Every finding on record at Baptist Health & Rehab

Based on review of a facility reported incident (FRI) investigation, record review, policy review, and staff interview, the facility failed to provide appropriate respiratory care for 1 of 1 closed resident record (Resident #1) who required respiratory support from a ventilator. Failure to provide care consistent with professional standards of practice and the physician's orders may have resulted in or contributed to Resident #1's death and placed all other ventilator-dependent residents at risk of injury or death. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following discovery of the incident.The State Survey Agency (SSA) conducted an on-site investigation and determined an Immediate Jeopardy (IJ) situation existed on 07/15/25 when a nurse (#3) delegated a non-qualified staff member (#2) to turn off Resident #1's ventilator, and the nurse (#3) failed to disconnect the resident from the ventilator and deflate the tracheostomy cuff. The survey team notified the administrator and the director of nursing (DON) of the IJ, provided the IJ template, and requested a plan for removal of the IJ on 07/21/25 at 12:52 p.m. The SSA received the removal plan on 07/21/25 at 1:16 p.m. and accepted the removal plan and verified implementation at 2:40 p.m. The survey team confirmed by interview and record review the facility removed the IJ on 07/15/25 and corrected the deficient practice prior to the start of the survey on 07/16/25, therefore considered past non-compliance. The deficient practice remained at a G scope and severity following the removal of the IJ. Findings include: Review of the facility policy titled Tracheostomy [surgically created opening in the neck into the windpipe] Care and suctioning of resident with tracheostomy occurred on 07/16/25. This policy, dated 03/10/25, stated, . [Tracheostomy] Tubes can come with or without a cuff. These cuffs can be filled with air or foam.Review of the facility policy titled Trilogy Non-Invasive Ventilator (NIV) occurred on 07/16/25. This policy, dated 03/10/25, stated, . Responsibility: Licensed nurse . Cuffed tracheostomies should always have the cuff inflated during NIV use unless otherwise ordered by the physician. Monitor alarms as needed . Review of Resident #1's medical record occurred on 07/16/25. Diagnoses included chronic respiratory failure with hypoxia (low level of oxygen in body tissues). The care plan stated, Alteration in comfort related to Chronic respiratory failure with hypoxia, trach [tracheostomy], . pneumonia, and URI [upper respiratory infection] . apnea [cessation of breathing] . Approach: . Trach cares per facility protocol and physician orders. Trilogy machine per physician orders . A physician's order, dated 10/09/17, included a ventilator used daily at bedtime from 8:00 p.m. to 7:00 a.m. An order, dated 01/15/18, stated, Inflate cuff with 8 ml [milliliter] of STERILE WATER while on the Trilogy. Deflate cuff when not on the trilogy, twice a day. A nurse's note, dated 07/15/25 at 8:21 a.m., stated, Nurse went to resident's room and found resident to be unresponsive and without a pulse. 2 nurses confirmed death. On 07/15/25, the facility initiated a root cause analysis (RCA) of the event as part of their investigation. The RCA, completed 07/16/25, stated, Resident's [#1] trilogy was alarming so [name of medication aide (MA) (#2)] entered the resident's room to check on resident. Resident did not appear in distress. He asked the nurse what to do about the alarming trilogy machine. [Name of nurse (#3)], LPN [licensed practical nurse] told [name of MA (#2)] to turn the machine off and that he would be in to take care of it in a minute. [Name of MA (#2)] turned the machine off. Approximately an hour later, when [name of nurse (#4)], LPN entered the room to do [name of Resident #1]'s breathing treatments, [name of Resident #1] had passed away. During an interview on 07/16/25 at 3:14 p.m., a MA (#2) stated on 07/15/25 at about 7:05-7:10 a.m., he heard an alarm beeping from Resident #1's breathing machine (ventilator). The MA (#2) went to the desk and observed the night nurse (#3) giving report to the day nurse (#5) and asked them if he should turn the machine off and one nurse (#3) said yes. I asked how do you do that, push the button? The nurse [#3] said 'yes.' I returned to the room, selected the power button, and pushed it off. The MA (#2) stated after he turned the ventilator off, I made sure she was breathing, and she looked like she was. Then I asked the nurse, 'Being she still has that breathing apparatus on, she can still breathe, right?' The MA (#2) stated the nurse (#3) said yes. During an interview on 07/16/25 at 6:02 p.m., a nurse (#5) stated she received report from the night nurse (#3) on 07/15/25 starting at 7:00 a.m. During the report, the nurse (#5) stated two certified nurse aides (CNAs) reported they thought Resident #1's respirations were increased. The nurse (#5) stated about 5-10 minutes later, the MA (#2) came and asked, Can I turn that machine off, it's beeping - [Resident #1]'s vent. [Nurse #3] said 'yes.' [MA #2] asked, 'Where is the button to turn it off' and [nurse (#3)] said, 'If you look at the front of the machine, it is the power button.' The nurse (#5) stated the night nurse usually removed the ventilators from residents by the time her shift started, So, this was unusual to still be on. She stated the MA (#2) returned to the desk and asked, Are you sure she can breathe with that machine turned off. [Nurse #3] said 'yes.' During an interview on 07/16/25 at 2:21 p.m., a nurse (#4) stated she found Resident #1 unresponsive with no breathing or circulation on 07/15/25 at about 8:15 a.m. The nurse observed Resident #1's trach tube connected to the ventilator, which was turned off. When asked who is responsible to turn on/off the ventilator, the nurse (#4) stated, A nurse should be doing everything with the vents.During an interview on 07/16/25 at 1:50 p.m., a nurse (#1) explained a nurse deflated the trach cuff when removing a resident from the ventilator and inflated the cuff when connecting to the ventilator. She stated, Only nurses are allowed to connect or disconnect the vent from the trach or inflate/deflate the cuff. Only nurses check on the vent alarm to see if there is a concern.The facility failed to ensure only nurses or other qualified staff turned off a resident's ventilator.The facility completed the following steps to remove the immediacy and correct the deficient practice:* Completed an investigation of the incident by interviewing staff working the shift prior to and following the incident.* Placed the MA (#2) and the nurse (#3) on administrative leave during the investigation and then terminated the nurse (#3).* Education provided to all facility staff who worked on 07/15/25. Provided the policy on Change in Condition and Delegation, along with education on tracheostomies and ventilators, and providing care within your scope of practice to all staff on 07/15/25 to read and sign before their next shift. Nursing management staff assigned to be on site and provide education to all nurses prior to their next shift. * Provided the policies on the Trilogy Non-Invasive Ventilator, tracheostomy site care, and suctioning on 07/15/25, and information on the importance of acting quickly to assess alarms and change in conditions to all nurses on 07/16/25 to review and sign prior to providing patient care.* Started a Root Cause Analysis (RCA) of the incident on 07/15/25 and completed it on 07/16/25.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate treatment/services to prevent complications from a gastrostomy tube (G-tube) (a tube inserted through the abdomen that brings nutrition directly to the stomach) for 1 of 1 sampled resident (Resident #47) observed with a G-tube. Failure to flush the tube with water before and after medications may lead to dehydration and G-tube occlusion. Findings include: Review of the facility policy titled Medication via enteral tube occurred on 04/16/25. This policy, dated 06/26/23, stated, . Administering each medication separately and flushing between each medication is considered standard of practice . flush tube with 30 cc [cubic centimeters] of water . administer each prepared medication flushing with 5-10 cc warm water after each medication. attach syringe to feeding tube and flush it with 30 cc warm water . Review of Resident #47's medical record occurred on all days of survey and identified G-tube placement. Observation on 04/14/25 at 3:37 p.m. showed a nurse (#2) checked Resident #47's G-tube placement and administered medications mixed with water via the G-tube. The medications were slow to flow down the tubing and the nurse kneaded the tubing while administering. The nurse (#2) failed to flush Resident #47's G-tube before and after administering medications. During an interview on 04/16/25 at 1:50 p.m., an administrative nurse (#3) confirmed nursing staff failed to flush the G-tube per policy.

Based on observation, record review, and review of facility policy, the facility failed to follow standards of infection control and prevention for 3 of 6 sampled residents (Residents #49, #73 and #436) on enhanced barrier precautions (EBP) and observed during cares. Failure to follow EBP during tracheostomy (an opening through the neck into the windpipe) and percutaneous gastrostomy (PEG) tube (feeding device inserted into the stomach through the abdomen) care for Resident #49, tracheostomy care (cleaning the airway tube and surrounding skin) for Resident #436, and wound care for Resident #73 has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Transmission-based precautions and enhanced barrier precautions occurred on 04/16/25. This policy, revised 05/03/24, stated, . requiring gown and glove use for enhanced barrier precautions include . feeding tube, tracheostomy/ventilator . Wound care: Any skin opening requiring a dressing . - Review of Resident #49's medical record occurred on all days of survey. Medical devices included a tracheostomy and PEG tube. The current care plan stated, . requires enhanced barrier precautions . Observations on 04/15/25 at 8:12 a.m. showed an EBP sign on the inside of Resident #49's room. A nurse (#1) entered the room and without applying gloves and a gown, removed a soiled 4 x 4 gauze dressing from the PEG site and removed the nebulizer equipment from the tracheostomy site. The nurse (#1) failed to follow EBP and apply a gown and gloves during high contact cares. - Review of Resident #73's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified an unstageable pressure injury/ulcer. A progress note, dated 04/08/25, identified an order to clean and wrap the right foot wounds twice a day. An observation on 04/15/25 at 9:16 a.m. showed a nurse (#6) entered Resident #73's room, applied gloves, and provided wound care. The nurse (#6) failed to follow EBP and apply a gown during high contact wound care. - Review of Resident #436's medical record occurred on all days of survey. Medical devices included a tracheostomy and a PEG tube. The current care plan stated, . requires enhanced barrier precautions . Observation on the afternoon of 04/14/25 showed an EBP sign inside of Resident #436's room. A nurse (#2) suctioned the resident's tracheostomy wearing sterile gloves. The staff nurse (#2) failed to follow EBP and apply a gown during high contact cares. 52000 27221

Based on observation, record review, review of the facility reported incident, review of the facility policy, and staff interview, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) investigated for a fall. Failure to ensure staff used a mechanical lift properly and verified proper installation of attachments to the Broda chair (specialized wheelchair) resulted in a fall from the mechanical lift. Finding include: Review of the facility policy titled Floor based, Full Body Sling Lift use occurred on 01/23/25. This policy, dated 10/27/21, stated, . Transfer resident from chair to bed . Push the UP button on the hand control for the lift until there is slight tension on the sling loops. PERFORM SAFETY CHECK i. Once there is tension on the loops, double check each loop to be sure each is securely in the hook. ii. Double-check the position and stability of all straps and other equipment. v. Lift the resident about 2 inches off the surface and verify that weight is evenly spread between the straps of the sling. vi. Verify the resident will not slide out of the sling or tip backward or forward. Review of the facility reported incident, stated, . At approximately 1815 [6:15 p.m.] on 1/4/25, a resident, [Resident #1], was involved in a witnessed fall during a transfer with a full body lift. The nurse on duty was promptly notified and called to the resident's room. The CNAs [certified nurse aides] involved in the incident [CNA names], explained that they were transferring the resident from a broda wheelchair to the bed using a full body lift per the residents [sic] care plan. During the transfer, the residents [sic] sling became caught on part of the wheelchair. In an attempt to free the sling, the CNA moved the resident's wheelchair, causing the lift to become unbalanced. As a result, the lift struck the CNA in the head, and a portion of the lift subsequently made contact with the residents [sic] face. This impact caused a skin tear above the resident's right eye and on the bridge of his nose. The lift then tipped over on its left side and fell on to the floor causing the resident to fall from a height of about 3 feet onto his bottom while still in the sling. The resident reported no pain, aside from discomfort related to the skin tear. A raised area potentially a hematoma was noted to residents [sic] back. Resident #1's nursing progress notes stated the following: * 01/04/25 at 8:10 p.m. After further assessment this nurse found a lump on the resident's right lower back, upon palpation resident said bump was painful. No redness or bruising was found at this time and bump was blanchable. Family was called and updated and consented to sending in. This nurse called on call to get order to send resident in for further assessment. Metro ambulance arrived about 2100 [9:00 p.m.] . * 01/05/25 at 3:15 p.m. This nurse spoke with resident's wife, [name]. Per [wife's name], the sutures above resident's right eye are dissolvable. An email from the facility's purchasing employee, dated 01/14/25, stated, [Staff member name] and I met and looked at chair [Resident #1's Broda chair]. I found the handles at the end of arm rest were placed upside down which could have been where the sling got caught, but I'm not sure. I adjusted them to the proper placement. An Occupational therapist note, dated 12/09/24 at 5:02 p.m., stated, Review of broda chair . Resident continues using the broda chair for comfort per family request. (The therapist failed to mention the handles at the end of the arm rests.) During an interview on the afternoon of 01/23/25 while observing Resident #1's Broda chair an administrative nurse (#1) explained that the handles on the resident's Broda chair were turned downwards and therefore the sling could have easily been caught on these handles. This staff member was unsure how long the handles had been on the Broda chair and if the resident utilized the handles.

Based on record review, review of the facility reported incident, review of facility policy, and staff interview, the facility failed to report an incident of abuse within 24 hours to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #2) who experienced an injury. Failure to report an event of potential abuse in the required time frame does not comply with regulations established to protect residents. This citation is considered past noncompliance based on review of the corrective action the facility implemented. Findings include: The surveyor determined a deficient practice existed on 11/02/24. The facility implemented and completed corrective action on 11/08/24. Review of the facility policy titled Vulnerable Adult - ND [North Dakota] occurred on 01/23/25. This policy, dated 10/14/22, stated, . Report all alleged violations . no later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury to the North Dakota Department of Health . The facility investigation report stated, . On Friday 11/01/24, at the afternoon social, resident [Resident #3] grabbed [Resident #2's] finger and bent it back. Health Department . notified 11/04/24. Resident #2's nursing progress note, dated 11/02/24 at 10:18 a.m., stated, Resident was in activities on Friday. During activities he had a fell ow resident pull his right pointer finger. Now today the finger is swollen by the joint . He reports mild discomfort to the finger. During an interview on the afternoon of 01/23/25, an administrative nurse (#1) confirmed the facility failed to report this incident to the SSA within 24 hours. Based on the following information, noncompliance at F609 is considered past noncompliance. The facility implemented corrective actions as follows: * An email was sent to all facility staff on 11/05/24 defining abuse and to report any form of abust the the manager and the SSA within 24 hours. * On 11/08/24, education related to abuse was assigned to all facility staff to be completed within one week. *Additionally, the facility directors and team leads were required to print off the email sent on 11/05/24, along with the definition of abuse and reporting guidelines, and have staff sign and acknowledge when they completed the education.

Based on record review, review of the facility reported incident, investigation documents, and review of the facility policy, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) investigated for falls. Failure to ensure staff use a gait belt during transfers resulted in a fracture and hospitalization . This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 12/18/24. The facility implemented and completed corrective action on 12/20/24. Review of the facility policy titled Fall assessment and managing fall risk occurred on 01/02/25. This policy, dated 03/28/24, stated, . If a resident is on the floor after falling they should be lifted with a mechanical lift to ensure safety. Transfer/gait belt use is required during any transfer or ambulation where the resident needs stand by or higher level of assistance during transfers or ambulation. When a resident falls, the nurse is responsible to assess the resident . prior to moving the resident. Review of the facility reported incident report, dated 12/18/24, stated, . At 1735 [5:35 p.m.] CNA [certified nurse aide] came to nurses station and reported that the resident was on the floor. This nurse entered room and found resident sitting in her recliner. The CNA then reported that the resident fell but she was able to get her into her recliner. Resident stated, I hit my head. The CNA reported the resident fell on to the floor and she go [sic] her up and put her into her recliner. bump on her head . weakness to left leg and reports pain . when tries to push on nurses hand. This nurse updated resident's son . placed call to on call [provider's name] . order received: OK to send to . ER [emergency room ] for evaluation post fall . The facility investigation report stated, . the CNA had assisted the resident from the dining area back to her room. the resident requested to sit in her recliner. The resident later described to the nurse that the CNA had set the recliner at an angle and told her to stand while the CNA went to grab a cushion. The resident, thinking the CNA was behind her, stood up and fell . The resident pointed towards the middle of the room when asked where the CNA was. According to the CNA, the resident had asked her to help lift her from the floor, which she did, before sitting the resident back into the recliner. The CNA also reported that a gait belt was not used at the time of the fall, nor was the full body lift utilized to help the resident into the recliner. Review of Resident #1's medical record occurred on 01/02/25. The quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident's care plan stated, . History of falls . Transfer and ambulate within room with FWW [front wheeled walker], gait belt, assist of 1 [one staff]. Offer to ambulate back to her room from dining room with FWW, gait belt, assist of 1 with wheelchair to follow. at risk for fractures r/t [related to] DX [diagnosis] osteopenia [weak bones prone to fractures] . Review of Resident #1's progress notes identified the following: * 12/18/24 at 7:19 p.m., Witnessed Fall: At 1735 CNA came to nurses station and reported that the resident was on the floor. This nurse entered room and found resident sitting in her recliner. This nurse asked if she fell on her floor or was the fall prevented. Resident stated, 'I hit my head.' . The CNA reported the resident fell on to the floor and she go [sic] her up and put her into her recliner. New order received: OK to send to . ER for evaluation post fall, on blood thinners, bumped back of head and c/o [complaints of] of [sic] left thigh pain. Review of Resident #1's emergency room visit notes, dated 12/18/24, identified a left hip fracture and the resident evaluated by an orthopedic surgeon. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions as follows: * Completed immediate education on gait belt use and transfer policy and procedure to staff working on the neighborhood where the resident resided. * The provider and resident representative notified of the incident and the resident transferred to the emergency room . * Placed CNA (#1) on administrative leave on 12/18/24 until further investigation and education provided. * Completed written education through the facility notification system to all direct care staff regarding gait belt use, transfer safety, and referencing resident care plans for ordered transfer status on 12/20/24. * Implemented required completion of skill competency for all direct care staff related to gait belt use and proper transfer technique in and out of wheelchairs. * Updated the orientation competency checklist to include gait belt use and proper transfer technique for new hire and travel direct care staff. * An in-depth root cause analysis completed on 12/19/24.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to assess the use of a wheelchair seatbelt and vest straps as a possible restraint for 1 of 2 sampled residents (Resident #2) observed with a wheelchair seat belt and vest straps . Failure to assess the wheelchair seatbelt and vest straps as possible restraints, monitor their use, and evaluate the need for continued use placed Resident #2 at risk for an unnecessary restraint and injury related to their use. Findings include: Review of the facility policy titled Physical assistive device assessment occurred on 03/07/24. This policy, dated 02/27/23, stated, . When appropriate, physical assistive devices will be used for resident safety, assisting with positioning or mobility and/or to help achieve and maintain a resident's highest practicable level of functioning. All assistive devices will be assessed by the interdisciplinary team to assess the risk versus benefit of the device. *Prior to initiation of the device. *A quarterly review of the assessment with the MDS [Minimum Data Set] schedule. *With significant changes in health status. Licensed nurse will conduct the assessment of the assistive device(s), utilizing the designated observation in the EHR [electronic health record]. This assesses whether the physical device properly meets the resident needs and medical symptom that the device is employed to address. This assessment will minimally include . if the device will restrict the resident in any way, How the device will assist the resident, Evaluation of the resident ability to safely use the device, potential risks of the device. Review of Resident #2's medical record occurred on all days of survey. The current care plan failed to address the wheelchair seat belt and vest straps. Observations showed the following: * 03/04/24 at 4:28 p.m.: Resident up in wheelchair. Seat belt and vest straps in place. * 03/07/24 at 9:54 a.m.: Resident up in wheelchair. Seat belt and vest straps in place. The record lacked evidence of an assessment regarding the use of the wheelchair seatbelt and vest straps as possible restraints, monitoring, and evaluation of their continued indications for use. During an interview the morning of 03/07/24, an administrative nurse (#1) confirmed the record lacked an assessment or ongoing evaluation and monitoring of Resident #2's continued use of the wheelchair seat belt and vest straps.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 3 of 28 sampled residents (Resident #2, #63, and #99). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care plan and baseline care plan occurred on 03/07/24. This policy, revised 10/14/22, stated, . The resident care plan is constantly changing. It is to be updated routinely in the electronic record to reflect resident's current condition. Care plans are updated with MDS [Minimum Data Set] /Care conference schedule and as needed to assure that they are an accurate reflection of the resident and their care needs. - Review of Resident #2's medical record occurred on all days of survey. The current care plan stated, Impaired physical mobility: potential for falls r/t [related to] impaired mobility . W/C [wheelchair] for locomotion. Observations on 03/04/24 at 4:28 p.m. and 03/07/24 at 9:54 a.m. showed Resident #2 in a wheelchair with seat belt and vest straps in place. Resident #2's current care plan lacked the interventions of the wheelchair seat belt and vest straps. - Review of Resident #63's medical record occurred on all days of survey. The current care plan stated,. Impaired physical mobility: potential for falls r/t impaired mobility . W/C for locomotion. An occupational therapy evaluation, completed 12/06/23, stated, . Clinical Impressions/Findings: Residents custom seating equipment arrived this date. Pelvic belt to be fabricated and installed by seating specialist. Observations on 03/05/24 at 10:14 a.m. and 03/06/24 at 10:45 a.m. showed Resident #63 in a wheelchair with seat belt, vest straps, and foot straps in place. Resident #63's current care plan lacked the interventions of the wheelchair seat belt, vest straps, and foot straps. During an interview the morning of 03/07/24, an administrative nurse (#1) confirmed the care plans for Resident #2 and Resident #63 failed to include the assistive devices to be used when the residents were in their wheelchairs. Review of the facility policy titled Dialysis occurred on 03/05/24. This policy, dated 11/06/23, stated, . Residents who require dialysis will receive this service consistent with professional standards of practice . The coordinated, person-centered care plan will include . Adverse responses/complications to dialysis and treatment of these complications included how to manage concerns with the vascular access device [fistula] . - Review of Resident #99's medical record occurred on all days of survey. Resident #99's current care plan stated, . Dialysis . Type of dialysis access: Left upper arm Arteriovenous fistula . Resident #99's care plan lacked the interventions to monitor the fistula for adverse responses/complications and how to manage concerns with the fistula. 27221

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of nursing practice for 1 of 1 supplemental resident (Resident #135) observed during medication administration. Failure of staff to ensure residents swallowed medications, reported behaviors during medication administration, and re-administered unswallowed or refused medications may lead to adverse health conditions. Findings include: Review of the facility policy titled Medication administration occurred on 03/07/24. This policy, revised 07/18/19, stated, . Medications will be administered by licensed nurses or trained medication aides . under the supervision of a licensed nurse. Review of Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., Massachusetts, page 837, stated, . Administering Medications Safely . Some older people may be confused by the prescription of several medications and may passively accept their medications from nurses but not swallow them, spitting out tablets or capsules after the nurse leaves the room. For this reason, the nurse is advised to stay with clients until they have swallowed the medications. page 840, stated, . Medication Administration. Stay with the client until all medications have been swallowed. Rationale: The nurse must see the client swallow the medication before the drug administration can be recorded. The nurse may need to check the client 's mouth to ensure that the medication was swallowed and not hidden inside the cheek. If medication was refused or omitted, record this fact on the appropriate record; document the reason, when possible, and the nurse's actions according to agency policy. Review of Resident #135's medical record occurred on 03/05/24. Diagnoses included Alzheimer's disease. Observations identified the following: * 03/05/24 at 8:18 a.m. showed a medication aide (MA) (#4) administered medications from a cup to Resident #135. After the MA walked away, before ensuring the resident had swallowed the medication, Resident #135 removed a pill from her mouth and placed it on top of her water cup lid * 03/05/24 at 8:25 a.m. showed the MA (#4) observed the pill on top of Resident #135's water cup lid, picked the pill up and placed it in the garbage. The MA did not re-administer the medication. Review of the electronic medical administration record (EMAR), dated 03/05/24 from 7:00 a.m. to 10:00 a.m. identified the following medications signed off by the MA (#4). ASA chewable 81 milligrams (mg) Eliquis 2.5 mg (blood thinner) Fludrocortisone 0.1 mg (steroid) Memantine 5 mg (treat Alzheimer's) Risperdal 2 mg (antipsychotic) Tylenol 325 mg 2 tablets During an interview on 03/05/24 at 5:38 p.m., the staff nurse (#7) confirmed the MA (#4) failed to notify her of any medication concerns with Resident #135. During an interview on 03/05/24 at 5:39 p.m., the MA (#4) initially denied Resident #135 spitting out a medication with the morning medication pass. After the surveyor informed the MA of the observation, the MA (#4) stated she administered the medication later. On 03/05/24 at 5:41 p.m., an administrative nurse (#1) verified the incident had not been reported to the unit nurse, and the medical record showed no documentation of the incident. During an interview on 03/06/24 at 2:12 p.m., an administrative nurse (#1) confirmed staff had not re-administered any medication to Resident #135 during the previous morning's medication pass.

Based on observation, record review, review of facility policy, and family interview, the facility failed to provide an ongoing program of meaningful activities designed to meet the interests and physical, mental, and psychosocial well-being for 1 of 5 sampled residents (Resident #60) dependent on staff for activities. Failure to provide meaningful activities for residents limited Resident #60's ability to reach her highest practicable level of physical, mental, and psychosocial well-being. Findings include: During an interview on 03/05/24 at 10:50 a.m., a family member (A) stated, [Resident #60] sits out by the nurses' station. They [residents] are always sitting in the lounge. They are lined up and not stimulated. Not one aide will be sitting there, engaging them. I can go up any time of the day, but there is no one interacting with them. Review of the facility policy titled One to One Therapeutic Activity Programs occurred on 03/07/24. This policy, revised 05/01/22, stated, . One to One Activity programs will be provided per assessed needs for sensory stimulation . alternative individual program choices . One to One Activity Programs may include but are not limited to . Music Therapy . Sensory visits with a theme . Pet Therapy Visits, Reading Out Loud, Spiritual programs . Physical Movement . Social or emotional support visits . Grooming such as manicures . Favorite snacks or taste activities . Outdoor walks or exposure . Review of Resident #60's medical record occurred on all days of survey. The admission Minimum Data Set (MDS), dated [DATE], identified animals, books, music, the outdoors, and religious services were very important to Resident #60. The current care plan stated, . [Resident #60] typically enjoys activities such as listening to music, attending Catholic services, going outdoors when the weather is good, social gatherings, small sensory activities, reading group, current events and special events as tolerated. Observations on all days of survey showed Resident #60 sitting/dozing in her wheelchair in the lounge with the television on in the background and not participating in any individual or group activities. Review of the activity log, dated January 1-March 5, 2024, showed facility staff failed to provide any activity programming and/or provided Resident #60 approximately 15 minutes of programming on 33 of the 65 days reviewed. Staff failed to provide the variety of activities Resident #60 enjoyed as listed in the care plan.

Based on observation, record review, review of professional reference, review of facility policy, and family interview, the facility failed to offer fluids to 1 of 3 sampled residents (Resident #60) who were observed during cares and required staff assistance for fluid intake. Failure to provide assistance with fluid intake may result in dehydration, constipation, and urinary tract infections (UTIs). Findings include: During an interview on 03/05/24 at 10:50 a.m., following cares, a family member (A) indicated staff often fail to offer liquids, stating, Here [on the bedside table] sits her [Resident #60's] water. She's had three UTIs in the last few months. Review of the facility policy titled Hydration occurred on 03/07/24. This policy, dated 04/13/23, stated, . Each resident will receive and the facility will provide fluids, including water and other liquids consistent with resident needs and preferences and sufficient to maintain proper hydration . CNA [certified nurse aide] staff will provide and encourage intake of fluids on a daily and routine basis as part of daily care. Review of Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., Massachusetts, page 677, stated, . Infection Prevention . Inform of the importance of maintaining sufficient fluid intake to promote urine production and output. This helps flush the bladder and urethra of microorganisms. Review of Resident #60's medical record occurred on all days of survey. Diagnoses included dementia, dysphagia, and history of constipation and urinary tract infections (12/19/23, 01/22/24 and 02/08/24). The physician's orders, dated March 2024, identified, . Diet . mildly thick liquids. close supervision. Feeding assist . The current care plan also identified, . Encourage intake of fluids . Nursing to assess for dehydration . decreased urine output, constipation . infection . Observations throughout the survey showed staff providing Resident #60's cares without offering liquids and/or Resident #60 sitting in her wheelchair in the lounge with no liquids available.

Based on record review, policy and procedure review, professional reference review, and resident and staff interviews, the facility failed to provide the care and services consistent with professional standards of practice for 2 of 3 sampled residents (#79 and #99) on hemodialysis with an arterial-venous fistula (vascular access for hemodialysis). Failure to assess the hemodialysis vascular access site (fistula) may result in complications and adverse effects, such as clotting and possible loss of the access site. Findings include: Review of the facility policy titled Dialysis occurred on 03/05/24. This policy, dated 11/06/23, stated, Responsibility: Licensed Nurse 1. Residents who require dialysis will receive this service consistent with professional standards of practice . 2. Facility will provide ongoing assessment of the resident's condition and will monitor for complications before and after each dialysis treatment received at a certified dialysis facility. 4. The coordinated, person-centered care plan will include: . f. Adverse responses/complications to dialysis and treatment of these complications included how to manage concerns with the vascular access device. Review of the Core Curriculum for the Dialysis Technician - A Compressive Review of Dialysis, Fifth Edition, page 121 and 127 states, . Vascular access makes chronic hemodialysis (HD) possible . An access is an HD patient's lifeline. Each access must be cared for as if it is the last one a patient can have. access failure means loss of the HD life-line. The access must be repaired or replaced - if the patient has a site left. Access problems can cause hospital stays, surgery illness, limb loss, and death. Examine the fistula [vascular access] . listen for Bruit - the sound and pitch of whooshing (a higher or louder pitch may mean stenosis [a narrowing of the blood vessel]). Feel for: skin temperature - more warmth (could be infection) or cold (could mean less blood flow). Thrill - should be present and constant, not a strong pulse. A fistula should have a strong flow of blood. Teach . patients to feel their thrill at least once a day . a change in the thrill (or the volume of the bruit) can mean blood flow through the access is slowing down. The fistula may be clotting, and quick action could help save it. - During an interview on 03/04/24 at 3:03 p.m., Resident #79 stated he has a fistula in his arm for hemodialysis. Review of Resident #79's medical record occurred on all days of survey. Resident #79's current care plan stated, Approach Start Date: 08/29/2023 . Resident is scheduled for hemodialysis 3 days a week. Check fistula site every shift. Monitor bruit in fistula every HS [bedtime] . Review of Resident #79's nurses' progress notes, from December 1st, 2023 to March 4th, 2024, identified nursing staff failed to monitor the resident's fistula for bruit and/or thrill on 30 of 31 days in December, 27 of 31 days in January, 27 of 29 days in February, and 0 of 4 days in March. - Review of Resident #99's medical record occurred on all days of survey. The current care plan stated, . Dialysis on Tue [Tuesday], Thur. [Thursday], and Saturday . Type of dialysis access: Left upper arm Arteriovenous fistula . Monitor for S/SX [signs/symptoms] of fluid excess such as . increased blood pressure, full bounding pulse . No blood pressure readings in Left arm d/t [due/to] shunt . If Dialysis access dislodges, is bleeding or develops a hematoma, apply pressure to the site and notify the provider. In the event of uncontrolled bleeding, call 911 . Monitor access site for S/SX of infection . Review of the nurses' progress notes, dated February 6-March 5, 2024, identified nursing staff failed to monitor Resident #99's fistula for bruit on 15 of the 29 days. During an interview on 03/07/24 at 12:00 p.m., an administrative nurse (#1) agreed facility staff failed to monitor Resident 99's fistula for complications, stating, Since there is no order, they [nursing staff] would not be prompted to write a progress note. The facility failed to obtain a physician's order/ensure staff assessed Resident #79 and #99's fistula sites consistent with professional standards for dialysis vascular access. 27221

Based on observation, record review, facility policy review, and staff interview, the facility failed to follow standards of infection control for 3 of 10 sampled residents (#60, #124, and #131) observed during cares. Failure to follow infection control standards during perineal cares and with transmission-based precautions (TBP) has the potential to transmit infections to residents, staff, and visitors. Findings include: TRANSMISSION BASED PRECAUTIONS Review of the facility policy titled COVID -19 protocol occurred on 03/05/24. This policy, dated 09/16/20, stated, . Employees providing care for COVID-19 positive residents will wear N-95 masks, gown, gloves and eye protection . Review of Resident #131's medical record occurred on all days of survey. The progress notes identified the following: * 03/01/2024 at 4:22 p.m., . [resident] is being admitted to the hospital. tested Covid + [positive] . * 03/03/2024 at 6:53 p.m., Resident returned from the hospital. Resident was diagnoses [sic] with COVID on 3/01/24. Resident is on Droplet and contact isolation . Observations showed the following: * 03/04/24 at 9:48 a.m., signage on Resident #131's door for contact and droplet/contact precautions. The signage directed staff to wear gown, gloves, face mask and eye protection before entering the resident's room. Observation also showed isolation supplies stored outside the resident's room. * 03/05/24 at 9:15 a.m., a certified nurse aide (CNA) (#5) entered Resident #131's room without eye protection. * 03/05/24 at 9:30 a.m., a CNA (#5) entered Resident #131's room and sat at the resident's bedside with no eye protection in place. Facility staff failed to use the appropriate personal protective equipment for encounters with Resident #131 who was on contact/droplet precautions. PERINEAL CARE Review of the facility policy titled Perineal care occurred on 03/07/24. This policy, dated 05/01/19, stated, . Wash the perineal area [groin] . Wash and rinse the rectal area thoroughly. Observation on 03/05/24 at 9:50 a.m. showed a CNA (#2) provided perineal care for Resident #124 by cleansing the rectal area prior to the perineal area. The CNA failed to provide perineal care in the correct order to prevent the risk of infection for Resident #124. During an interview on 03/07/24 at 1:28 p.m., two administrative staff members (#1 and #3) confirmed the CNA should clean the perineal area before the rectal area. HAND HYGIENE Review of the facility policy titled Hand Hygiene occurred on 03/07/24. This policy, dated 01/11/24, stated, . Hand washing/sanitizing is necessary . Before and after providing care to resident . After handling . urine . Observation on 03/06/24 at 4:06 p.m. showed two CNAs (#8 and #9) assisted Resident #60 with toileting. One CNA (#8) donned gloves, provided perineal care, adjusted Resident #60's clothing, transferred/lowered her into the wheelchair utilizing a stand lift, removed the sling, placed Resident #60's glasses on her face and feet on the foot pedals, straightened and then patted Resident #60's hair into place, made the bed, removed her gloves, and washed her hands. The CNA (#8) failed to remove her gloves and perform hand hygiene after toileting the resident and prior to performing other tasks. 27221 37620

Based on record review, review of the facility reported incident investigation, review of facility policy, and staff interview, the facility failed to ensure an environment free of hazards for 1 of 2 sampled residents (Resident #1) injured while consuming a hot beverage. Failure to provide the appropriate adaptive drinking aids with a mug for hot beverages contributed to Resident #1's injuries This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: The surveyors determined a deficient practice existed on 09/30/23. The facility implemented corrective action and completed all staff education on 10/06/23. Review of the facility policy titled Hot Liquid Screen occurred on 01/31/24. This policy, updated 01/26/24, stated, Policy: The purpose of the hot liquid screen is to assess the Resident's ability to safely drink hot liquids independently. Procedures: 1. Each resident will be assessed at their initial nutritional assessment, at their quarterly nutrition assessment and as needed. 2. Modifications and/or adaptive equipment will be provided per assessment if resident is not able to drink hot liquids independently. Review of Resident #1's medical record occurred on 01/31/24 and included the diagnoses of Parkinson's disease, muscle weakness, and reduced mobility. Review of Resident #1's care plan stated, . Nutrition/Hydration: . Resident needs close supervision for safety with eating and drinking foods and liquids. Approach Start Date: 08/30/2023 Diet per MD [physician] order. Close Supervision . liquids in plastic mugs w/ [with] lids and straws . Review of Resident #1's progress notes identified the following: *09/30/23 at 9:00 a.m. NUTRITION: Request by nursing was made Friday morning 09/29/23 after breakfast as resident had spilled coffee on her hand and leg during breakfast meal. It was agreed upon that we would place all liquids in plastic mugs with lids and straws to prevent further mishaps and spilling from resident. I will update her meal card to reflect this and will update her supervision to close supervision. Dietitian will monitor and follow up. *10/01/23 at 11:12 a.m. 09/30/23 resident spilled hot liquids on her at supper time. Lids and straws were not in place at this time. Resident was noted to have burns on inner thighs. Cold wash cloths was [sic] put in place. Nurse assessed an hour later. Two burns were noted on the R [right] inner thigh but the redness to the surrounding area was no longer visible. Bacitracin [antibiotic ointment] was applied along with cold ice pack. See wound management for details. Provider and family aware. CNAs [certified nurse aides] were educated that resident is needing more help with drinks as she is shaky at times and is more at risk for spilled [sic] even with lids and a straws. Review of Wound Management Detail Report identified the following: *09/30/23 at 6:57 p.m. Both burn areas described as Partial thickness: redness, blistered, moist, painful. The burn measurements identified as follows: one the length of four centimeters (cm) and width of five cm. the second burn the length of one cm and width of one cm. *10/01/23 at 1:44 p.m. Both burn areas described as Superficial: painful, no edema, redness, blanches with pressure. The burn measurements identified as follows: one the length of two centimeters (cm) and width of one cm. the second burn the length of one cm and width of one cm. *10/03/23 at 12:00 p.m., Indicated, only one blister remains to right inner thigh. The burn described as partial thickness: redness, blistered, moist, painful . Comments: Fluid filled blister remains to right inner thigh. Surrounding skin is intact with no further erythema or concerns. Burn measurement identified as a length of 0.6 cm and width of 1.2 cm. The facilities investigation report dated 10/05/23 included the following documentation: . On 09/29/23, Resident spilled coffee on her hand and leg during the breakfast meal. The team lead, [name of staff] and dietician, [name of staff] met to discuss the situation. [name of staff] completed a hot liquid screen on [Resident #1] and decided that we would place all liquids for resident in plastic mugs with lids and straws in hopes to prevent further mishaps and that resident should be close supervision. Resident's meal cards were updated to reflect liquids in plastic coffee mugs with lids, straws and close supervision. Supervision and adaptive equipment lists were also updated. On Saturday, 09/30/23, resident was eating supper and accidentally spilled her hot chocolate on herself. A CNA that usually does not work that neighborhood, was helping on [name of neighborhood] that day. She was assisting residents and serving liquids to them before mealtime. The CNA served [Resident #1] a cup of hot chocolate. However, the root cause analysis revealed that the CNA was not aware that [Resident #1] was supposed to have lids/straws with all liquids. So, the hot chocolate did not have a cover/lid on it, nor was there a straw in it. [Resident #1] states that she went to set down her cup of hot chocolate and she set the glass to close to the edge of the table. The liquid spilled on her lap causing redness and irritation. During an interview on 01/31/24 at 1:45 p.m. an administrative staff member (#1) stated she expects facility staff to follow the dietary's list of adaptive equipment for the specific residents. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for the deficient practice by: *The facility completed an investigation with interviews of staff that determined the cause of the incident (lack of lid on mug). *Provided immediate staff education regarding resident safety with hot liquids and reminder to follow the resident's menu card list of adaptive equipment. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: *On 10/02/23 Implemented the use of a dining information binder located in each kitchenette for staff to follow the specific adaptive equipment needs for a resident. *On 10/06/23 provided all staff education via written information e-mailed to all unit managers/charge nurses who then provided verbal and written education to all staff on individual units to include staff initials to acknowledge education received. *Implemented weekly temperature taking of brewed coffee and hot water in all kitchenettes. *Implemented audits to verify resident specific adaptive equipment lists are consistent in the dining information binder and resident care plan, and complete observations to ensure the appropriate adaptive equipment in place for the resident. *Implemented random staff interviews to ensure staff members are aware of the location of the adaptive equipment binder and supplies, with immediate education provided to staff when needed.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 27 sampled residents (Resident #101). Failure to accurately complete the MDS results in an inaccurate reflection of the resident's current status and may affect the development of the comprehensive care plan and the care provided to the resident. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2019, page N-6 states, . N0410B, Antianxiety: Record the number of days an anxiolytic medication was received by the resident at any time during the 7-day look-back period . Review of Resident #101's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified staff coded Section N410B anti-anxiety use on 7 of 7 days of the look-back period. The record failed to show an order for an anti-anxiety medication. During an interview on 03/22/23 at 2:55 p.m., a nurse (#1) confirmed Resident #101 has never received an anti-anxiety medication and confirmed the 02/12/23 quarterly MDS was marked in error.

Based on record review, review of the North Dakota Provider Manual Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 3 sampled residents (Resident #44) reviewed for PASARR. Failure to complete a change in status assessment with a newly diagnosed mental illness may result in the delivery of care and services that are inconsistent with the resident's needs. Findings include: The North Dakota PASARR Provider Manual, revised December 2020, page 13, states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC [mental illness, intellectual disability, and conditions related to intellectual disability referred to in regulatory language as related conditions or RC] was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #44's medical record occurred on all days of survey and identified an original PASARR completed on 08/11/20. Upon admission to the facility on [DATE], the resident was prescribed Seroquel (an antipsychotic medication) and received a new diagnosis of psychotic disorder with delusions due to known physiological condition. The record lacked evidence of an updated PASARR being completed which included the new diagnosis and medication. During an interview on 03/23/23 at 2:20 p.m., an administrative staff member (#2) confirmed the facility failed to complete a new PASARR for Resident #44.

Based on record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 closed resident record reviewed (Resident #1). Failure to safely utilize an mechanical lift with a sling resulted in a fall with serious injury for Resident #1, and placed all residents requiring this type of transfer at risk for accidents and/or injury. Findings include: Review of the facility procedure titled Ez Lift (Full Body Lift or FBL) occurred on [DATE]. This procedure, revised [DATE], stated, . The EZ Lift (Full Body lift/FBL) was designed primarily to lift residents from the bed, chair toilet and floor. Transferring a resident from bed to chair . position sling under resident . Position EZ Lift . Attach sling to lift. Attach the loops by the resident's shoulders to the lift. Take the wing that is lying over the left leg and hook it on the right hook. Then take the wing lying over the right leg, cross it over and hook it on the left hook . Lifting the resident. Push UP button on hand control. Once there is tension on loops, double check the loops to make sure that they are securely in the hooks. Review of Resident #1's medical record occurred on [DATE]. Resident #1's care plan identified . Impaired physical mobility: persistent vegetative state, left arm contracture, [CONDITION(S)] . Transfer with full body lift and assist of two. Review of Resident #1's nursing notes identified: * [DATE] at 5:00 p.m., . fell during transport via Hoyer lift [mechanical full body lift]/hourglass sling from bed on way to WC [wheelchair]. Resident was in doorway of room. CNAs [certified nursing assistants] noted hearing a loud snap and top left sling hook off and resident fell to floor head first and laceration to left temporal area, possible laceration and hematoma to back of head. Pressure held to laceration while assistance of other nurses obtained. Resident did not lose consciousness, VS [vital signs] WNL [within normal limits] and pupils equally round, 5mm [millimeter] and reactive. Transported to [name of hospital] via [name of ambulance]. Sling inspected and intact, Hoyer lift functional, no equipment issues noted. * [DATE] at 5:41 p.m., . report from ER [emergency room ] Nurse and resident will return to facility. Transport called and on way. No fractures determined . Adhesive to laceration and steri strips. Family elected not to CT [computerized tomography - series of X-ray images provide more-detailed information] scan or x-ray. * [DATE] at 6:50 p.m., . Resident returned via facility van and has no adhesive dressing to linear shaped laceration that is 1.5 cm [centimeter] x 3mm. No bruising surrounding area at this time. Does make eye contact and pupils are equal and reactive. ROM [range of motion] is unchanged. Tissue adhesive will gradually peel off and the steri strips will come off within next week. BP [blood pressure] 88/ 59, Pulse 109, Resp [respirations] 15 and sats [oxygen saturation] 93% [percentage]. * [DATE] at 10:08 p.m., . BP ,d+[DATE], pulse 122, resp. 14, temp. 98.9. Resident makes eye contact. Resident is nonverbal. Face pale. Additional 1cm laceration to left back of head cleansed. Left temple laceration intact. At 2100 [9:00 p.m.] resident is transferred into bed per Hoyer and 3 [staff] assist. When pants removed noted large deformity with swelling and bruising to right hip. Resident grimaces with movement. Brief changed while trying to keep leg stable . Call to Physician on call [name]. Ordered send [him/her] back to ER for evaluation right hip. * [DATE] at 2:49 a.m., . phone call from [hospital name] ER Nurse [name]. Informed that resident is being admitted for a comminuted right Femur fracture. * [DATE] at 9:36 a.m., . The hospital SW [social worker] called a short time later to indicate that [Resident #1] would be returning to the facility on hospice/comfort care today. * [DATE] at 3:36 p.m., . Resident returned to the facility via ambulance from [hospital name] . Resident returned from injury due to previous fall on [DATE] and fx [fracture] to R [right] femur and laceration to L [left] temporal area. Resident was admitted to hospice care . * [DATE] at 5:16 p.m., . Resident expired this shift, on [DATE]. Review of Resident #1's physician notes identified: * [DATE] at 4:06 a.m., . Initially patient was brought in around 5 PM yesterday after falling from a Hoyer lift . had a small scalp laceration to the left . no other injuries were reported at the time. head laceration was repaired . Long discussion between family and ER provider, resulted in family choosing not to go ahead with imaging, as this would not change treatment, as well as a head trauma being relatively minor. Patient was transported to [name of nursing home] . returned to our ER several hours later . found to have fracture of right femur. met with [Resident #1] . sister is in the room . States that [Resident #1] appears a little more comfortable now, and they would not like extreme measures or treatments or imaging performed. Orthopedic surgery on-call was contacted from the ED, and given patient's significant history, and severe [CONDITION(S)] due to immobility, surgical repair of the fracture is most likely impossible. Review of the facility's investigation of the fall, dated [DATE], stated, During a hoyer transfer on [DATE] at approximately 1540 [3:40 p.m.], with a hour glass sling, two CNAs present, as they moved from the bed . they reported hearing a loud snap and resident fell head first to floor. Top loop of sling was off and feet were in air. Resident was lowered to floor . Resident found lying on the floor just outside of doorway to room with . legs out in front . and lower back on leg of Hoyer . The facility failed to ensure the necessary care and services to promote safety for Resident #1. The failure resulted in an avoidable fall from the full body lift resulting in head laceration, femur fracture, and pain.

Based on record review, review of State Survey Agency reports, review of facility policy, and staff interview, the facility failed to report to the State Survey Agency a potential incident of neglect with serious bodily injury for 1 of 1 closed records reviewed (Resident #1). Failure to report all alleged incidents of neglect with injury placed all residents at risk of neglect and subsequent injury. Findings include: Review of the facility policy titled Vulnerable adult-ND [North Dakota] occurred on 07/06/21. This policy, revised 06/14/21, stated, . Alleged violation: Is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse . Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Report all suspected/alleged violations immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury . to the state agency . Review of Resident #1's medical record occurred on 07/06/21. Nursing notes identified: * 06/24/21 at 5:00 p.m., . fell during transport via Hoyer lift/ hourglass sling [full body mechanical lift and sling] from bed on way to WC [wheelchair]. Resident was in doorway of room. CNAs [certified nursing assistants] noted hearing a loud snap and top left sling hook off and resident fell to floor head first and laceration to left temporal area, possible laceration and hematoma to back of head. Sling inspected and intact, Hoyer lift functional, no equipment issues noted. * 06/25/21 at 2:49 a.m., . Informed that resident is being admitted for a comminuted [broken into more than two pieces] right Femur fracture. The facility failed to report the fall with serious bodily injury to the State Survey Agency. During an interview on 07/06/21 at 2:21 p.m., an administrative staff (#1) stated the facility completed an investigation on the incident immediately, and had not reported the incident within 2 hours, the investigation, or the serious bodily injury (comminuted femur fracture) to the State Survey Agency. See F689

Based on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility staff failed to wear personal protective equipment (PPE) according to national and local guidelines for residents on transmission based precautions (TBP) due to symptoms related to COVID-19 (Resident-R4). Staff did not change their mask after providing care to R4 before providing care to other residents in the neighborhood. This practice had the potential for cross-contamination of a communicable illness to other residents in the neighborhood. According to the review of the National Institute for Occupational Safety and Health (NIOSH), Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings, dated 3/27/2020, revealed the practice of extended use was well suited for patients that are infected with the same respiratory pathogen. Specifically, Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters. Extended use is well suited to situations wherein multiple patients are infected with the same respiratory pathogen and patients are placed together in dedicated waiting rooms or hospital wards. Extended use has been recommended as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics. (10, 11). During the entrance interview on 11/9/2020, at approximately 3:00 PM, the Administrator, Director of Nursing (DON) and Infection Preventionist (IP) stated their PPE supplies were okay and that the State Health Department had helped them obtain more N95 masks. On 11/9/2020 beginning at 4:00 PM, a facility tour and concurrent interview with the IP included an observation and explanation of a resident room on TBP. Specifically, R4's room had signage on the door to indicate he was on droplet and contact precautions. The IP stated that R4 was on precautions because of a high temperature. The IP stated they suspected the cause of the fever was a urinary tract infection but that when a resident displayed any symptoms of COVID-19, they were immediately isolated and put on TBPs and tested for COVID-19. Further observation revealed the PPE bins outside R4's room had clean gowns, disposable disinfectant wipes, hand sanitizer and gloves. There were no masks or face shields present. The IP stated that staff must clean their hands and put on a clean gown and gloves before they enter R4's room. The IP stated when then exit the room, the staff were to disinfect their face shield but they did not have to change their mask because the facility was wearing the same mask for the entire shift unless it became soiled or damaged. Additional observation revealed R4 was on a neighborhood with other residents that were not on TBPs. The IP stated that staff will wear the same mask in and out of all the resident rooms on that neighborhood. Review of facility policy titled, COVID-19 protocol (Formerly Phase 2 and Phase 3)-SNF (skilled nursing facility), reviewed 10/5/2020 revealed (in part): - all employees will wear a surgical mask at all times and they should be changed if they become wet or soiled. - all employees will wear eye protection at all times when they are in shared space with residents and other employees. - Residents that are symptomatic and have pending COVID-19 test results will be placed in contact and droplet precautions. All staff entering these rooms will wear gloves, gown, mask, and eye protection. Review of the Contact and Droplet transitional protective precautions sign, dated 10/2020, revealed staff were directed to take PPE off and dispose of it in the following order: gloves, eye protection, gown, mask and perform hand hygiene. There was no direction on the sign about the extended use of eye protection and masks. During an interview on 11/10/2020 at 12:00 PM, the IP reviewed the Contact and Droplet transitional protective precautions sign and stated the signage did not explain the extended use of the face mask and face shield. During a telephone call on 11/10/2020 at 1:40 PM with the State Health Department, Administrator, DON and IP, the State Health Department stated they expected that staff would change their mask after providing care to residents who were suspected of COVID-19 before providing care to other residents in the neighborhood. During an interview on 11/10/2020 at 1:55 PM, the IP stated she thought they were appropriately extending the use of face masks according to the CDC's optimization of PPE supplies. The IP also stated there was no national or local guidance that specifically said the mask had to be changed between a resident who was symptomatic and one who was not. The IP also stated she thought it was an accepted practice to wear the same mask as long as the face shield was worn over top of the mask. During continued interview on 11/10/2020 at 1:55 PM, the Administrator stated, at this time, the facility had enough surgical masks to follow the guidance from the State Health Department and that facility staff would change their mask after providing care to residents who were suspected of COVID-19 before providing care to other residents in the facility.

Based on observation, review of facility policy, resident group interview, and staff interview, the facility failed to ensure sufficient staff for meal service on 4 of 6 units (Prairie View, Western Skies, Meadow Lark, and Northern Lights). Failure to serve resident meals in a timely manner did not enhance the dining experience for the facility's residents. Findings include: Review of the facility policy titled Open Dining Frequency of Meals occurred on 01/21/20. This policy, revised 11/26/19, stated, . Breakfast 7:30 am (morning) to 10:30 am . Lunch 11:00 am to 3:00 pm (afternoon) . Dinner 3:30 pm to 6:00 pm . All residents may choose from the restaurant menu for all 3 meals. There will be a Special of the Day available from 4:30 pm to 6:00 daily . Every effort will be made to serve all residents together who are sitting at the same table, however orders will also be filled on a first come first serve basis with the exception of those who require priority serving . - Observation of the noon meal on 01/21/20 of Prairie View dining room showed the following: * At 11:50 a.m. - 15 residents sitting at tables in the dining room. An unidentified CNA stated the meal ticket orders for these residents had been placed at 11:30 a.m. * 12:15 p.m. - Three residents sitting at Table #1, with only one of the three residents receiving their meal. The last resident was served his/her meal at 12:30 p.m., 45 - 60 minutes after placing the order. * 12:04 p.m. - Four residents sitting at Table #2, with only one of the four residents receiving their meal. The last resident was served his/her meal at 12:25 p.m., 34 - 55 minutes after placing the order. * 12:30 p.m. - Three residents sitting at Table #3, with only one of the three residents receiving their meal. The last resident was served his/her meal at 12:50 p.m., 60 - 80 minutes after placing the order. * 12:30 p.m. - Three residents sitting at Table #4, with only one of the three residents receiving their meal. The last resident was served his/her meal at 12:41 p.m., 60 - 70 minutes after placing the order. - Observation of the noon meal on 01/21/20 of Western Skies dining room showed the following: * Resident #7 arrived at 11:48 a.m., placed her lunch order with staff, and received her meal at 12:14 p.m., 26 minutes later. * Resident #15 arrived at 11:54 a.m., placed his lunch order with staff, and received his meal at 12:19 p.m., 25 minutes later. * An unidentified resident arrived at 11:57 a.m., placed her order with staff, and received her meal at 12:27 p.m., 30 minutes later. - Observation of the evening meal on 01/21/20 of Meadow Lark dining room showed the following: * 5:08 p.m. - An unidentified residents observed sitting at the dining room table. The resident received her meal at 5:39 p.m. (31 minutes later). - Observation on 01/21/20 of Northern Lights dining room identified the following: *8:15 a.m. - Resident #119 arrived to the dining room table and received her meal at 8:57 p.m. (42 minutes later). * 4:18 p.m. - identified Resident #126 arrived to the dining room table. The resident ordered the featured supper meal (pureed food), the food tray arrived to the table at 5:45 p.m., (87 minutes later). During the Resident Council interview on 01/22/20 at 11:00 a.m., Resident A, B, C, and D stated they have to wait a minimum of 45 minutes after they order before the food will be delivered. They also stated they thought the special meal of the day would be served faster since it is already prepared ahead of time, however that is not the case. During an interview on the afternoon of 01/22/20, two dietary managers (#4 and #5) stated staff serve trays by a first-come, first-serve basis and they use a restaurant style menu. The goal is for the residents to receive their meal within 30 minutes. The facility failed to serve the residents meals in a timely manner.

1. Based on observation, medical record review, review of professional reference, review of facility policy, and staff interview, the facility failed to ensure 1 of 5 sampled residents (Resident #1) receiving insulin injections received care and services necessary to prevent [DIAGNOSES REDACTED]. Failure to ensure Resident #1 ate promptly after the administration of a rapid-acting insulin (on 12/04/12) and failure to ensure Resident #1 consumed adequate nutrition to stabilize blood sugar levels after receiving insulin resulted in repeated hypoglycemic episodes which required emergency intervention (i.e. glucose gel and IM [MEDICATION NAME]). Findings include: The Nursing 2011 Drug Handbook, page 1064-1065, stated, ". . . [MEDICATION NAME] . . . ADMINISTRATION . . . Give [MEDICATION NAME] 5 to 10 minutes before the start of a meal. . . . ACTION . . . Onset . . . 15 min (minutes) . . . Peak . . . 1-3 hr (hours) . . . Duration . . . 3-5 hr . . ." Review of the facility policy titled "[DIAGNOSES REDACTED], Insulin Reactions, Insulin Shock Treatment Guidelines" occurred on 12/06/12. This undated policy stated, ". . . Insulin reactions can occur at any time and come on quickly. They are most apt to occur: a. Before meals or if meals are delayed. . . . Peak action times of the insulin. . . . Be alert to the signs and symptoms of an insulin reaction. These include: . . . shaking . . ." Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified extensive assistance from one person for eating and a weight loss (not physician-prescribed). Current physician's orders included: *4 units [MEDICATION NAME] (a rapid-acting insulin) at breakfast *Sliding Scale [MEDICATION NAME] before meals and at bedtime *[MEDICATION NAME] (a long-acting insulin) 3 units at bedtime *Accu-checks (blood glucose monitoring) before meals (7:30 a.m., 11:30 a.m., and 5:30 p.m.) and at bedtime (8:00 p.m.) Observation of medication pass occurred on 12/04/12 at 8:23 a.m. with a nursing staff member (#8). The nurse (#8) checked Resident #1's blood sugar (which was 81 mg/dl (milligrams per deciliter)) and drew up four units of [MEDICATION NAME] insulin. Observation showed the resident in bed wearing her pajamas. The nurse administered the insulin in the resident's abdomen and left the room. At 9:12 a.m. (nearly an hour later), a certified nursing assistant (CNA) (#4) entered the room and assisted Resident #1 with morning cares. During the observation, Resident #1 was visibly shaking. The CNA finished assisting Resident #1 with cares and brought her to the dining room. Observation showed the staff served Resident #1 her breakfast tray at 9:54 a.m. (an hour and a half after she received her insulin injection). Observation on 12/04/12 at 10:05 a.m. showed Resident #1 did not consume any of her breakfast. A CNA (#4) stated, "She didn't eat anything. Drank a few sips of water and that was it." Observations throughout the morning showed Resident #1 in the living room, dozing off and on in her wheelchair. During an interview on 12/04/12 at 12:52 p.m., a nurse (#8) stated she checked Resident #1's blood sugar "around noon" and it was 46. She then gave the resident glucose gel from the emergency kit, and a CNA fed Resident #1 pudding and some juice. At 1:45 p.m., the nurse (#8) checked Resident #1's blood sugar, which measured 193 mg/dl. During an interview on 12/04/12 at 12:52 p.m., a CNA (#4) stated Resident #1 had a low blood sugar before lunch. She also stated, "Well, you know, she hasn't had anything to eat or drink all morning." The CNA also reported Resident #1 was groggy all morning and didn't eat much for lunch. During an interview on the morning of 12/05/12, a nursing staff member (#9) stated she administered Resident #1's [MEDICATION NAME]"around 7:45 (a.m.)." Observation showed Resident #1 did not receive her breakfast tray until approximately 8:50 a.m. (one hour later). Nurses' notes, blood sugar monitoring reports, meal intake reports, and medication administration records (MARs) showed the following previous episodes of [DIAGNOSES REDACTED]: *12/01/12: ". . . Called into (Resident #1) room at 2100 (9:00 p.m.) resident is unresponsive, color pale, eyes open with fixed glare. Accu check with blood glucose of 43 mg/dl. [MEDICATION NAME] 1 mg IM (intramuscular) given STAT (immediately) per standing orders, phone call to (physician name), orders received. (Resident #1) blood glucose was 145 at 2230 (10:30 p.m.), resident did take one glass of orange juice . . ." Resident #1's MAR indicated [REDACTED]. Meal intake records showed that Resident #1 did not consume any of her evening meal (zero percent). *11/27/12: The MAR indicated [REDACTED]. At 7:40 p.m., Resident #1's blood sugar was 154 mg/dl. Meal intake records showed that Resident #1 ate 10 percent of her supper meal and none of her bedtime snack. At 11:30 p.m., Resident #1's blood sugar was 46 mg/dl. The record failed to identify any staff intervention after obtaining this reading. At 12:35 a.m., Resident #1's blood sugar was 104 mg/dl. *11/18/12: The MAR indicated [REDACTED]. Meal intake records showed Resident #1 did not consume any of her evening meal and 25% of her bedtime snack. At 9:05 p.m., Resident #1's blood sugar was 37 mg/dl. Staff administered one mg of IM [MEDICATION NAME] STAT per physician's order. At 10:05 p.m., Resident #1's blood sugar was 155 mg/dl. *11/16/12: The MAR indicated [REDACTED]. Meal intake records showed Resident #1 consumed 15% of her evening meal and did not consume a bedtime snack. The next recorded blood sugar reading (obtained at 10:00 p.m., not 8:00 p.m. as ordered by the physician) showed Resident #1's blood sugar was 49 mg/dl. Nurses' notes identified staff gave Resident #1 milk with sugar, and her blood sugar was 96 mg/dl upon recheck. Refer to F312 for additional information relating to Resident #1. 2. Based on observation, medical record review, and staff interview, the facility failed to provide care and services in accordance with physician's orders for 3 of 10 sampled residents (Resident #1, #6, and #8) with TED ([MEDICAL CONDITION]-Embolic Deterrent) hose/Tenoshape stockings (medically prescribed, tight-fitting stockings used to help improve venous return and decrease [MEDICAL CONDITION]). Failure to ensure residents wore compression stockings as ordered may result in increased [MEDICAL CONDITION] and/or blood clot formation. Findings include: - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified extensive assistance from one person for dressing. A physician's order, dated 02/21/12, stated, "(B) (bilateral) Tenoshape garments to be worn daytime/off HS (bedtime). (DX {diagnosis}: Symptom, [MEDICAL CONDITION]- L/E {lower extremity} [MEDICAL CONDITION])." Observation on 12/04/12 at 9:12 a.m. showed a CNA (#4) assisted Resident #1 with morning cares. The CNA stated, "Your feet are swollen today," to Resident #1. Observation showed both Resident #1's feet and lower legs were visibly swollen. The CNA failed to apply Resident #1's Tenoshape garments as ordered. Observations throughout 12/04/12 and 12/05/12 showed staff failed to apply Resident #1's Tenoshape stockings. Resident #1's CNA care card (used by the CNAs to help direct care) failed to identify the use of the Tenoshape stockings, although the intervention was listed on Resident #1's care plan. - Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Current physician's orders included "Bilateral knee high Tenoshape stockings, on a.m., off HS." A physician's progress note, dated 08/13/12, stated, ". . . 1-2 + [MEDICAL CONDITION] noted to bilateral lower extremities. She does not have TED hose one (sic) . . .ASSESSMENT/PLAN . . . Peripheral [MEDICAL CONDITION]. I did write orders for bilateral knee high Tensoshape (sic) stockings on in the morning and off at h.s. We will see if this helps improve her lower extremity [MEDICAL CONDITION]. . . ." The CNA care card listed the intervention- "Tenoshapes on in AM." Observation on 12/04/12 at 8:43 a.m. showed a CNA (#10) assisted Resident #8 with morning cares. The CNA failed to apply Resident #8's Tenoshape stockings. - Review of Resident #6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The resident's current quarterly MDS, dated [DATE], identified extensive assistance of one person for dressing. Resident #6's current physician's orders stated, "Knee high ted hose (on in a.m., off at HS). Once a day." The current care plan for Resident #6 stated problems of "Decreased cardiac output related to a [DIAGNOSES REDACTED].: Assist." Observations throughout the survey showed facility staff failed to apply Resident #6's TED hose.

THIS IS A REPEAT CITATION FROM THE STANDARD SURVEY CONDUCTED ON 07/29/10. Based on observation, record review, review of facility policies and procedures, and staff interview, the facility failed to ensure staff appropriately used assistive devices to prevent accidents for 6 of 18 sampled residents (Resident #9, #10, #13, #14, #15, and #20) requiring assistance with transfers. Failure to appropriately use assistive devices resulted in Resident #9, #14, and #15 experiencing pain during lift transfers and placed the residents at risk of sustaining an injury. Findings include: Review of the facility policy "Pro Assist Lift" occurred on 07/14/11. The undated policy stated, "DESCRIPTION: The Pro-Assist is designed for semi-ambulatory patients (patients that have adequate upper body strength) PROCEDURE: 1. Transfer of a resident with use of the Pro-Assist will be accomplished with the assist of two staff. 2. Choose the proper size sling that is most comfortable for the resident. The sling fits across the back just above the waistline with the Velcro safety restraint strap fitted very snugly (without pinching) across the chest (on top of the bosom). 3. On a pear-shaped person (whose chest is smaller than midsection), slide the sling higher under the arms and adjust the safety strap very snugly. . . . Sling will have the tendency to ride up and pinch if not adjusted very snugly. . . . 6. Attach both sling couplings and adjust evenly. Encourage the resident to grasp the handgrips (any of the three positions) and use as much arm and leg strength as possible during the transfer. . . ." Review of the facility policy "Gait Belt Policy" occurred on 07/14/11. The undated policy stated, "POLICY: Staff must provide safety and protection during transfers. In most cases a gait/transfer belt is used for assisting a resident to ambulate. The gait/transfer (sic) gives you control over the resident during transfer/ambulation. If the resident begins to fall, you can ease them down to the floor with more control, using the belt. . . . PROCEDURE: . . . the general rule being 'If you have to lay hands on the resident they must have a gait belt on during transfers.' . . . Sit-to-Stand lift: Standing lift used for transfers with assist of 1 unless other wise care planned. . . . Do not lift resident under their arms or hold on to their arm to lift them. . . . One hand should be holding the belt in an underhand fashion at all times. . . ." The facility's Gait Belt Policy conflicts with the Pro-Assist Lift policy which stated transfers with the lift should be accomplished with the assist of two staff members. Failure to ensure consistency of policies and procedures could result in inappropriate use of assistive devices. - The medical record for Resident #9, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #9 required extensive assistance of two or more persons with transfers. The care plan, dated 03/14/11, stated, "Problem: Impaired physical mobility: History of falls and potential for recurrent falls related to poor balance and unsteady gait." Approaches to the problem included, "5/9/11 May use standing lift with ext. (extensive) assist of 1 or 2 PRN (as needed)" On 07/12/11 at 9 a.m., observation showed a Certified Nursing Assistant (CNA) (#19) assisted Resident #9 to the bathroom with the stand lift. During the transfer, the resident did not stand erect and the sling slid upward, suspending the resident by her arms in the sling. On 07/12/11 at 3:15 p.m. observation showed a CNA (#20) assisted Resident #9 to the bathroom with the stand lift. As the CNA raised the lift to the standing position, the sling slid up, suspending the resident by her arms. Resident #9 stated, "Owie, owie, that hurts, that hurts my arms." The CNA stated, "Ya, this thing does hurt your arms doesn't it?" After the resident voided, the CNA transferred her back to her wheel chair with the lift. As Resident #9 stood, the sling again slid up suspending the resident by her arms. The resident stated, "Owie, owie, my back, my back, my back hurts." When informed of the above observation, during an interview on 07/13/11 at 8:50 a.m., an administrative nurse (#14) stated she would check on obtaining a different size sling for staff to use when transferring Resident #9 with the stand lift. On 07/13/11 at 10:30 a.m., two CNAs (#12 and #13) stated they just transferred Resident #9 with a gait belt because a staff member would be "fitting" Resident #9 for a different sling for use with the stand lift. They stated the gait belt transfer went "well." Observation on 07/13/11 at 3:30 p.m. showed two CNAs (#11 and #13) assisted Resident #9 to the bathroom using the stand lift. As the resident stood, the sling slid up suspending the resident by her arms during the transfer. When asked if this was a different sling, the CNAs (#11 and #13) stated the sling was the same one used for prior transfers for Resident #9. On 07/14/11 at 8:50 a.m., observation showed two CNAs (#10 and #12) transferred Resident #9 using the stand lift. Again, the sling slid up, suspending the resident by her arms during the transfer. When asked if this was a different sling, the CNAs stated the same sling is used for all lifts. During an interview on 07/14/11 at 9:10 a.m., an administrative nurse (#4) stated Resident #9 may need an evaluation to determine the appropriate transfer device for the resident. - Review of Resident #14's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and required extensive assistance for transfers. Resident #14's current care plan identified a problem related to mobility. Interventions included, "Transfer with extensive assist of 1 or 2 and standing lift. Full body mechanical lift with total assist of 2 PRN (as needed.) Observation of 07/13/11 at 7:55 a.m. showed two CNAs (#21 and #22) dressed Resident #14 and positioned her on the edge of the bed. As the CNA (#21) brought the standing lift into the room, Resident #14 stated, "I don't like that thing." The CNA (#22) placed the harness around the resident's waist, secured the belt, and transferred her from her bed to the bathroom. The belt loosened during the transfer and the harness slid upward under her armpits. The CNA (#21) provided incontinence cares for Resident #14 as she stood in the lift. The resident stated, "My arms hurt" and "Is there an end to this." After completing cares, the CNAs transferred the resident to her wheelchair. During the transfer to the wheelchair, the harness remained under Resident #14's arm pits. This caused her shoulders to shrug upward towards her ears. The CNAs (#21 and #22) failed to tighten the belt around the resident's waist at anytime during this observation. - Review of Resident #15's medical record occurred on July 13-14, 2011. Medical [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified severely impaired cognition and required extensive assistance with transfers. Resident #15's current care plan identified a problem with mobility. Interventions included, ". . . Transfer with assist of two and full body mechanical lift . . . May use standing lift (with) extensive assist of (two) to the toilet per her request." The resident's bowel and bladder maintenance record located in her bathroom stated, ". . . when resident asking for the bathroom may use standing lift extensive assistance with bottom sling and 2 (assistance of two persons) . . ." On 07/13/11 at 4:25 p.m., two CNAs (#2 and #16) utilized a standing lift and transferred Resident #15 from the wheelchair to the bathroom. Observation showed Resident #15 unable to bear weight. The lift harness slid upward behind the resident's head and neck, forcing her elbows to bow upward above her ears. The resident stated, "Ouch" and the CNA (#2) stated, "Stand up (resident name)." On 07/14/11 at 3:25 p.m., two CNAs (#2 and an unidentified CNA) utilized a stand lift and transferred Resident #15 from her wheelchair to the bathroom. Observation showed Resident #15 unable to bear weight. Again, the lift harness slid upward, behinds the resident's head and neck, forcing her elbows to bow upward above her ears. The resident stated, "Ouch, ow, ow, ow, ow." The CNA (#2) stated, "We should use a different size sling with her." Failure of facility staff to utilized the standing lift appropriately resulted in Resident #14 and #15 experiencing pain and discomfort, and has the potential to cause injury. - Review of Resident #10's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. An annual MDS, dated [DATE], identified Resident #10 required extensive assistance of one staff member with transfers. The resident's current care plan, dated 04/23/08, identified the problem of "Impaired physical mobility: History of falls and potential for recurrent falls related to poor balance and unsteady gait." Approaches for this problem included extensive assistance of one or two staff members and a walker for transfers and ambulation. Resident #10's progress notes identified a history of falls, with the most recent fall occurring on 07/01/11. Observation of a CNA (#8) assisting Resident #10 with toileting occurred on 07/11/11 at 3:40 p.m. The CNA (#8) lifted under the resident's arms to transfer her from the wheelchair to the toilet and back, without using a gait belt. Resident #10 was unsteady and took small, shuffling steps as she pivoted to the toilet while holding onto the grab bar on the wall. - Review of Resident #13's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], identified Resident #13 required limited assistance of two or more staff members with transfers. The resident's current care plan, dated 06/23/11, identified the problem of "Impaired physical mobility: History of falls and potential for recurrent falls related to poor balance and unsteady gait." Approaches for this problem included limited assistance of one staff member and a walker for transfers. Resident #13's progress notes identified the resident experienced frequent falls (one fall resulting in a laceration to the resident's head on 07/03/11), with the most recent fall occurring on 07/10/11. Resident #13's initial Restorative Nurse Therapy Note, dated 07/07/11, stated, ". . . (Resident #13) has been needing more assistance from staff for all ADL's (activities of daily living), transfers and ambulation. His gait is extremely unstable . . ." An observation on 07/12/11 at 8:40 a.m. showed a CNA (#5) lifted Resident #13 under his arms to assist him to rise from his bed. The resident used his walker and the CNA held on to the back of the resident's pants as he walked to the bathroom. While in the bathroom, the resident used the toilet, washed his hands, and brushed his teeth with staff assistance. Throughout the observation, the resident was very unsteady and took small, shuffling steps. The CNA (#5) stepped out of the bathroom momentarily to grab the resident's toothbrush from his bedside stand and stated, "Don't move. I don't want you to fall." Resident #13 then used his walker and the CNA (#5) placed her hand on the resident's back as he walked to the tub room, approximately 50-60 feet away. The resident was very unsteady and took small and shuffled steps as he walked. The CNA (#5) failed to utilize a gait belt during the entire observation of cares. An observation on 07/13/11 at 2:30 p.m. showed three CNAs (#6, #8, and #9) assisting Resident #13 with transferring and incontinence cares. The resident exhibited spontaneous movements, was agitated, unsteady, and walked with a shuffled gait. The staff members failed to use a gait belt when assisting the resident. During an interview on 07/14/11 at 8:00 a.m., an administrative nurse (#4) stated she expected staff to use a gait belt when transferring Resident #10 and #13. - A random observation on 07/13/11 at 8:25 a.m. showed Resident #20 in her wheelchair outside the dining room. Observation showed the resident slouched low in her wheelchair, her feet resting off the footpedals on the floor. Two unidentified CNAs repositioned Resident #20 in her chair by holding underneath her arms (axilla) and lifting upward. The CNAs failed to use a gait belt. Staff's failure to appropriately position Resident #9, #14, and #15 in the stand lift and to ensure the sling fit snugly prior to transferring the residents resulted in the residents experiencing pain during the transfers. Failure to appropriately use the assistive devices (stand lifts and gait belts) placed Resident #9, #10, #13, #14, #15, and #20 at risk for injury during transfers. 2. Based on observation, hot water temperature readings, record review, review of policies/procedures, review of professional literature, and staff interview, the facility failed to ensure the environment was as free of accident hazards as possible on 3 of 5 resident care areas (Third floor special care unit - New Horizons, Three South and Two North) regarding water temperatures, resident room fixtures, and hazardous chemicals/items. Failure to maintain safe water temperatures, maintain resident room fixtures in good repair, and secure chemical/hazardous item storage has the potential to result in injuries to the residents, especially residents who have dementia and wander. Findings include: Review of the facility policy "Potential Hazard Reports" occurred on 07/14/11. This undated policy stated, "A Potential Hazard Report form shall be completed when an employee is involved in or witness to a close call resulting in no damage or personal injury but had the potential for one or both to occur. . . ." Review of the "Potential Hazard Report" form occurred on 07/14/11. This form, dated June 2000, stated, "This form is to be used to report a potential hazard or incident . . . Unsafe working conditions . . . It is everyone's responsibility to report and/or correct these potential accidents/incidents immediately." Review of the facility policy "Safe Chemical Storage" occurred 07/18/11. This undated policy stated, "Purpose: To ensure that residents are safe from accidental exposure to hazardous chemicals. 1. Units in the facility are provided with a safe chemical storage area. . . . Key For Safe Chemical Storage: . . . 2. Keep cabinet doors locked at all times. . . ." The Centers for Medicare and Medicaid Services (CMS) has outlined standards of practice regarding hot water temperatures which states water may reach hazardous temperatures in hand sinks, showers, and tubs. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. Third degree burns can occur after five minutes of exposure to water at 120 degrees Fahrenheit (F), three minutes exposure at 124 degrees F, and one minute exposure at 127 degrees F. - On 07/11/11 at 3:25 p.m. observation showed two CNAs (#23 and #24) assisted Resident #5 to use the bedpan. After providing cares, the CNAs washed their hands in Resident #5's bathroom. Both CNAs stated the water was very hot as they washed their hands. On 07/11/11 the water temperatures taken randomly in two resident bath room sinks on the second and third floor revealed the following hot water temperatures: *Room 258 at 5:10 p.m.-123.5 degrees F *Room 363 at 5:17 p.m.-121 degrees F (special care unit) On 07/12/11 repeat water temperatures taken in the sinks of the resident bathrooms, while on the environmental tour with an administrative housekeeping staff member (#29), revealed the following: *Room 258 at 2:30 p.m.-121.5 degrees F *Room 363 at 2:00 p.m.-120.4 degrees F (special care unit) During an interview on 07/13/11 at 3:00 p.m., an administrative maintenance staff member (#30) stated the facility had no policy regarding safe water temperatures in resident care areas and does not conduct monitoring of water temperatures. - A random observation, on 07/12/11 at 9:00 a.m., showed an unlocked cabinet in the living room of the special care unit. The cabinet contained three cans of hair spray, one can of salon nail dryer, and a pair of scissors. Observations throughout the survey showed residents with dementia wandering in and out of the living room in the special care unit. During the environmental tour, with an administrative housekeeping staff member (#29), from 1:30 p.m.-3:00 p.m., on 07/12/11, observation showed the following in the storage cabinet in the living room of the special care unit: * Three cans of hair spray - The label identified "Danger - Flammable Avoid spray in eyes . . . keep out of reach of children." * One can of salon nail dryer - The label identified "Keep away from children Danger! Flammable. Harmful if taken internally. In case of eye contact flush with water and get medical attention." During the environmental tour, when informed of the unlocked cabinet in the special care unit, the administrative housekeeping staff member (#29) stated the activity department is responsible to keep the storage cabinet locked. On 07/14/11 at 1:40 p.m., observation revealed the cabinet in the special care unit with the doors closed, but easily opened. A CNA (#6) in the hallway of the special care unit stated the cabinet "probably wasn't locked." - During the initial tour of the facility on the morning of 07/11/11, observation showed the resident bathrooms in Rooms 317 and 325 had rusty, sharp metal registers with exposed electrical wires on the floor. During the environmental tour on the afternoon of 07/12/11, administrative housekeeping staff member (#29) agreed the registers in the resident bathrooms in rooms 317 and 325 were unsafe and expected staff to report the need for repair of the registers by filling out a work order. During an interview on 07/13/11 at 3:00 p.m., an administrative maintenance staff member (#30) stated his department does not complete walk through monitoring of resident care areas and expects facility staff to report such conditions.

1. Based on observation, record review, review of facility policies and procedures, and staff interview, the facility failed to ensure staff appropriately used assistive devices to prevent accidents for 3 of 8 sampled residents (Resident #3, #4, #7) requiring assistance with transfers. Failure to use assistive devices correctly places Residents #3, #4, and #7 at risk of pain or injury. Findings include: Review of the facility policy "Pro Assist Lift" occurred on August 24-25, 2011. The undated policy stated, "DESCRIPTION: The Pro-Assist is designed for semi-ambulatory patients (patients that have adequate upper body strength) PROCEDURE: 1. Transfer of a resident with use of the Pro-Assist will be accomplished with the assist of two staff. 2. Choose the proper size sling that is most comfortable for the resident. The sling fits across the back just above the waistline with the Velcro safety restraint strap fitted very snugly (without pinching) across the chest (on top of the bosom). 3. On a pear-shaped person (whose chest is smaller than midsection), slide the sling higher under the arms and adjust the safety strap very snugly. . . . Sling will have the tendency to ride up and pinch if not adjusted very snugly. . . . 6. Attach both sling couplings and adjust evenly. Encourage the resident to grasp the handgrips (any of the three positions) and use as much arm and leg strength as possible during the transfer. . . ." Review of facility policies and procedures occurred on August 24-25, 2011. A facility policy, titled, "GAIT BELT POLICY," dated 04/08, stated, "POLICY: Staff must provide safety and protection during transfers. In most cases a gait/transfer belt is used for assisting a resident . . . PROCEDURE: . . . 1. Apply the belt snugly around the waist, over the clothing; it is best to position the belt under the abdominal girth . . . 2. Fasten the safety buckle in the front . . . 3. Bring the resident to a standing position, using one or two hands. Do not lift resident under their arms or hold onto their arm to lift them. If the belt loosens, snug it again after the resident is standing. . . ." The facility's Gait Belt Policy conflicts with the Pro-Assist Lift policy which stated transfers with the lift should be accomplished with the assist of two staff members. Failure to ensure consistency of policies and procedures could result in inappropriate use of assistive devices. - Record review for Resident #7 occurred on August 24-25, 2011. Medical [DIAGNOSES REDACTED]. The current care plan identified 1-2 person assistance with transfers and toileting. Observation on 08/24/11 at 10:15 a.m. identified two certified nursing assistants (CNAs #6 and #7) transferred Resident #7 to her recliner. The CNA (#6) applied a gait belt around the resident's waist. Observation showed the gait belt loose around the resident's waist and the wheelchair brakes not locked. The CNAs assisted Resident #7 to stand, and as the resident stood the wheelchair rolled backwards. The CNA (#6) grabbed Resident #7 underneath her arm with one hand and held the gait belt with the other hand. The CNAs did not tighten or re-adjust the gait belt after the resident stood. Observation on 08/24/11 at 1:40 p.m. identified two CNAs (#6 and #8) transferred Resident #7 from her wheelchair onto the toilet. The CNAs applied a gait belt loosely around the resident's waist. The CNAs did not lock the brakes on the wheelchair prior to the transfer. The resident held onto the grab bar and the CNAs held onto the gait belt. The gait belt rode upward toward the resident's mid back and the wheelchair rolled backwards out from under the resident as she stood. The CNAs did not adjust or tighten the gait belt. - Record review for Resident #4 occurred on August 24-25, 2011. Medical [DIAGNOSES REDACTED]. The current care plan identified Resident #4 required a standing lift and 1-2 person assist for transfers. Observation on 08/24/11 at 11:10 a.m. identified two CNAs (#9 and #10) transferred Resident #4 to the bathroom using a stand lift. The CNAs applied the belt around the resident's waist. The CNAs transferred Resident #4 to a standing position. Observation showed the resident unable to bare full weight as the CNAs encouraged her to stand up straight. Further observation showed the safety strap rode upward toward the resident's upper back and the leg strap not fastened. The CNAs tightened the safety strap around the resident's waist but did not adjust the position. Observation showed Resident #4's elbows bowed outward parallel to her shoulders, the belt at her upper back, and sling underneath her under arms (axilla). Observation on 08/24/11 at 12:50 p.m. identified a CNA (#10) transferred Resident #4 to the bathroom using a stand lift. The CNA utilized the stand lift in the same manner as above. Observation showed Resident #4's elbows bowed outward parallel to her shoulders, the belt at her upper back, and sling underneath her under arms (axilla). - Record review for Resident #3 occurred on August 24-25, 2011. Medical [DIAGNOSES REDACTED]. The current care plan identified Resident #3 on a toileting plan and required assistance of 1-2 staff with toileting and ambulation. Observation on 08/24/11 from 11:15-11:25 a.m. in the New Horizon's unit identified two CNAs (#6 and #11) assisted Resident #3 to the bathroom. Observation showed the CNAs applied a gait belt loosely around the resident's waist. Observation showed Resident #3 unsteady when transferred to the toilet. The CNAs did not tighten or adjust the gait belt. After toileting, the CNAs took the resident for a walk around the unit. Observation showed Resident #3 unsteady on his feet during ambulation. The CNAs held onto the loose gait belt, still observed around the resident' waist, but did not tighten it prior to ambulation. 2. Based on observation and staff interview, the facility failed to ensure the environment was as free of accident hazards as possible on 1 of 1 resident special care unit - New Horizons regarding storage of hazardous chemicals/items. Failure to secure chemical/hazardous item storage has the potential to result in injuries to the residents, especially residents who have dementia and wander. - An initial tour of the New Horizon's unit occurred on 08/24/11 at 9:00 a.m. Observation showed a nook area off the hallway containing a desk with a chair and a wooden shelf. The shelf contained a 19 ounce can of "Clorox Disinfecting Spray" labeled "Keep out of reach of children." This surveyor reached up and grabbed the can of spray from the shelf. A CNA (#6) stated the unit does have a resident who wanders, but he "has not tried to grab the spray can yet." Observation later that morning showed the spray can removed from the shelf and stored in a secure location. Failure of the facility to correctly use assistive devices and failure to store chemicals in a safe manner has the potential to injury/pain to residents in the facility.

Based on record review, review of professional reference, and staff interview, the facility failed to meet professional standards of quality for 1 of 1 resident (Resident #9) selected for closed record review. Failure to follow professionally accepted standards of practice regarding medication administration resulted in Resident #9 receiving an excessive dose of a potentially lethal medication ([MEDICATION NAME] sulfate) and an admission to the emergency department (ED). Findings include: Kozier & Erb's "Fundamentals of Nursing, Concepts, Process and Practice," 8th Edition, dated 2008, page 842, states, ". . . The nurse should always question the primary care provider about any order that is ambiguous, unusual (e.g., an abnormally high dosage of a medication), or contraindicated . . ." Page 846 states, ". . . Nurses who administer medications are responsible for their own actions. . . . Be knowledgeable about the medications you administer. You need to know why the client is receiving the medication. Look up the necessary information if you are not familiar with the medication. . . ." Lippincott, Williams, and Wilkins, "Nursing 2011 Drug Handbook", pages 760-761, states, ". . . [MEDICATION NAME] sulfate (i.e. MS Contin) . . . INDICATIONS AND DOSAGES . . . Severe pain . . . For extended-release tablet, give 15 or 30 mg (milligrams) PO (by mouth) every 8 to 12 hours. . . . ADVERSE REACTIONS . . . CNS (central nervous system): . . . dizziness, sedation, [MEDICAL CONDITION] . . . Respiratory: apnea, respiratory arrest, respiratory depression . . . CAUTIONS . . . Use with caution in elderly or debilitated patients . . . Overdose S&S (signs and symptoms) . . . CNS depression, respiratory depression, [MEDICAL CONDITION] . . . NURSING CONSIDERATIONS . . . Monitor circulatory, respiratory, bladder, and bowel functions carefully. Drug may cause respiratory depression, [MEDICAL CONDITION], . . . altered level of consciousness regardless of the route. If respirations drop below 12 breaths/minute, withhold dose and notify prescriber." Review of Resident #9's medical record occurred on 12/01/10. [DIAGNOSES REDACTED]. A notification to the resident's provider, dated 09/25/10, identified a request from facility staff for scheduled pain medication for Resident #9. A health care provider order, dated 09/27/10, identified a new order for [MEDICATION NAME] release tablet 60 mg po bid (twice a day). Licensed nurses administered the first dose of [MEDICATION NAME] or around 8:00 p.m. on 09/28/10, and a second dose of [MEDICATION NAME] or around 8:00 a.m. on 09/29/10. Review of Nurses' Notes revealed the following: *09/29/10 at 1:31 p.m.: . . . fax sent to (physician name) that resident does not want to take the [MEDICATION NAME] was ordered because he said it makes him feel light headed and he can't think right . . ." *09/29/10 at 5:00 p.m.: ". . . telephone call from (physician name) to DC (discontinue) MScontin (sic). . . ." *09/29/10 at 6:09 p.m.: ". . . Resident not 'feeling like himself'. . . . Assessed, resident in recliner and declined to come to dining room for supper . . ." (No evidence of vital signs recorded during this time frame.) *09/30/10 at 12:24 p.m.: ". . . Wet respirations 7 at rest, decreased Level of Consciousness, does not make eye contact unless specifically requested, speech garbled. Uncontrolled left sided twitching. Call to (physician name) with orders to send to ER (emergency room ). . . ." Vital signs at this time included a respiratory rate of 7 breaths per minute and a blood pressure of 97/60 mmHg (millimeters of mercury, a measurement of pressure), a decreased reading for this resident. *09/30/10 at 1:25 p.m.: Vital signs included a respiratory rate of 7 breaths per minute and a blood pressure of 96/60 mmHg. *09/30/10 at 4:32 p.m.: ". . . Resident returned from ER . . . resident remains confused, paranoid . . ." *10/01/10 at 2:20 a.m.: Vital signs included a respiratory rate of 6 breaths per minute. *10/01/10 at 5:08 a.m.: ". . . resident has been sleeping all night. . . . respirations 6-8 at beginning of shift, resps (respirations) are now 10-12 most of the time. . . ." Documentation indicated emergency department staff evaluated Resident #9 for decreased respiratory status, decreased level of consciousness, and left sided twitching. Vital signs obtained in the ED included a blood pressure of 97/60 mmHg and a respiratory rate of 7 breaths per minute. The ED physician documented a [DIAGNOSES REDACTED]. A discharge plan signed by the ED physician stated, ". . . You have been evaluated and/or treated for [REDACTED]. . . ." During an interview on 12/01/10 at 4:05 p.m., an administrative nurse (#1) stated she expected nurses to review new medication orders and "look it (the medication) up if it's unfamiliar." She agreed the dose of [MEDICATION NAME] sulfate ordered and administered was an excessive dose. The administrative nurse stated it is "a part of nursing practice" to question unclear medication orders. Failure of facility staff to ensure the dose of [MEDICATION NAME] sulfate ordered was appropriate before administration of the medication resulted in Resident #9 receiving two excessive doses of [MEDICATION NAME] sulfate and experiencing severe respiratory depression, which then resulted in an admission to the emergency department.

Based on record review, review of professional reference, and staff interview, the facility failed to ensure a drug regimen free from unnecessary medications for 1 of 1 resident (Resident #9) selected for closed record review. The administration of an excessive dose of a potentially lethal medication ([MEDICATION NAME] sulfate) resulted in Resident #9's admission to the emergency department (ED). Findings include: The Centers for Medicare and Medicaid Services, State Operations Manual, gives the following definition for "excessive dose": ". . . the total amount of any medication (including duplicate therapy) given at one time or over a period of time that is greater than the amount recommended by the manufacturer's label, package insert, current standards of practice for a resident's age and condition, or clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals . . ." Lippincott, Williams, and Wilkins, "Nursing 2011 Drug Handbook", pages 760-761, states, ". . . [MEDICATION NAME] sulfate (i.e. MS Contin) . . . INDICATIONS AND DOSAGES . . . Severe pain . . . For extended-release tablet, give 15 or 30 mg (milligrams) PO (by mouth) every 8 to 12 hours. . . . ADVERSE REACTIONS . . . CNS (central nervous system): . . . dizziness, sedation, [MEDICAL CONDITION] . . . Respiratory: apnea, respiratory arrest, respiratory depression . . . CAUTIONS . . . Use with caution in elderly or debilitated patients . . . Overdose S&S (signs and symptoms) . . . CNS depression, respiratory depression, [MEDICAL CONDITION] . . . NURSING CONSIDERATIONS . . . Monitor circulatory, respiratory, bladder, and bowel functions carefully. . . ." Review of Resident #9's medical record occurred on 12/01/10. [DIAGNOSES REDACTED]. A notification to the resident's provider, dated 09/25/10, identified a request from facility staff for scheduled pain medication for Resident #9. A health care provider order, dated 09/27/10, identified a new order for [MEDICATION NAME] release tablets 60 mg po bid (twice a day). Licensed nurses administered the first dose of [MEDICATION NAME] approximately 8:00 p.m. on 09/28/10, and a second dose of [MEDICATION NAME] approximately 8:00 a.m. on 09/29/10. Review of Nurses' Notes revealed the following: *09/29/10 at 1:31 p.m.: . . . fax sent to (physician name) that resident does not want to take the [MEDICATION NAME] was ordered because he said it makes him feel light headed and he can't think right . . ." *09/29/10 at 5:00 p.m.: ". . . telephone call from (physician name) to DC (discontinue) MScontin (sic). . . ." *09/29/10 at 6:09 p.m.: ". . . Resident not 'feeling like himself'. . . . Assessed, resident in recliner and declined to come to dining room for supper . . ." (No evidence of vital signs recorded during this time frame.) *09/30/10 at 12:24 p.m.: ". . . Wet respirations 7 at rest, decreased Level of Consciousness, does not make eye contact unless specifically requested, speech garbled. Uncontrolled left sided twitching. Call to (physician name) with orders to send to ER (emergency room ). . . ." Vital signs at this time included a respiratory rate of 7 breaths per minute and a blood pressure of 97/60 mmHg (millimeters of mercury, a measurement of pressure), a decreased reading for this resident. *09/30/10 at 1:25 p.m.: Vital signs included a respiratory rate of 7 breaths per minute and a blood pressure of 96/60 mmHg. *09/30/10 at 4:32 p.m.: ". . . Resident returned from ER . . . resident remains confused, paranoid . . ." *10/01/10 at 2:20 a.m.: Vital signs included a respiratory rate of 6 breaths per minute. *10/01/10 at 5:08 a.m.: ". . . resident has been sleeping all night. . . . respirations 6-8 at beginning of shift, resps (respirations) are now 10-12 most of the time. . . ." Documentation indicated emergency department staff evaluated Resident #9 for decreased respiratory status, decreased level of consciousness, and left sided twitching. Vital signs obtained in the ED included a blood pressure of 97/60 mmHg and a respiratory rate of 7 breaths per minute. The ED physician documented a [DIAGNOSES REDACTED]. A discharge plan signed by the ED physician stated, ". . . You have been evaluated and/or treated for [REDACTED]. . . ." During an interview on 12/01/10 at 4:05 p.m., an administrative nurse (#1) stated she expected nurses to review all new orders and look up medications with which they are unfamiliar. She agreed the dose of [MEDICATION NAME] sulfate ordered and administered was an excessive dose. Failure of facility staff to ensure the dose of [MEDICATION NAME] sulfate ordered by the provider was appropriate before administration of the medication resulted in Resident #9 receiving two excessive doses of [MEDICATION NAME] sulfate and experiencing severe respiratory depression, which then resulted in an admission to the emergency department.