 11/22/16. --Departments heads, maintenance, and housekeeping had attended that meeting. --No direct care staff (nurses and CNAs) had attended that meeting they never do. -There was no documentation to show the direct care staff had received that infection control training from the DOH, but they had been informed of the processes by her after that training meeting. -There had not been any audits done of direct care staff performing care for residents with infections to ensure they had done so properly. Phone interview on 1/5/17 at 10:20 a.m. with the medical director revealed: *He had just taken on the medical director role at the beginning of December 2016. -That was his first time being a medical director for a nursing facility. *He stated he had not been aware of the survey concerns that had been found the week before. -He was disappointed the administration had not called and notified him. *Survey concerns of resident neglect related to repositioning, toileting, and personal hygiene, along with infection control practices, pressure ulcers and other areas were discussed. -He stated the information is disturbing. -He had seen some of it from his working at the hospital and noted clear neglect concerns. *He had attended the 12/20/16 QAPI meeting and planned to continue to attend monthly. *He confirmed he would like to be involved with improving the quality of care and services for the residents. Interview on 1/5/17 at 11:30 a.m. with the FSCD regarding her role and the survey concerns revealed she: *Had been aware of some of the concerns prior to this survey identifying them. *Helped with the plan of correction from the previous complaint survey in September that had resulted in citations of harm to residents. *Knew the DON and ADON both had been working here only about a year and both had hospital experience as their background of work. *Stated a travel DON had been in the facility with the current DON and ADON from when they had started until May 2016 to help them orientate to their roles. *Assisted to bring in nurse consultant Ia after the complaint survey in September 2016 due to concerns she had noticed. -Nurse consultant Ia started visiting around late November 2016. *Felt her role was to be a resource to them, she was not a part of the leadership team in the building. *Had attended the monthly QAPI meetings. *Had started her role as FSCD in April 2016. *Indicated she had also been helping another facility in town. *Also had fifteen other facilities she was a resource to until October 2016 when that changed to only four facilities. *Indicated her role depended on what they needed for help depending on what information they sent to her. -She received monthly quality measures information and based on that assisted them. Interview on 1/5/17 at 2:45 p.m. with the administrator revealed he: *Started in June 2016 and had no orientation to his role. *Had been aware of concerns with pressure injuries and wounds. -They had a designated wound nurse who was no longer working there. -They were trying to hire for that position again. -When she left the wound care and assessments went back to the charge nurses to handle with the DON and ADON overseeing. *They had been working on staff retention, reducing turnover, reducing the amount of temporary staff they needed, and hoping to get more consistent staffing since he had started. -Staff turnover had gone down. *Was aware nurse consultant Ia had been brought in to help the DON and ADON. -He thought that was because they needed more support and resources. *Expected the nursing leadership to oversee resident care and to be out and about to know what was happening in the building. *Felt the ADON has had a lot dumped on her and had not received appropriate training to perform those duties. *Confirmed he had not notified the medical director of the survey concerns from the week before, and he should have. -The medical director was new to the role in December. Refer to F224, F280, F281, F314, F441, F493, F514, and F520.

A. Based on observation, record review, interview, and policy review, the provider failed to ensure one of one sampled resident (11) who had been identified as having a possible communicable disease had infection control precautions put in place. Findings include: 1. Observation on 1/4/17 from 8:00 a.m. through 8:15 a.m. revealed resident 11 was assisted to use the bedside commode. She had a unformed bowel movement. Review of resident 11's medical record revealed:*She had been readmitted from the hospital on [DATE]. *Review of her 12/27/16 interdisciplinary progress notes included: -She had three loose watery bowel movements at two different times. -Stool did not have the clostridium difficile (C-Diff) characteristics as far as looks, consistency, or smell. -Was reported to her physician and a physician's orders [REDACTED]. -The stool sample was not collected until 12/29/16 and was sent to the laboratory at 8:56 a.m. -It had been reported on 12/29/16 at 11:58 a.m. as being positive for[DIAGNOSES REDACTED]. -The first documentation of any infection control precautions was on 12/31/16 at 3:05 a.m. *Review of her 11/23/16 care plan revealed a focus area had been initiated on 12/30/16 to follow contact precautions due to her[DIAGNOSES REDACTED] infection. Interview on 1/5/17 at 2:30 p.m. with the director of nurses revealed she was aware precautions should have been put in place when resident 11 had been suspected of having a communicable disease. Review of the provider's August 2012 Isolation Initiating Transmission Based Precautions policy revealed if a resident was suspected of or identified as having a communicable infectious disease the infection preventionist would have been notified. B. Based on observation, record review, interview, and policy review, the provider failed to follow-up on a laboratory test result that indicated one of one sampled resident (10) might have had a [DIAGNOSES REDACTED]. Findings include: 1. Observation on 1/4/17 at 12:35 p.m. through 1:15 p.m. of resident 10 during a dressing change revealed she was not on isolation precautions. Review of the resident 10's medical record revealed: *She was admitted on [DATE]. *She had [DIAGNOSES REDACTED]. *Her discharge health summary from the hospital revealed: -A wound culture on 12/7/16 showed growth of staphylococcus aureus. -A urine culture on 12/7/16 showed growth of [DIAGNOSES REDACTED] pneumoniae. *No additional documentation regarding the wound and urine cultures were present in the medical record. Interview on 1/5/17 at 4:15 p.m. with the administrator, director of nursing, assistant director of nursing, and the nurse consultant revealed: *It would have been the expectation that the facility would have followed-up on the wound and urine culture results. *The resident would have been placed on isolation precautions while further testing was completed. *No response was given when asked if the expectation was not met in this case. Review of the provider's 10/11/16 Isolation- Initiating Transmission-Based Precautions policy revealed: *If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor shall notify the Infection Preventionist and the resident's Attending Physician for appropriate Transmission-Based Precautions. *Transmission-based precautions include the use of protective equipment, an appropriate notice at the room entrance door, appropriate waste and linen hamper, dedicated equipment and supplies, hand hygiene products readily available, and resident education provided. C. Based on observation, interview, record review, policy review, and procedure review, the provider failed to ensure: *An effective and ongoing infection control program had been in place. *A qualified professional with infection control training directed the infection control program since February 2016. *All staff had been educated on the proper protocols to follow when providing care and services for one of one sampled resident (8a) who had a carbapenem-resistant [MEDICATION NAME] (CRE) infection. *Isolation precautions had been maintained for one of one sampled resident (5a) who had active methicillin-resistant staphylococcus aureus (MRSA) in open and draining wounds. *Staff had been informed of what appropriate personal protective equipment (PPE) to use for two of two sampled residents (3a and 7a) who had infectious diseases. *Ongoing communication between the direct care staff had occurred regarding residents with active infectious diseases for two of two sampled residents (3a and 7a). *Four of four certified nursing assistants (CNA) (Aa, Ba, Fa, and Ga) had performed proper hand hygiene during personal care for four of four sampled residents (1a, 2a, 6a, and 8a). *Necessary supplies to provide care and services had been readily available and accessible for five of five sampled residents (1a, 2a, 3a, 5a, and 6a). *The cleaning of resident shared equipment had occurred between resident use for four of four sampled residents (a1, 2a, 6a, and 7a). *Appropriate room placement had been reviewed for two of two sampled residents (13a and 14a) who had separate and active infectious diseases and shared a room. *Appropriate documentation had been completed for three of three sampled discharged residents (9a, 11a, and 12a) who had infections. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 12/29/16 at 9:07 a.m. to the administrator, the field services clinical director (FSCD), the director of nursing (DON), and the assistant director of nursing (ADON). They were asked for an immediate plan of correction to ensure all residents would be safe from further uncontrolled infection care and measures. PLAN: On 12/29/16 at 4:40 p.m. the administrator and FSCD provided the surveyors with an immediate written plan of correction (POC). That POC dated 12/29/16 was accepted at 4:55 p.m. by the surveyors and included: IJ Abatement POC - 441 *All residents with identified Infections have been reviewed (12/29/16) to assure the specific Infection remains accurate, the treatment plan remains appropriate; Isolation precautions remains appropriate if in effect. *All staff will be educated, prior to their next scheduled shift on Infection Control Policies and Procedures to included; protocols for Transmission Based Isolation, Cleaning and Disinfecting Non-Critical Resident Care Items, and Environmental Surfaces and Hand Washing. All staff will be educated on the placement of a folder on the isolation carts. All staff will be educated on CRE - What is is; How it is spread; Interventions to reduce transmission. All staff will have education on donning and doffing PPE (personal protective equipment). All staff will have education on the use of mechanical devices, slings and equipment used in Isolation situations. *Licensed staff will be educated prior to next shift worked on identification of infections, and interventions to put into place. Clean Dressing Change Protocol, to include removal of dressing from the treatment cart, cross contamination prevention, following physician's orders [REDACTED]. Licensed staff will also be educated to continue with identified precautions until the causative agent has been deemed no longer a threat to the health/safety of resident and/or others as determined by the MD, culture of the infected area, or accepted infectious disease protocol. *CNA assignment sheets will be updated by the end of business December 29, 2016 to include appropriately identified precautions for identified causative agents in infected resident and individualized interventions to follow. Any deviation from the identified interventions will be discussed immediately with the Licensed Nurse. *All rooms of residents with identified Isolation precautions will have signage placed to alert staff and visitors to see a Licensed Nurse prior to entering the room. This will assure all persons entering the room are aware of the precautions prior to visitation. *PPE equipment has been placed outside of rooms of residents identified to need infectious disease precautions, a Transmission Based Isolation Grid, will be placed on the isolation cart identifying the appropriate type of isolation which will be highlighted on the grid. *Monitoring to ensure compliance - every shift for 3 consecutive days by the DNS/Designee, that Infection Control Procedures are being followed- to include dressing changes, isolation precautions, handwashing, use of PPE, availability of supplies in the Isolation room and appropriate cleaning of resident use equipment. Audit results will be reviewed during an Ad Hoc QAPI (quality assurance performance improvement) committee meeting on December 31, 2016 to provide further recommendations. On 12/29/16 at 5:10 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Review of resident 8a's medical record revealed: *An origianl admission date of [DATE] and a readmission date of [DATE] from a hospital. *[DIAGNOSES REDACTED]. *She had been dependent upon the staff to assist her with bed mobility, toileting, personal hygiene, transfers, and eating. *On 10/18/16 she had been hospitalized for [REDACTED]. *On 11/3/16 her urine had been tested for a possible UTI. -That urine specimen had tested positive for CRE. *She was isolated to her room due to the CRE. *Her 10/18/16 significant change in status MDS revealed her memory was intact. Observation on 12/28/16 from 11:18 a.m. through 11:30 a.m. with CNAs Fa and Ga with resident 8a revealed: *They had prepared to assist the resident with personal care. *They had applied the appropriate PPE prior to assisting the resident. -They had not performed hand hygiene prior to putting on clean gloves. *While CNA Fa had her gloves on she: -Pulled the resident's blanket down and assisted CNA Ga with removing her soiled incontinent brief. -Opened a package of disposable wet wipes. -Provided perineal care (peri-care) for the resident. -Cleaned a large amount of bowel movement off the resident's bottom. *CNA Fa continued to wear those soiled gloves when she: -Assisted CNA Ga with putting a clean incontinent brief on the resident. -Positioned the resident up higher in her bed. -Adjusted the resident's pillow and covered her with blankets. -Touched the water faucet handle turning it on. -Retrieved a clean wash cloth and wet it. -Washed the resident's face with the wet wash cloth. -Positioned the resident's call light, so she could touch it. *After they had completed personal care: -They disposed of their soiled supplies, removed their PPE, and exited her room. -CNA Fa went into an unidentified resident's room and washed her hands. -CNA Ga went into an unidentifed resident's room and washed her hands. Interview on 12/28/16 at 1:47 p.m. with CNA Ha regarding resident 8a revealed he: *Confirmed she had CRE in her urine and was on isolation precautions. *Agreed the staff should wash their hands prior to leaving her room. *Had observed several staff leave the resident's room before washing their hands. -Those staff had been observed going into other residents' rooms to wash their hands. *Would have educated those staff upon observation on the correct process. *Stated: -The communication regarding infection control precautions has been poor. -We have had a problem with knowing who is on infection control precautions, what kind of infection they have, and proper PPE to wear. -If there is PPE on the door we just put it on. -We do not always get a report at shift change. Interview on 12/28/16 at 1:55 p.m. with CNA Ga regarding resident 8a revealed she: *Confirmed: -The above observation had been her usual process for providing personal care for the resident. -She had gone into another resident's room to wash her hands after personal care had been done for the resident. *Stated It doesn't make sense going back into her room to wash my hands. *Agreed the process above had not been sanitary and created the potential for other residents to acquire that infectious disease. Interview on 12/28/16 at 2:30 p.m. with CNA Ba revealed: *The CNAs would have done walking rounds together at shift change. *The CNAs would not always get a shift report from the charge nurse. *She stated We don't get a report from the charge nurse unless it is important. 2. Observation on 12/27/16 at 5:00 p.m. of resident 5a in her room revealed she: *Had been sitting in her wheelchair (w/c) looking out the window. *Was rotund with a large body build. *Had gauze dressings covering the lower part of both her legs. -Those gauze dressings had several areas of yellow discoloration on the outside of the dressings. *There was PPE attached to her door. Interview on 12/27/16 at 5:15 p.m. with the assistant director of nursing (ADON) revealed: *Resident 5a had: -Venous stasis ulcers to both of her legs. --Those venous stasis ulcers had been infected with methicillin-resistant staphylococcus aureaus (MRSA). -Been placed on isolation precautions for those leg wounds. *She was not sure when the MRSA had been identified in those leg wounds. *She stated: -I'm not sure, but I think she was just put in isolation for precautionary measures. -I think the infection is colonized. *She had been the infection control nurse for the facility since February 2016. Review of resident 5a's medical record revealed: *A readmission date of [DATE]. *[DIAGNOSES REDACTED]. *She had a history of [REDACTED]. -The left leg venous stasis leg ulcers had been present since December 2015. -The right leg venous stasis leg ulcers had been present since 7/17/16. -Laboratory (lab) test results from 7/21/16 and 12/22/16 supported active MRSA in her leg wounds. *Since 12/23/16 she had been receiving the antibiotic Bactrim DS 800 milligrams twice a day for the current infection in her leg wounds. *On 11/28/16 the physician had ordered: -Woundcare: --BLE (bilateral lower extremeties) dressing change to be every 8 hours. --Three times a day for wound care. --Cleanse with NS (normal saline) or wounds cleanser, pat dry. Apply calcium alginate to wound bed, cover with super absorbent dressing. *A stage 2 pressure ulcer had been identified to her right buttock on 12/2/16. *She: -Was non-compliant with resting in her bed to relieve pressure off her bottom and elevating her legs. -Preferred to sit-up in her w/c. --No documentation to support the staff had identified other measures to assist her with that non-compliance. -Had required supervision with one staff person assistance with toileting, personal hygiene, bed mobility, transfers, and dressing. -Was occassionally incontinent of urine and required the use of an incontinent brief. *Her 10/26/16 quarterly Minimum Data Set assessment (MDS) revealed her memory was intact. Review of resident 5a's 12/23/16 CNA care sheet had not mentioned: *Her current wounds and MRSA present in those wounds. *She was on isolation and what type of precautions the staff should follow. Interview on 12/28/16 at 8:00 a.m. with licensed practical nurse (LPN) Ca regarding resident 5a revealed: *The surveyor had confirmed LPN Ca would be completing dressing changes to both of the resident's legs at 1:30 p.m. *She had been aware the surveyor had requested to watch those dressing changes. *She stated The dressing changes are every eight hours and the night nurse already did the dressing changes for this morning. Interview on 12/28/16 at 8:05 a.m. with certified nursing assistant (CNA) Fa regarding resident 5a revealed: *The surveyor had requested to watch all and any care provided for the resident. *She stated She is independent with her cares and toileting. She refuses care from us. *She used the CNA care sheet to assist her with taking care of the resident. Random observations and interview at the following times with staff on 12/28/16 of resident 5a revealed: *From 8:10 a.m. to 8:45 a.m. she was in her room sitting in her w/c. -Her legs were wrapped with gauze bandages. -Those bandages: --Were covered with a large amount of yellow discoloration on the outer layer. --Were dated 12/27/16 with a time of 2:30 p.m. and initialed by an unidentified staff member. -At 9:27 a.m. she had propelled herself out of her room and was sitting in the hallway. -At 9:43 a.m. certified nursing assistant (CNA) Ea stated: --I believe she has MRSA and possibly another infection in her legs. --We only have to gown and glove when taking care of her. If you're visiting I don't believe you have to. --I'm not sure but I think she can be out in the hallway, she doesn't really go anywhere. --She is independent with toileting. *From 10:15 a.m. to 10:40 a.m. she continued to sit in her w/c out in the hallway. *From 11:05 a.m. until 12:45 p.m. she continued to sit in her w/c but had propelled herself into her room. -The yellow discoloration to both of her leg dressings had become increasingly worse and covered a larger area of the dressing. *She had wore clog type shoes that were open in the back and exposed her heels. -There had been Kleenex placed inside of her shoes underneath both of her heels. *No staff had been observed attempting to assist the resident with personal care during the above time frames. Observation and interview on 12/28/16 at 1:15 p.m. with LPN Ca regarding resident 5a revealed: *The resident was propelling herself down the hallway and past the nurses' station. -The gauze dressings to both of her legs remained unchanged from the prior observations documented above. *The surveyor again confirmed LPN Ca would be completing those dressing changes to both of the resident's legs at 1:30 p.m. *The nurse stated: -I am busy and the only nurse here today so will have (nurse's name) do them when she comes on at 2:30 p.m. -The night nurse did them so we will still be within that eight hour time frame. Continued random observations on 12/28/16 from 1:30 p.m. through 2:45 p.m. of resident 5a revealed: *She had been downstairs participating in an activity. *At 2:45 p.m. an unidentified staff member had assisted her back to her room. -The yellow discoloration on her leg dressings had become worse and had increased in size. -Those soiled dressings were loose and were dragging on the floor as the unidentified staff member propelled her down the hallway and into her room. *She continued to have Kleenex inside of her shoes and underneath both of her heels. Interview on 12/28/16 at 2:35 p.m. with CNA Fa regarding resident 5a and confirmation of the following revealed: *The resident was independent with toileting and personal cares. *The staff would not be assisting her with any care today. *CNA Fa stated (Resident name) does her own thing. We don't do anything unless she asks. Observation and interview on 12/28/16 from 3:10 p.m. through 4:00 p.m. with LPN Da regarding resident 5a revealed she confirmed the following and stated: *She had MRSA to her leg wounds. -Was on contact precautions due to the infection in her wounds. *I believe she can be out of her room as long as the drainage is contained in the dressings. *Had gathered supplies to complete dressing changes to both of the resident's leg ulcers. -That process had been lengthy as not all the supplies had been on the treatment cart. *Had returned to the supply closet and treatment cart several times to obtain needed supplies. *Had to remove and reapply new personal protective equipment (PPE) twice due to this issue. *Put on the appropriate contact isolation PPE to perform the dressing changes to those wounds. *The dressing changes should have been completed three times a day. *The documentation on the current dressings indicated those wounds had not been treated for [REDACTED]. -The old dressings were saturated with drainage from her wounds and would not have been considered contained. *When they complete these dressing changes like they are suppose to she does not have this kind of drainage on the dressings. *Could not remember a time when the resident had refused a dressing change for her wounds. *Completed the dressing changes and removed the Kleenex from the resident's shoes. -The resident stated I put the Kleenex in there, because the wounds weep and drain into my shoes. *Removed the old dressings from the resident's legs. -Both of her legs were red, swollen, had peeling skin, and several weeping/draining wounds. *Completed the dressing changes, disposed of her supplies, washed her hands, and exited the resident's room. Interview on 12/28/16 at 4:10 p.m. with resident 5a revealed: *She thought her dressing changes to her legs were to have been done twice a day, but was not sure. *She stated: -They don't always do them like they are suppose to. -I take care of myself. I don't need help. Review of resident 5a's treatment assessment record (TAR) from 12/1/16 through 12/28/16 revealed: *She was scheduled to have dressing changes completed at 5:30 a.m., 1:30 p.m., and 10:00 p.m. every day. *She should have received a total of eighty-three dressing changes. -Three entries had been documented as a 2 indicating she had refused treatment to her legs wounds. -Four entries had been documented as a 7 indicating to check her nurses' notes on those days. --There had been no documentation on those dates and time of day when a 7 was charted that she had refused a treatment. -Eighteen out of eighty-three times there had been no documentation to support a dressing had been completed. --No documentation in her medical record from 12/1/16 through 12/28/16 she had refused a treatment at those specific times. Review of resident 5a's Behavior log from 12/18/16 through 1/4/17 revealed no documentation to support she had refused care. Interview on 12/29/16 a 2:05 p.m. with the DON, the ADON, and nurse consultant Ia regarding residents 5a and 8a revealed: *They confirmed the above medical record reviews for both of the residents. *The staff used the CNA care sheets to assist them with taking care of the above residents. *If either of the residents had refused care from the staff there should have been documentation to support those refusals. *The DON had been aware of the incomplete documentation by the staff on the TARs. -She agreed if there was no documentation on the TAR the treatment or care was not completed. a. The CNA care sheet had not been complete for resident 5a. *She was non-compliant with elevating her legs and laying down in her bed. -They had not reviewed other options to assist her with repositioning and elevating her legs. *She had a history of [REDACTED]. *she could be out of her room as long as the drainage from her leg wounds had been contained. -They agreed the above observations had not supported proper containment of her draining wounds with MRSA. *They confirmed she should have had her dressings changed to her legs TID. *They were unaware her dressings had not been changed for over twenty-four hours. b. They had not been aware the staff were washing their hands in other resident's rooms after assisting the resident with care. *They agreed the above processes had not been performed in a sanitary manner. -Those processes had created the potential for cross-contamination of bacterial germs from one resident to another of those infectious diseases. *There had been no formal education provided for the direct care givers after it was identified that she had had CRE in her urine. -All the education had been informal. *There was no documenation to support formal or informal education had been provided on the infectious disease CRE for the direct staff care givers. 3. Review of resident 7a's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She required staff assistance with personal hygiene, toileting, transfers, and bed mobility. *On 8/25/16 and 9/15/16 a urine specimen had been collected and both times tested positive for VRE. *On 12/2/16 her urine was collected and tested for VRE. -Those test results revealed no active VRE at that time. Observation and interview on 12/28/16 at 9:13 a.m. with CNA Fa assisting resident 7a with personal care revealed: *The resident had been sitting in a w/c in the dining room. *CNA Fa assisted the resident to her room. *There had been: -PPE attached to the resident's door. -No signage on the door directing the staff and visitors to check with the nurse prior to entering her room. -Two garbage containers located on the resident's side of the room. --Those garbage containers were red and yellow in color. *The resident shared her room and bathroom with another resident. *CNA Fa: -Retrieved an EZ stand lift from the hallway to assist the resident with transferring to the toilet. -Did not put on any of the PPE attached to the resident's door. -Stated: --I'm not sure but I think she had MRSA or something in her urine. --At first we had to put a gown on when we took care of her but now I was told I didn't have to. --I'm not sure why we don't I wasn't informed of that. --She use to be incontinent but starting yesterday had been using the toilet. -Agreed the staff should have been informed by the charge nurse of the infection and if PPE was required to be worn or not. -Had not been aware of the purpose of those type of garbage containers. *Without washing or sanitizing her hands CNA Fa put on clean gloves. *While CNA Fa had on gloves she: -Removed the pedals from the w/c and locked the brakes. -Positioned the EZ stand lift in front of the resident. -Removed a support sling from the EZ stand, positioned the sling behind the resident's back, and attached it to the lift. -Pulled the resident's pants down and removed her soiled incontinent brief. -Positioned the resident on the toilet. -Pulled back the resident's blankets on her bed and respostioned her call light. -Used toilet paper to provide perineal care for the resident. -Put a clean incontinent brief on the resident, pulled up her pants, and assisted her to the bed. -Placed the sling back on the lift. -Positioned the resident in her bed. -Removed the resident's shoes and pulled the blankets up over the resident. -Removed her gloves and washed her hands. -Pushed the EZ stand lift into an empty room. *CNA Fa: -Used the same pair of gloves for the entire process observed above. -Washed her hands once during the above process. -Did not check with the charge nurse prior to providing personal care for the resident to ensure no PPE was required to be worn. -Did not leave the EZ stand lift in the resident's room. -Did not clean the lift after using it with the resident. 4. Review of resident 6a's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He received dialysis services every Monday, Wednesday, and Friday. *On 10/26/16 two stage 2 pressure sores had been identified on each of his heels. -Those stage 2 pressure sores had been facility acquired and had worsened to unstageable by 11/19/16. *He was dependent upon the staff to assist him with personal hygiene, transfers, w/c mobility, toileting, and bed mobility. Observation on 12/28/16 at 11:40 a.m. with CNAs Fa and Ga with resident 6a revealed: *They had prepared to assist the resident with personal care and transferring to his bed. *They had retrieved the Hoyer lift from an empty room. *They attempted to put on clean gloves. -There were no gloves located in his room. *CNA Fa: -Left the room, went into another resident's room, and retrieved two sets of gloves. -Gave one pair of the gloves to CNA Ga and kept one set for herself. *They had not performed hand hygiene prior to putting on the clean gloves. *With those clean gloves on they: -Pushed the resident's w/c up closer to the Hoyer lift. -Adjusted the sling underneath of his body. -Retrieved plastic back support bars from a bag handing on the Hoyer lift. --Placed those plastic bars inside of his sling to support the head and back. -Pulled back the blankets on his bed and assisted him to lay down. -Pulled his pants down and removed a soiled incontinent brief. *CNA Ga continued to wear those soiled gloves when she: -Assisted CNA Fa with removing the sling from underneath of the resident. -Removed the plastic back support bars and placed each one on his pillow until all three were removed. -Placed those plastic back support bars back inside of the plastic bag on the Hoyer lift. -Opened a package of disposable wet wips. -Provided perineal care for the resident. -Assisted CNA Fa with putting a clean brief on the resident. -Folded a blanket and placed it between the resident's knees. -Adjusted his pillow and placed another pillow behind his back. -Attached his call light to his shirt. *After they had completed personal care: -They removed their gloves and exited his room without washing their hands. -CNA Ga moved an EZ stand lift located in the hallway into another resident's room. --She disposed of their soiled supplies in the soiled utility room. --She then washed her hands at the nurses' station. -CNA Fa placed the Hoyer lift in an empty room. --She went down to the nurses' station to wash her hands. Interview on 12/28/16 at the time of the above observation with CNA Fa revealed she: *Confirmed: -That had been her normal process for providing personal care for the residents. -They were not informed to clean the lifts between each resident's use. -The EZ stand slings were used for multipled residents. -The plastic support bars were shared between other residents. --Those bars were not cleaned between each resident's use. *Agreed: -The processes above had not been performed in a sanitary manner. -That process had created the potential for cross-contamination of bacterial germs to other residents. -She should have checked with the charge nurse to ensure: --No PPE was required to be worn when assisting resident 7a. --The resident could use the shared toilet. 5. Interview on 12/28/16 at 2:20 p.m. with CNA Ea regarding the residents' transfer lifts revealed: *The transfer lifts had been shared between the residents. *They had been directed to wipe the transer lifts down with bleach wipes. *She could not gaurantee that process had always occurred. *The EZ stand slings had been shared between the residents. *She stated: -We don't have enough for everyone to have their own. -When they are washed its takes so long for them to dry, because they can't be put in the dryer. *She agreed the above process for the EZ stand lifts had not been sanitary and created the potential for cross-contamination of bacteria from one resident to another. 6. Interview on 12/28/16 at 3:00 p.m. with LPN Da revealed: *She confirmed t

Based on observation, interview, record review, and policy and procedure review, the provider failed to ensure four of five sampled residents (1a, 2a, 5a, and 8a) who were identified as at risk for potential skin breakdown and required staff assistance with personal care had not been neglected and had received appropriate repositioning, toileting, and personal hygiene assistance. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 12/29/16 at 9:07 a.m. to the administrator, the field services clinical director (FSCD), the director of nursing (DON), and the assistant director of nursing (ADON). They were asked for an immediate plan of correction to ensure all residents, including resident 1a, 2a, 5a, and 8a, would receive appropriate staff assistance with personal care. PLAN: On 12/29/16 at 4:40 p.m. the administrator and FSCD provided the surveyors with an immediate written plan of correction (POC). That POC dated 12/29/16 was accepted at 4:55 p.m. by the surveyors and included: IJ Abatement POC - Patient care *All residents CNA (certified nursing assistant) Care sheets have been reviewed (12-29-16) to assure the specific individualized care needs are correct and appropriate including transferring, turning and repositioning, Infection remains accurate, the treatment plan remains appropriate; Isolation precautions remain appropriate if in effect. *All staff will be educated, prior to their next scheduled shift on providing the individualized care residents need based on Nursing assessment; incontinent care; wound care basics; dignity; Abuse and Neglect. Any deviation from the identified interventions will be discussed immediately with Licensed Nurse. *Licensed staff will be educated prior to next shift worked on Supervision of care givers and the resident daily care needs. *CNA assignment sheets will be updated by the end of business December 29, 2016 to include appropriately identified, individualized interventions to follow. *Shift to shift report will be completed between Licensed Nurses and CNAs to assure the Isolation status changes for residents with precautions is communicated in a timely manner. Bath aides will also report to Licensed Nurses at the start and end of their shift for a separate report time. Any changes in resident condition during the shift will result in a Staff Huddle. *Monitoring to ensure compliance - every shift for 3 consecutive days by the DNS (director of nursing services)/designee, that individualized personal cares are being followed- to include transfers, toileting, bathing and incontinent care, turning and repositioning, isolation precautions. Audit results will be reviewed during an Ad Hoq QAPI (quality assurance performance improvement) committee meeting on December 31, 2016 to provider further recommendations. On 12/29/16 at 5:10 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Observation on 12/27/16 at 5:00 p.m. of resident 5a in her room revealed she: *Had been sitting in her wheelchair (w/c) looking out the window. *Was rotund with a large body build. *Had gauze dressings covering the lower part of both her legs. -Those gauze dressings had several areas of yellow discoloration on the outer layer. Interview on 12/27/16 at 5:15 p.m. with the assistant director of nursing (ADON) revealed: *Resident 5a had: -A stage 2 pressure sore to her right buttock. -Acquired the pressure sore during her stay in the facility. -Venous stasis ulcers to both of her legs. --Those venous stasis ulcers had been infected with [MEDICAL CONDITION]-resistant staphylococcus aureaus (MRSA). -Been placed on isolation precautions for those leg wounds. *She was not sure when [MEDICAL CONDITION] had been identified in those leg wounds. *She stated: -I'm not sure, but I think she was just put in isolation for precautionary measures. -I think the infection is colonized. *She had been the infection control nurse for the facility since February 2016. *She completed weekly measurements on all the wounds and was considered their wound nurse. Review of resident 5a's medical record revealed: *A readmission date of [DATE]. *[DIAGNOSES REDACTED]. *She had a history of [REDACTED]. -The left leg venous stasis leg ulcers had been present since December 2015. -The right leg venous stasis leg ulcers had been present since 7/17/16. -Laboratory (lab) results from 7/21/16 and 12/22/16 supported [MEDICAL CONDITION] in her leg wounds. *Since 12/23/16 she had been receiving Bactrim DS 800 milligrams twice a day for the current infection in her leg wounds. *On 11/28/16 the physician had ordered: -Woundcare: --BLE (bilateral lower extremities) dressing change to be every 8 hours. --Three times a day for wound care. --Cleanse with NS (normal saline) or wound cleanser, pat dry. Apply calcium alginate to wound bed, cover with super absorbent dressing. *A stage 2 pressure ulcer had been identified to her right buttock on 12/2/16. *On 12/2/16 the physician had ordered a treatment for [REDACTED]. -That treatment had been Cleanse wound to right buttock with wound cleanser, pat dry, skin prep to surrounding skin. [MEDICATION NAME] foam Q (every) 3 days and PRN (as needed). *She was non-compliant with resting in her bed to relieve pressure off of her bottom and elevate her legs. *She preferred to sit-up in her w/c. *There was no documentation to support the staff had identified other measures to assist her with this non-compliance. *She had required supervision with one person assistance with toileting, personal hygiene, bed mobility, transfers, and dressing. -Was occasionally incontinent of urine and required the use of an incontinent brief. *Her 10/26/16 quarterly Minimum Data Set assessment (MDS) revealed her memory was intact. -She was oriented to time, place, person, and situation. Review of resident 5a's 12/23/16 CNA care sheet had not mentioned: *Her current wounds and [MEDICAL CONDITION] was present in those wounds. *She was on isolation and what type of precautions the staff should follow. *If she was on a toileting or repositioning schedule. *The stage 2 pressure ulcer on her right buttock. Interview on 12/28/16 at 8:00 a.m. with licensed practical nurse (LPN) Ca regarding resident 5 revealed: *The surveyor had confirmed LPN Ca would be completing dressing changes to both of the resident's legs at 1:30 p.m. *She had been aware the surveyor had requested to watch those dressing changes. *She stated The dressing changes are every eight hours and the night nurse already did the dressing changes for this morning. Interview on 12/28/16 at 8:05 a.m. with certified nursing assistant (CNA) Fa regarding resident 5a revealed: *The surveyor had requested to watch all and any care provided for the resident. *She stated She is independent with her cares and toileting. She refuses care from us. *She used the CNA care sheet to assist her with taking care of the resident. Random observations and interview at the following times with staff on 12/28/16 of resident 5a revealed: *From 8:10 a.m. to 8:45 a.m. she was in her room sitting in her w/c. -Her legs were wrapped with gauze bandages. -Those bandages: --Were covered with a large amount of yellow discoloration on the outer layer. --Were dated 12/27/16 with a time of 2:30 p.m. and initialed by an unidentified staff member. -At 9:27 a.m. she had propelled herself out of her room and was sitting in the hallway. -At 9:43 a.m. certified nursing assistant (CNA) Ea stated: --I believe she [MEDICAL CONDITION] and possibly another infection in her legs. --We only have to gown and glove when taking care of her. If you're visiting I don't believe you have to. --I'm not sure but I think she can be out in the hallway, she doesn't really go anywhere. --She is independent with toileting. *From 10:15 a.m. to 10:40 a.m. she continued to sit in her w/c out in the hallway. *From 11:05 a.m. until 12:45 p.m. she continued to sit in her w/c but had propelled herself into her room. -The yellow discoloration to both of her leg dressings had become increasingly worse and covered a larger area of the dressing. *She had wore clog type shoes that were open in the back and exposed her heels. -There had been Kleenex placed inside of her shoes underneath both of her heels. *No staff had been observed attempting to assist the resident with personal care during the above time frames. Observation and interview on 12/28/16 at 1:15 p.m. with LPN Ca regarding resident 5a revealed: *The resident was propelling herself down the hallway and past the nurses' station. -The gauze dressings to both of her legs remained unchanged from the prior observations documented above. *The surveyor again confirmed LPN Ca would be completing those dressing changes to both of the resident's legs at 1:30 p.m. *The nurse stated: -I am busy and the only nurse here today so will have (nurse's name) do them when she comes on at 2:30 p.m. -The night nurse did them so we will still be within that eight hour time frame. Continued random observations on 12/28/16 from 1:30 p.m. through 2:45 p.m. of resident 5a revealed: *She had been down stairs participating in an activity. *At 2:45 p.m. an unidentified staff member had assisted her back to her room. -The yellow discoloration on her leg dressings had become worse and had increased in size. -Those soiled dressings were loose and were dragging on the floor as the unidentified staff member propelled her down the hallway and into her room. *She continued to have Kleenex inside of her shoes and underneath both of her heels. Interview on 12/28/16 at 2:35 p.m. with CNA Fa regarding resident 5a and confirmation of the following revealed: *The resident was independent with toileting and personal care. *The staff would not be assisting her with any care today. *CNA Fa stated (Resident name) does her own thing. We don't do anything unless she asks. Observation and interview on 12/28/16 from 3:10 p.m. through 4:00 p.m. with LPN Da regarding resident 5a revealed she confirmed the following and stated: *She [MEDICAL CONDITION] to her leg wounds. -Was on contact precautions due to the infection in her wounds. *I believe she can be out of her room as long as the drainage is contained in the dressings. *Had gathered supplies to complete dressing changes to both of the resident's leg ulcers. -That process was lengthy as not all the supplies had been on the treatment cart. *Had returned to the supply closet and treatment cart several times to obtain needed supplies. *She had to remove and reapply new personal protective equipment (PPE) twice due to this issue. *Put on the appropriate PPE to perform the dressing changes to those wounds. *The dressing changes should have been completed three times a day. -The documentation on the current dressings indicated those wounds had not been treated for [REDACTED]. -The old dressings were saturated with drainage from her wounds and would not have been considered contained. *When they complete these dressing changes like they are suppose to she does not have this kind of drainage on the dressings. *She could not remember a time when the resident had refused a dressing change for her wounds. *She completed the dressing changes and removed the Kleenex from the resident's shoes. -The resident stated I put the Kleenex in there, because the wounds weep and drain into my shoes. *Agreed the staff should have offered to assist her today with personal care. *Agreed sitting for that amount of time in one position was not appropriate care and could cause further skin breakdown. *The staff should check or reposition the residents every two hours. *Removed the old dressings from the resident's legs. -Both of her legs were red, swollen, had peeling skin, and several weeping/draining wounds. *Completed the dressing changes, disposed of her supplies, washed her hands, and exited the resident's room. *Had not: -Offered to assist the resident to the bathroom or with any other personal care. -Checked her right buttock to ensure the [MEDICATION NAME] foam dressing was intact. Interview on 12/28/16 at 4:10 p.m. with resident 5a revealed: *She thought her dressing changes to her legs were to have been done twice a day, but she was not sure. *She stated: -They don't always do them like they are suppose to. -I take care of myself. I don't need help. Review of resident 5a's treatment assessment record (TAR) from 12/1/16 through 12/28/16 revealed: *She was scheduled to have dressing changes completed at 5:30 a.m., 1:30 p.m., and 10:00 p.m. every day. *She should have received a total of eighty-three dressing changes. -Three entries had been documented as a 2 indicating she had refused the treatment to her legs wounds. -Four entries had been documented as a 7 indicating to check her nurses' notes on those days. --There had been no documentation on those dates and time of day when a 7 was charted that she had refused a treatment. -Eighteen out of eighty-three times there was no documentation to support a dressing had been completed. --No documentation in her medical record from 12/1/16 through 12/28/16 she had refused a treatment at those specific times. Review of resident 5a's Behavior log from 12/18/16 through 1/4/17 revealed no documentation to support she had refused care. Review of resident 5a's activities of daily living (ADL) flow sheet for December 2016 revealed: *Several entries were documented as a 0 or 8. -Those entries indicated she required no assistance or the activity had not occurred. *Occasionally she would have required support of one staff person. *The entries were related to transferring, toilet use, dressing, and personal hygiene. 2. Observation on 12/27/16 at 4:50 p.m. of resident 8a in her room revealed she had: *Been laying on her left side in her bed watching television. *Been laying on a pressure relieving air flow mattress. *PPE attached to her door. -That PPE consisted of gloves, gowns, and masks. *A sign attached to her door directing the staff and visitors to check with the nurse prior to entering her room. *Two large enclosed garbage containers located just inside of her doorway. -Those garbage containers were yellow and red in color. *Not shared her room with any other residents. Interview on 12/27/16 at 5:20 p.m. with the ADON regarding resident 8a revealed she: *Had carbapenem-resistant [MEDICATION NAME] (CRE) in her urine. *Had been placed on isolation precautions for that infection. *Was not identified as one of the residents with an open area or pressure sore. Review of resident 8a's medical record revealed: *An original admission date of [DATE], and a readmission date of [DATE] from the hospital. *[DIAGNOSES REDACTED]. *She had been dependent upon the staff to assist her with bed mobility, toileting, personal hygiene, transfers, and eating. *On 10/18/16 she had been hospitalized for [REDACTED]. *On 10/22/16 she had been readmitted to the facility. -Had physician's orders [REDACTED]. *On 11/3/16 her urine was tested for a possible UTI and had tested positive for CRE. *She was isolated to her room due to the CRE. *Her 10/18/16 significant change in status MDS revealed her memory was intact. *Her 10/22/16 Braden Scale assessment score had been a ten indicating she was at high risk for developing skin breakdown. *On 12/29/16 a wound was identified to her left buttock and had been documented as a shearing wound. Review of resident 8a's 12/23/16 CNA care sheet revealed she was to have been turned and repositioned every two hours. Interview on 12/28/16 at 7:55 a.m. with CNA Fa regarding resident 8 revealed: *The surveyor had requested to watch all and any care provided to the resident. *She had just completed personal care and assisting the resident with her breakfast. *She would not be assisting her again until around 11:00 a.m. *She stated: -She does not get out of her bed. -She does not like to be moved too much because of pain. -She is incontinent and will use her call light if she needs to be changed or assistance. -She usually puts her call light on around 11:00 a.m. *She confirmed the CNA care sheet was used to assist her with taking care of the resident. Random observations and interviews on 12/28/16 from 8:15 a.m. through 11:18 a.m. of resident 8a revealed: *At 8:15 a.m., 9:12 a.m., 10:15 a.m., and 11:05 a.m. she had remained in bed and positioned on her left side. *No staff had been observed going into her room and offering any assistance during the above time frame. Observation on 12/28/16 from 11:18 a.m. through 11:30 a.m. with CNAs Fa and Ga with resident 8a revealed: *They had prepared to assist the resident with personal care. *They had applied the appropriate PPE prior to assisting the resident. *The resident: -Had been incontinent of both bowel and urine. -Her extremities were severely contracted. --Her legs were bent and had been pulled up to her abdomen. --Her arms were bent and had been pulled up to her chest. *CNA Ga identified a reddened area to her left buttock. -That reddened area was approximately 0.5 centimeters in diameter. --That area had not been opened but did not blanch when CNA G had pressed on it. --Appeared to be a stage 1 pressure sore. *After they had completed personal care: -They positioned her up higher in her bed. -Did not attempt to re-position her onto the right side. -Did not attempt to nor checked with her to confirm she did not want to be re-positioned onto her right side. *Disposed of their soiled supplies, removed their PPE, and exited her room. Interview on 12/28/16 at 11:35 a.m. with CNA Fa regarding resident 8a revealed she stated: *She doesn't like to lay on her right side. She has too much pain. *She lets us know when she needs anything. Interview on 12/28/16 at 11:40 a.m. with resident 8a revealed and stated: *I push the call light when I need anything. *I can lay on my right side I just don't like to for very long. It hurts. *Some will put me on my right side but most don't. They know I don't like it. *She confirmed the staff would have waited to assist her with personal care until she asked. Interview on 12/28/16 at 2:30 p.m. with CNA Ba revealed all residents should have been repositioned every two hours. Interview on 12/28/16 at 2:35 p.m. with CNA Fa revealed: *She had been working a sixteen hour day (shift) and would continue to provide care for resident 8a. *The surveyor again requested to watch any and all care performed for resident 8 that afternoon. *CNA Fa stated I will not be changing or repositioning her unless she calls. -She will tell you, (the resident would tell the CNA when she wanted care). Random observations on 12/28/16 from 12:20 p.m. through 4:45 p.m. of resident 8a revealed: *She remained on her left side during that entire time frame. *Medication aide/CNA Ea had been the only staff member to enter her room at 1:45 p.m. -Administered medication to the resident. *CNA Fa had not informed the surveyor of any personal care that was going to be provided for the resident during the above time frame. Review of resident 8a's December 2016 ADL (activity of daily living) Flow Sheet log revealed: *She had been assisted with bed mobility and personal hygiene once per shift. *There was no documentation to support she had been assisted more than that. Review of resident 8a's 12/18/16 through 1/4/17 Behavior log revealed she had no instances of refusing care from the staff. 3. Interview on 12/29/16 a 2:05 p.m. with the DON, ADON, and nurse consultant (Ia) regarding residents 5a and 8a revealed: *They confirmed the above medical record reviews for both of the residents. *The staff used the CNA care sheets to assist them with taking care of the above residents. *If either of the residents had refused care from the staff there should have been documentation to support those refusals. *The DON had been aware of the incomplete documentation by the staff on the TARs. -She agreed if there was no documentation on the TAR the treatment or care was not completed. a. The CNA care sheet had not been complete for resident 5a. *Resident 5a was at high risk for skin breakdown and currently had a stage 2 pressure sore on her right buttock. *She was incontinent of urine at times and required the use of an incontinent brief. *She was non-compliant with elevating her legs and laying down in her bed. -They had not reviewed other options to assist her with repositioning and elevating her legs. *Even though she preferred her independence with care the staff should have attempted to reposition and toilet her. *The standard of nursing practice was for all the residents to have been repositioned every two hours. *She had a history of [REDACTED]. *She could be out of her room as long as the drainage from her leg wounds had been contained. -They agreed the above observations had not supported proper containment of her draining wounds [MEDICAL CONDITION]. *They confirmed she should have had her dressings changed to her legs TID. -They were unaware her dressings had not been changed for over twenty-four hours. b. They had not been aware the physician had ordered resident 8 to not be positioned on her left side for more than 50% of the time. *The staff were not attempting to reposition her every 2 hours. *She had a new wound on her left buttock. -The staff had not informed them of that wound. *They agreed the staff should have attempted to reposition her. *The DON stated That is just unacceptable care and the staff should be disciplined. Continued review of resident 8a's medical record revealed no documentation on 12/28/16 to support the wound to her left buttock had been identified. 4. Observation on 12/27/16 at 5:00 p.m. of resident 2a in his room revealed he: *Was thin and had a small body build. *Was laying in bed on his left side in the fetal position. *Appeared uncomfortable stating Oh my hip, my leg. *Had his pants pulled down to his mid-thigh area exposing his disposable brief. *Was not covered with a blanket. *Had the fitted sheet coming off the top third of his bed, and his pillow case was also coming off. -The bare mattress and pillow were exposed. *Had a wheelchair with a saddle-type cushion and a mechanical lift sling sitting in the seat of it. Interview on 12/27/16 at 5:15 p.m. with the ADON regarding resident 2a revealed: *He had three pressure injuries. -Those were on his right buttock, sacrum, and left buttock. *She thought the left buttock and sacrum were healed, but the right buttock area was still opened. *She was unsure if those were facility acquired or not. *She completed weekly measurements on all the pressure injuries and was considered their wound nurse. On 12/28/16 at 7:50 a.m. it was discussed with the FSCD to inform nursing staff that all of resident 2a's care including transfers, toileting, and dressing changes would need to be observed that shift by the surveyors. Observations and interviews with staff on 12/28/16 at the following times regarding resident 2a revealed: *At 8:55 a.m. spoke with licensed practical nurse (LPN) Ca regarding the need to watch all care including dressing changes for him. -She confirmed she was aware of that. *At 9:53 a.m. he was sitting in his wheelchair (w/c) in his room. *At 9:55 a.m. CNA Aa stated he did not like to lay down, and they tried to get him to whenever they could. -Requested to watch any care that her or any other nursing staff would be providing to him that day. *At 10:20 a.m. he was sitting in his w/c in his room. *At 10:35 a.m. he was in his w/c in his room with his head down and appeared to be sleeping. *At 10:36 a.m. LPN Ca was again requested to watch care for him. She stated he: -Was usually the last to lay down after lunch, because he did not like to lay down. -Was noncompliant, and that should have been documented in his record. *At 11:03 a.m. he was still in his w/c in his room with his head down appearing to be sleeping. *At 11:32 a.m. he was wheeled to the dining room in his w/c by staff. *At 12:15 p.m. he was in his w/c at the dining room table by himself. *At 1:00 p.m. he was still at the dining room table in his w/c. *At 1:30 p.m. he was by the door of the dining room in his w/c. *At 2:00 p.m.: -He was back in his room sitting in his w/c with his head propped up on his left hand. -CNA Aa stated: --They tried offering to lay him down between meals, but he often refused. --He used a mechanical lift to transfer. --Therapy had worked with him on using a standing lift to transfer to the bathroom only. --He should have been taken to the bathroom even if he had not laid down, but he usually would not let them do that. Observation and interview on 12/28/16 from 2:00 p.m. through 2:20 p.m. with CNAs Aa and Ba during resident 2a's personal care revealed: *He had been sitting in his wheelchair with the lift sling underneath him. *They brought in the mechanical lift, hooked up the sling to the lift, and moved him from the wheelchair to his bed. *During the moving process he stated Ow, ow, Murder my legs, and Don't abuse me, let me die. *He did not attempt to strike out or be combative with the staff during his care. *He followed their directions and let them assist him. *When they got him in bed they assisted him with changing his wet disposable brief. *The brief appeared to be soaked with urine. *CNA Ba performed perineal care (peri-care) only to his buttocks area; she had not cleaned his front side. *There were three intact dressings to his left buttock, right buttock, and sacrum. -His skin around the dressings was excoriated and pink to red in color. *The CNAs applied a new disposable brief and pulled his pants back up. Continued interview and record review with CNA Ba following the above observation regarding resident 2a revealed: *He usually spent most of the day shift in his w/c. *He had not liked to lay down and would yell or cry out when they tried to lay him down. *He was not combative to the staff during care. *The sore areas on his buttocks had been there a few months. *He should have been repositioned and toileted at least every two to three hours because of those areas. -That had not occurred during this shift. *Her and CNA Aa were the staff assigned to assist him during that day shift. *She had not helped him at all that day with care until the above observation. *She thought he had a bath that morning before breakfast and had been in his wheelchair since that time. -Breakfast had started at 7:30 a.m. *She confirmed he had sat in his wheelchair and had not been assisted to the bathroom for several hours. *She should have completed peri-care to his front side along with his buttocks due to his incontinence. *Review of her updated 12/23/16 CNA sheet for Second Floor West revealed: -It had not mentioned: --His current pressure areas to his buttocks and sacrum. --If he was on a toileting or repositioning schedule. --That he was incontinent of urine. -It had indicated: --He used a w/c propelled by himself. --He used a Hoyer lift for transfers. *She confirmed the CNA sheet was what the CNAs used as a reference to care for their residents. -It should have listed his pressure areas and if he was supposed to have been repositioned more often. Interview on 12/28/16 at 2:35 p.m. with LPN Da regarding the above observations for resident 2a revealed: *He should have been repositioned at least every two hours due to his pressure areas. *He should have received complete peri-care and not just care to his buttocks area. *Sitting for that amount of time could have caused further pressure injuries and was not appropriate care for healing pressure injuries. Interview on 12/28/16 at 2:45 p.m. with LPN Ca regarding the above observations for resident 2a revealed: *She was his charge nurse that day. *She had not been aware of any refusals of care for him that day but knew he had frequently refused to lay down in the past. -CNAs were supposed to let the nurse know if a resident refused care. *He should have been repositioned at a minimum of every two hours along with taken to the bathroom. *She stated the above observations of his care would have been considered neglect and was unacceptable. *As a charge nurse she relied on the CNAs to do their assigned work and reposition residents at risk for skin breakdown every two hours. *Repositioning and toileting were important factors in preventing pressure injuries from developing and healing current pressure injuries. Interview on 12/28/16 at 4:00 p.m. with the DON and ADON regarding resident 2a revealed: *When he remained in his wheelchair most of the day shift as indicated in the above observations and interviews that was unacceptable care. *The CNAs responsible for him should have been disciplined. *All residents should have been repositioned every two hours as a standard of nursing practice. *They confirmed he was a high risk for skin breakdown and already had pressure injuries. *Even though he argued with staff during care they should have attempted to reposition and toilet him due to his skin breakdown. *If he had refused care from the staff there should have been documentation of his refusals. *Incontinence care should have been performed completely and not just for his buttocks area. *They confirmed the 12/23/16 CNA sheets: -Had not mentioned his pressure areas or his need for repositioning or bathrooming. -Should have been updated routinely by the Minimum Data Set (MDS) coordinator nurse. -Should have indicated his need for repositioning every two hours and his pressure areas to buttocks and sacrum. *He had multiple risk factors for skin breakdown including: -Incontinence. -Inability to walk and using a wheelchair for mobility. -Dependence on staff for assistance with mobility, toileting, personal hygiene, transfers, and positioning. -Poor nutritional intake. -Potential for friction and shearing of his skin during care. *He had not received appropriate care that day. Refer to F314, finding 1. 5. Observation and interview on 12/27/16 at 4:45 p.m. with resident 1a in his room revealed he: *Was a large man in an extra wide high back wheelchair. *Had a right leg above-the-knee amputation. *Wore a left foot and heel cushion to his left leg. *Had an air mattress on his bed. *Had a cushion in his wheelchair. *Stated he had a sore on his rump that the nurses had been treating. -That it had been there for awhile. *Stated it was okay for the surveyor to observe his sore and the dressing change to that area. Interview on 12/27/16 at 5:15 p.m. with the ADON regarding resident 1a revealed: *He had a stage two pressure injury to his right buttock that was healed today. -That was an in-house acquired area. *On 12/2/16 they had implemented a bariatric air mattress for him. *The treatment to his pressure area was a [MEDICATION NAME] type dressing but she had changed it to a [MEDICATION NAME] today for protection since it was healed. *She comp

Based on observation, interview, record review, and policy and procedure review, the provider failed to ensure five of five sampled residents (1a, 2a, 5a, 6a, and 8a) identified at risk for skin breakdown had received appropriate care and service to prevent new pressure injuries from occurring or prevent current pressure injuries from worsening. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 12/29/16 at 9:07 a.m. to the administrator, the field services clinical director (FSCD), the director of nursing (DON), and the assistant director of nursing (ADON). They were asked for an immediate plan of correction to ensure all residents, including residents 1a, 2a, 5a, 6a, and 8a, would be safe from further skin breakdown. PLAN: On 12/29/16 at 4:40 p.m. the administrator and FSCD provided the surveyors with an immediate written plan of correction (POC). That POC dated 12/29/16 was accepted at 4:55 p.m. by the surveyors and included: IJ Abatement POC - Wounds *All residents with identified wounds have been reviewed on 12/29/16 to assure proper identification of the wound type, appropriate treatment ordered, individualized care plan and the CNA (certified nursing assistant) care guides to identify appropriate care interventions. *All residents will have a head to toe skin assessment completed. *All Licensed Nursing staff will receive education prior to the start of their next scheduled shift which included the Skin Integrity guidelines, Pressure Risk/Identification Guidelines, Clean Dressing Changes, Professional Standards of practice for following physician's orders [REDACTED]. *CNAs will be educated of the importance of repositioning residents with skin integrity concerns. *The designated Wound Nurse will receive appropriate training and education. *Shift to shift report will be completed between Licensed Nurses and CNAs to assure the wound status changes for residents is communicated in a timely manner. Bath aides will also report to Licensed Nurses at the start and end of their shift for a separate report time. Any changes in resident condition during the shift will result in a Staff Huddle. *Monitoring to ensure compliance - every shift for 3 consecutive days by the DNS (director of nursing services)/designee, that wound care, incontinence care and repositioning are being completed as identified by assessment and wound protocol/MD orders to include clean dressing changes, universal precautions, handwashing, use of PPE (personal protective equipment), availability of supplies, turning and individual repositioning requirements. Audit results will be reviewed during and Ad Hoq QAPI (quality assurance performance improvement) committee meeting on December 31, 2016 to provide further recommendations. On 12/29/16 at 5:10 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Observation on 12/27/16 at 5:00 p.m. of resident 2a in his room revealed he: *Was thin and had a small body build. *Was laying in bed on his left side in the fetal position. *Appeared uncomfortable stating Oh my hip, my leg. *Had his pants pulled down to his mid-thigh area exposing his disposable brief. *Was not covered with a blanket. *Had the fitted sheet coming off the top third of his bed, and his pillow case was also coming off. -The bare mattress and pillow were exposed. *Had a wheelchair with a saddle-type cushion and a mechanical lift sling sitting in the seat of it. Interview on 12/27/16 at 5:15 p.m. with the ADON regarding resident 2a revealed: *He had three pressure injuries. -Those were on his right buttock, sacrum, and left buttock areas. *She thought the left buttock and sacrum were healed, but the right buttock was still opened. *She was unsure if those were facility acquired or not. *She completed weekly measurements on all the pressure injuries and was considered their wound nurse. On 12/28/16 at 7:50 a.m. it was discussed with the FSCD that she inform nursing staff that all of resident 2a's care including transfers, toileting, and dressing changes would need to be observed during the shift by the surveyor. Observations and interviews with staff on 12/28/16 regarding resident 2a at the following times revealed: *At 8:55 a.m. spoke with licensed practical nurse (LPN) Ca regarding the need to watch all care including dressing changes for him. -She confirmed she was aware of that. *At 9:53 a.m. he was sitting in his wheelchair (w/c) in his room. *At 9:55 a.m. CNA Aa stated he did not like to lay down and they tried to get him to lay down whenever they could. -Requested to watch any care that her or any other nursing staff would be providing to him that day. *At 10:20 a.m. he was sitting in his w/c in his room. *At 10:35 a.m. he was in his w/c in his room with his head down and appeared to be sleeping. *At 10:36 a.m. LPN C was again requested to watch care for him. She stated he: -Was usually the last to lay down after lunch, because he did not like to lay down. -Was noncompliant and that should have been documented in his record. *At 11:03 a.m. he was still in his w/c in his room with his head down appearing to be sleeping. *At 11:32 a.m. he was wheeled to the dining room in his w/c by staff. *At 12:15 p.m. he was in his w/c at the dining room table by himself. *At 1:00 p.m. he was still at the dining room table in his w/c. *At 1:30 p.m. he was by the door of the dining room in his w/c. *At 2:00 p.m.: -He was back in his room sitting in his w/c with his head propped up on his left hand. -CNA Aa stated: --They tried offering to lay him down between meals but he often refused. --He used a mechanical lift to transfer. --Therapy had worked with him on using a standing lift to transfer to the bathroom only. --He should have been taken to the bathroom even if he had not layed down, but he usually would not let them help him. Observation and interview on 12/28/16 at from 2:00 p.m. through 2:20 p.m. with CNAs Aa and Ba during resident 2a's personal care revealed: *He had been sitting in his w/c with the lift sling underneath him. *They brought in the mechanical lift, hooked up the sling to the lift, and moved him from the wheelchair to his bed. *During the moving process he stated Ow, ow, Murder my legs, and Don't abuse me, let me die. *He did not attempt to strike out or be combative with the staff during his care. *He followed their directions and let them assist him. *When they got him in bed they assisted him with changing his wet disposable brief. *The brief appeared to be soaked with urine. *CNA Ba performed perineal care (peri-care) only to his buttocks area, she had not cleaned his front side. *There were three intact dressings to his left buttock, right buttock, and sacrum. -The left buttock foam and [MEDICATION NAME] dressing had a 12/27/16 date on it. -The other two dressings had no dates written on them. -The skin surrounding the dressings was excoriated and pink to red in color. *The CNAs applied a new disposable brief and pulled his pants back up. Continued interview and record review with CNA Ba following the above observation regarding resident 2a revealed: *He usually spent most of the day shift in his w/c. *He had not liked to lay down and would yell or cry out when they tried to help him. *He was not combative to the staff during cares. *The sore areas on his buttocks had been there a few months. *He should have been repositioned and toileted at least every two to three hours because of those areas. -That had not occurred during this shift. *Her and CNA Aa were the staff assigned to assist him during that day shift. *She had not helped him at all that day with care until the above observation. *She thought he had a bath that morning before breakfast, and had been in his w/c since that time. -Breakfast had started at 7:30 a.m. *She confirmed he had sat in his w/c and had not been assisted to the bathroom for several hours. *She should have completed peri-care to his front side along with his buttocks due to his incontinence. *Review of her updated 12/23/16 CNA sheet for Second Floor West revealed: -It had not mentioned: --His current pressure areas to his buttocks and sacrum. --If he was on a toileting or repositioning schedule. --That he was incontinent of urine. -It had indicated: --He used a w/c propelled by himself. --He used a Hoyer lift for transfers. *She confirmed the CNA sheet was what the CNAs used as a reference to care for their residents. -It should have listed his pressure areas and if he was supposed to have been repositioned more often. Interview on 12/28/16 at 2:35 p.m. with LPN Da regarding the above observations for resident 2 revealed: *He should have been repositioned at least every two hours due to his pressure areas. *He should have received complete peri-care and not just to his buttocks area. *Sitting for that amount of time could have caused further pressure injuries and was not appropriate care for healing pressure injuries. Interview on 12/28/16 at 2:45 p.m. with LPN Ca regarding the above observations for resident 2a revealed: *She was his charge nurse that day. *She had not been aware of any refusals of care for him that day but knew he had frequently refused to lay down in the past. -CNAs were supposed to let the nurse know if a resident refused care. *He should have been repositioned at a minimum of every two hours along with taken to the bathroom. *She stated the above observations of his care would have been considered neglect and was unacceptable. *As a charge nurse she relied on the CNAs to do their assigned work and reposition residents at risk for skin breakdown every two hours. *Repositioning and toileting were important factors in preventing pressure injuries from developing and healing current pressure injuries. Interview on 12/28/16 at 4:00 p.m. with the DON and ADON regarding resident 2a revealed: *When he remained in his w/c most of the day shift as indicated in the above observations and interviews that was unacceptable care. *The CNAs responsible for him should have been disciplined. *All residents should have been repositioned every two hours as a standard of nursing practice. *They confirmed he was at high risk for skin breakdown and already had pressure injuries. *Even though he argued with staff during care they should have attempted to reposition and toilet him due to his skin breakdown. *If he had refused care from the staff there should have been documentation of his refusals. *Incontinence care should have been performed completely and not just for his buttocks area. *They confirmed the 12/23/16 CNA sheets: -Had not mentioned his pressure areas or his need for repositioning or bathrooming. -Should have been routinely updated by the Minimum Data Set (MDS) coordinator nurse. -Should have indicated his need for repositioning every two hours and his pressure areas to buttocks and sacrum. *He had multiple risk factors for skin breakdown including: -Incontinence. -Inability to walk and using a wheelchair for mobility. -Dependence on staff for assistance with mobility, toileting, personal hygiene, transfers, and positioning. -Poor nutritional intake. -Potential for friction and shearing of his skin during care. Review of resident 2a's medical record revealed: *He was originally admitted on [DATE] from the hospital with [DIAGNOSES REDACTED]. *His 10/20/16 Discharge with Transfer Orders and addendum from the hospital stated: -Right buttock pressure ulcer, stage two. -Continue offloading measures appropriate for pt's (resident) braden score. -Nutrashield barrier cream bid (twice daily) and prn (as needed). *His Brief Interview for Mental Status (BIMS) score was: -Eight on 10/23/16 indicating he had moderately impaired cognition. -Fourteen on 11/1/16 and 12/20/16 indicating he had minimal impairment and memory problems. *He was sent back to the hospital on [DATE] then re-admitted on [DATE] with new [DIAGNOSES REDACTED]. *His 10/25/16 Discharge with Transfer Orders from the hospital stated: -Sacrum pressure ulcer, stage two. -[MEDICATION NAME] sacral dressing. -Change dressings on Mon and Thurs and PRN, for soilage, wetness. *He had physician's telephone orders: -On 12/5/16 to Clean shearing to right buttock, left buttock and sacral area with NS (normal saline), pat dry, hydrogel, skin prep to surrounding skin, cover with protective dressing, tape with mepore tape QD (daily) and PRN soilage - one time only for one day. -On 12/6/16 to Cleanse wound to right buttock with NS, pat dry, skin prep, [MEDICATION NAME] Q (every) 3 days and PRN - every day shift every 3 day(s) AND as needed. -On 12/6/16 to Cleanse Left buttock with NS, pat dry, skin prep, [MEDICATION NAME] Q 3 days and PRN - every day shift every 3 day(s) AND as needed. -On 12/6/16 to Cleanse sacrum with NS, pat dry, skin prep to surrounding skin. [MEDICATION NAME] Q 3 days and PRN - every day shift every 3 day(s) AND as needed. -On 12/23/16 to Ensure repositioning is done at a maximum of every 2 hours. *His most recent physician's orders [REDACTED]. Review of resident 2a's 10/20/16 Clinical Health Status nursing assessment from his original admission on that date indicated: *Current [DIAGNOSES REDACTED]. *He had short and long term memory problems. *For skin conditions the only areas mentioned were a [MEDICATION NAME] on his left upper arm and a redden small area to R (right) gluteal (buttock). -There was no description or measurement of that right buttock area. *His Braden assessment score for predicting pressure area risk had not been completed. -If they had totaled his score, it would have been thirteen. -A score of thirteen indicated he was at moderate risk for pressure areas. *He was unable to ambulate or transfer independently or with limited assistance. *He was frequently incontinent of urine. Review of resident 2a's 10/25/16 Clinical Health Status nursing assessment from his hospital return admission on that date indicated: *Current [DIAGNOSES REDACTED]. *His short and long term memory were okay. *For skin conditions the areas mentioned included a small opened area to his left buttock and a reddened area that blanched on his right buttock. -There was no description or measurements of those areas. -There was no indication of a sacral pressure area. *His Braden score for predicting pressure area risk had been thirteen indicating he was at moderate risk for developing them. *He was unable to ambulate or transfer independently or with limited assistance. *He was frequently incontinent of urine. Review of resident 2a's 10/21/16 Lift Mobility Status assessment that was reviewed 10/25/16 with no changes indicated he used a Hoyer lift for transfers. Review of resident 2a's 10/21/16 Bladder Evaluation assessment form that was reviewed 10/25/16 with no changes indicated he was continent of bladder. That had not matched his clinical health status assessments on 10/20/16 and 10/25/16 that stated he was incontinent. Review of resident 2a's 12/28/16 care plan revealed: *A focus area of pressure ulcer actual or at risk due to: assistance required in bed mobility, [DIAGNOSES REDACTED]. -The interventions for that included: --Conduct weekly skin inspection. --Provide pressure reduction/relieving mattress. Air mattress on bed. --Treatments as ordered. --Weekly Wound assessment. --All those interventions had been initiated on 10/25/16. *A focus area of Pressure ulcer Stage II Left Buttock due to: Assistance required in bed mobility, Bowel incontinence. Measures 3.5 X 3.0 X 0.1 (centimeters (cm)). -Date initiated was 12/1/16. -Interventions included: --Complete Braden Scale per Living Center Policy. --Conduct weekly skin inspection. --Do not massage over bony prominence. --Nutritional and Hydration support. --Offer/encourage Turning and repositioning Q 3 hours and PRN. --Provide pressure reducing wheelchair cushion. --Provide pressure reduction/relieving mattress. Air mattress on bed. --Provide thorough skin care after incontinent episodes and apply barrier cream. --Skin assessment to be completed per Living Center Policy. --Treatments as ordered: Xeroform. --Weekly Wound Assessment. *A focus area of Pressure ulcer Stage II Right Buttock due to: Assistance required in bed mobility, Bowel incontinence: Measures 1.4 X 1.5 X 0.1 (cm). -Date initiated was 12/1/16. -Interventions were the same as the above for the left buttock except: --Turning and repositioning schedule per assesment was listed but not how often it should have been done. --Treatment as ordered was listed but not the specific treatment. *A focus area of Pressure ulcer Stage II Sacrum due to: Assistance required in bed mobility, Bowel Incontinence, Skin desensitized. Measures 7.0 X 4.0 X 0.1 (cm). -Date initiated was 12/1/16. -Interventions were the same as the above for the left buttock except Turning and repositioning schedule per assesment was listed. --It did not specifiy how often to reposition him. *A focus area of Altered skin integrity non pressure related to: Searing (shearing) to Right buttock, left buttock and sacral area. -Date initiated was 12/5/16. -Interventions were the same as the left buttock except: --Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings. --Treatment as ordered; Hydrogel. --Turning and repositioning schedule per assessment was listed with no mention of how often it should have been done. *A focus area of I have a physical functioning deficit related to: Mobility impairment, ROM (range of motion) limitations, Self care impairment. -Date initiated was 12/23/16. -Interventions included: --For bed mobility and toileting he needed extensive assistance of two staff. --For transfers, dressing, and personal hygiene he needed extensive assistance of one staff person. --For locomotion he self-propelled his w/c. --For ambulation Does not walk at this time. *There was no mention of: -His refusal of care. -His noncompliance with care. -The 12/23/16 physician's orders [REDACTED]. -That his pressure areas to his right buttock and sacrum were present in October according to the hospital records. -His urine incontinence or toileting related to his incontinence. Review of resident 2a's December 2016 treatment administration record (TAR) revealed: *Treatments that had not been signed by the nurse as completed: -On 12/1/16, 12/3/16 through 12/5/16, 12/6/16 through 12/13/16 to his left buttock area. -On 12/13/16 and 12/20/16 for his left gluteal fold shear area. -On 12/20/16 and 12/27/16 for his coccyx area. -On 12/3/16 through 12/5/16, 12/6/16 through 12/20/16, and 12/27/16 for his right buttock area -On 12/6/16 through 12/13/16 for his sacrum area. *The orders for treatments to those areas changed frequently. *It was difficult to identify if they were the same areas or new areas when the orders had changed. -The treatments had dates initiated and discontinued that did not have physician's orders [REDACTED]. *The above treatment areas had not matched the current pressure areas of left buttock, right buttock and sacrum. Review of resident 2a's interdisciplinary progress notes from 10/20/16 through 12/28/16 revealed: *On 10/20/16 the initial nursing note stated .resident buttock is red . and no further mention of skin concerns. -There was no mention of the right buttock pressure ulcer as indicated on the hospital transfer sheets. *On 10/25/16 in the hospital return nursing note it stated .Upon skin assessment resident has multiple bruises noted . -There was no mention of the sacral pressure ulcer as indicated on the hospital transfer sheets nor any other skin concerns. *On 10/28/16: - .He requires assistance from staff for majority of ADL's (activities of daily living) .He always has something to complain about but does not want to listen if your're trying to explain something to him. He uses a lift for transfers per staff. - .He is incontinent of B&B (bowel and bladder) and wears a brief for protection. he is a hoyer for lifts and an assist of 1 for ADLs . *On 10/30/16 .Skin is dry and warm to touch. Assist X 1 with HS (bedtime) cares and transfers via hoyer with assist of 2. He is continent of B&B this shift and uses a urinal at noc . -There was no mention of any skin concerns. *On 11/2/16 Open area to sacrum present on admit measures 1.0 cm X 0.8 cm X 0.1 cm. Small amount of bloody drainage noted. Wound bed pink. Periwound pink. Site cleansed. Dressing applied. -That was the first mention of an opened area in the notes. *On 11/7/16 a dietary note stated .He has a stage II pressure ulcer. *On 11/17/16 .skin warm and dry to touch . and no further mention of skin concerns. *On 11/28/16 was the first documentation of him refusing care: Resident refused to let the CNA cut his fingernail today. The author of this note went in and tried to see if the resident would let me cut them and he still refused . *On 11/30/16 was the first documentation of him refusing care related to his skin concerns: CNA notified SN resident had bleeding to sacral area, SN noted reddened area where allevyn was placed. SN returned to get clean and recover wound. REs refused with yelling not allowing SN to change bandage or CNA to change brief, SN teaching to resident the importance of remaining dry to prevent wounds from occurring. *On 12/1/16 an MDS note for a Medicare fourteen day/change of therapy assessment stated: .Extensive assist with bed mobility, transfers, w/c locomotion on and off unit, dressing, eating, toilet use, personal hygiene. Total assist with bathing. Urinary incontinence X 17, continent X 3, bowel incontinence X 3, continent X 1 this assessment period. Incontinence/comfort cares provided with each episode -There was no mention of pressure areas or skin concerns. *On 12/1/16 a change of condition note stated .Pt (resident) noted to have new breakdown to bilateral buttocks .Pt refused brief changes this morning, as well as scheduled dressing change to current ulcer, or to get out of wheelchair get in bed for pressure relief and pressure healing as pt has a current ulcer. Pt offered and encouraged multiple times by CNAs and this nurse but pt would refuse stating 'No' or 'I don't want to' or 'You cant make me do anything' or 'I don't need it' .Left buttock has 1.7 cm diameter area with slough with 0.2 cm open redness around it; right upper buttock has red open area 4.5 X 4.0 X 0.1 cm open area below it with a 4 0.4 cm diameter open red areas around it. Below these the right lower buttock has an open red area of 3.8 X 3.2 X 0.1 cm. Cleansed areas with NS and applied hydrogel and covered with [MEDICATION NAME] dressings while pending response from MD requesting to start hydrogel and [MEDICATION NAME] daily and PRN to areas. Pending response at this time .After pericares provided pt propped onto side with pillow. Pt immediately removed pillow himself to lay flat on his back. Pt again educated on need to stay off buttocks for pressure relief and wound healing. Pt states 'Im fine'. Notified pt of current wounds and pt responded 'If they start hurting I'll move but this is how I want to lay'. Pt did agree to stay lying down in bed at this time 'for now.' *On 12/1/16 an MDS note for a Medicare thirty day assessment stated: .Extensive assist with bed mobility, w/c locomotion on unit, dressing, eating, toilet use, personal hygiene. Total assist with transfers and bathing. More assist needed with transfers r/t knee pain, mech. lift use. Urinary incontinence X 9, continent X 14, bowel incontinence X 1, continent X 1 this assessment period. Incontinence/comfort cares provided with each episode . -There was no mention of pressure areas or skin concerns. *On 12/6/16 .Wound care provided to buttock per order . *On 12/13/16 a wound care note Resident Stage II to Left Buttock healed, Stage II Sacrum Healed. Resident Stage II Right buttock improved by decreased surface area. Has area at 3'O clock measures 1.2 X 1.3 X 0.1, 9 O' Clock measures 1.0 X 1.2 with surrounding skin pink, intact. Resident new Shear on Left gluteal fold measures 6.0 X 2.5 X 0.1. Areas small amount bright red bleeding. Resident transfer by Lift and cont. sit for long periods before allow staff to provide rest period. Resident cont. with air mattress on bed, pressure redistrubution, cushion in chair and cont. encourage for rest periods and turn. Resident turned and repositioned on Right side but ask over and over When do I get up, how long do I have to stay in bed. Resident made aware would be assisted back up for supper with approximately 2 hours in bed. Resident aggress to rest in bed and states I know my bottom is better, it is not hurting so I don't see why I need to rest in bed. *On 12/13/16 an MDS note for a change of therapy assessment stated .Skin concerns with excoriation on buttocks . *On 12/15/16 .Resident has healing pressure and shearing wounds to buttocks. Resident is encouraged to rest in bed between meals and as often as possible to offload areas. However resident is often non-compliant with staff request to rest in bed and be offloaded for healing . *On 12/16/16 Had a bowel movement and dressing became very soiled and bleeding. The dressing was half off so CNA took dressing off and informed this nurse that resident need a new dressing put on. When this nurse went in to apply a new dressing the resident refused. He said that the dressing he had on was fine. This nurse explained to the resident that he did not have a dressing on his bottom and she needed to put one on. He refused again. This nurse explained to him that she was going to chart his refusal X 2 for a dressing to be applied. He said I'm going to report you to the nurse. This (nurse) said make sure you tell them you refused the dressing change. He said awe just cover me up. *On 12/19/16 Resident continues with dressing changes to bilateral buttocks. Resident is noncompliant with repositioning et often refuses to lay down between meals. *On 12/19/16 At 10:06 p.m. .Resident has been resting in his bed quietly this shift and repositioning is offered for offloading, of which he is noncompliant. Wound care provided to buttock per order . *On 12/25/16 at 10:52 p.m. .Resident has been resting in his bed quietly this shift and repositioning is offered for offloading. Wound care provided to buttock per order . *There was no mention in the notes of: -How often repositioning was occurring. -That he was refusing care as frequently as staff indicated in the above interviews or prior to his pressure area on his sacrum on 11/2/16. -The frequent physician's orders [REDACTED]. Review of resident 2a's December 2016 CNA documentation on the ADL Flow Sheet Log revealed: *Several entries where 0 or 8 was documented for the shift indicating the activity had not occurred. *Those entries were related to transferring, toilet use, dressing, and personal hygiene. Interview on 1/4/17 at 12:20 p.m. with CNA Ha and the FSCD regarding resident 2a's above CNA documentation revealed: *A documentation of 0 or 8 indicated the resident had not needed assistance or the activity had not occurred. -An 8 should not have been documented related to transferring, toilet use, dressing, and personal hygiene care because he required staff assistance. *The resident was dependent on staff assistance for those cares, and they should have been completed and documented appropriately. *If he had refused care that should have been documented in his behavior charting. *Copies of the behavior charting were requested for December 2016. Review of resident 2a's Resident Behavior Log documentation by the CNAs from 12/28/16 through 1/4/17 revealed: *He had no behaviors or refusals of care documented during that time frame. *Documentation for December 2016 had been requested from the FSCD on 1/4/17 at 12:20 p.m. and was not received by the end of survey on 1/5/17. Review of resident 2a's Wound Evaluation Flow Sheet assessments containing multiple weeks from his admission on 10/20/16 through 12/29/16 revealed: *There were no assessments for: -The right buttock pressure area as indicated on his initial admission on 10/20/16. -The sacrum pressure area as indicated on his hospital return on 10/25/16. *The first wound assessments had been done on 12/2/16 and revealed: -Stage 2 right buttock pressure area. -Stage 2 sacrum pressure area. -Stage 2 left buttock pressure area. *The right buttock assessment indicated it: -Was identified on 12/2/16 but that had not matched the 12/1/16 nurses note. -Measured 2.0 cm by 1.5 cm by 0.1 cm. -Was a stage 2 pressure area. -Was acquired in-house. -Had current preventative measures of a w/c cushion and a specific turn/repositioning program. -Was a new wound with multiple open excoriated areas. -Was assessed and signed as completed by the nurse for week two on 12/6/16, for week three on 12/27/16, and for week four on 12/27/16. *The sacrum assessment indicated it: -Was identified on 12/2/16 but that had not matched the 12/1/16 nurses note. -Measured 7.0 cm by 4.0 cm by 0.1 cm. -Was a stage 2 pressure area. -Was acquired in-house. -Had current preventative measures the same as the right buttock. -Was assessed and signed as completed by the nurse for week two on 12/6/16 and for week three on 12/15/16. --The surveyor had only received pages one through nine of that assessment but indication was that it had been thirty-three pages total. *The left buttock assessment indicated it: -Was identified 12/2/16 but that had not matched the 12/1/16 nurses note. -Measured 3.5 cm by 3.0 cm by 0.1 cm. -Was a stage 2 pressure area. -Was acquired in-house. -Had the same preventative measures as the right buttock and sacrum. -Was assessed and signed as completed by the nurse for week two on 12/6/16 and for week three on 12/15/16. -Was healed on 12/15/16 per the nurse documentation. *There was another left buttock assessment with an effective date of 12/27/16 that indicated it: -Was identified on 12/2/16. -Measured 5.0 cm by 2.0 cm by 0.1 cm. -Was a stage 2 pressure area. -Was acquired in-house. -Only had preventative measures of a pressure redistribution mattress. -Was assessed and signed as completed by the nurse on 12/27/16. -Indicated at the top of the sheet that it was not a continuation of another wound assessment form, it was a new area. *There was another sacrum assessment with an effective date of 12/20/16 that indicated it: -Was identified on 12/20/16. -Measured 1.6 cm by 1.1 cm by 0.1 cm. -Was a stage 2 pressure area. -Was acquired in-house. -Only had preventative measures of a pressure redistribution mattress. -Was assessed and signed as completed by the nurse on 12/27/16 and for week two on 12/27/16. -Indicated at the top of the sheet that it was not a continuation of another wound assessment form, it was a new area. 2. Review of resident 1a's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].

Based on record review, interview, and job description review, the provider failed to ensure medically necessary social services had been completed for one of one sampled resident (3) who was experiencing psychological stress regarding the death of her husband and a room change. Findings include: 1. Resident 3 had a significant loss in October 2015 with the death of her husband. She was moved from the first floor to the second floor without notification. She has had increased loss of hair and an increase in her anti-depressant medications. No interventions had been put in place to reduce her stress. Refer to F319.

Based on record review, interview, and job description review, the provider failed to ensure one of one sampled resident (3) with mental and psychosocial needs had those needs addressed. Findings include: 1. Interview on [DATE] at 4:30 p.m. with resident 3 revealed she:*Had not been asked if she had wanted to move from her room on the first floor to the second floor. *Was still upset that she had not been given an option or notified in advance. *Stated she liked to be able to sit outside when she was on the first floor and was mad she could not do that anymore. Review of resident 3's medical record revealed: *She had been admitted on [DATE]. *She had [DIAGNOSES REDACTED]. *Her husband who had been at the same facility and had died last year. *She had been moved from the first floor to the second floor on [DATE]. *There was no documentation she had been informed prior to that room change. *An interdisciplinary progress note on [DATE] at 4:39 p.m. regarding a conversation with her daughter revealed her hair was falling out in clumps. *There was no further documentation of her hair loss until [DATE] at 10:41 a.m. of depression - hair loss. *An [DATE] fax communication was sent to her physician with an attached note from the registered nurse assessment coordinator. That note included her daughter having concerns of her hair loss. *Her physician responded on [DATE] with an order to decrease her [MEDICATION NAME] to 7.5 milligram (mg) in two weeks due to stress and move of floors. He also wrote Stress from move most likely causing hair loss. *There was an [DATE] physician's orders [REDACTED]. *On [DATE] she and her family were notified a different room with the bed by the window was available. She was moved to that room on [DATE] and was very happy with the room change. *She was seen again by her physician on [DATE]. That physician progress notes [REDACTED].>-Pt. (patient/resident) is stressed due to having to move from 1st to 2nd floor, with diff (different) roommate and staff. Pt is losing her hair will check TSH ([MEDICAL CONDITION] function test) but most likely due to move. -She was diagnosed with [REDACTED]. -Physician orders [REDACTED]. She was also started on [MEDICATION NAME] 10 mg daily for twenty-one days. Those medications were for depression. Review of resident 3's revised [DATE] care plan revealed:*A focus area that included Resident has the potential to show signs and symptoms of moods and behaviors due to Dx. of Alzheimer's and [MEDICAL CONDITION]. *A goal of Resident has baseline of 5 moods/behavior triggers per month. *Interventions that included: -Attempt to refocus behavior to something positive when resident is upset or moody and provide reassurance as needed. -Listen attentively to resident and discuss concerns with resident as needed. -Social services to monitor moods and behaviors on a regular basis. *The care plan had not been updated since her hair had been falling out. *There were no interventions related to her grieving from the loss of her husband or her stress from moving. Interview on [DATE] at 10:50 a.m. with the social services coordinator (SSC) revealed she: *Had a previous assistant ask resident 3 if she wanted to move and she had agreed. *Agreed there was no documentation resident 3 had been asked about her move. *Had never been seen by Deer Oaks counseling. A referral had been sent on [DATE], but her daughter had cancelled the referral on [DATE]. *Agreed there was no documentation of the Deer Oaks referral or cancellation. She stated she had just called them and had been given that information. *Agreed no interventions had been put in place for resident 3's stress related to her move. *Agreed she had not documented anything regarding the death of her spouse. *Had not reassessed her for any signs or symptoms of depression. *Agreed her previous mood interview for the [DATE] Minimum Data Set assessment indicated no depression. *Agreed no behaviors had been documented by staff from [DATE] through [DATE]. Review of the provider's [DATE] Social Services Coordinator job description revealed the SSC:*Would have identified and provided for each resident's social, emotional, and psychological needs. *Develop a care plan which identified pertinent problems and needs, realistic goals to be accomplished and the specific action to be taken in resolution of the problems and/or needs. *Document progress notes which would have related to each resident's care plan when necessary.

A. Based on record review, interview, and policy review, the provider failed to ensure professional standards were followed for one of one sampled resident (5) who was: *Identified as a high risk for falls. *To have been monitored for anti-anxiety and anti-depressant drug side effects. *To have had neurological assessment checks done after a fall. *To have had a fall analysis documented on her after the fall. Findings include: 1. Review of resident 5's current care plan revealed the following focus areas: *At risk for falls related to: Unsteadiness with transitions and use of [MEDICAL CONDITION] meds (medication). -That focus area was initiated on 3/19/14. -There were also handwritten notes from the past director of nursing services (DNS) that stated: -- Fall 2/1/15; Nurse needs to remind aide when this Resident receives a laxative to monitor closely. --fell on [DATE]. *Potential for drug related complications associated with use of [MEDICAL CONDITION] medications related to: Anti-Depressant medication, Anti-psychotic medication, PRN (as needed) Antiquity. -That focus area was initiated on 3/19/14. The typed interventions for the above focus areas were: *Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, [MEDICAL CONDITIONS](faster than normal heart rate), muscle tremor, agitation, headache, skin rash, photo sensitivity, and excess weight gain. *Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (extra pyramidal symptoms (unstable walk and muscle spasms)), weight gain, [MEDICAL CONDITION] (swelling), postural [MEDICAL CONDITION] (light-headed upon standing), sweating, loss of appetite, [MEDICAL CONDITION]. -The interventions were to be initiated on 3/19/14. -Handwritten notes with the same wording were written above the above interventions. They were dated 3/20/15 and 1/5/15 respectively. The responsible position for the above interventions were NS (nursing services) and SS (social services). Interview on 9/2/15 at 4:10 p.m. with the interim DNS revealed: *She had located a monthly behavior/mood assessment dated [DATE] that had been completed by the SS. *She stated the behavior mood committee met monthly to monitor for side-effects of medication. *She agreed the side-effects listed on the April 2015 assessment for resident 5 were mental and not physical. *She had no other documentation from NS to ensure a physical assessment as requested in the care plan interventions had been completed on resident 5. *She had no evidence the April 2015 assessment had been sent to resident 5's physician. Review of the provider's 11/13/14 Falls Change of Condition Guidelines for Completion policy revealed: *To assess individual condition after a fall occurs and to identify the reason and/or risk factors for the fall in order to prepare a plan of care to reduce the potential for future falls. *The interdisciplinary Care Plan team will complete a review of the Change in condition Report-Post Fall Investigation. This will be completed within 72 hours. Review of the provider's 1/22/15 Falls Management Guideline policy revealed: *Following a resident's fall: The licensed nurse assesses the resident for injuries (including neuro checks if indicated) and provides necessary treatment and initiates the Change in Condition Report - Post Fall/Trauma. *Licensed nurse completes Change in Condition Report - Post Fall Analysis following a resident fall. Neurological Checks policy dated 12/18/14 revealed: *1. Conduct neurological checks as follows: -Every 15 minutes for the first hour; -Every 30 minutes x (times) 4; -Every 60 minutes times 2; then Every shift for 72 hours. *2. Neurological checks shall be documented on the designated record and changes in neurological status reported immediately to the resident's physician by licensed nursing staff. 15-minute checks shall be reinitiated whenever there is a deterioration in the neurological status until the physician can give further guidance and/or consider further diagnostic testing. *3. Neurological assessment and documentation on the flow sheet shall include: a. date and time of assessment b. eye opening c. verbal response d. motor response e. pupillary response f. limb response g. vital signs. Review of resident 5's chart revealed: *A 2/1/15 neurological assessment had been completed by a nurse every fifteen minutes after a fall with a head injury. *A 5/21/15 neurological assessment had only one column completed for a fall with a head injury. Additional information had been completed on a vital signs and weight flow sheet. There were one hour gaps between 10:50 p.m., 11:50 p.m., and 12:50 a.m. There were four hour gaps between 00:50 a.m. and 4:50 a.m., 8:50 a.m. and 12:50 p.m. -No assessment information was written for the 8:50 a.m. check. -No information was given for the 5/22/15 assessment after 12:50 p.m. -The 5/21/15 9:05 p.m. comments were: --0 (with a line through the zero) Injury --resident A & O (alert and oriented). --All other comments were PERLA (pupils equal, reactive to light and accommodation) - resting in bed. --No comments were given for 08:50, 12:50, and the additional date after 12:50. - No base lines were given for: --BP (blood pressure) --Temperature --Pulse --Respirations. -The on-call physician had been notified when: --The BP was 190/130 --Temperature was 97.2 --Pulse was 204 resting --Respiration was 40 --O2 (oxygen saturation) was 72% (percent). -There was no physician notification on 5/21/15 at 21:50 when: --The BP was 58/44 --Temperature was 96.7 --Pulse was 117 resting --Respiration was 24 --O2 was 91. Review of the nurses notes (NN) and progress notes from 2/18/15 through 5/22/15 revealed: *2/20/15 11:15 (11:15 a.m.) NN: Resident was found on bathroom floor, with blood on R (right) elbow. Was called into resident bathroom by aide. Resident states she was transferring back to wheelchair when she slipped. *No post fall analysis/plan or assessment could be located by the interim DON for that date. B. Based on record review, interview, and policy review, the provider failed to transcribe and follow physician's orders [REDACTED]. Findings include: 1. Review of resident 2's medical record revealed: *A 6/26/15 physician's orders [REDACTED]. -Apply Lopress (type of compression wrap) (small wrap 4 (inches) and 6 large) from base of toes up LE (lower extremity), 1 below bend of knee. re-wrap every 12 hours. *A 7/9/15 physician's orders [REDACTED]. -Lopress wraps to RLE (right lower extremity). Start with smaller wrap, beginning at base of right toes, wrapping upward overlapping wrap 50%. When smaller wrap runs out, tape in place. then use larger lopress wrap and being at ankle, Wrap upwards, overlapping 50% to 1 below bend of knee, secure in place with tape. *A 7/23/15 physician's orders [REDACTED]. --Lopress wraps to RLE (right lower extremity). Start with smaller wrap, beginning at base of right toes, wrapping upward overlapping wrap 50%. When smaller wrap runs out, tape in place. then use larger lopress wrap and being at ankle, Wrap upwards, overlapping 50% to 1 below bend of knee, secure in place with tape. *A 7/30/15 physician's orders [REDACTED]. --Lopress wraps to RLE (right lower extremity). Start with smaller wrap, beginning at base of right toes, wrapping upward overlapping wrap 50%. When smaller wrap runs out, tape in place. then use larger lopress wrap and being at ankle, Wrap upwards, overlapping 50% to 1 below bend of knee, secure in place with tape. Review of the narrative documentation from the WCC included: *7/8/15 Pt (patient) not wearing lopress wraps-Type of ACE (compression) wrap in place. Type of ACE wraps in place to BLEs (bilateral (both) lower extremity), no lopress wraps noted to the RLE as previously ordered. When asked, pt stated that the wraps were applied by a person at GLC (facility name). Pt reported that staff person insisted that both legs be wrapped, but had to use ACE wraps instead of Lopress wraps as they were out of supplies. *7/23/15 No lopress wraps noted to RLE as previously ordered. When asked, pt stated the wraps haven't been applied for 3 days. *7/30/15 ACE wraps in place to legs, note that wraps are not the previously ordered lopress wraps. No dressing noted to the right posterior knee wound, wound open to air and draining. [MEDICATION NAME] Gentle dressing covering the right lateral leg, with what appeared to be [MEDICATION NAME] and dry 2x2 gauze beneath. When asked, the pt stated that the SNF (skilled nursing facility) staff do not always change the [MEDICATION NAME] dressing twice a day as instructed, pt state that sometimes the staff only change it once a daily. Review of resident 2's treatment administration records (TAR) for June, July, and August 2015 revealed: *June 2015 TAR included: --Order Date-6/26/15 1606 (4:06 p.m.) wrap LLE (left lower extremity) with 4 and 6 ace wraps q (every) 12 hours. Two times a day wrap over wound care dressing. *July 2015 TAR included: --Order Date-6/26/15 1606 (4:06 p.m.) wrap LLE (left lower extremity) with 4 and 6 ace wraps q (every) 12 hours. Two times a day wrap over wound care dressing. --Order Date-7/10/15 1500 (3:00 p.m.) Wrap RLE with lopress wraps q12 hours per Dr. ____(physicians name). *August 2015 TAR included: --Order Date-6/26/15 1606 (4:06 p.m.) wrap LLE (left lower extremity) with 4 and 6 ace wraps q (every) 12 hours. Two times a day wrap over wound care dressing. --Order Date-7/10/15 1500 (3:00 p.m.) Wrap RLE with lopress wraps q12 hours per Dr. ____(physicians name). Review of the documentation on the July 2015 TAR revealed Wrap RLE with lopress wraps q12 hours had not been documented as having been done four times. Review of the documentation on the August 2015 TAR revealed Wrap RLE with lopress wraps q12 hours had not been documented as having been done five times. Interview on 9/2/15 at 2:00 p.m. with the interim director of nursing confirmed: *The 6/26/15 WCC physician's orders [REDACTED]. *The 7/10/15 WCC physician's orders [REDACTED]. Review of the provider's revised 5/13/15 Non-Control Medication Order Requirements policy and May 2012 Medication Administration -General Guidelines policy revealed no information on transcribing physician's orders [REDACTED].

Based on observation, interview, record review, and policy review, the provider failed to ensure the safety for one of one sampled resident (4) from elopement (leaving the facility without staff knowing). Findings include: 1. Random observations of resident 4 throughout the survey from 9/1/15 through 9/2/15 revealed: *He ambulated with a walker with a steady gait (sequence of foot movement). *He ambulated throughout the facility without assistance. Interview on 9/2/15 at 2:10 p.m. with certified nursing assistant (CNA) A revealed: *She had been working and assigned to care for resident 4 the evening of his elopement on 7/16/15. *There had been one nurse and three CNAs working on the second floor. -That had been the usual staffing pattern. *The resident's wife had been visiting. -He had a history of [REDACTED]. -His wife had left the facility about 3:00 p.m. -The wife had said to her Watch out he is in a mood. *He had a Wanderguard (a device that would set off an alarm of an equipped door as he passed through it) applied to his walker and on his belt. *He had been cued to go to the dining room for the supper meal. *She had been busy with another resident who had been having escalating behaviors. *After supper she went to find him and could not find him. *She notified her supervisor. -At that same time another resident's family member had called the facility to tell them resident 4 was at (name of restaurant). *She stated the front doors were locked at 7:00 p.m. -The nurses were responsible for locking them. -She had seen the nurses locking them. -The alarms went off frequently due to visitors to the facility. Review of the dietary intake record in the electronic medical record revealed resident 4 had consumed 100 percent of his evening meal. This meal had been served at approximately 5:30 p.m. according to the dining room service times. Review of resident 4's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Dementia (decline in mental abilities) with behavioral disturbances. -Chronic kidney disease. -Diabetes (problem with blood sugar levels). -Cancer of the bladder. -Hypercholeterolemia (high cholesterol). -Alzheimer's disease (decline in mental abilities). -[DIAGNOSES REDACTED] (low thyroid function). -Coronary Athrosclerosis (narrowing of the arteries of the heart). *He had been identified as an elopement risk upon admission. *He had three Wanderguard's in place (two on his walker and one on his belt). *The treatment administration records (TAR) for May, June, July, August, and September 2015 revealed no documentation of monitoring the Wanderguard's. *The 5/13/15 Minimum Data Set assessment (MDS) revealed a Brief Interview for Mental Status (BIMS) test had a score of six. That score indicated severe cognitive (thought process) impairment. Review of the nursing progress notes from admission to current revealed: *5/25/15 at 10:26 a.m. Has wanderguard as attempts to leave building. *5/28/15 at 11:41 p.m. Elopement risk. *5/30/15 at 2:16 p.m. Resident went out the side door of the building and went and sat in the courtyard. The alarm was sounding (door alarm). *6/3/15 at 3:15 p.m. Resident found exit seeking at front door. Resident does have wanderguard in place which is attached to his walker. Resident made his way downstairs without his walker. *6/13/15 at 8:14 p.m. Resident was standing in elevator (elevator locked d/t (due to) Wanderguard) without his walker. *6/13/15 11:04 p.m. Wanderguard in place. Exit seeking behavior noted this evening. *6/16/15 2:25 p.m. Gait unsteady without walker. Has history of exit seeking behaviors, none noted this shift. *6/17/15 at 11:11 p.m. Wanderguard in place. History of exit seeking. Walks independently with wheeled walker and steady gait. * 6/25/15 at 10:30 a.m. (name of physician) states to have (name of nurse practitioner) in for psych (psychological (thought processes)) eval (evaluation) and to check UA (urine sample). *6/26/15 at 11:30 a.m. Urine sample collected by clean catch. *7/14/14 at 12:38 p.m. Resident evaluated by (name of facility). *7/15/15 at 10:02 a.m. (name of nurse practitioner) in to see resident to day, no new orders. *7/17/15 at 1:52 p.m. Resident is being re-evaluated by (name of facility). SSA (social services assistant) notified spouse of the evaluation and added wanderguard. *7/17/15 at 2:16 p.m. (name of physician) recommendation to transfer pt (patient) to (name of facility) locked unit when possible. *7/18/15 at 8:09 a.m. Resident checked often due to wandering outside of building. Checked wanderguard this AM. *7/20/15 at 10:50 p.m. Wanderguard placed on belt and on walker. Resident is an elopement risk. *8/5/15 at 3:54 p.m. Resident has been exit seeking, and has wanderguard on his walker but does leave his walker behind. Refuses to have wanderguard bracelet on self. Resident a need to be evaluated for (name of facility). *There had been no 7/16/15 progress note that had been the date of the elopement. Review of the urine analysis obtained on 6/26/15 at 11:30 a.m. revealed: *The physician had been faxed the results on 6/29/15. *The results indicated a few bacteria, with none of the criteria met to perform a culture (to determine which antibiotics were needed to treat an infection). Review of resident 4's care plan revealed: *An immediate plan of care for elopement risk had been implemented on 8/6/15. *There had been a care plan that had a focus area of I forget things and it creates possible safety risks for me. DX (diagnosis) of dementia, new environment. -It had been initiated on 5/15/15. *Handwritten below the above was Elopement risk; there had be no initialized date. *The interventions for the elopement risk were: -8/5/15 (date written) Be aware that resident refuses wanderguard on self and has left his walker behind. -8/5/15 (date written) Family will consider placement in (name of facility). Review of the behavior log for the time frame of 7/15/15 through 7/17/15 revealed None of these behaviors apply. Review of the ADL (activities of daily living) detail report for 7/16/15 revealed he had been independent with no set-up or physical help from staff for: *Bed mobility (repositioning self). *Transfers. *Walking in room and corridor. *Locomotion (getting around) on unit and off unit. *Dressing. *Eating. *Toilet use. *Personal hygiene. Review of the evaluation completed on resident 4 for (name of facility) revealed there was: *No date the assessment had been completed. *No name of the person completing the assessment. *A total score of 3.6 that revealed between Mild, minimal impairment that is clinically verifiable with detailed questioning and Moderate, marked impairment which is readily evidenced clinically. Review of the 1/29/09 Golden Living Admission/Discharge Criteria to Alzheimer Care Units revealed The resident must score between 4.5 and 6.5 on the Global Deterioration Scale. Interview on 9/2/15 at 10:00 a.m. with social service assistant (SSA) B revealed: *Resident 4 lived on the second floor at the time of the elopement on 7/16/15. *She stated, He had taken the elevator down to the first floor, went out the front door, turned right and went to (name of restaurant). *At that time he had Wanderguards on his walker and his belt. *He was taking the Wanderguards off. *She stated the incident had occurred after 5:00 p.m. -She knew that because it happened after she had left for the day. *She stated the front door was alarmed at 5:00 p.m. Observation throughout the survey revealed the front door exited toward a busy four lane highway with no crosswalk or signal lights in front of the building. Interview on 9/2/15 at 12:00 noon with resident 3's mother revealed: *She had been the one that had found resident 4 at (name of restaurant). *She had called the facility to inform them of the resident's whereabouts. *She had brought him back to the facility. *The incident had occurred after the supper meal. *She had entered the facility, noted the alarms sounding, and had shut them off herself. -There usually had been no staff around when she had shut the alarms off. Review of the provider's undated Elopement Guideline policy revealed: *The definitions of elopement was Elopement, for purposes of this policy and procedure, is defined as that situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety, needs, and therefore at risk for injury outside the confines of the living center, has left the living center without knowledge of staff. *Under prevention for this policy had been Staff will: -Observed that each resident's bracelet alarm/device is still in place each shift. -Establish a process to check bracelet alarm/device batteries according to manufactures directions. -Document findings on the TAR or other form of documentation. *Door alarms and resident protection alarms section revealed: -Door alarms are tested daily. -The provider was to Maintain roster of bracelet battery expiration dates and replace prior to expiration date. *Monitoring compliance section revealed: -Care plans for elopement are in place and interventions individualized and implemented per physical observation. -Door alarms are checked and documented in Building Engines. -Alarm bracelet function is checked daily and documented. Review of the 2015 Signaling Device Testing Calendar for resident 4 revealed: *He had been stared on a Wanderguard on 5/29/15. *The device had not been documented as checked on the following dates: -6/30/15. -7/3/15 and 7/4/15. -7/6/15 through 7/18/15. -7/20/15 through 7/23/15. -7/26/15 through 9/1/15. Review of the provider's updated 9/13/13 Door Security Policy and Procedure revealed: *The front door/main entrance will be locked at 10:00 p.m. *The front/main entrance will be disarmed at 8:00 a.m. until 4:30 p.m. M-F (Monday through Friday) while monitored by the business office personnel. The front/main entrance will be alarmed M-F 4:30 p.m. until 8:00 a.m., from 4:30 p.m. Fridays until 8:00 a.m. Monday and any other times that business office personnel are not available to monitor this exit. *Those exits that require continuous monitoring and/or alarms are alarmed through our (specific brand name) wander management system . Interview on 9/2/15 at 1:50 p.m. with the interim executive director and the field services clinical director revealed: *The front door was alarmed when business office personnel were not present. *The alarms randomly activated in the evening. *Door alarms were monitored daily.

Based on observation, interview, record review, testing, and policy review, the provider failed to ensure the facility was operated and administered in a manner that attained or maintained the highest practicable physical, mental, and psychosocial well-being of all 101 residents. Findings include: 1. Interview on 2/19/15 at 1:30 p.m. with the administrator confirmed the overall operation and administration of the facility was her responsibility. Interviews, observations, record reviews, testing, and policy reviews throughout the course of the survey from 2/10/15 through 2/12/15 and from 2/17/14 through 2/19/15 revealed the administration had not ensured all 101 residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being. Refer to F176, F221, F241, F273, F278, F280, F281, F309, F314, F315, F323, F441, F464, F490, F514, and F520.

Based on observation, interview, record review, and policy review, the provider failed to ensure an effective incontinence (lack of control of bowel and bladder) prevention and individualized toileting programs were initiated and/or maintained for 11 of 23 sampled residents (1, 2, 5, 8, 9, 10, 11, 13, 17, 23, and 24) Creating a situation of immediate jeopardy that had the potential for causing harm to all residents with incontinence. NOTICE: Notice of immediate jeopardy was given verbally to the administrator and the director of nursing services (DNS) on 2/11/15 at 4:45 p.m. The administrator was asked for an immediate plan of correction to ensure all residents who were incontinent were monitored and provided toileting and personal care. PLAN: On 2/11/15 at 5:45 p.m. the administrator provided the surveyors with the written plan of correction (POC). The written POC dated 2/11/15 was accepted by the surveyors at 5:45 p.m. That immediate POC included: *Education: Nursing staff would be re-educated on meeting the individual needs of the residents in regards to incontinence management, including pericare (personal care), frequent toileting, turning, and repositioning. Staff currently working would be educated immediately by the DNS and oncoming staff would be educated prior to starting their shift by the registered nurse (RN) in charge. *Supervision: RN in charge of current shift and ongoing night shift would receive education in regards to frequent rounding (frequent checking on residents), incontinence care, and toileting being provided by DNS for current shift and RN in charge for oncoming night shift. RN will supervise and ensure residents incontinence needs were being met throughout the shift. Certified nursing assistants (CNA) will use check list throughout current shift and oncoming night shift to document incontinence care provided. Check list will contain care performed with time and initials of staff. *Designee: DNS will be the designee for this plan of correction. On 2/12/15 at 2:00 p.m. the administrator provided the surveyors with the written abatement (correction) plan. This was accepted by the surveyors on 2/12/15 at 2:00 p.m. That abatement plan included: *All residents will maintain or reach their highest practicable well-being. *What correction action will be accomplished for those residents found to be affected by the deficient practice? -All nursing staff will be re-educated on meeting the individual needs of the residents in regards to incontinence management including pericare, frequent toileting, turning, and repositioning before the start of their next shift. *A bladder tracking tool completed to identify any trends or patterns the resident may have in relation to incontinence. A bladder evaluation will be completed to identify potentially reversible (transient) causes of urinary incontinence. The bladder evaluation will include: --Conditions, environmental factors, and hydration status. --Identification of a contributing diagnosis/medical condition. --Identification of medications that may be contributing to bladder dysfunction problem. --Continuing evaluation that includes past medical history/laboratory results, etc. --Depiction (written picture) of the incontinence symptoms the resident has present with-stress, urge, mixed, overflow, or functional incontinence. --Upon completion of this evaluation as well as the tracking tool a toileting/bladder program can be determined. --A note to summarize the findings will be written. --The care plan will be updated to include the findings of the bladder evaluation and interventions to manage incontinence. --This evaluation and care plan review will be done on 2/12/15 for all residents identified. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. *Residents who triggered (were identified) for low risk incontinence on the most recent Minimum Data Set (MDS) assessment will have a bladder tracking tool completed to identify any trends or patterns the resident may have in relation to incontinence. *A bladder evaluation will be completed to identify potentially reversible (transient) causes of urinary incontinence. The bladder evaluation will include: -Conditions, environmental factors, and hydration status. -Identification of a contributing diagnosis/medical condition. -Identification of medications that may be contributing to bladder dysfunction. -Continuing evaluation that includes past medical history/lab results, etc. -Depiction of the incontinence symptoms the resident has present with-stress, urge, mixed, overflow, or functional incontinence. --Upon completion of this evaluation as well as the tracking tool a toileting/bladder program can be determined. --A note to summarize the findings will be written. --The care plan will be updated to include the findings of the bladder evaluation and interventions to manage incontinence. --This evaluation and care plan review will be completed by 2/20/15. -All residents with catheters will be evaluated for appropriateness and care plan updated by 2/20/15. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur includes: *All nursing staff on the current shift were immediately educated on meeting the individual needs of the residents in regards to incontinence management including pericare, frequent toileting, turning, and repositioning by the DNS. Oncoming night shift was educated on this by the RN in charge. *RN in charge of current shift and oncoming night shift received education in regards to frequent rounding, incontinence care, and toileting being provided by DNS for current shift and RN in charge for oncoming night shift. -RN in charge supervised and ensured residents incontinent needs were being met throughout the shift. -CNAs used check list throughout current shift and oncoming night shift to document incontinence care provided. Check list contained care performed, time, and initials of staff. *All nursing staff would be re-educated on the Golden Living Incontinence Management/Bladder Function Guideline, pericare, frequent toileting, turning, and repositioning to meet the individual needs of each resident, activities of daily living (ADL) assistance, and dignity for residents with incontinence, and use of absorbent material for leaking catheters prior to the start of their next shift. -The nursing administration team will be educated on including comprehensive documentation and rationale to bladder and bowel assessments and appropriate use of catheters for residents before the start of their next shift. *New admissions, re-admissions, and significant changes of condition that experience incontinence will have a bladder tracking tool completed to identify any trends or patterns that the resident may have in relation to incontinence. -A bladder evaluation will be completed to identify potentially reversible (transient) causes of urinary incontinence. The bladder evaluation will include: -Conditions, environmental factors, and hydration status. -Identification of a contributing diagnosis/medical condition. -Identification of medications that may be contributing to bladder dysfunction. -Continuing evaluation that includes past medical history/lab results, etc. -Depiction of the incontinence symptoms the resident has present with-stress, urge, mixed, overflow, or functional incontinence. --Upon completion of this evaluation as well as the tracking tool a toileting/bladder program can be determined. --A note to summarize the findings will be written. -The care plan will be updated to include the findings of the bladder evaluation and interventions to manage incontinence. -CNAs sheets will be reviewed at nursing start-up and changes to residents incontinence program will be added. -Current residents who experience incontinence will have their individual incontinence management/bladder function program evaluated with each quarterly MDS assessment to ensure continued appropriateness of the current program. How will the corrective actions be monitored to ensure the deficient practice will not recur? *The DNS or designee will complete an audit weekly for four weeks and monthly for two weeks for newly admitted residents and residents who have had a quarterly MDS completed to ensure a bladder evaluation and appropriate incontinence management interventions are in place. -Audit results will be reviewed during the monthly quality assurance performance improvement (QAPI:) meeting for further recommendations. *The DNS or designee will complete a weekly visual audit of five CNAs performing toileting and pericare to ensure that CNAs are following resident's individual care plans. -This audit will be completed weekly for four weeks and then monthly for two months. Audit results will be reviewed during the monthly QAPI meeting for further recommendations. *Both audits will be started immediately. During the survey on 2/12/15 at 2:00 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Review of resident 1's complete medical record revealed: *She had a current brief interview of mental status (BIMS) (test of thinking processes) score of 13, indicating her thought processes were intact. *She had [DIAGNOSES REDACTED]. *She had four falls in the past six months (7/29/14, 11/25/14, 12/29/14, and 1/17/15). *All falls had occurred when trying to take herself to or from the bathroom. *She was not on a toileting program. Review of her 1/20/14 care plan revealed: *A focus area of "at risk for falls" with an initiation date of 3/30/11. -Under the interventions it stated "resident ambulates independently." The date initiated was 3/12/12 and revised on 1/20/14. *She had been found sitting on her bottom in the bathroom on 7/29/14. The fall intervention was to "encourage to use call light for help and ensure resident is wearing glasses when awake." *An 11/28/14 intervention from the 11/25/14 fall had been to change her activities of daily living (ADL) ability from mostly independent to "assist of 1 for toileting." Review of her current care plan dated 2/10/15 revealed: *A focus area of "at risk for falls" with an initiation date of 3/30/11. An intervention of "resident ambulates with SBA (stand by assist) and gait belt" initiated 3/12/12 and was revised 1/8/15. *A focus area of "alteration in elimination of bladder related to frequent bowel incontinence, occasional bladder incontinence, and assistance required with toileting" had an initiation date of 6/17/11. There was a goal dated 3/12/13 and revised on 2/10/15 of "I will improve my current level of bladder continence which is occasionally incontinent." Interventions were as follows: -Extensive assist of one staff with toileting, initiated 1/9/15. There had been no indication that status should have changed from "assist of 1" to extensive assistance. That should have been initiated on 11/28/14 as stated on the previous care plan. -Received a diuretic medication which may cause increase urination, initiated 3/12/13 and revised 1/9/15. -Report changes in ability to toilet or continence status to interdisciplinary team, initiated 3/12/13 and revised 1/9/15. *A focus area of "extensive assist with bathing, transfers, dressing, bed mobility, and toilet use" initiated 4/1/10. -An intervention of "uses walker with assist of staff 1-2 with gait belt" initiated 3/11/13 and revised 1/8/15. The two above care plans had conflicting information and dates between focus areas and interventions. The current care plan had conflicting information about the resident's ADL abilities, transfer assistance needed, and bowel and bladder continence frequency when compared to the following nursing progress notes and fall reports. Review of resident 1's November 2014 nursing progress notes revealed: *11/19/14, 10:57 p.m. She had a headache rated 8 out of 10 for pain and was given Tylenol. *11/21/14, 10:37 a.m. "Resident having slurred speech and difficulty finding words. Order received to send resident to emergency room (ER)," left with daughter for ER at 10:56 a.m. *11/21/14, 9:38 p.m. Returned from the ER, and "encouraged to call for help this pm, since some dizziness persists. Is usually independent with ADL's and transfers." *11/22/14, 8:05 p.m. She had headache pain rated 7 out of 10 and was given Tylenol. *11/23/14, 9:59 a.m. "Resident is weak. Using call light appropriately. Complaining of headache. Loose stools reported and complaints of upset stomach." *11/24/14, 1:32 a.m. She had gone to the nurses station in her wheelchair because her headache had returned. *11/25/14, 3:43 a.m. after a fall, it was noted she had a "history of a dizziness episode, unsteadiness, and a headache. It was currently recommended that she use her wheelchair." Review of resident 1's 11/25/14 at 3:45 a.m. fall report revealed: *Fall occurred when she was walking back from the bathroom. *She had tripped over her wheelchair. *That had resulted in broken ribs. *Fall interventions were "resident reminded to always call for help every time she needs to get out of bed/using toilet." Review of her November 2014 bowel and bladder detail report revealed she had been incontinent of bowel three times and incontinent of bladder once in the two days before the fall on 11/25/14. She had not been incontinent of bowel any other times in November. Review of resident 1's December nursing progress notes revealed: *12/18/14, 12:16 p.m. Resident "requires assist of one with ADL's and transfers, is reminded to use a call light for staff assist due to weakness, toilets with staff assist, wears pull ups." *12/24/14, 7:46 a.m. Resident refused [MEDICATION NAME] powder (for constipation), because she "was up all night." *12/27/14, 7:27 a.m. Resident stated she "had been having loose stools lately." *12/29/14, 7:05 a.m. When she had been found after her fall she had been "incontinent to stool." *12/31/14, 9:26 a.m. Resident "reminded to ask for assistance as needed." Review of her 12/29/14 at 5:30 a.m. fall report revealed: *She had tried to transfer herself to the bathroom and tripped on her nightgown. *She hit her head with a reddened area noted. *Fall report interventions were to encourage her to use her call light and ask for assistance. Review of resident 1's January nursing progress notes revealed: *1/8/15 11:35 p.m. "Resident continues on [MEDICATION NAME]. Displays mild cold symptoms-nasal congestion and "stuffy head". *1/9/15 10:37 a.m. "Unsteady but able to stabilize during transitions and walking." *1/16/15 2:33 p.m. The [MEDICATION NAME] course had been completed. *There were no notes between 1/9/15 and 1/16/15 regarding her condition. *1/17/15 1:46 p.m. the fall follow-up note stated she was "reminded to use call light to ask for assistance as needed." Review of her 1/20/14 care plan and 1/17/15 at 6:00 a.m. fall report revealed: -The fall had occurred when she tried to take herself to the bathroom. *She had been found on her room floor incontinent of bowel with loose stool. There had been stool smeared on the floor. *The fall intervention had been to "remind resident to wait for assistance-even if urgent." Review of her 12/27/14 Clinical Health Status assessment revealed: *Under urinary incontinence she had been marked as usually continent. *For programs, briefs had been checked as used. Review of resident 1's 1/2/15 bowel and bladder assessment forms revealed she had been checked off for the following: *Was continent and incontinent of bowel. *Recognized the appropriate time and place to toilet. Treatment/management program placement decisions: provide incontinent care and comfort PRN. *Was continent and incontinent of bladder partially due to "urgency and unable to suppress." -Had strong, uncontrolled urgency prior to incontinence, urine loss on the way to the bathroom, and mixed incontinence. *Had decreased vision due to [MEDICATION NAME] degeneration (eye condition). -Decreased vision might have been an environmental option for what may cause incontinence. *Contributing [DIAGNOSES REDACTED]. *"Not appropriate for a toileting program" because "resident with one episode of bowel incontinence and two episodes of bladder incontinence during week lookback. Wears pullups for security. Able to make needs known, uses call light appropriately. Requires limited to extensive assist with ADLs." Review of the provider's 1/13/15 Incontinence Management/Bladder Function Guideline revealed the purpose was to: *Enable the resident to control urination without a catheter whenever possible. *Prevent skin problems such as pressure areas and excoriation (a superficial break in the skin such as a scratch). *Improve the morale of the resident. *Restore the resident's dignity. *Manage urinary incontinence, restore or maintain as much normal bladder function as possible. General guidelines to retain bladder function included "develop a schedule of toileting times specific to the resident. Observe and record the resident's voiding pattern and revise the toileting schedule to meet the residents toileting needs. Keep floor clear of obstacles." The "choosing a program that fits the resident after evaluation" section of the guideline included: *"Scheduled toileting/habit training- If the resident has no pattern of urinary incontinence due to functional or transient incontinence then schedule the residents toileting at regular intervals to increase continent episodes per habit such as upon arising, before and after meals and before going to bed. Schedule toileting is a timed voiding." *"Prompted voiding- If the resident displays a usual pattern of incontinence due to urge or mixed incontinence establish toileting times prior to an accident. Prompted voiding is a behavioral technique." *"Absorbent products/external collection devices- If the resident is cognitively impaired and is unsuccessful at toilet training or is unable to participate in retraining then the resident should be placed on incontinence care program." Monitoring/compliance to the guideline included the following: *"Incontinent residents are assessed per guideline." *"Evaluation of casual factors determines program initiated." *"Care plan reflects individualized program." *"Observation of care provided matches the plan of care." Surveyor: 2. Review of resident 5's medical record revealed:*She had acquired a stage two pressure ulcer (open area on skin) to her lower left buttock (side of bottom) on 12/1/14. *The pressure ulcer had increased in size and was a stage three (deeper open area on skin) on 12/9/14. *A physician's orders [REDACTED]. *The pressure ulcer was healed on 1/12/15. *A facsimile request to her physician was sent on 1/12/15 to continue the use of the urinary catheter due to a [DIAGNOSES REDACTED]. Review of resident 5's 12/2/14 immediate plan of care for pressure ulcer risk revealed an intervention of "Resident at risk for urinary incontinence." There were no other interventions present for pressure ulcer risk. Review of resident 5's 3/30/10 initial care plan for incontinence revealed: *A focus of incontinent of urine. Urine was crossed out and bowel added on 1/16/15. Had [MEDICAL CONDITION] for bowels. *Goals included: "Skin around [MEDICAL CONDITION] intact and free from breakdown/redness." *Interventions included: -"Wears briefs to help manage incontinent episodes and maintain dignity." -"Check and change brief upon rising, before and after meals, bedtime, NOC (night) rounds, and as needed initiated on 1/21/14." -"Indwelling catheter, catheter care per MD (physician) orders initiated on 1/16/15." 3. Review of resident 10's medical record revealed *She had been admitted on [DATE] with a [DIAGNOSES REDACTED]. *Her 10/14/14 admission MDS revealed she was frequently incontinent of urine and bowel. *A 10/9/14 bladder evaluation assessment revealed:-She was currently continent of bladder was checked yes. --If the above had been checked yes the form was considered to have been completed. The form was only to have been completed if a no had been checked for bladder incontinence. -She was currently incontinent of bladder was checked yes -For potentially reversible causes of urinary incontinence impaired mobility/ambulation was checked. -For contributing diagnosis/medical conditions impaired mobility status [REDACTED]. -For medication that might contribute to bladder dysfunction narcotic and sedatives were checked. -For further evaluation physical examination performed and history and physical was checked yes. -Incontinence symptom profile, functional urinary incontinence due to mobility and medication use was checked. *A 2/2/15 quarterly update to the bladder evaluation assessment revealed: -She required assistance of one staff for her ADLs. -She made her needs known to staff. -Four out of seven bowel movements were incontinent for the prior two weeks. -Forty-three out of fifty-one urination's were incontinent over the prior two weeks. -Wore a brief for security. -Was not appropriate for toileting or retraining program at this time. Review of resident 10's 10/24/14 care plan for alteration in elimination of bowel and bladder due to immobility related to pelvic fracture revealed: *Goals that she would improve her current level of bowel and bladder continence by 10% by the next review with a target date of 1/2/15. *Interventions included use of briefs for incontinence protection. 4. Review of resident 17's record revealed: *She had been admitted [DATE] due to a fracture of her left lower leg. *She had been admitted with an indwelling urinary catheter. *The catheter had been discontinued on 9/24/14. *Review of 9/23/14 bladder evaluation revealed: -She was continent of bladder had been checked yes. -No further bladder evaluation's had been completed after her urinary catheter had been discontinued on 9/24/14. Review of resident 17's following MDSs revealed: *Admission 9/10/14 MDS she used a urinary catheter. *Re-admission 12/3/14 MDS she was frequently incontinent of urine. *Quarterly 12/10/14 MDS she was frequently incontinent of urine. Review of resident 17's 9/19/14 alteration in elimination of bowel and bladder, indwelling urinary catheter, constipation, and assistance required with toileting and bowel incontinence care plan revealed: *She would improve her current level of bowel incontinence, currently always incontinent. *She would have no complications from the use of the indwelling urinary catheter such as pain, infection, or obstruction. *The interventions for her urinary catheter had been crossed out with a date of 2/12/15. Her urinary catheter had been discontinued on 9/24/15. *Use of briefs for incontinence protection. *Monitor and report changes in ability to use toilet or continence status to the interdisciplinary team. *Provide extensive assistance for toileting, uses bedpan at times. 5. Review of resident 9's medical record revealed: *The 8/15/14 Annual Clinical Health Status assessment contained the following regarding incontinence: *The Braden Scale for Predicting Pressure Sore Risk indicated he had been "often moist." The urinary continence sections indicated he was frequently incontinent. *The 1/12/15 through 2/11/15 Bowel and Bladder Detail Report indicated seventy-two of seventy-three times he had been incontinent of urine. *The 2/4/15 CNA Report Sheet indicated he had been incontinent of bowel and bladder. He currently was on an incontinence toileting schedule. *The comprehensive care plan did not indicate he had been on a incontinence toileting schedule. 6. Review of resident 11's medical record revealed: *The 1/30/15 Minimum Data Set (MDS) assessment revealed a BIMS score of 15 indicating her thought processes were intact. *The 1/23/15 Admission Clinical Health Status assessment indicated she did not have a catheter (tube into the bladder), she was frequently incontinent, she had a history of [REDACTED]. There had been a supra-pubic catheter present upon admission. *Review of the 2/4/15 Bowel and Bladder Evaluation forms revealed: -She had been incontinent of bowels. -She had been "able to recognize appropriate time/place to defecate (stool)." -She had "[MEDICAL CONDITION] (unable to empty bladder completely) with persistent overflow incontinence, symptomatic infections and/or renal (kidney) dysfunction (abnormal function)." --There had been no documentation of the catheter leaking urine onto her skin. Surveyor: Observation on 2/10/15 at 4:45 p.m. revealed CNAs R, T, and U began to provide personal care for resident 11. Before the care started resident 11 stated she was feeling chilled and uncomfortable due to being wet. During the observation of personal care it was noted that a bath towel had been placed around resident 11's supra-pubic catheter (tube through opening in abdomen into bladder to drain urine). That bath towel when removed by CNA U was noted to have been soaked with urine. Resident 11's abdomen was also noted to be red. Surveyor: Review of the 2/4/15 CNA Report Sheet indicated resident 11 had a history of [REDACTED]. The form indicated she used the bedpan for toileting needs. The comprehensive care plan did not include the catheter leaking and the care needed to protect the skin from wetness. 7. Review of resident 13's medical record revealed: *The 11/13/14 MDS assessment revealed a BIMS score of 14 indicating her thought processes were intact. *Review of the 2/9/15 Re-admission from a hospital stay Clinical Health Status assessment revealed he was able to pivot transfer (how to move) with limited assistance. *He was occasionally incontinent. *He was not on a scheduled toileting plan or bladder retraining program. The Braden scale for predicting pressure sore risk had been coded as occasionally moist. Observation on 2/10/15 from 8:30 a.m. through 11:00 a.m. revealed resident 13 had been sitting in his wheelchair in his room. His pants were wet and remained wet during that time. Review of the following reports and care plan revealed: *The 2/4/15 CNA Report Sheet revealed no documentation on how he was to have been transferred or if he had been incontinent of bowel and bladder. *The Bowel and Bladder Detail Report for 1/12/15 through 2/11/15 revealed urinary incontinence had been documented sixty-nine out of eighty-nine times. *The 2/17/15 revised comprehensive care plan revealed he had been incontinent of bowel and bladder with no incontinent scheduled toileting or toileting plan, and he required the assistance of one staff person with transfers. 8. Review of resident 23's medical record revealed: *The 1/29/15 MDS assessment revealed a BIMS score of 14 indicating her thought processes were intact. *The 1/22/15 Admission Clinical Health Status assessment indicated she had been continent of bladder. *The 2/4/15 Bowel and Bladder Evaluation Forms indicated she had been continent of urine but had functional urinary incontinence. *The 2/17/15 CNA Report Sheet revealed she was to use a walker or wheelchair for mobility (getting around), she had required assistance of one staff person to stand by assistance for transfers. It stated she toileted herself independently. *The 2/11/15 comprehensive care plan revealed the resident had the potential to be incontinent due to functional incontinence. *The comprehensive care plan included a risk for pressure ulcer care plan that had an intervention to "provide thorough skin care after incontinent episodes and apply barrier cream to any redness and/or excoriation (soreness)." The physical functioning care plan indicated she needed limited assistance from staff with toileting and transfers. 9. Review of resident 24's medical record revealed: *The 11/24/14 MDS assessment revealed a BIMS score of 15 indicating her thought processes were intact. *Review of the 12/18/18 (14) Quarterly Interdisciplinary Resident Review indicated a bowel and bladder assessment had been completed and the summary section stated "Resident is a potential candidate for nursing, restorative/rehabilitation, or bladder training program." The Braden Scale section for predicting pressure sore risk indicated she had been "occasionally moist." *Review of the 12/18/14 Bladder Evaluation Form indicated she was continent and both her "clothes or incontinence pad were wet." That assessment determined she had overflow and functional urinary incontinence, and she was not a candidate for toileting or retraining program. That assessment did not indicate how many times she had been continent or incontinent over the last two weeks. *Review of the 12/8/14 Bowel Assessment Form indicated she had been continent and incontinent of bowel. It indicated she "recognizes appropriate time/place to defecate and is able to feel urge sensation for bowel movement." It indicated she was unable to participate in a program due to "new admit, has been incont (incontinent) and continent of bowel, will continue to monitor for B&B (bowel and bladder)." *Review of the 2/17/15 CNA Report Sheet indicated she required the assistance of one staff member for transfers, she had been incontinent of urine, she used the toilet, and she received incontinent care with a toileting schedule. *Review of the 12/2/14 revised comprehensive care plan indicated bowel and bladder incontinence, it did not indicate she had been on a toileting schedule. Interview on 2/18/15 at 3:15 p.m. with the director of nursing revealed the toileting schedule for the resident was to be toileted upon rising, before and after meals, at bedtime, and during rounds at night. Rounds at night were at midnight, 2:00 a.m., and 4:00 a.m. Preceptor: 10. Interview on 2/10/15 at 1:45 p.m. with resident 2 revealed she: *Had an indwelling Foley catheter. *Stated she "had it a long time. It's because I had sores from my diapers not being changed like they should." *Stated it would be too much trouble to put her on the toilet because she needed the lift (equipment) to be moved. *Had not tried a commode (portable toilet) since she had been there. *Used a bed pan maybe once a week. *Sometimes just went in her pants. Interview on 2/10/15 at 1:30 p.m. with LPN D revealed resident 2 used a bed pan for bowel movements and did not use the toilet. She stated the resident had a history of [REDACTED]. She further stated the catheter was in place due to incontinence, and she needed the total lift for transfers. Observation on 2/10/15 at 5:42 p.m. of catheter care for resident 2 revealed she had a Foley catheter in place and was incontinent of bowel. Interview at that same time with CNAs S and R revealed the resident was frequently incontinent of bowel, and she occasionally used a bed pan. The CNAs stated "Resident does not use a commode or the toilet and does not know when she goes." Interview on 2/11/14 at 11:30 a.m. with the wound care nurse revealed the resident preferred to use a bed pan due to contractures (a condition that changes the body causing a difference in appearance and stiffness in the joints). She had pain when she sat for too long. The nurse was unsure if staff had ever tried to use the toilet or a commode for the resident. She knew the resident had worked with therapy in the past but did not know if therapy had worked on toileting with the resident. She stated the resident had been aware of when she needed to have a bowel movement. She stated the only open area the resident had now was on her left middle finger, all the other open areas had healed. Interview on 2/11/15 at 2:30 p.m. with the DON revealed resident 2 was unable to sit on the toilet or a commode due to her contractures. She used the bed pan for bowel movements. When asked about a toileting schedule or program he stated staff checked on her frequently, and s

Based on observation, interview, record review, and admission packet review, the provider failed to ensure residents' self-esteem and dignity had been maintained with bowel (stool) and bladder incontinence (loss of control) for 3 of 12 sampled residents (9, 11, and 13). Findings include: 1. Interview on 2/10/15 at 8:30 a.m. revealed resident 11 had not been able to use the bathroom due to needing a mechanical lift for transfers. She stated the staff were physically unable to manage a lift into the bathroom. She also stated she used her incontinent pads as the bathroom. She had been directed to do so by the CNA (certified nursing assistant) staff. She also stated she did not routinely use the bedpan when in bed. She stated she had used a bathroom prior to her admission. Surveyor: Observation on 2/10/15 at 4:45 p.m. revealed CNAs R, T, and U began to provide personal care for resident 11. Before the care started resident 11 stated she was feeling chilled and uncomfortable due to being wet. During the observation of personal care it was noted that a bath towel had been placed around resident 11's supra-pubic catheter (tube through opening in stomach into bladder to drain urine). That bath towel when removed by CNA U was noted to have been soaked with urine. Resident 11's abdominal skin was also noted to be red. After resident 11 had been placed in bed and personal care given she had been given a supper tray as getting her out of bed again would have caused her more discomfort. Surveyor: Review of the 1/30/15 Minimum Data Set (MDS) assessment revealed the BIMS (testing of thought processes) score of 15. That score indicated she had intact thought processes or capable of thinking and making her own decisions. Review of the 2/4/15 bowel assessment revealed: *She had been incontinent of bowel with abdominal cramping/discomfort/bloating and diarrhea." *She had been able to "recognize appropriate time/place to defecate (bowel movement)." *Staff were to "provide scheduled incontinent care and comfort." Review of the 2/4/15 bladder assessment revealed: *She had a supra-pubic (SP) catheter. *She had "persistent overflow incontinence (unable to totally empty the bladder), symptomatic (having symptoms) infections and/or renal (kidney) dysfunction (not properly functioning)." *She had been able to "make her needs known." *She was "not appropriate for toileting or retraining program at this time." Review of the 1/22/15 through 2/11/15 nursing progress notes revealed: *The resident had a SP catheter that leaked urine. -"Towels had been placed around the catheter to absorb the leakage." *The resident had been continent and incontinent of bowels. *The resident had a "C Diff ([MEDICAL CONDITION]) infection." That infection of the bowel causes diarrhea. Review of the 1/26/15 revised comprehensive care plan for resident 11's urinary incontinence revealed: *She used pad/briefs. *She used an indwelling SP catheter. *The care plan did not indicate her catheter leaked and what cares would have needed to be done for that leaking. There had been no care plan for bowel incontinence or the [MEDICAL CONDITION] infection. Review of resident 11's 1/23/15 through 2/11/15 Bowel and Bladder Detail Report revealed: *The resident had been incontinent of urine twenty-eight times. -That had been due to the catheter leaking. -She had not been continent at any time. *The resident had been incontinent of bowel eighteen times. Review of the provider's 1/23/15 assessments for resident 11 revealed: *The Braden Scale for Predicting Pressure Sore Risk had been 15 which indicated high risk. -The moisture section had been coded as often moist. --"Skin is often, but not always moist. Linen must be changed at least once a shift." *The urinary incontinence section revealed she had been "frequently incontinent." *The appliance/programs section indicated: -No documentation of history of catheter use within the last forty-eight hours. That section had been left blank when she did in fact have a catheter. -The liner/briefs used line had been checked. Review of the provider's revised 2/4/15 CNA Report Sheet revealed resident 11 had been: *Transferred with assistance of two staff members. -There was no indication a mechanical lift was needed for transfers. *She had a SP catheter. *She was to use the bedpan for toileting needs. *She had been on[DIAGNOSES REDACTED] precautions (special handling needed when providing care). 2. Random observation on 2/10/15 from 8:30 a.m. through 11:00 a.m. revealed resident 13 sitting in a wheelchair in his room beside his bed. The front of his pants had been wet and remained wet during that time frame. Review of the [DATE] readmission Clinical Health Status assessment revealed: *He had been occasionally incontinent. *Under the section appliances/programs the only item checked had been "liners/briefs used." -It did not indicate if he had been on a scheduled or bladder retraining program, or if he used the toilet or commode. *The Braden Scale for Predicting Pressure Sore Risk indicated he had been at high risk with a score of 18. -Under the section moisture it indicated he had been "occasionally moist." -"Skin is occasionally moist, requiring an extra linen change approximately once a day." Review of the 11/13/14 MDS assessment revealed a BIMS score of 14. That score indicated an intact thought process. Review of the 2/17/15 revised comprehensive care plan indicated he had been incontinent of bowel and bladder. *The goals listed indicated: -"I will improve my current level of frequently incontinent bladder by next quarter." -"I will improve my current level of bowel continence through next review." --Hand written under under that statement was "currently frequently incontinent." *The interventions were to: -"Monitor and report changes in ability to toilet or continence status to IDT (interdisciplinary team)." -"Use of briefs for incontinence protection." -"Provide pericare (personal care to the bottom) with each incontinent episode." There had been no documentation the resident was or had been on a scheduled or toileting retraining program. Review of the provider's 2/4/15 revised CNA Report Sheet revealed the following areas had not been addressed: *If he was incontinent of bowel and/or bladder. *How he was to have been transferred from one position to another. 3. Review of resident 9's medical record revealed he had a history of [REDACTED]. That had been added to his behavior care plan on 11/13/14. In reviewing the care plan for incontinence of bowel and bladder revealed: *"Offer toileting often." *"Continue to reeducate on use of call light." Review of his most current 2/2/15 MDS assessment revealed a BIMS score of 9. That score indicated moderate thought process impairment. Review of the 8/15/14 bowel assessment revealed: *He had "prolonged straining during defecation (having a bowel movement)." *He had "conditions associated with chronic diarrhea or constipation." *The resident had been "able to feel the urge sensation for bowel movement." Review of the 8/15/14 bladder assessment revealed: *He had "leakage on way to the bathroom." *He had "urgency-unable to suppress (stop)." *He had "daytime frequency and night time bedwetting." *The summary section stated "staff anticipate most needs." Review of the 1/14/15 through 2/11/15 nursing progress notes revealed entries stating: *The "needs (are) anticipated by staff" six times. *The "rsd (resident) was always incontinent of bowel and bladder" five times. *The "rsd needed extensive assistance with toileting" *On 2/11/15 at 1:04 p.m. the nursing progress note stated the "resident was found with his hands full of BM (bowel movement)." Review of fall records revealed he had fallen: *On 6/17/14 at 7:47 p.m. At that time he had been incontinent. His last toileting had occurred at 4:45 p.m. The recommendation had been to "toilet him immediately following meals." *On 11/15/14 at 4:03 p.m. At that time he had been incontinent. -The summary of activities during the three hours prior to the fall stated he had been resting in bed and had been up fifteen minutes. -The recommendations stated "Resident needs to lay down between lunch and dinner." *On 2/1/15 at 1:42 p.m. The report did not indicate if the resident had been continent or incontinent. -The recommendation was to apply a seat belt alarm. Review of the 8/25/14 revised care plan revealed: *The at risk for falls care plan indicated he had been on a toileting schedule. -That schedule was "upon rising, before and after meals, HS (bedtime), NOC (night) rounds and PRN (as needed)." -That intervention had been initiated on 3/1/13 and revised on 8/25/14. *The potential for moods and behavior care plan revealed: -On 11/13/14 the resident had eaten feces (stool). --There had been no updating of the care plan after that incident. Interview on 2/12/15 at 10:40 a.m. with the director of nursing revealed: *He felt the following statements on the urinary incontinence care plan indicated how to care for the urinary and bowel incontinence. -"Keep resident clean and dry. Check on resident rounds..." Interview on 2/18/15 at 3:15 p.m. with the director of nursing revealed: *The CNA Report Sheets were considered "care sheets." -Those care sheets were for the nursing staff and indicated the care needed for the residents. *A toileting schedule had been completed when a resident had been taken to the bathroom upon rising, before and after meals, at bedtime, and on rounds during the night. -Rounds at night occurred at 12 midnight, 2:00 a.m., and 4:00 a.m. *A toileting plan was a restorative program, and the facility did not have anyone on a toileting plan. -That would have been a program to restore continence. Review of the provider's 1/19/15 revised Incontinence Management/Bladder Function Guideline revealed: *"The purpose was to: -Enable the resident to control urination without a catheter whenever possible. -Prevent skin problems such as pressure areas and excoriation (raw irritated skin). -Improve the morale of the resident. -Restore the resident's dignity. -Manage urinary incontinence, restore or maintain as much normal bladder function as possible." *"The general guidelines when working to retrain bladder function were to: -Develop a schedule of toileting times specific to the resident. -Observe and record the resident's voiding pattern, and revise the toileting schedule to meet the residents toileting needs." *In "Choosing a Program that fits the resident after evaluation was to determine: -Scheduled toileting/Habit training-if the resident has no pattern of urinary incontinence due to functional or transient incontinence then schedule the residents toileting at regular intervals to increase continent episodes per habit. -Prompted voiding-if the resident displayed a usual pattern of incontinence due to urge or mixed incontinence established toileting times prior to an accident. Prompted voiding is a behavioral technique. -Absorbent products/External collection devices-if the resident is cognitively impaired and is unsuccessful at toilet training or is unable to participate in retraining then the resident should be placed on an incontinence care program." *"Monitoring/Compliance-observation of care provided matches the plan of care." Review of the Long-Term Care Facilities Resident's Bill of Rights booklet by the Department of Social Services, Adult Services and Aging: Ombudsman Program revealed the following. The booklet stated "When you enter a long-term care facility, you must be treated as an individual with respect, dignity and consideration." This booklet is provided to each resident upon admission.

Based on observation, interview, record review, and protocol review, the provider failed to assess, identify, and implement interventions for residents at risk of developing pressure ulcers (injury to skin and tissue from prolonged pressure on the skin) for 2 of 11 residents (8 and 17) with pressure ulcers acquired in the facility. Findings include: 1. Review of resident 8's medical record revealed she fell on [DATE]. That fall had resulted in a fracture to the left femur (upper leg bone). She had been placed in a leg brace to prevent movement in that leg. Review of a 12/23/14 fax revealed the nurse had questioned resident 8's primary physician as to whether or not she should have a follow-up appointment with the orthopedic doctor. Her primary physician replied on 12/24/14 "Please have the pt (patient) follow-up with ________ (name of facility) asap (as soon as possible). I would like to see her get a less obtrusive (large) brace for leg. Or better yet be given the OK to remove completely." Review of her 12/25/14 nurses notes revealed resident 8 had complained frequently the brace was too large. A skin assessment on that day revealed an open area to the left back upper thigh that "appears to be from brace worn to left leg." A fax had been sent to the physician on that day for a follow-up appointment with the orthopedic doctor. Continued review of the nurse's notes revealed an open area was first noted on her upper thigh on 12/28/14. That area was reported to the wound care nurse and was described as "possibly related to the leg immobilizer. Does not appear to be pressure related." The measurement of the "slit" at that time was 0.2 centimeters (cm) by 2 cm by 0.1 cm. A [MEDICATION NAME] border dressing had been applied for protection. Review of the 1/1/15 skin assessment revealed "Top of brace rubbing on skin near peri (upper inner thigh) area and left thigh. [MEDICATION NAME] bandages applied to left inner thigh and top of rear left thigh. Follow up appt (appointment) scheduled for brace evaluation. No other skin concerns at this time." Review of her 1/2/15 nurse's note revealed the resident was at risk for pressure areas. No current pressure areas were being treated at that time. Review of her 1/5/15 nurse's note revealed she had a follow-up visit that day with the physician "re: (regarding) brace-breakdown from brace-will monitor." Review of the 1/5/15 clinic referral note revealed she had been seen that day by her psychologist. The leg brace had not been addressed during that visit. Review of her 1/6/15 nurse's note revealed the wound care nurse continued to follow the "thigh wound r/t (related to) the brace." Review of her 1/7/15 progress notes from her visit to the orthopedic physician revealed the nurse had alerted the physician to the open areas on the upper thigh. The physician had not addressed the need for a different leg brace. He had ordered an increase in the range of motion in the hinged knee brace by 10 to 20 degrees weekly. Review of her 1/8/15 weekly nurse's skin review revealed a dressing was "replaced to the posterior (back) left thigh where the brace irritates the skin." Those nurse's notes also stated the physician had been notified of the resident's skin issues on the last visit. Review of her 1/15/15 nurse's skin assessment revealed she continued to have a "sore area to upper rear left thigh." No other skin issues were noted. Review of her 1/16/15 occupational therapy treatment notes revealed "Pt was found by PT (physical therapist) to have wounds on her L (left) foot/ankle on the anterior (front) and posterior (back) sides from the brace. Wound care has dressed the pt at this time; pt's brace is being adjusted by maintenance. Interview on 2/18/15 at 2:10 p.m. by telephone with the director of therapy revealed she had seen resident 8 on 1/16/15. She stated her leg brace was to have been worn "around the clock" at that time. She stated the resident complained of her leg and ankle hurting. She stated she had complained of leg pain before but had not complained of ankle pain prior to that time. She stated she noted two "large" wounds, one on the top of her foot and the other on the back of her ankle. She stated she immediately notified the second floor resident care coordinator and the wound care nurse. They removed the brace, and it slid down easily on the leg when the resident was in bed. The brace was adjusted by maintenance at that time, and two inches were removed from the top of the brace. She stated she felt the brace fit the resident well at that point. She also stated she did not feel a wound of that size could have developed within one day. Review of the resident's 1/16/15 change of condition report revealed "resident has unstageable (covered by scab and not able to measure the depth or severity) pressure ulcers to anterior (1.5 x 4 cm) and posterior ankle (0.7 x 5 cm). Pressure ulcers are a result of immobilizer brace rubbing." The physician was notified by fax on that day. The physician had replied regarding treatment for [REDACTED]. Review of her 1/21/15 nurse's notes revealed dressings were intact to the sore areas on her ankle and thigh. Review of her 1/23/15, 1/27/15, and 1/30/15 nurse's notes revealed she continued to wear a stabilizing brace at all times. Wound care was to follow the pressure ulcer areas on her left ankle related to the brace. Review of the 1/30/15 weekly skin care note revealed "Left anterior and posterior ankle pressure ulcers remain present. Both wounds noted to be getting smaller. Left leg immobilizer brace remains in use and repositioned prn (as needed) to prevent further skin breakdown." Review of the 2/6/15 weekly skin care note revealed " Pressure ulcer to left anterior and posterior ankle remain present. Both wounds continue to decrease in size." Review of her 2/6/15 nurse's notes revealed "Resident went to _______ (name of orthopedic provider) earlier in the day and received a new smaller brace and new orders for TTWB (toe touch weight bearing) and brace on when up." Review of the physician's notes from that day revealed he had not mentioned the change to a smaller brace. Review of the weekly wound evaluation flow sheets for the ankle ulcers from 1/16/15 through 2/17/15 revealed they had been measured weekly and had remained unstageable. The areas had decreased in size from the original measurement. Observation on 2/10/15 at 8:45 a.m., 10:55 a.m., and 1:40 p.m. revealed resident 8 was laying on her back in her bed. The leg brace was on her left leg. Observation on 2/10/15 at 1:45 p.m. with the wound care nurse revealed the wounds on both ankles had remained unstageable and had scabbed over. The measurements of those wounds at that time were: *Anterior ankle: 1 cm x 2.5 cm. *Posterior ankle: 1.5 cm x 2.8 cm. Interview on 2/18/15 at 2:15 p.m. with the second floor resident care coordinator revealed she could not find documentation to support: *The orthopedic physician had been notified of the primary physician's 12/24/14 concern of the need for a different leg brace or complete removal of the brace. *The orthopedic physician had been notified of the irritation from the leg brace prior to the 1/7/15 visit. *The nurse had contacted the orthopedic physician after receiving the consultation report back from the above visit regarding the concerns related to the leg brace. *The nurse had contacted the physician regarding the ill-fitting leg brace after his reply did not address it. *A physician had been notified prior to 2/6/15 regarding the continuation of the leg brace and clarification of whether or not it could have been changed to a different brace. *In that same interview the care coordinator confirmed: -Resident 8 should not have been wearing the leg brace when in bed as indicated in the 2/6/15 physician's orders [REDACTED]. -The use of the leg brace had not been care planned for use. -The ill-fitting brace should have been addressed sooner and may have prevented the sores from developing on the ankles. Surveyor: 2a. Review of resident 17's medical record and right heel wound evaluation flow sheet revealed:*She had been admitted on [DATE]. *She had [DIAGNOSES REDACTED]. *On 11/18/14 an unstageable pressure ulcer was noted to her right heel. *The measurements were 3.5 cm in length by 5.5 cm in width. *It was an intact fluid filled blister. *A Prevalon boot was initiated at that time. *She was admitted to the local hospital due to an infection in her left heel pressure ulcer. *On re-admission the pressure ulcer measured 6 cm in length by 6.5 cm in width and 0.2 cm in depth. *It had a moderate amount of drainage. *A foam heel lift boot was in place. *A specific turn and reposition program of every one to two hours was in place. Interview on 2/12/15 at 10:30 a.m. with licensed practical nurse (LPN) E/resident care coordinator revealed:*Her left heel pressure ulcer had been discovered when the physician had removed the splint. *She believed the right pressure ulcer had resulted in resident 17 resting her heel against the foot plate of her electric wheel chair. *She agreed the pressure ulcer was preventable. *She agreed the clinical interdisciplinary reviews did not have the diabetic foot screenings completed. *She agreed that did not follow the care plan for pressure ulcers. b. Review of resident 17's medical record and 9/16/14 initiated wound evaluation flow sheet revealed: *She had a left leg fracture. That leg including her foot and heel had been in a splint. *There were physician's orders [REDACTED]. *On 9/16/14 she was seen by the orthopedic physician, and the splint was removed. *It revealed an unstageable (Full thickness tissue loss in which the base of the ulcer is covered by yellow, tan, gray, green, or brown tissue, and/or eschar (scab), deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) deep tissue injury pressure ulcer. *A unstageable pressure ulcer to her left heel. *It measured 1.8 cm in length by 2.4 cm in width. *It was not open at that time and was described as a blood-filled blister. *On 11/18/14 it measured 1 cm in length by 2 cm in width. *It was not open but had been marked as 100% necrotic (dead) tissue. *She was readmitted to the local hospital on [DATE] due to an infection in the left heel pressure ulcer. *She was placed on intravenous (medication given directly into a vein) antibiotics while in the hospital and on wound care treatment of [REDACTED]. Review of resident 17's Braden score assessments (evaluates skin for the risk of breaking down) revealed: *A 9/3/14 admission assessment with a score of 16 (at risk for developing a pressure sore). *A 11/26/14 re-admission assessment with a score of 15 (at risk for developing a pressure sore). *A 12/22/14 quarterly assessment with a score of 15 (at risk for developing a pressure sore). Review of resident 17's clinical health status/interdisciplinary assessments revealed:*The 9/3/14 admission assessment indicated "If diabetic proceed to diabetic foot screen." *That screen had not been completed. *There was no preventative foot care initiated. *The 11/26/14 re-admission assessment for skin conditions had not been completed. It only had documentation of a pressure ulcer to the left and right heels. There were no measurements. *The diabetic foot screen had not been completed. *The 12/22/14 quarterly assessment under skin concerns had "Yes" checked. Written in was "L (left) heel, R (right) heel, Abd pad (thick dressing), heel lift boots, and reposition." *The diabetic foot screen had not been completed. Review of resident 17's 9/19/14 care plan revealed: *All interventions for the reduction of pressure ulcers had been initiated after the left heel pressure ulcer had been found. *Diabetic foot monitoring quarterly and with change in condition had been started. *Encourage resident to float (keep the pressure off) right heel with pillow while in bed or in recliner. *Encourage turning and repositioning frequently. *The interventions for her diabetes mellitus included: -Assessment of skin and foot condition weekly by licensed nurse. -Diabetes foot screen upon admission, quarterly, and with change in condition. *The interventions for her nutritional risk was initiated on 9/11/14. *There were no goals or interventions related to her pressure ulcers. Review of the provider's revised 2013 Skin Integrity Guideline policy and Skin Care protocol revealed: *Residents were to have been observed daily by CNAs for reddened/open areas. Any changes were to have been reported to the licensed nurse and documented. *If there was a decline in skin integrity (condition) pressure redistribution surfaces (devices used to relieve pressure) were to have been reviewed for appropriateness. *All residents would be assessed/observed for risk of skin breakdown within twenty-four hours of admission, quarterly, and as necessitated by change in condition. *The interdisciplinary plan of care would address problems, goals, and interventions directed toward the prevention of pressure ulcers. *If identified at risk or with actual alterations in skin integrity of feet footwear would be addressed for appropriateness.

Based on record review, interview, and policy review, the provider failed to ensure appropriate discharge planning had been completed for one of two sampled residents (3) who had suffered emotional upset due to lack of discharge planning. Findings include: 1. Review of resident 3's medical record revealed: *She had been admitted on [DATE]. *She had a [DIAGNOSES REDACTED]. *She received physical, occupational, and speech therapy services. *Medicare would pay for her stay while she participated in therapy services. *Her daughter was also a resident. Interview on 9/5/14 at 12:05 p.m. with resident 3 revealed: *She vaguely remembered being told about her one-hundred Medicare days at the time she had been admitted . *She did not think the discharge process happening so quickly was good for her. *She had cried when she heard she was "going to be kicked out." *She and her husband had contacted the ombudsman (resident advocate) from the Department of Social Services to assist them. *She and her husband had found the ombudsman to have been the most help with the discharge planning process. *She stated "That's the only person who got the ball rolling." *She and her daughter (who was also a resident) would be going home that day and had hoped "it would work out." *She was aware she could not completely care for her daughter, but her husband and home health services were going to help. Review of resident 3's interdisciplinary progress notes revealed: *On 6/6/14 at 8:42 a.m. an initial social services (SS) note completed by the social services assistant (SSA) included "She wishes to return to live in her home, where she was the caregiver for her daughter. She is uncertain whether she will be able to." "SS will establish care plan for resident as well as to continue to support and encourage resident. SS will also make community referrals as needed, prior to discharge, per therapy and nursing recommendations."*On 6/6/14 at 1:19 p.m. "SSC (social services coordinator) notified by DON (director of nursing) that resident does not want husband to visit her or _______ (name of daughter) anymore. Husband notified and stated understanding. Daughter _______(name of daughter) was notified and son _____(name of son) was also notified." *On 6/13/14 at 1:11 p.m. a fourteen day MDS note completed by the SSA included "Resident continues to attend therapy. She had a goal to return to live in home, it is uncertain whether she will attain this goal." *On 6/15/14 at 1:40 p.m. a nurses note "Resident was very upset off and on today. Changes her mind about ____(husband's name) being able to come or not. Calls him several times a day. Agreed that _____(husband's name) could come see his daughter _____(daughter's name) and she would not be around that area. Approx. (approximately) 5 -10 minutes later came out of dining room stating how she was going to be a part of that and so forth." *On 6/19/14 at 11:13 a.m. "Resident called this social worker (SSA) into her room today and said 'somethings going down', and my daughter and the Doctor are trying to deem me incompetent because I changed my daughter's code status after all these years. _________(resident 3's name) stated she had to take all this psych (psychiatric testing). SS asked her if she were afraid she wouldn't pass. She stated no. SS told her that this facility has to follow Doctors orders but she could ask SS for 1-1 (one-to-one) visits to express her feelings anytime. Later, her husband came to the nurses station and asked if could visit today. _____(resident 3's name) at this time was in her room crying and talking to her friend. When staff asked _____(resident 3's name) if he could visit, she said talk to ______ or ________(SSC's name and SSA's name)." *On 6/19/14 at 2:34 p.m. a nurses note "She is upset that she has to retake psych evaluation, and if she doesn't pass it this will be her home forever." *On 6/24/14 at 10:45 p.m. a nurses note "at 2215 (10:15 p.m.) CNA (certified nursing assistant) reported to this author that resident fell out of wheelchair in her room as she was attempting to self transfer. Resident hit her head at roommate's bed room. Resident stated "I have called 911 so the officer can take me away from this place. I need to get out of here." "Resident was upset because they think she is crazy (resident had neuropsych evaluation on 6/14/14.)" *On 6/25/14 at 11:40 a.m. a late entry nurses note "_______(physician's name) phoned this author and wanted to discuss the multiple falls that resident has had. She stated _______(resident 3) is 'not all there after her stroke' she stated it is a bad idea to have her daughter in the same room as her because she will try to tend to every needs and she can not take care of her. She stated that she would call ____(son's name) and talk with him on moving the daughter out of the room and she would call this author back and inform us of the conversation." *On 6/30/14 at 11:11 a.m. a thirty day MDS note completed by the SSA included "Resident continues to attend therapy. She had a goal to return to live in home, it is uncertain whether she will attain this goal. SS will continue to support and encourage resident." *There were no further progress notes in relationship to her discharge goal or a discharge plan. Review of resident 3's 6/12/14 care conference form revealed: *Resident 3, SSA, certified occupational therapy assistant, physical therapist, her daughter, and her son had attended. *Her discharge goal when she was admitted was to return to her home. *The time frame for her to reach her goals were six to eight weeks. *That was the only care conference that had been held for her. Review of resident 3's initial psychosocial assessment completed on 6/6/14 revealed:*She was alert and oriented. *She wished to return home. Review of resident 3's psychosocial quarterly progress note completed on 9/4/14 revealed: *She scored a fifteen on her brief interview for memory. *That score indicated she had no memory difficulties. *She could clearly make her needs known. *She planned to return home. *She had support systems (financial and emotional) when discharge occurred. *Post discharge services would be needed upon discharge. *Unsure of the extent of services she would have needed upon discharge. *She continued to work with therapies with a goal to return home. Review of a neuropsychiatric evaluation completed on 8/11/14 for resident 3 revealed: *She had improved cognitively (mental ability). *She was able to make her own decisions. *A report would be sent to her primary care physician. *There was no copy of the report in her medical record. Review of resident 3's initial 6/10/14 care plan revealed: *A focus was that she was in the facility for rehabilitation. *Her goal was to return to live in her own home. *Interventions included: -Hold regularly scheduled care conferences at least quarterly, and as required or needed. -Meet with resident and family/support persons to discuss expectations, preferences, feelings in regards to care, and barriers towards discharge. *Social services to make community referrals as needed and prior to discharge, per nursing and therapy recommendations. Interview on 9/4/14 at 2:50 p.m. with the licensed social worker (LSW) revealed: *Resident 3's goal was to return to her home. *She had told resident 3 on admission that she had one-hundred days of Medicare coverage. *She had not informed resident 3 until 9/4/14 that her one-hundred days of Medicare coverage would be on 9/5/14. *She agreed resident 3 had been very upset when she had been told that information. *An initial care conference was usually completed within two weeks after a resident's admission. *The next care conference would have occurred on a quarterly basis. *A care conference in-between the first and the quarterly care conference would have occurred if the provider, resident and/or family, or therapy would have requested one. *Reasons an extra care conference would have been completed was for increased or changed behaviors, psychosocial issues, changes in the plan of care for the appropriateness of discharge to home, or the resident had reached a plateau (as far as they were capable of going) in their therapy. *She agreed resident 3 had psychosocial issues that would have necessitated another care conference. *She had not asked for a copy of resident 3's 8/11/14 neuropsychiatric evaluation. *She did not know the outcome of that evaluation. *A weekly Medicare meeting had been conducted. *All residents who received Medicare services were discussed. *The residents' progress towards their goals were discussed. *Therapy would have given a general idea of when their services would have been finished for each resident. Interview on 9/4/14 at 4:36 p.m. with the director of rehabilitation services revealed: *Resident 3's goal was to return home. *She had not asked for a copy of resident 3's 8/11/14 neuropsychiatric evaluation. *She did not know the outcome of that evaluation. *She would lead the weekly Medicare meetings. *Information was provided on how the resident was doing on obtaining their therapy goals. *She would give the rest of the team a one-week advance notice of when a resident was close to obtaining their goals. *There was no discussion or documentation for resident 3 on any discharge planning. *She would have liked resident 3 to have stayed longer on part B Medicare services. *She had recommended resident 3 could go home, but she did not think she could also take care of her disabled daughter at home. Review of the provider's revised October 2009 Assessment, Evaluation, and Documentation for the Discharge Plan policy revealed:*The discharge plan was used to assist the resident in preparation for discharge and to address continuing care needs after discharge. *When the interdisciplinary team determined a resident had potential for discharge in the next ninety days, social services would address the following: -Mental and/or psychosocial barriers to discharge. -Necessary supportive relationship in the community to meet his/her emotional needs. -The cost of needed services and financial resources necessary to pay for services. -Education needed by resident/family about available community resources and how to access those services. *A discharge assessment would be started upon admission. The discharge plan would be incorporated into the resident's interdisciplinary care plan. *Progress notes should have recorded contacts made and services provided on behalf of the resident.

Based on record review, interview, job description review, and guideline review, the provider failed to ensure appropriate care had been provided to one of one sampled resident (4) with dementia (loss of the ability to think or reason). Findings include: 1. Review of resident 4's complete medical record revealed he had a [DIAGNOSES REDACTED]. Review of resident 4's 6/3/14 care plan revealed he had a focus area for the potential to show signs and symptoms of moods and behaviors. He had a history of [REDACTED]. He had been short tempered with staff and had refused meals and medications. He had an intervention that when he refused care staff would leave and come back after a few minutes and try again. Staff were to explain to him why the care was needed and beneficial. Review of resident 4's nursing progress notes revealed on 6/22/14 at 1:00 p.m. "It was observed that resident 4 has bruising on both wrists with a scabbed laceration on his right forearm." Review of the provider's 6/22/14 5-day working day investigation report completed by the director of nursing (DON) revealed "It was observed on 6/22 that resident 4 had bruising on both of his wrists, and a lesion (cut) on his right forearm. I believe that the wounds may have occurred around 6/18 or 6/19. Initial staff interviews conducted on 6/22 did not reveal any cause to these bruises. Resident 4 has a history of senile dementia, anxiety, and depression. He has a documented history of physical and verbal abuse towards staff and residents. There is no documentation to show that resident 4 has had any behaviors within the last week. Resident 4 is not on any blood thinning agents which would make him prone to bruising. Interviews with staff working during that week say that resident 4 was agitated on the evening of 6/20. Resident 4 was refusing to go to bed. The aide working on that unit has worked with resident 4 for a couple of years. This aide knows that resident 4 went to sleep without incident. An interview was conducted with an overnight aide and the question was asked "how do you think it happened?' His response was that when resident 4 starts being physically abusive he would hold his wrists so resident 4 would not hit him. He was asked if he had done this in the last two weeks and he responded "yes(.)". Interview on 9/5/14 at 8:50 a.m. with resident 4's daughter revealed she and her two sisters had come to visit her dad on 6/22/14. They had noticed their dad had bruising to both wrists and lower arms with what had appeared to be finger marks in the bruising. He also had a skin tear to one of his arms. She stated the bruising looked like her dad had been held down by the wrists. They had been concerned with their dad and had taken pictures of his bruised wrists and skin tear. She had reported the bruising to the provider. The provider had not been aware of the bruising until the daughter had reported it to them. It was later reported to her from the DON that he had found the certified nursing assistant (CNA) that had bruised her dad's wrists. She had told the DON that she did not want CNA B around her dad again. Her dad was afraid of him. He had felt threatened with a "big guy" standing over his wheelchair. Resident 4's daughter stated her dad had dwelled on the incident for several days. She stated that was unusual for him with his dementia. He usually would not remember something that happened in the morning that same afternoon. She stated her dad kept telling her that a "big man tried to break his arms." She said she could tell that it really bothered him emotionally. She stated she felt like there was a lack of training, and that CNA B had not known how to care for a resident with dementia. She stated CNA B should have walked away and not tried to physically restrain her dad's wrists. She said CNA B made her dad nervous when he stood over her dad's wheelchair. She stated the incident bordered on abuse. To her knowledge CNA B was no longer allowed to work with her dad per her request. Review of resident 4's June 2014 Behavior Detail report revealed no physical behaviors had been documented through 6/22/14. Interview on 9/4/14 at 11:00 a.m. with registered nurse assessment coordinator E regarding resident 4 revealed he could become combative with care. When that happened they gave him time to cool off and then reapproached him. Interview on 9/4/14 at 4:50 p.m. with the director of rehabilitation revealed when interacting with a resident with dementia that became agitated staff were to keep an arm's distance away. Staff were to try redirection and give the resident down time. Interview on 9/4/14 at 5:15 p.m. with the education coordinator revealed when interacting with a resident with dementia became agitated staff were to stay out of the resident's personal space and reapproach the resident. Interview on 9/5/14 at 7:40 a.m. with the DON regarding resident 4 revealed: *CNA B should not have held his wrists down when he became physically combative. *His expectation would have been that when a resident became agitated or combative for staff to back off and reapproach the resident at a later time. Interview on 9/5/14 at 10:00 a.m. with the DON regarding CNA B who had held resident 4's wrists when he became combative revealed: *He should have known through his training how to appropriately handle a resident with dementia who became agitated or combative, but he had not in this circumstance. *He should not have held down the resident's wrists. *He should have reapproached the resident at a later time. *He should have followed the resident's care plan. *The CNA had not documented the behaviors, because the behavior had not seemed out of the ordinary to him. *The CNA had not reported the bruises and had stated he had not noticed a skin tear. *His expectation would have been that all behaviors should always have been documented. *The CNA had not been able to work with the resident for approximately one week during the investigation. *CNA B was currently able to work with the resident. *He was unaware the resident's family had requested for CNA B not to work with their father again. Review of the provider's 10/10/11 CNA job description revealed: *"Assist with promoting a [MEDICATION NAME] physical and psychosocial environment for the residents(.)" *"Provide resident care as directed by (the) care plan and/or nursing staff(.)" *"Ensure residents' comfort while assisting them in achieving their highest practicable level of functioning(.)" *"Must adhere to the company's code of conduct and business ethics policy including documentation and reporting responsibilities(.)" Review of the provider's Residents Who Resist Care form revealed: *"Resistance of care may be caused by fear, loss of control over the physical or environment, dementia, depression, or personal conflict with the time frame for care and treatments." *"Use a calm, gentle reassuring approach." *"When met with resistance, leave and return later." Review of the provider's undated Guidelines For Staff Interaction With Patients Who Have Cognitive Deficits revealed: *"Staff will interact with residents in a manner that supports dignity and enhances the resident's ability to successfully participate in life." *'Staff should never stand over the resident. This conveys that the resident is childlike and dependent. Step back and try to see from the resident's eyes."

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure care plans were followed for care to three of four sampled residents (2, 3, and 4). Findings include: 1. Observation on 9/4/14 at 3:00 p.m. of resident 2 revealed she had twelve staples in a wound on the top of her head. She also had a healed area on her forehead that previously had stitches removed. Review of resident 2's 8/27/14 nurse's note revealed she had fallen off the toilet after being left alone by certified nursing assistant (CNA) D. CNA D had left resident 2 alone on the toilet in order to assist another resident. That fall had resulted in two two-inch lacerations (cuts) on her forehead and on the top of her head. Interview on 9/4/14 at 4:20 p.m. with CNA A revealed she had worked at the facility for over six years. She stated she was familiar with resident 2's care and knew she was never to have been left on the toilet alone. CNA A stated the resident was unsteady and did not have good balance. Interview on 9/4/14 at 4:25 p.m. with resident 2 revealed she confirmed she had been left alone on the toilet when she had fallen. Review of resident 2's 6/19/14 care plan revealed: *She required the assistance of one person for all transfers. *She needed the assistance of one person to use the toilet. *She was never to have been left alone on the toilet. Interview on 9/4/14 at 5:20 p.m. with the director of nursing (DON) revealed all CNAs were to utilize care sheets for the residents they cared for. Those care sheets were a shortened version of the care plan and indicated if there were special needs for any of the residents. He confirmed the care plan had not been followed by CNA D for the care of resident 2. 2. Review of complaint documents received by the South Dakota Department of Health on 7/2/14 revealed resident 3 had complained of arm pain on 6/30/14. Those documents stated the arm pain was a result of a "rough transfer." Review of the provider's 6/30/14 investigation report revealed resident 3 had complained of arm pain. She had stated CNA B had hurt her arm when transferring her into a wheelchair. She stated he had pulled on her arm and had not used a gait belt (adjustable belt applied to resident's waist to steady them) to transfer her. Review of resident 3's 6/6/14 care plan revealed she required assistance of one with transfers and toileting. Interview on 9/4/14 at 4:30 p.m. with the director of rehabilitation services revealed the therapy staff were responsible for training all staff on proper transfer techniques. She stated gait belts were to have been used with all residents for any transfer. She stated all CNAs had been given instruction in the use of gait belts and transferring techniques. Interview on 9/4/14 at 5:20 p.m. with the DON revealed he had expected a gait belt to have been used for all transfers. He stated staff were never to grab a resident by their arm to move them. He confirmed that had happened during the 6/30/14 transfer of resident 3. He stated CNA B had been re-educated on the need for the gait belt to have been used on all residents with any transfer. He stated the provider did not have a specific policy on transferring and gait belt use. He confirmed all staff had been trained in the use of a gait belt and proper transfer techniques. Interview on 9/5/14 at 11:45 a.m. with resident 3 revealed she recalled the transfer that had resulted in arm pain. She stated she had been "pulled roughly" into her wheelchair and then onto the toilet. She stated she remembered no gait belt had been used for that transfer. She pointed to the gait belt that was around her waist at that time. She stated "They are always supposed to use this." 3. Review of resident 4's 6/3/14 care plan revealed he had a focus area for the potential to show signs and symptoms of moods and behaviors. He had a history of [REDACTED]. He had been short tempered with staff and had refused meals and medications. He had an intervention that when he refused care staff would leave, come back after a few minutes, and try again. Staff were to explain to him why the care was needed and beneficial. Review of resident 4's nursing progress notes revealed on 6/22/14 at 1:00 p.m. "It was observed that resident 4 has bruising on both wrists with a scabbed laceration on his right forearm." Review of the provider's 6/22/14 5-day working day investigation report completed by the DON revealed: ... "An interview was conducted with an overnight aide and the question was asked "how do you think it happened?' His response was that when resident 4 starts being physically abusive he would hold his wrists so resident 4 would not hit him. He was asked if he had done this in the last two weeks and he responded "yes(.)". Interview on 9/5/14 at 10:00 a.m. with the DON regarding CNA B who had held resident 4's wrists when he became combative revealed: *He should have known through his training how to appropriately handle a resident with dementia who became agitated or combative, but he had not in this circumstance. *He should not have held down the resident's wrists. *He should have reapproached the resident at a later time. *The CNA had not documented the behaviors, because the behavior had not seemed out of the ordinary. *The CNA had not reported the bruises and had stated he had not noticed a skin tear. *His expectation would have been that all behaviors should always have been documented. *The care plan should have been followed. Review of the provider's 10/10/11 CNA job description revealed: *Assist with promoting a [MEDICATION NAME] physical and psychosocial environment for the residents. *Provide resident care as directed by the care plan and/or nursing staff. *Ensure residents' comfort while assisting them in achieving their highest practicable level of functioning. *Must adhere to the company's code of conduct and business ethics policy including documentation and reporting responsibilties. Refer to F281, finding 1.

A. Based on record review, interview, and policy review, the provider failed to ensure factors were addressed to reduce the risk of recurrent and acquired urinary tract infections [MEDICAL CONDITION] for eight of nine sampled residents (3, 4, 5, 6, 7, 8, 9, and 11). Findings include: 1. The highest practicable level of well-being had not been maintained for residents 3, 4, 5, 6, 7, 8, 9, and 11 due to the occurrence or re-occurrence of UTIs. Quality assurance measures had been ineffective in reducing the overall rate of UTIs for those dependent residents and the other residents at the facility. Refer to F441, findings 1 through 11. B. Based on record review, interview, and policy review, the provider failed to ensure nine of ten sampled residents (2, 3, 6, 10, 12, 13, 14, 15, and 16) had been assessed and monitored for pain. Findings include: 1. Review of resident 2's physician's orders [REDACTED]. *Tylenol with [MEDICATION NAME] one tablet every four to six hours as needed (PRN) started on 5/2/13. *[MEDICATION NAME] 325 milligrams (mg) tablets every four hours PRN started on 5/2/13. *[MEDICATION NAME] to right thigh daily started on 5/29/13. *[MEDICATION NAME] 5 mg every six hours PRN started on 6/5/13. *[MEDICATION NAME] 500 mg twice daily started on 7/24/13. *[MEDICATION NAME] 5 mg twice daily started on 7/30/13 and discontinued on 8/15/13. *[MEDICATION NAME] 300 mg every bedtime started on 8/7/13 and changed to [MEDICATION NAME] 300 mg twice daily started on 8/21/13. *[MEDICATION NAME] 5 mg three times daily started on 8/15/13 and discontinued on 8/28/13. *[MEDICATION NAME] 5 mg every six hours started on 8/28/13 and discontinued on 9/6/12. *[MEDICATION NAME] 10 mg at 12:00 midnight and 5 mg at 6:00 a.m., 12:00 noon, and 6:00 p.m. started on 9/6/13 and discontinued on 10/3/13. *Additional [MEDICATION NAME] to left hip started on 9/6/13. *Scheduled [MEDICATION NAME] discontinued on 10/3/13 and MS ([MEDICATION NAME])[MEDICATION NAME] mg twice daily started. Review of the physician's progress notes revealed on: *7/30/13 "States had left shoulder injected, but no help yet. Taking [MEDICATION NAME] 1-2 X (times)/day but not routinely. Will schedule BID (twice daily) and see if it improves." *8/15/13 "Having more pain to left arm/shoulder. Discussed increasing scheduled [MEDICATION NAME] to TID (three times daily). Pt. (patient) agrees that it would be a good idea." *8/21/13 "States left hip is hurting. Pt. sitting in such a way that pressure is on left hip." *8/28/13 "Increased pain to left shoulder and side of body. Will increase [MEDICATION NAME] dosing." *10/3/13 "He is having chronic pain issues in head, neck, and generalized despite oxy ([MEDICATION NAME]) 5/5/5/10 (5 mg at 6:00 a.m., 5 mg at 12:00 noon, and 5 mg at 6:00 p.m; and 10 mg at 12:00 midnight) throughout the day." "Pain - Dc (discontinue) scheduled oxy ([MEDICATION NAME]), schedule [MEDICATION NAME] mg BID with PRN oxy for breakthrough pain." Review of the care conference minutes for resident 2 revealed on: *5/16/13 No mention of pain management. *6/20/13 No mention of pain management. *9/5/13 No mention of pain management. Review of resident 2's 5/9/13 admission Minimum Data Set (MDS) assessment revealed he had occasional pain present, he had rated it a four out of ten (on a scale of one to ten), had received PRN pain medication, and had stated it had an effect on his activities. Review of resident 2's 7/31/13 quarterly MDS assessment revealed he had occasional pain present, had rated it a eight out of ten, had received scheduled and PRN pain medication, and had stated it had an effect on his sleep and activities. Review of resident 2's 5/2/13 clinical health status form revealed a zero had been circled for pain. No other pain assessments had been completed during resident 2's stay from 5/2/13 to 10/7/13. Review of resident 2's 5/17/13 care plan revealed: *Focus: "Needs pain management and monitoring related to left shoulder pain." *Goals: -"Patient will achieve acceptable pain level goal." -"Will maintain adequate level of comfort as evidenced by no s/sx (signs and/or symptoms) of unrelieved pain or distress, or verbalizing satisfaction with level of comfort." *Interventions: -"Administer pain medication as ordered." -"Evaluate and establish level of pain on numeric scale/evaluation tool." -"Evaluate characteristics and frequency/pattern of pain." -"Evaluate need for routinely scheduled medications rather than PRN pain medication administration." -"Evaluate need to provide medications prior to treatment or therapy." -"Evaluate what makes the patient's pain worse." -"Implement the patient's preferred non-pharmacological pain relief strategies." -"Observe for potential medication side effects." -"Refer to rehab (rehabilitation services) as needed." Review of resident 2's medical record revealed: *Only one formal pain assessment had been completed during the 5/2/13 to 10/7/13 time period. *The physician and certified nurse practitioner had addressed pain after visiting with him and his family when they had made their weekly visits. *No evaluations of characteristics, non-pharmacological pain relief strategies, what made the pain worse, or frequency/pattern of pain were completed. Interview on 10/9/13 at 9:45 a.m. with the MDS coordinator revealed: *The resident care coordinators (RCC) and the assistant director of nursing (ADON) were responsible for completing the clinical health status forms. *They were behind in those assessments. *The MDS coordinator and the ADON were responsible for completing the care plans. *The licensed nurses could also update the care plans. *The pain assessment was completed based on what the resident stated or was observed at that time. The use of pain medications was not reviewed. Interview on 10/9/13 at 2:30 p.m. with resident 2's certified nurse practitioner revealed:*She saw resident 2 on a weekly basis. *The nursing staff had not contacted her regarding any increased or change in his pain. *She completed an assessment of his pain after reviewing his pain medication use and input from him and his family. Review of the provider's revised January 2011 Pain Management Guideline revealed: *Upon admission the licensed nurse screened each resident for pain. *The physician would have been notified of the pain assessment findings and orders for pharmacological interventions, if indicated. *The nurse developed a plan of care for pain management. *Based on the initial screening/assessment results the licensed nurse would have established a frequency of ongoing pain monitoring based on the resident's needs. Findings would have been documented on the medication administration record (MAR) and/or progress note. *The licensed nurse would have periodically evaluated the frequency of as needed (PRN) medication usage and consulted the physician in regards to routine pain medication, if indicated. *The licensed nurse would have updated the plan of care to reflect interventions for ongoing pain management. *The interdisciplinary team would have evaluated the effectiveness of each resident's pain management plan at the time of the initial comprehensive assessment, quarterly, following a significant change, and annually. 2. Review of residents 3, 6, 10, 12, 13, 14, 15, and 16's medical records revealed they had incomplete or missing pain assessments. Refer to F280, findings 3. a through i.

Based on observation, record review, interview, and guideline review, the provider failed to ensure two of two sampled residents (2 and 11) did not acquire or re-acquire pressure ulcers. Findings include: 1. Review of resident 11's medical record revealed: *She had been admitted on [DATE]. *She had [DIAGNOSES REDACTED]. *She required extensive assistance of one to two staff with bed mobility, transfers, ambulation, locomotion (moving in wheelchair from place to place) in a wheel chair, dressing, toilet use, and personal hygiene. *She had been hospitalized on [DATE] and had returned on [DATE] for a left leg [MEDICAL CONDITION] (skin infection) and bilateral (both) heel blisters. *The left heel blister was unstageable (could not determine the base of the wound) and was healed on [DATE]. *The right heel blister was unstageable and was then a stage II (two) pressure ulcer (shallow open ulcer) on [DATE] as the wound had opened. Review of resident 11's clinical health status forms revealed on: *[DATE] her Braden scale (scale for predicting pressure ulcer risk) score was a twelve which indicated a high risk for pressure ulcers. *[DATE] her Braden scale score was a fourteen which indicated a moderate risk for pressure ulcers. She had two unstageable pressure ulcers to her bilateral heels. *[DATE] her Braden scale score was a thirteen which indicated a moderate risk for pressure ulcers. She continued to have two unstageable pressure ulcers to her bilateral heels. Review of resident 11's physician's orders [REDACTED]. *[DATE] "[MEDICATION NAME] border dressing to her right heel blister. Change every two to three days. Heel protectors boots continuously; no street shoes." *[DATE] "Right heel care 2X (two times) wks (week) and PRN (as needed) - [MEDICATION NAME] & (and) apply round 5 ,[DATE] X (by) 5 ,[DATE] in (inch) [MEDICATION NAME] foam adhesive." Review of the wound evaluation flow sheet for resident 11's right heel revealed she was to have had a wheelchair cushion, pressure redistribution mattress, a specific turn/reposition program, and her care plan reviewed weekly. There was no mention of bilateral heel boots or the use of street shoes. Review of resident 11's [DATE] care plan that was kept at the second floor nurses station revealed no problems, goals, or interventions for pressure ulcers. On [DATE] the Minimum Data Set (MDS) registered nurse coordinator printed a care plan. That [DATE] care plan had a problem of a pressure ulcer present. Goals were for the pressure ulcer to heal without complication and would remain free from further breakdown. Interventions that included float heels as indicated and heel boots. It did not state when to float her heels or when the heel boots were to have been worn. Observation of resident 11 from [DATE] through [DATE] revealed she was in a wheelchair. She had on street shoes and self-propelled her wheelchair using her heels. Interview on [DATE] at 1:40 p.m. with the wound care nurse revealed she: *Had just started on [DATE] as the wound care nurse. *Was aware resident 11's right heel had opened up and was now a stage II pressure ulcer. *Had not updated the care plan. *Had told staff not to have resident 11 wear street shoes, as she thought that was what had caused the pressure ulcer. *Had not thought of resident 11 self-propelling her wheelchair with her heels as a cause of the pressure ulcer. *Was aware the heel boots were only worn during the night. 2. Review of resident 2's medical record revealed: *He had been admitted on [DATE] with a stage II pressure ulcer to his tailbone area. *That had been declared healed on [DATE]. *On [DATE] his tailbone area had opened up again. *It had been declared healed on [DATE]. *On [DATE] he had acquired a stage II pressure ulcer to the outside of his right foot. *He died on [DATE]. Review of resident 2's clinical health status form completed on [DATE] revealed his Braden scale score was fifteen. That score indicated he was at risk for developing a pressure ulcer. It was documented that he had been admitted with a stage II pressure ulcer to his tailbone area. No further Braden scale scores had been completed. He had MDS assessments completed on [DATE], [DATE], [DATE], and [DATE]. Those assessments all indicated he was at risk for the development of a pressure ulcer. Review of the certified nurse practitioner's (CNP) orders revealed on: *[DATE] "Please have _____ (wound nurse) evaluate pt's (patients) buttocks d/t (due to) complaints of pain. Gel pad for wheelchair please." *[DATE] "Barrier cream to bottom/coccyx (tailbone) area with each brief change. Whirlpool bath -- not shower -- twice weekly please. Tuesday and Friday if possible. [MEDICATION NAME] heart shaped dressing to coccyx/sacral (tailbone) area M-W-F (Monday, Wednesday, and Friday) when available please." *[DATE] "Air mattress please. Turn/reposition q (every) 2 hrs (hours)." *[DATE] "Please check on air mattress status." Review of resident 2's MDS assessments revealed it had been coded for the use of a pressure reducing chair and mattress cushion on [DATE] and [DATE]. Just a pressure reducing chair cushion on [DATE], and no pressure reducing chair or mattress cushions on [DATE]. Review of resident 2's wound evaluation flow sheets from [DATE] through [DATE] revealed:*Weekly charting from [DATE] through [DATE] documented a stage II pressure ulcer to his tailbone area. A wheelchair cushion, a specific turn/reposition program, and care plan reviewed had been checked. That area was healed on [DATE]. *Weekly charting on [DATE] documented "Found by charge nurse on [DATE]." Stage II pressure ulcer to left middle buttock. A wheelchair cushion, a specific turn/reposition program, and care plan reviewed had been checked. That area had been healed on [DATE]. *Weekly charting on [DATE] documented a stage II pressure ulcer to the right outer foot. A wheelchair cushion, air mattress, heel boots, keep feet off bed, a specific turn/reposition program, and care plan reviewed had been checked. Review of resident 2's [DATE] care plan revealed: *A focus area for risk of development of pressure area due to assistance required for bed mobility (appropriate positioning), bowel and bladder incontinence, and a pressure ulcer present. *A goal of pressure ulcer wouldl heal without complication and would remain free from further breakdown. *Interventions included: Float heels as indicated, pressure reducing wheelchair cushion, turning and repositioning schedule per assessment, and weekly wound assessment. A pressure reduction/relieving mattress had been discontinued and had been dated [DATE]. A treatment of [REDACTED]. Review of the physician's progress notes for resident 2 revealed: *On [DATE] "Staff report that pt. (patient) has an open area to bottom - wound care will assess." *On [DATE] "Skin is breaking down on feet. Air mattress ordered last week has not arrived. Will check on this." Review of resident 2's interdisciplinary progress notes on [DATE] at 4:23 p.m. revealed an air mattress had been placed on the bed. Interview on [DATE] at 1:30 p.m. with the director of nursing and the wound care nurse regarding resident 2 revealed: *The resident had been admitted with a waffle type air mattress. It had been removed, as it had caused the resident to be unstable in a sitting position while in bed. *The resident wife and daughter had requested an air mattress, but it had been explained to them that an air mattress would have bunched up in the middle when he was in a seated position in bed. *The use of an air mattress had been discussed with the interdisciplinary team and physical therapy and had been determined not be appropriate. *There was no documentation regarding any conversation with the wife and daughter in regards to an air mattress. *Turning and repositioning of a resident was not formally documented. It was either on a dry erase board in the resident's room or the nursing staff would document on their assignment sheets. 3. Review of the provider's revised [DATE] skin integrity guideline revealed: *The interdisciplinary plan of care would address problems, goals, and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. *If there was a decline in skin integrity pressure redistribution surfaces would have been reviewed for appropriateness. *Initiate positioning schedule to meet individual resident needs and minimize concentrated pressure to skin. *If identified at risk or with actual alterations in skin integrity of feet, footwear would have been addressed for appropriateness.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure adequate supervision and safety for one of two residents (26) who smoked and used oxygen and for two of four sampled residents (21 and 22) who smoked. That failure created a situation of immediate jeopardy that had a potential for causing harm to residents who smoked. NOTICE: Notice of immediate jeopardy was given verbally to the administrator, director of nursing (DON), and clinical services consultant on 8/31/11 at 1:15 p.m. The administrator was asked for an immediate plan to ensure resident safety related to residents who smoked. PLAN: On 8/31/11 at 5:00 p.m. the administrator provided the surveyors with an initial written plan of correction (POC) to remove the immediate jeopardy to residents in the facility. The written POC dated 8/31/11 was accepted by the surveyors at 5;15 p.m. On 9/1/11 at 7:35 a.m. the administrator was requested to supply an addendums to the POC that included: *All other staff would be educated upon return to work. *All residents that require supplemental oxygen will be supervised. The POC was accepted after the addendums had been received. The POC signed by the administrator stated the following: "The residents that smoke and wear oxygen were educated on the need to be safe with oxygen and that oxygen cannot be on while smoking. All staff in facility were educated on oxygen safety and smoking policy. All other staff will be educated upon return to work. Smoking Policy updated to contain sign-in and sign-out of resident smoking materials (i.e. cigarettes, cigars, lighters, etc.). Unlocked container will be secured in 1st floor med room along with sign-in/out notebook and marker to store resident smoking materials immediately." "All smoking materials will be kept at nurses station. Items will be marked with resident name. Residents that desire to smoke will check at nurses station to check out material and sign out. Associates will provide the smoking material and remove oxygen from residents that require oxygen. Residents will check back at the nurses station to turn in smoking material, sign in, and have oxygen turned back on. Designated smoking times will be from 7:00 am - 9:00 p.m. Smoking will be available every two hours for a 15 minute period. All residents that require supplemental oxygen will be supervised." "Charge nurse for assigned floor will review sign-in sign-out book for residents that smoke at the beginning of their assigned shift. Unit nurse managers (RCC) or designee will make random checks of assigned smoking area. Monthly updates on residents that smoke will be reported to the QAA committee monthly to identify any issues or concerns." Prior to leaving the facility on 8/31/11 at 5:15 p.m. the surveyors confirmed the components outlined in the above written plan of correction had been implemented. During the survey on 8/31/11 the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Observation on 8/31/11 at 10:10 a.m. revealed resident 26 was in a wheelchair. He exited the building from the first floor lounge area to an outside patio area enclosed by a fence. Resident 26 had a portable oxygen tank that hung on the back of his wheelchair. It was also noted he had the oxygen nasal cannula tubing in place to both nostrils. Resident 26 was noted to withdraw a cigarette from his shirt pocket and used a lighter to light the cigarette. Resident 24 was also noted to be seated in a wheelchair and was also smoking a cigarette. Continued observation until 10:13 a.m. revealed no staff were present in the first floor lounge. The first floor lounge had two doors on each end to enter/exit. There was approximately 10 to 12 feet of wall that obstructed the view from the corridor between those two doors. At 10:14 a.m. this surveyor asked the DON, who was in her office, to check to see if resident 26's portable oxygen tank was on. The DON immediately left her office and went through the first floor lounge to the outside patio area. She was noted to turn off resident 26's portable oxygen tank. Resident 26 at that time also removed the oxygen nasal cannula tubing from his nostrils. Interview immediately after with the DON confirmed resident 26 did have his oxygen on while he had been smoking. She also stated: *Resident 26 was usually very good about his oxygen being turned off before he smoked. *No staff had accompanied resident 26 outside when he smoked to ensure his oxygen had been shut off. Review of resident 26's 3/28/11 care plan revealed: *A focus for being at risk for smoking related injury. *A goal that he would have no smoking related injuries. *Interventions that included: -Observe resident for unsafe smoking behaviors or attempts to obtain smoking materials from outside sources. Immediately inform facility management. -Provide smoking apron while smoking. Refuses to wear smoking apron. -Remove supplemental oxygen device prior to entering designated smoking area. Leaves tank with nurses, at door, or turns tank off. -Review smoking policy with resident. -Resident was non-compliant with smoking policy/smoking area. (Hand written with no date noted.) Continued interview on 8/31/11 at 1:45 p.m. with the DON revealed: *The smoking area had recently been moved, and resident 26 would at times still go and smoke outside in the previous smoking area. *The intervention that had been hand written on resident 26's care plan was added as the smoking area had been relocated. *The new smoking area had been initiated on 8/17/11 due to resident 21 having behaviors and the need for closer supervision. *The provider did not have any smoking aprons that resident 26 could have used. *She agreed resident 21 was the only resident that had supervision while she smoked. Observation on 8/30/11 at 9:00 a.m. revealed resident 26 was outside the first floor east exit of the building. He was seated in his wheelchair and was noted to be smoking. He did not have a portable oxygen tank. That area was noted to be the employee smoking area. Review of the provider's undated resident specific smoking policy revealed: *It was the responsibility of all staff to monitor smoking safety practices of residents and to intervene appropriately to keep residents safe. *The approved designated smoking area was located outside the first floor lounge on the fenced in patio. Residents who had been deemed unsafe to smoke independently would be accompanied/observed by a staff member. *Residents who had been deemed safe to smoke alone would be advised and shown where the designated smoking area was located. *"The care plan/Kardex will indicate how the smoking materials will be stored, i.e. secure/locked cabinets for residents deemed safe to smoke independently, allowing independent residents to maintain their smoking material on their own person, maintenance of all smoking material at a secure designated area or another system as indicated to meet resident needs and within the ability of the facility." 2. Interview on 8/31/11 at 1:50 p.m. with certified nursing assistant (CNA) K confirmed she: *Had known resident 22 kept his smoking materials in his room. *Had observed that he took himself outside to smoke in his electric wheelchair. *Had never noticed any burn holes in the resident's clothing. Observation on 8/31/11 at 2:00 p.m. of resident 22 revealed: *He was seated in his electric wheelchair. *Had a shirt on that had a small hole with blackened edges at the mid-chest level. Interview on 8/31/11 at 2:00 p.m. with resident 22 confirmed: *He stored his smoking materials in his room. *He wheeled himself outside when he wanted to smoke with no assistance. *The hole in his shirt was a burn hole from cigarette ashes. *The burn hole had occurred when he still lived at home. *He had to flick ashes off of his clothing when he smoked since he moved into the nursing home. Interview on 8/31/11 at 2:30 p.m. with CNA H confirmed she: *Had known resident 22 kept his smoking materials in his room. *Had observed that he took himself outside to smoke in his electric wheelchair. *Had never noticed any burn holes in the resident's clothing. *Thought he usually told someone when he went outside to smoke. Interview on 8/31/11 at 2:50 p.m. with registered nurse (RN) I confirmed: *She had known resident 22 kept his smoking materials in his room. *She had observed that he took himself outside to smoke in his electric wheelchair. *She had never noticed any burn holes in the resident's clothing. *He had not always told staff when he went outside to smoke. *The door alarm had usually sounded when he went outside to smoke. Interview on 8/31/11 at 2:55 p.m. with nurses I and J confirmed: *They had never heard of smoking aprons. *They had no smoking aprons to protect the clothing of the residents that smoked. Review of resident 22's progress notes from his admitted on 8/10/11 through 8/29/11 revealed no entries that had addressed that he smoked. Review of resident 22's 8/23/11 care plan revealed no focus, goal, or interventions that had addressed his smoking. Review of his 8/10/11 clinical health status form, section N, revealed he was able to: *Hold the device while he smoked. *Safely contain the ash while he smoked. *Remain alert while he smoked. *Store the materials used to smoke. *Communicate he had understood not to share the materials and smoke in designated areas only. Review of resident 22's 8/17/11 initial Minimum Data Set assessment revealed: *He had a [DIAGNOSES REDACTED]. *He had functional limitations on one side in his upper and lower extremities. *He used tobacco. Interview on 8/31/11 at 3:05 p.m. with the director of nursing confirmed: *The provider had no smoking aprons. *She had not noticed the burn holes in resident 22's clothing. 3. Interview on 8/31/11 at 2:25 p.m. with CNA B regarding resident 21 confirmed: *She had known the resident had kept smoking materials in her room. *There was a smoking schedule for the resident every two hours. *Staff were to escort the resident to the smoking patio off the first floor lounge. *Staff did not stay with the resident while she smoked. *The resident had been left unattended and would find her way back to second floor when she had finished smoking. *She was aware the resident had eloped on 8/2/11. *That was why the every two hour smoking schedule and the escort down to the smoking patio had been implemented. Review of resident 21's progress notes on 8/2/11 revealed: *She went out to smoke at the start of the shift. *At 12:10 a.m. She was found ambulating about the parking lot with her walker. She had refused to go into the facility stating "My sister is just ready to come down." *At 3:58 p.m. social services had a note she had visited with the resident due to cognitive concerns. The resident stated "Gloria in surveillance would be calling me." The resident was not easily redirected to the building. A Wanderguard (exit monitoring device) was placed on her ankle. *At 4:13 p.m. the resident was found outside and was assessed for heat exhaustion. *At 4:30 p.m. The resident was found across the street in a parking lot, was showing signs of paranoia, had attempted to leave the facility multiple times while out smoking, was not easily redirected, and a Wanderguard had been applied. Review of resident 21's care plan revealed there was an undated smoking schedule with two hour increments from 9 a.m. to 9 p.m. It also had a hand written note that stated, "To be accompanied by staff" signed by the resident care coordinator F. Interview on 8/31/11 at 2:50 p.m. with resident 21 who was out smoking on the smoking patio with a staff member stated "Are you going to watch me too?" B. Based on observation, record review, interview, and policy review, the provider failed to ensure a trauma wound following an accident was documented, investigated, and the family properly notified for 1 of 17 sampled residents (4). Findings include: 1. Observation of resident 4's dressing change and interview on 8/30/11 at 1:40 p.m. and an additional interview at 4:50 p.m. with wound care nurse E revealed: -The wound was located on the left upper buttock. -It was noted as a trauma wound and not a pressure ulcer. -It had started as a hematoma. -The accident had happened during a mechanical lift transfer from the bed to the wheelchair. -The arm of the wheelchair was up revealing a metal circular bar. -When the resident was placed into the chair her left buttock hit that bar. -The next day a bruise was reported, and nurse E measured the area. It matched the size of the metal circular bar. -She believed it had happened about 11/9/10. -She did not remember what staff were involved in the transfer. -She did not remember if an accident report had been done or documentation had been noted in the resident's medical record. -She thought she had called the family, but she did not remember when and what had been said. Review of resident 4's wound evaluation flow sheet revealed: -An entry dated 11/9/10 of a bruise measuring 1.2 centimeters (cm) by 1.3 cm. -An entry dated 11/15/10 noted a 1.5 cm by 1.5 cm by 0.1 cm area with trauma bruising darkened. The physician was notified and an order was received to cleanse with normal saline and apply a DuoDerm every three days. The area was tender. -An entry dated 1/30/11 noted the wound had increased to its largest size of 2.9 cm by 4.2 cm by 0.1 cm with moderate serous drainage. New wound care orders had been received from the physician. -The resident was turned and repositioned frequently, had an air mattress, and a wheelchair cushion. -Weekly wound care charting was done by nurse E. The current wound measurement was 0.6 cm by 0.6 cm by 0.6 cm. Interview on 8/30/11 at 4:00 p.m. with resident care coordinator (RCC) F revealed he had not known how the trauma to resident 4's left buttock had happened. He had thought it had happened at another facility. Interview on 8/31/11 at 10:05 a.m. with nurse aide A and at 11:40 a.m. with RN G revealed they had not known how the trauma to resident 4's left buttock had happened. Interview on 8/31/11 at 4:30 p.m. with the DON regarding resident 4 revealed: -The procedure for reporting an incident or bruise was to report it to the RCC and/or the DON. It was then discussed as to how/when the incident had happened and if it would have been reportable to the state health department. An internal investigative report should have been done. -No internal report was noted on the trauma incident. -No documentation in the chart was noted on that incident except for the wound care flow sheet. -The wound care flow sheet had not explained how the trauma had occurred. -The DON remembered wound care nurse E coming into her office and talking about the wheelchair/lift incident. -The DON had not remembered what staff were involved in the incident or when it had happened. -She had not remembered if any education had been done with the staff involved in the incident. -She expected there should have been something documented about that incident. -She would have expected family to have been notified when the bruise opened up into a wound, but would not have necessarily told the family about the wheelchair/lift incident. -An SBAR (situation, background, action, and response) was put into place not too long ago for incidents and physician/nurse communications. The SBAR would take the place of the Change in Condition Report. Review of the provider's Quality Control Guideline reviewed 4/24/06 revealed: -"The Center utilizes the Quality Control Event Reporting process for reporting incidents and accidents. -Tracking is completed and submitted electronically for all events and the documentation reflects a brief description of the event. -Nursing documentation is completed post event with ongoing monitoring, as indicated by center practice. -Family/Physician notification is evident and timely. -There is evidence that the QAA committee reviews events and the minutes reflect analysis of trends with action plan." Review of the provider's Change in Condition Guides reviewed 4/24/06 revealed: -"Change of condition is noted. -Select the appropriate Change in Condition Guide or Report. -Contact the physician and provide assessment information or fax Change of Condition Report. Document notification and information relayed. -Receive, transcribe, and implement new physician's orders [REDACTED]. -Monitor resident and document ongoing assessment, intervention and response to treatment as condition warrants until condition resolves or becomes a permanent change in condition. Update care plan to reflect residents current condition." Surveyor Interview on 8/30/11 at 5:20 p.m. with resident 4's daughter revealed: *The resident had been transferred from another long term care facility, and there were no prior skin issues. *The facility had reported the resident's wound had been caused from lying on her bottom too long. *The resident was unable to get up on her own and had needed a lift for transfers.

Based on record review, nursing standard of practice review, and interview, the provider failed to assess, monitor, and intervene in the individualized care and service to maintain the highest practical physical and psychosocial well being for: *Two of twenty-six sampled residents (4 and 25) who had fecal impactions. *Four of twenty-six sampled residents (4, 13, 14, and 25) with no recorded bowel movement (BM) varying from three to seven days. Findings include: 1. Review of resident 4's medical record revealed: *An admission date of [DATE] from an acute care facility. *A discharge summary dated 9/13/10 from that facility noted discharge [DIAGNOSES REDACTED]." *The Minimum Data Set (MDS) for 10/1/10, 10/31/10, 4/4/11, and 6/27/11 answered constipation not present. The MDS for 10/1/10 and 10/31/10 left that question unanswered. *Admission medications dated 9/13/10 for constipation included [MEDICATION NAME] 17 grams (gm) every morning, [MEDICATION NAME] 6 gm twice daily, and Senna S 8.6 milligram (mg)/50 mg twice daily. *Admission medications dated 9/13/10 for pain included [MEDICATION NAME] 5/325 mg (1-2 tablets) every 6 hours as needed, [MEDICATION NAME] 50 mg every 4 hours as need for pain, and [MEDICATION NAME] 650 mg orally or suppository every 6 hours. *A [MEDICATION NAME] 25 micrograms (mcg) every 3 days for pain was started on 10/6/10. *A Facsimile (Fax) Communication form to the physician dated and signed on 11/2/10 added [MEDICATION NAME] 5/325 mg 2 tablets three times a day for pain and [MEDICATION NAME] 0.5 mg three times a day for anxiety. *A Fax Communication form to the physician dated and signed on 12/3/10 discontinued all laxatives due to the resident having loose stools. *A Bowel Assessment Form dated 12/16/10 was completed. Constipation was not noted as a problem under bowel status. *A Fax Communication form to the physician dated 12/27/10 noted intermittent abdominal pain. The resident was treated for [REDACTED]. *A Fax Communication form to the physician dated and signed 1/6/11 requested as needed (PRN) laxatives for constipation. Fleets/soap suds enema every 3 days PRN and [MEDICATION NAME]/[MEDICATION NAME] suppository every 3 days PRN. *A Fax Communication form to the physician dated and signed 8/8/11 stated "Recently Nursing has had to digitally remove XL (extra large) hard stool from rectum. Would you like to add any medications such as 17 grams [MEDICATION NAME] Powder in 4-8 oz (ounce) of H20 (water) QDay (every day)? Please advise." The physician responded yes to the medication request. *No further documentation was noted in the medical record regarding that incident. Review of the resident 4's continence log, medication administration record (MAR), and PRN administration/monitoring tool revealed: *The continence log dated December 2010 had no BM noted from 12/7/10 through 12/11/10 (5 days). Milk of Magnesia was noted as given on 12/10/10 per the PRN monitoring form but was not noted as given on the MAR. No further medication was given, and no BM was noted until 12/12/10. *The continence log dated January 2011 had no BM noted: -From 1/3/11 through 1/5/11 (3 days). Milk of Magnesia was noted as given on 1/6/11 at 12:00 noon, and a BM was noted later on that day. -From 1/8/11 through 1/11/11 (4 days). Milk of Magnesia was noted as given on 1/11/11 per the PRN monitoring tool but not noted as given on the MAR. -From 1/17/11 through 1/21/11 (5 days). No PRN laxative was noted as given for that time period. *The continence log dated May 2011 had no BM noted for 5/12/11 through 5/15/11 (4 days) and 5/28/11 through 5/31/11 (4 days). No PRN laxative was noted as given for May 2011. *The continence log dated June 2011 had no BM noted from 6/3/11 through 6/5/11 (3 days). No PRN laxative was noted as given for June 2011. *The continence log dated July 2011 had no BM noted: -From 7/10/11 through 7/12/11 (3 days). No PRN laxative was noted as given for that time period. -From 7/14/11 through 7/17/11 (4 days). Milk of Magnesia was given on 7/17/11 and a [MEDICATION NAME] suppository was given on 7/18/11. -From 7/19/11 through 7/21/11 (3 days). No PRN laxative was noted as given for that time period. *The continence log dated August 2011 had no BM noted: -From 8/3/11 through 8/6/11. Milk of Magnesia was given on 8/5/11, and a suppository was given on 8/6/11. A BM was noted on 8/7/11, but no BM was noted on 8/7/11 and 8/8/11. On 8/8/11 the Fax Communication form regarding the digital BM removal was sent. The [MEDICATION NAME] order was received. -From 8/11/11 through 8/13/11 (3 days). A suppository was given on 8/14/11 and a BM was noted later that day. 2. Interview on 8/30/11 at 2:00 p.m. with resident care coordinator (RCC) F revealed: *The bowel/constipation procedure was a nursing standard of practice. *There was no written policy/procedure for that standard of practice. *The standard of practice consisted of: -The night shift nurse printed off the "No BM list." The list included any resident with no BM for 3 days. -A PRN laxative (Milk of Magnesia, suppository, or enema) was given on that third day. -On the fourth day of no BM the physician was contacted. *Nursing sometimes consulted with dietary to increase the fiber intake or add prune juice to help with constipation. Interview on 8/30/11 at 3:00 p.m. with licensed practical nurse (LPN) D revealed she agreed with the above standard of practice. Interview on 8/31/11 at 4:15 p.m. and on 9/1/11 at 7:40 a.m. with the director of nursing (DON) revealed she: *Agreed the provider's bowel protocol was a nursing standard of practice. *Stated the source of the standard of practice was from a nursing textbook, but she had no specific textbook to cite it from. *Agreed there was no written policy or procedure regarding that practice. *Agreed with the standard of practice the above nurses followed. *Stated on the fourth day with no BM it was the nurse's decision/judgement whether the physician should have been called. *Agreed on the third day a PRN laxative should have been given and on the fourth day another PRN laxative should have been given or the physician called. *Agreed the Care Tracker or incontinence log should have reflected an accurate assessment of the residents' BMs. *Stated CNAs documented on the no BM for three days list if the resident had a BM since the list was printed out. The DON realized those were not entered into the Care Tracker, and no record was kept of the BM list printout. *Agreed documentation should have been done on the MAR and the PRN monitoring form for any PRN medication given. *Stated a new form (SBAR) was used now to document physician notification for each resident. It consisted of the situation, background, action, and response. It was located in the interdisciplinary progress notes in each resident's medical record. *No SBAR was noted for resident 4 regarding the 8/8/11 incident. 3. Review of a 6/19/11 at 1:31 p.m. progress note for resident 25 revealed "Resident had moderate amount of blood in stool. Resident received suppository last NOC (night). Dr. called, received order to do a digital check and Preparation H suppository q (every) 12 hours for 5 days. Digital check showed impaction. Fleet's enema administered with very large results. Will continue to monitor for blood in stool." Review of resident 25's June 2011 pain and PRN administration and monitoring tool revealed on 6/19/11 at 10:00 a.m. he had received an enema for "impaction" and had "XXL" results at 10:30 a.m. Record review for resident 25 revealed he had [DIAGNOSES REDACTED]. Review of resident 25's June and July 2011 continence logs revealed: *A BM on 6/1/11 with no BM documented until 6/5/11 (4 days). *A BM on 6/10/11 with no BM documented until 6/16/11 (5 days). *A BM on 6/16/11 with no BM documented until 6/19/11 (3 days). *A BM on 6/19/11 with no BM documented until 6/24/11 (5 days). *A BM on 7/1/11 with no BM documented until 7/8/11 (7 days). *The BM on 7/8/11 was listed as "D" for diarrhea; the next BM was listed as large on 7/11/11. Review of resident 25's June 2011 MAR revealed he had received a [MEDICATION NAME] (laxative) 10 mg suppository every three days at bedtime and [MEDICATION NAME] sodium 100 mg two tabs twice daily for constipation. He also had received medications that could contribute to constipation that included: *[MEDICATION NAME] 400 mg every bedtime. *[MEDICATION NAME] 25 mg every bedtime. *[MEDICATION NAME] 4.6 mg every 24 hours. *[MEDICATION NAME] 50 mcg every 72 hours. *[MEDICATION NAME] 150 mg daily. *[MEDICATION NAME] 20 mg twice daily. *[MEDICATION NAME] 2 mg twice daily. *[MEDICATION NAME]/[MEDICATION NAME] 5/325 mg one tablet every four hours as needed for pain. He had received that medication on 6/5/11, twice on 6/6/11, 6/7/11, 6/9/11, 6/10/11, 6/16/11, 6/17/11, and 6/19/11. 4. Record review for resident 14 revealed she had [DIAGNOSES REDACTED]. Review of resident 14's August 2011 MAR revealed she had received [MEDICATION NAME] calcium 240 mg one capsule twice daily for bowel management. She also had received medication that could contribute to constipation that included: *Donepezil [MEDICATION NAME] 10 mg one tablet daily. *[MEDICATION NAME] 0.25 mg on capsule daily. *[MEDICATION NAME] 40 mg one tablet daily. *[MEDICATION NAME] 2.5 mg one tablet twice daily. *Sevelamer 800 mg one table three times daily. Review of resident 14's May, June, July, and August 2011 continence logs revealed: *A BM on 5/4/11 with no BM documented until 5/9/11 (5 days). *A BM on 5/12/11 with no BM documented until 5/18/11 (6 days). *A BM on on 5/18/11 with no BM documented until 5/23/11 (5 days). *A BM on 6/1/11 with no BM documented until 6/5/11 (4 days). *A BM on 6/18/11 with no BM documented until 6/23/11 (5 days). *A BM on 6/23/11 with no BM documented until 6/28/11 (5 days). *A BM on 6/28/11 with no BM documented until 7/2/11 (4 days). *A BM on 7/2/11 with no BM documented until 7/7/11 (5 days). *A BM on 7/15/11 with no BM documented until 7/21/11 (6 days). *A BM on 7/23/11 with no BM documented until 7/27/11 ( 4 days). *A BM on 8/6/11 with no BM documented until 8/10/11 (4 days). *A BM on 8/10/11 with no BM documented until 8/14/11 (4 days). *A BM on 8/14/11 with no BM documented until 8/19/11 (5 days). *A BM on 8/20/11 with no BM documented until 8/24/11 (4 days). Review of resident 14's May, June, July, and August 2011 MARs revealed no use of PRNs for bowel management. Resident 14 did have physician ordered medications that included: *[MEDICATION NAME] 10 mg suppository every three days PRN. *Fleet enema every three days PRN. 5. Review of resident 13's August 2011 MAR revealed he had received [MEDICATION NAME] 17 grams every day for constipation. He also had received medications that could contribute to constipation that included: *[MEDICATION NAME] 1000 mg twice every day. *[MEDICATION NAME] 0.2 mg twice every day. *[MEDICATION NAME] 12.5 mg twice every day. *[MEDICATION NAME] 50 mg every day. He had the following PRN medications ordered to address constipation: *[MEDICATION NAME] suppository 10 mg rectally every 3 days for constipation. *[MEDICATION NAME] suppository every 3 days for constipation. *Milk of Magnesia 30 ml every day times 3 consecutive doses for constipation. *Soap suds enema rectally 1 dose every third day for constipation. Review of resident 13's continence log, medication administration record (MAR), and PRN administration/monitoring tool revealed: -The continence log dated May 2011 through June 2011 had no BM noted from 5/27/11 through 6/2/11 (7 days). A [MEDICATION NAME] suppository was noted as given on 6/2/11 per the PRN monitoring form. No further medication was given, and no BM was noted until 6/3/11. -The continence log dated June 2011 had no BM noted from 6/24/11 through 6/30/11 (7 days). A [MEDICATION NAME] suppository was noted as given on 7/1/11 per the PRN monitoring form. No further medication was given, and no BM was noted until 7/1/11. -The continence log dated July 2011 had no BM noted from 7/7/11 through 7/11/11 (5 days). Milk of Magnesia was noted as given on 7/8/11 per the PRN monitoring form and was documented as not effective. No further medication was given, and no BM was noted until 7/12/11. -The continence log dated August 2011 had no BM noted from 8/28/11 through 8/31/11 (4 days). A [MEDICATION NAME] suppository was noted as given on 8/26/11 per the PRN monitoring form. No further medication was given, and no BM was noted. Review of resident 13's care plan revealed it did not specifically address constipation or the repeated episodes of no bowel movements for 4 or more days. Review of the provider's May 2001 care plan policy revealed it was to have been updated quarterly or more frequently if needed. Interview on 8/31/11 at 4:00 p.m. with the director of nursing confirmed: *She would have expected the nurses to have used the PRN medications to prevent extended days without a bowel movement. *She would have expected the care plan to address the resident's constipation.