Every finding on record at Benedictine Living Center of Garrison

Based on observation, record review, review of the facility competency guide, review of professional reference, and staff interview, the facility failed to follow professional standards for 1 of 2 sampled residents (Resident #3) reviewed for blood sugars levels, and 1 of 1 supplemental resident (Resident #27) observed during administration of an oral inhaler. Failure to notify the provider of out-of-range blood sugars levels may lead to inaccurate insulin dose administration and/or adverse health conditions, and failure to prompt a resident to rinse his/her mouth with water after administration of an inhaler has the potential to cause side effects in the oral cavity related to the medication. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures . ordered by the physician or primary care provider. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of the Annual Skills Competency Resource Guide occurred on 07/22/25. This undated guide stated, . Dry Power (sic) Inhaler (DPI) . Remove inhaler form (sic) mouth . Have individual rinse mouth . - Review of Resident #3's medical record occurred on all days of survey. Diagnoses included diabetes mellitus. A physician's order, dated 04/04/25, stated, Novolog FlexPen U-100 Insulin [rapid acting insulin] pen; 100 unit/mL [milliliter] amt: Per Sliding Scale; . Special Instructions: If BS [blood sugar] is 401 and above, give 12 units and Notify provider. Review of Resident #3's blood sugar levels from April 1, 2025 through July 21, 2025, identified the following: * 07/18/25 at 11:48 a.m., 406mg/dl (milligrams per deciliter) * 05/28/25 at 3:38 p.m., 410 mg/dL * 05/28/25 at 2:41 p.m., 410 mg/dL * 04/21/25 at 12:24 p.m., 416 mg/dL * 04/20/25 at 11:47 a.m., 417 mg/dL Resident #3's medical record lacked documentation staff notified the provider regarding the blood sugar levels over 401. During an interview on 07/22/25 at 12:29 p.m., an administrative staff member (#2) confirmed Resident #3's medical record lacked documentation facility staff notified the identifying provider of the resident's elevated blood sugars. - Observation of medication administration on 7/21/25 at 4:19 p.m. showed a medication aide (MA) (#4) administered an Advair [oral steroid] inhaler to Resident #27 and failed to have the resident rinse his/her mouth with water. During an interview on 07/22/25 at 2:14 p.m. an administrative nurse (#1) stated she expected staff to encourage residents to rinse their mouth with water after using an inhaler.

Based on observation, review of the facility competency guide, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 2 sampled residents (Resident #7) observed during a dressing change. Failure to practice infection control standards related to dressing changes and hand hygiene has the potential to spread infection throughout the facility.Findings include: Review of the Annual Skills Competency Resource Guide occurred on 07/22/25. This undated guide stated, . DRESSINGS/WOUND CARE: 1. Bring 2 pairs of clean gloves - one for removing the soiled dressing and another for applying clean dressing. 5. Wash your hands and apply gloves. 6. remove the soiled dressing . 7. Observe the wound . 8. Gather soiled dressing in gloved left hand. Remove left hand glove . right glove . dispose of soiled materials . 9. Wash your hands and apply a clean pair of gloves. Observation on 07/21/25 at 11:28 a.m. showed a licensed nurse (#3) performed dressing changes on Resident #7's abdominal wounds. The nurse (#3) applied gloves, removed the soiled dressings from both wounds, discarded the dressings and removed the gloves. Without performing hand hygiene, the nurse applied a new pair of gloves, cleansed the wounds with gauze and saline solution, discarded the gauze and then removed the gloves. The nurse applied a new pair of gloves, covered the two wounds with a dressing, applied tape, removed the gloves, and performed hand hygiene. The nurse failed to perform hand hygiene between glove changes. During an interview on the afternoon of 07/22/25, an administrative nurse (#2) confirmed staff should perform hand hygiene between glove changes.

Based on review of the facility reported incident (FRI) investigation, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell from a mechanical lift. Failure to safely use the mechanical lift resulted in a fall with injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 06/17/25. The facility immediately implemented corrective action, completed corrective action on 06/18/25, and continues with staff education and monitoring. Review of the facility policy titled Using a Mechanical Lift occurred on 06/18/25. This policy, dated October 2024, stated, . At least two (2) trained associates are needed to safely move a resident with a mechanical full body . lift . Review of Resident #1's medical record occurred on 06/18/25. The care plan stated, . Utilize the Hoyer lift with A2 [assist of 2 staff] for transfers. The FRI investigation, dated 06/17/25, stated, . At approx. [approximately] 9:00am by [therapy staff #2], came to SSD [social service designee] office to advise that just prior . CNA [certified nurse aide #1] came out of [Resident #1's room] and asked [therapy staff #2] to come to the room. [CNA #1] appeared very upset and had blood on her hands and yelled to [therapy staff #2] '[Resident #1] rolled out of bed.' [therapy staff #2] did respond to room where she found [resident #1] on the floor. [CNA #1] stated to [therapy staff #2], 'I didn't have her up in the stand because I know I need 2 people.' She [Resident #1] was laying on her left side next to her bed with her head at the head of the bed and feet at the foot of the bed. She [Resident #1] had blood on her head and there was blood on the floor. SSD interviewed [Resident #1's roommate, Resident #2] at approx. 9:25am and inquired about the events. Roommate [Resident #2] advised that she was lying in bed and woke up to see [Resident #1] in the hoyer lift sling. She stated the sling had been 'swinging' and then she saw [Resident #1] suddenly fall to the ground. [Resident #1] then began screaming. When asked who all was in the room at the time, [Resident #1's roommate] advised it was only her, [Resident #1] and [CNA #1]. SSD advised that [Resident #2] had already told SSD what had happened, at which point [CNA #1] . stated 'I did it, I dropped her from the sling .' . she [CNA #1] went on to explain that she had gotten [Resident #1] onto the sling, had raised the lift and was beginning to move the lift into position to put [Resident #1] in her chair and [Resident #1] slid out of sling, head first. A physician's progress note, dated 06/17/25, stated, . fell out of her Hoyer lift. She hit her head on the floor and had began to develop a goose egg. She does have pain where she hit her head. clinical impression . abrasion of scalp . Acute headache . The facility failed to ensure two staff assisted while transferring Resident #1 with a mechanical lift. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for all residents who may be affected by the deficient practice as follows: * Completed an investigation into Resident #1's fall. * Terminated CNA #1. * Inservice completed regarding the policy/procedure for mechanical lifts. * Education provided to all CNAs and nurses working on 06/17/25. * All other CNAs and nurses will be educated prior to the start of their next shift.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 1 of 1 closed record resident (Resident #4) reviewed for advanced directives. Failure to honor the resident/resident representative's wishes for code status resulted in unwanted treatment for Resident #4. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on [DATE]. The facility implemented corrective action and completed on [DATE]. Review of the facility policy titled Initiation of CPR/AED [cardiopulmonary resuscitation/automated external defibrillator] and BLS [basic life support] Associate Training Expectations occurred on [DATE]. This policy, dated 2018, stated, . CPR/AED will be initiated on a resident who is found unresponsive, except when: 1) a Provider medical order states a code status of DNR [do not resuscitate] . Review of Resident #4's medical record occurred on all days of survey. A Physician Order for Life Sustaining Treatment form, dated [DATE], stated, . DNR/DO NOT ATTEMPT RESUSCITATION . Review of Resident #4's nursing notes, dated [DATE], identified the following: * 7:39 a.m., At 0300hrs [3:00 a.m.], neighbor [Resident #4] was found irresponsive [sic] . was turning blue in color so I performed CPR . I checked . blood sugar and it was 66 mg/dL [milligrams per deciliter] and I called 911. [Resident #4] was sent out to [hospital] for further evaluation. * 10:13 a.m., 0920 [9:20 a.m.] - neighbor came back from [hospital] assisted by CNA [certified nurse aide] per wheelchair. Neighbor is alert, awake and conversant, confused at times. Neighbor still has dry cough, clear lung sounds, bilateral, audible grunting upon inspiration, SPO2 [oxygen saturation]: 91% [percent] at room air . [Resident #4] received only Glucagon [medication used to treat low blood sugar] nasal spray as per nurse, no IV [intravenous] fluids were given. Chest x-ray was done, no significant changes as per nurse. Labs done. During an interview on [DATE] at 1:25 p.m., an administrative staff (#1) confirmed the nurse (#2) performed CPR on Resident #4 even though the resident had a DNR order, and expected staff to follow resident code status orders. Based on the following information, non-compliance at F578 is considered past non-compliance. The facility implemented corrective actions as follows: * Educated staff nurse (#2) on the facility policy Initiation of CPR/AED and BLS Associate Training Expectations on [DATE]. * Implemented a new process to easily identify residents with a Full Code code status at the resident bedside and educated all staff on the new process on [DATE].

Based on record review, review of facility policy, and staff interviews the facility failed to ensure residents remained free from resident-to-resident abuse for 2 of 3 sampled residents (Residents #24 and #51) and 4 supplemental residents (Resident #3, #11, #31, and #36) who received or displayed physical and/or verbal abuse. Failure to identify physical altercations between residents as physical abuse placed residents at risk for possible emotional distress and/or physical injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incidents. Findings include: This surveyor determined a deficient practice existed on 06/08/24. The facility implemented corrective actions and staff education on 07/16/24. Review of the facility policy titled Abuse Prevention Plan occurred on 07/24/24. This policy, dated 2017, stated, Prevention Plan: . Population of neighbors [residents] who reside in facility vary in their ability to ambulate. Neighbors may have diagnoses of dementia or other cognitive impairment. These same neighbors may exhibit behaviors which place them or others at risk. Neighbors who are not able to verbalize needs may be at increased risk for abuse/neglect. 'Abuse': The willful infliction of injury, . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. In includes verbal abuse . physical abuse, and mental abuse . (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening: . - Review of Resident #24's medical record occurred on all days of survey. The record identified diagnoses of psychotic disorder, schizoaffective disorder, major depressive disorder, and Alzheimer's disease. The current care plan stated, I am susceptible to abuse related to cognitive impairment due to Alzheimer's, dementia, and psychosis and physical impairment due to obesity and gout. I have a hx [history] of verbal and physical aggression. Report and investigate suspected abuse cases in accordance with facility policies and procedures . If I become violent or physically aggressive the facility shall implement interventions to minimize risk to self, others within the facility, or visitors and community members as appropriate . Review of Resident #24's progress notes identified the following: * 06/13/24 at 10:16 a.m., at 8pm last night, [Resident #24] was at [Resident #3's room], [Resident #24] started kicking him and punch [sic] him like 3-4 times while he was checking the O2 [oxygen] tubing that was tangled at [Resident #24's] wheelchair. [Resident #3] then held her hand and told her to go, by the time CNA [certified nursing assistant] seen her in his room and moved her back to her apartment. no injury noted, nor neighbor reported any pain, although she has known dementia case [sic] and cannot recall what happened last night. neighbor to neighbor incident documentation done . * 06/17/24 at 10:30 a.m., IDT [interdisciplinary team] met to review neighbor to neighbor incident that was documented on 6/13/24. [Resident #3] was trying to help [Resident #24] out by untangling his oxygen tubing from her w/c [wheelchair]. [Resident #24] mistook the other neighbor's actions and was physically aggressive with him. His response was appropriate and did not cause any harm to [Resident #24]. Will educate neighbor to call for staff assistance to remove other neighbors from his room to avoid future conflict. Review of the facility's investigation documents identified the facility notified the POAs for each resident involved and completed 15-minute safety checks for 24 hours for each resident. -Review of Resident #31's medical record occurred on July 23, 2024. Diagnoses included bipolar disorder, current episode manic severe with psychotic features, primary insomnia, and other drug induced secondary parkinsonism. The current care plan stated, I am susceptible to abuse related to my mental health disorders. Report and investigate suspected abuse cases in accordance with facility policies and procedures; I will not commit abuse to other vulnerable adults. If I become violent or physically aggressive the facility shall implement interventions to minimize risk to self, others within the facility, or visitors and community members as appropriate. Review of Resident #31's progress notes identified the following: * 06/08/24 at 3:02 p.m., At 1:30pm, one neighbor reported to CNA that somebody slapped him, this morning the same CNA overheard a conversation of [Resident #31] that she slapped him telling at [sic] story to [another resident] about it. When [Resident #31] confronted about it, then she admitted that this was [sic] happened this morning around 6-6:30 am. She verbalized that [Resident #51] was all over her face following her from nook to chapel and she was annoyed and suddenly slapped him, cannot remember if once or 2 times. She verbalized she just got up and didn't sleep well, then upon realizing what happened, she then started avoiding him. * 06/10/24 at 11:06 a.m.,IDT [interdisciplinary team] to review neighbor to neighbor incident that occurred on 6/8/24 at approximately 6:30am. [Resident #31] did verbalize that she slapped another neighbor as he was following her around and she became irritated. This is not in [Resident #31's] baseline behavior and due to her current manic state she is having difficulty controlling her impulses. [Resident #31] was seen on rounds on 6/7/24 for her mania and was prescribed Lyrica [medication to treat nerve pain] as she complained to the provider of pain at that time. [Resident #31's] sister/POA [name] has advised IDT that the only way to get [Resident #31] out of this mania state is for her to sleep. All facility policies and procedures were followed including both neighbors being on 15 minute checks and all proper notifications were made. [Resident #31] has not exhibited any further instances of aggression towards staff or other neighbors since the incident. - Review of Resident #51's medical record occurred on all day of survey. The care plan stated Problem. Behavior: I may show fluctuations in behavior r/t [related to] Korsakoff's syndrome [brain changes due to prolonged alcohol consumption]. I explore my environment frequently. I enjoy moving things around within my environment. At times you may hear me talking to myself. I have been verbally and physically aggressive with staff. I become agitated when unable to locate my 'stuff' or my room. I have been involved in neighbor to neighbor incidents. I have made sexual comments to staff. Approach . If I am following other neighbors around and they don't like it, redirect me to another area. You may trial aromatherapy with me during times of restlessness, agitation, or tearfulness. Resident #51's nursing progress notes identified the following: * 06/08/24 at 2:47 p.m., at 1:30 pm, neighbor reported to CNA that some lady slapped him. Early that morning the CNA overheard a conversation of [Resident #31] that she slapped 'him' telling a story to [another resident] about it. when [Resident #31] were interviewed, she admitted that this happened this morning around 6-6:30 am. She verbalized that room [Resident #51] was all over her face following her from nook to chapel and she was annoyed and suddenly slapped him, cannot remember if once or 2 times. she verbalized she just got up and didn't [sic] sleep well, then upon realizing what happened, she then started avoiding him. this incident was unwitnessed. [Resident #51] was then interviewed and assessed for any injury and said the same thing that some lady slapped him, although he denies pain. no redness on face. * 06/10/24 at 11:11 a.m., IDT met to review neighbor to neighbor incident that occurred on 6/8/2024 at approximately 6:30am. Another neighbor did verbalize that she slapped [Resident #51] as he was following her around and she became irritated. Due to [Resident #51's] cognitive impairment he does follow other people around at times if not redirected. Staff will be educated that if he is following a neighbor around and they do not want him to, staff should redirect [Resident #51] to a different area. All facility policies and procedures were followed including both neighbors being on 15 minute checks and all proper notifications were made. The other neighbor has not exhibited any further instances of aggression towards staff or other neighbors since the incident. [Resident #51] has not exhibited any ill effects from the incident and his mood has been intact since. Will continue with current plan of care. * 06/22/24 at 3:36 p.m. Neighbor [Resident #51] was reported by the homemaker in Sunflower area that he hit neighbor [Resident #36], while the neighbor [Resident #36] is walking down the hallway at 2:25pm he hit him in [sic] the top of the head and cussed him. Neighbor came back to the homemaker and apologized. Aroma therapy given and monitored. After 15min, neighbor was seen in good mood and greeting other neighbors. [Resident #51 power of attorney (POA)] informed thru phone. * 06/24/24 at 9:45 a.m. IDT met to review neighbor-to-neighbor incident that occurred on 6/22/24 and behavior documented on 6/23/24. The neighbor to neighbor incident was not witnessed but was reported by the other neighbor involved. Although that neighbor also has cognitive impairment, it is within his cognitive ability to reliably report the incident. Staff reactions were appropriate to neighbor to neighbor incident. All notifications were made per facility policy. Nursing appropriately conducted necessary assessments. 15-minute checks were implemented and completed per facility policy as well. [Resident #51] has been showing increased anxiety and aggression in the afternoons. Staff reaction and interaction can exacerbate these symptoms at times. Many of these times it is difficult to determine a trigger. Food, fluids, and aromatherapy have been trialed with some effectiveness. It is also known that he does not sleep for long amounts of time and does not nap during the day. IDT recommends that [Resident #51] be seen by [Psychiatrist's name] on psych rounds on 6/25/24 as previously scheduled. Staff training and education also recommended on how to approach [Resident #51] when he is showing s/s [signs/symptoms] of anxiety and how to de-escalate the situation when he is seeming aggressive. * 07/15/24 at 8:00 p.m. [Recorded as Late Entry on 07/16/2024 12:34 AM] [Resident #51] had gotten upset about something said to him by a male neighbor. He was moved away from that neighbor. A female neighbor [Resident #11] was mad and put her fists up towards [Resident #51's] face. This triggered [Resident #51] to slap her across the left side of her face. Neighbors were again moved away from each other. CNA was able to redirect [Resident #51] to another area. [Resident #51's POA] was notified of the event. Told her that we would be doing 15-minute checks on him for the next 24 hours. She is worried that we are changing his meds to fast. Explained that we work with [Psychiatrist's name] and he does the actual med changes. She seem [sic] alright with this. * 07/16/24 at 5:55 p.m. IDT met to review neighbor-to-neighbor that occurred on 7/15/24. [Resident #51] had gotten upset about something said to him by a male neighbor. He was moved away from that neighbor. CNA was able to redirect [Resident #51] to another area. [Resident #51's POA] was notified of the event. Told her that we would be doing 15-minute checks on him for the next 24 hours. She is worried that we are changing his meds to fast. Explained that we work with [Psychiatrist's name] and he does the actual med changes. She seem alright with this. All community policies were followed and all notifications made per policy as well. [Resident #51] does not recall the situation and has not displayed any adverse effects from the incident. [Resident #51] has had multiple med changes since admission. Group staff education completed as well as 1:1 [one to one] staff education specific to redirecting and interacting with [Resident #51] throughout the day and during times of agitation. IDT has been unable to determine triggers and/or patterns as to the behaviors. Care conference will be held with [POA] to discuss appropriateness of placement. During an interview, on 07/23/24 at 11:45 a.m. an administrative staff member (#1) identified she provided education to the staff on interventions/tools for Resident #51 to prevent resident and/or staff harm. The facility failed to identify the above incidents as physical abuse. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions. * The IDT met after each incident to problem solve and implement changes * Policies were reviewed to make sure they were followed * Providers and resident representatives were notified * Group staff education was completed as well as 1 to 1 staff education specific to redirecting and interacting with residents' with behaviors 46259

Based on record review, review of facility policy, and staff interview the facility failed to report incidents of resident-to-resident abuse to the State Survey Agency (SSA) for 2 of 3 sampled residents (Resident #24 and #51) and 1 supplemental resident (Resident #31). Failure to report resident-to-resident abuse allegations and the results of the facility's investigation to the SSA placed all residents at risk for possible abuse. Findings include: Review of the facility policy titled, Abuse Prevention Plan occurred on 07/24/24. This undated policy stated, . All events will be investigated whether they cause injury or harm or no injury or harm. Events may include, but are not limited to, . resident to resident altercations [a resident to resident altercation is an incident involving a resident who willfully inflicts injury upon another resident. 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm], . If the event that caused suspicion involves abuse or results in serious bodily injury, the individual is to report the suspicion to the state immediately, but not later than 2 hours after forming the suspicion. If the event does not involve abuse and does not result in bodily injury, the individual is required to report to the state no later than 24 hours after forming the suspicion. - Review of Resident #24's medical record occurred on all days of survey. Diagnoses included psychotic disorder, schizoaffective disorder, major depressive disorder, and Alzheimer's disease. A progress note dated 06/13/24 at 10:16 a.m., stated, at 8pm last night, neighbor [Resident #24] was at [another resident] room, she started kicking him and punch him like 3-4 times while he was checking the O2 [oxygen] tubing that was tangled at [Resident #24's] wheelchair. [The other resident] then held her hand and told her to go, by the time CNA [certified nurse aide] seen her in his room and moved her back to her apartment. no injury noted, nor [sic] neighbor reported any pain, although she has known dementia [sic] and cannot recall what happened last night. neighbor to neighbor incident documentation done, POA [Power of Attorney] was notified. -Review of Resident #31's medical record occurred on 07/23/24. Diagnoses included bipolar disorder, current episode manic severe with psychotic features, primary insomnia, and other drug induced secondary parkinsonism. A progress note dated 06/08/24 at 3:02 p.m., stated, At 1:30pm, one neighbor reported to CNA that somebody slapped him, this morning the same CNA overheard a conversation of [Resident #31] that she slapped him telling at story to [another resident] about it. When [Resident #31] confronted about it, then she admitted that this [sic] happened this morning around 6-6:30 am. She verbalized that [Resident #51] was all over her face following her from nook to chapel and she was annoyed and suddenly slapped him, cannot remember if once or 2 times. She verbalized she just got up and didn't sleep well, then upon realizing what happened, she then started avoiding him. - Review of Resident #51's medical record occurred on all days of survey. The MDS, dated [DATE], showed Resident #51 unable to complete the BIMS interview. The care plan stated Problem. Behavior: I may show fluctuations in behavior r/t [related to] Korsakoff's syndrome [brain changes due to prolonged alcohol consumption] . Resident #51's progress notes showed the following: * 06/22/24 at 3:36 p.m. Neighbor was reported by the homemaker in Sunflower area that he hit [another resident], while the [Resident #51] is walking down the hallway at 2:25pm he hit him in [sic] the top of the head and cussed him. * 07/15/24 at 8:00 p.m. [Recorded as Late Entry on 07/16/2024 12:34 AM] [Resident #51] had gotten upset about something said to him by a male neighbor. He was moved away from that neighbor. A female neighbor was mad and put her fists up towards [Resident #51's] face. This triggered [Resident #51] to slap her across the left side of her face. Neighbors were again moved away from each other. CNA was able to redirect [Resident #51] to another area. The facility lacked evidence the above incidents were reported to the administrator and the SSA. During an interview on 07/23/24 at 11:45 a.m., an administrative staff member (#1) confirmed the resident-to- resident incidents had not been reported to the SSA. 13101

Based on observation, record review, review of manufacturer's instructions for use, and staff interview the facility failed to ensure staff followed standards of practice for 3 of 4 residents (Resident #6, #23, and #40) observed during administration of rapid acting insulin. Failure to administer rapid acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction. Findings include: Prescribing information for Humalog insulin (a raid acting insulin), found at https://www.humalog.com, occurred on 07/24/24 and stated, Administer HUMALOG . within 15 minutes before a meal or immediately after a meal. Important safety information for NovoLog (a rapid acting insulin), found at novolog.com, occurred on 07/24/24 and stated, Novolog starts acting fast. Eat a meal within 5 to 10 minutes after taking it. - Review of Resident #6's medical record occurred on all days of survey. Current physician's order included, Novolog insulin; 20 units with meals three times a day. Observations on 07/22/24 showed the following: * 3:38 p.m., a nurse (#2) prepared and administered 20 units of Novolog insulin to Resident #6. *4:50 p.m., Resident #6 received the evening meal. (One hour and 12 minutes after receiving a rapid acting insulin) - Review of Resident #23's medical record occurred on all days of survey. Current physician's order included, Humalog insulin; give 8 units three times a day and sliding scale insulin based on the resident's blood glucose level. Observations on 07/22/24 showed the following: * 4:04 p.m., a nurse (#2) prepared and administered 20 units of Humalog insulin to Resident #23. *4:33 p.m., Resident #23 received the evening meal. (29 minutes after receiving a rapid acting insulin) - Review of Resident #40's medical record occurred on 07/24/24. Current physician's order included, Novolog insulin; 2 units and sliding scale insulin based on the resident's blood glucose level. Observations on 07/23/24 showed the following: * 8:43 a.m., a nurse (#3) prepared and administered 2 units of Novolog insulin to Resident #40. * 9:11 a.m., Resident #40 received the morning meal. (28 minutes after receiving a rapid acting insulin) The facility failed to follow prescribing instructions for fast-acting insulin related to timing and meals for Resident #6, #23, and #40. During an interview on 07/24/24 at 10:40 a.m., an administrative nurse (#5) confirmed she expected staff to follow the manufacture's guidelines for administering rapid acting insulin

Based on observation, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 4 residents (Resident #20 and Resident #40) observed during medication administration. Four medication errors occurred during staff administration of 32 medications, resulting in a 12.5 percent error rate. Failure to properly prepare medications may result in residents receiving an ineffective dose and experiencing adverse reactions. Findings include: Review of the prescribing information for NovoLog insulin, found at www.novo-pi.com/novolog.pdf, occurred on 07/24/24, and stated, Instructions for use . C. Pull off the big outer needle cap . E. Turn the dose selector to select 2 units. F. Hold your NovoLog FlexPen with the needle pointing up. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to zero. - Observation of medication administration on 07/23/24 at 8:43 a.m. showed a nurse (#3) prepared a Lantus (long-acting) insulin pen and a Novolog (rapid-acting) insulin pen for Resident #40. The nurse attached a needle and with the cap on, dialed each pen to two units to prime the insulin pen. The nurse (#3) failed to remove the cap prior to priming the insulin pen. - Observation of medication administration on 07/23/24 at 9:00 a.m. showed a nurse (#4) prepared a Lantus (long-acting) insulin pen and a Novolog (rapid-acting) insulin pen for Resident #20. The nurse attached a needle, removed the cap, dialed each pen to two units, and held each pen pointed down to prime the insulin pen. The nurse (#4) failed to prime the insulin pen with the needle pointing upward. During an interview on 07/24/24 at 10:40 a.m., an administrative nurse (#5) stated she expects staff to prime the insulin pens with the cap off and with the needle pointing upwards.

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 5 of 13 sampled residents (Resident #11, #14, #21, #26, and #27) and one supplemental resident (Resident #33). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION K: SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI User's Manual, revised October 2019, page K-3 through K-9, stated, . Coding Instructions . K0310: Weight Gain . Code 0, no or unknown: if the resident has not experienced weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. Code 2, yes, not on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight gain was not planned and prescribed by a physician. - Review of Resident #14's medical record occurred on all days of survey. Diagnoses include congestive heart failure and chronic kidney disease. A dietary progress note dated, 06/28/23 at 9:11 a.m., stated, . Weight continues to increase with weight gain of 8.4# [pounds] (5.7%) in the past month and 20.8# (15.4%) in the past 6 months. The quarterly MDS, dated [DATE], identified section K0310, coded 0, no weight gain. During an interview 09/07/23 at 9:15 a.m., the dietary manager (#8) confirmed staff incorrectly coded section K of the MDS for Resident #14. SECTION I: ACTIVE DIAGNOSES IN THE LAST 7 DAYS The Long-Term Care Facility RAI User's Manual, revised October 2019, page I-7, stated, . Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis . in the last 60 days. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. Diagnostic information, including past history obtained from family members and close friends, must also be documented in the medical record by the physician to ensure validity and follow-up . Review of Resident #27's medical record occurred on all days of survey. The resident's current diagnosis list identified schizoaffective disorder as of 08/18/22. The quarterly MDS assessments, dated 11/04/22, 02/04/23, and 05/04/23, identified schizoaffective disorder as an active diagnosis. Resident #27's medical record failed to show a clinical rationale for the diagnosis of schizoaffective disorder. During an interview on 09/07/23 at 11:39 a.m., an administrative nurse (#1) confirmed the facility staff incorrectly coded Resident #27's MDSs for a diagnosis of schizoaffective disorder. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2019, pages N-6 and N-7, stated, . Coding Instructions . N0410E, Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). - Review of Resident #11's medical record occurred on all days of survey. Diagnoses included cerebral vascular accident (stroke) due to thrombosis (blood clot). A physician's order, dated 11/26/19, stated, Eliquis (apixaban) [anticoagulant] tablet; 5 mg [milligrams]; amt [amount]: 1 tab [tablet]; oral Twice A Day . The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #11 received an anticoagulant on 0 of 7 days. Staff failed to code the MDS accurately for anticoagulants. - Review of Resident #21's medical record occurred on all days of survey. A physician's order, dated 03/09/23, stated, Eliquis (apixaban) tablet; 5 mg; amt: 1 tab; oral Twice A Day. The quarterly MDS, dated [DATE], identified Resident #21 received an anticoagulant on 0 of 7 days. Staff failed to code the MDS accurately for anticoagulants. - Review of Resident #26's medical record occurred on all days of survey. A physician's order, dated 11/14/2022, stated, Xarelto (rivaroxaban) [anticoagulant] tablet; 20 mg; amt: 1 tab; oral Once A Morning . The annual MDS, dated [DATE], identified Resident #26 received an anticoagulant on 0 of 7 days. Staff failed to code the MDS accurately for anticoagulants. - Review of Resident #33's medical record on all days of survey. Diagnoses included embolism and thrombosis (blood clot). A physician's order, dated 12/26/22, stated, Eliquis (apixaban) tablet; 5 mg; amt: 1 tablet; oral Twice A Day . The quarterly MDSs, dated 03/26/23 and 06/23/23, identified Resident #33 received an anticoagulant on 0 of 7 days. Staff failed to code the MDS accurately for anticoagulants. During an interview on 09/07/23 at 9:20 a.m., an administrative nurse (#7) confirmed staff incorrectly coded section N of the MDS for Resident #11, #21, #26, and #33. 42397 46259

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 7 sampled residents (Resident #14 and Resident #27) and 5 supplemental residents (#1, #12, #18, #39, and # 47) observed during personal cares or transfers. Failure to practice infection control standards related to hand hygiene and cleaning of mechanical lifts has the potential to spread infection throughout the facility. Findings include: HAND HYGIENE: Review of the facility policy titled Hand Hygiene occurred on 09/06/23. This policy, effective June 2017, stated, . all associates will be trained and competent in following proper hand hygiene practices. Times to Perform Hand Hygiene are, but not limited to .Before and after direct resident contact . Before and after assisting a resident with personal cares . Before and after assisting a resident with toileting . After contact with a resident's mucous membranes and body fluids or excretions . After removing gloves or aprons . - Observation on 09/05/23 at 3:53 p.m. showed two certified nurse aides (CNAs) (#2 and #3) completed perineal cares for Resident #18. The CNA (#2) cleansed the resident's perineal area, discarded the wet incontinent product, removed his gloves, donned a new pair of gloves, and placed a clean incontinent product on the resident. The CNA (#2) without performing hand hygiene, placed the resident's shoes on, transferred the resident with a mechanical lift, removed the lift sling and strap, emptied the garbage, combed the resident's hair and turned on the television. The CNA failed to perform hand hygiene between glove changes and before completing other tasks. - Observation on 09/05/23 at 4:08 p.m. showed two CNAs (#2 and #11) completed perineal cares for Resident #27. A CNA (#11) cleansed the resident's perineal area with a wipe and rolled the resident onto their right side. The CNA (#11) then removed her gloves and donned a new pair of gloves without performing hand hygiene. While Resident #27 was on their side, the other CNA (#2) placed a clean incontinent product under the resident, cleansed the resident's bottom with a wipe, removed his gloves and donned a new pair of gloves without performing hand hygiene. Both CNAs transferred the resident with a mechanical lift, adjusted her clothing, and removed the lift sling and strap. CNA #2 sanitized the lift, combed the resident's hair, gave the resident a drink of water, and opened the blinds before washing his hands. CNA #11 exited the room with the lift and the garbage without performing hand hygiene prior to exit. Both CNAs (#2 and #11) failed to perform hand hygiene between glove changes and before completing other tasks. - Observation on 09/06/23 at 9:07 a.m. showed a CNA (#6) donned gloves, performed perineal cares for Resident #14, removed the soiled brief, removed her gloves, adjusted her uniform top, and without performing hand hygiene, donned new gloves, applied skin barrier cream and applied a clean brief. The CNA removed her soiled gloves, tied the garbage bag, adjusted her uniform top, and without performing hand hygiene donned new gloves, washed Resident #14's underarms, dressed the resident's lower half, and assisted the resident to the wheelchair. The CNA (#6) removed her gloves, exited the room, obtained a portable oxygen concentrator, and returned to the room. The CNA failed to perform hand hygiene when he/she exited/entered the room. The CNA (#6) switched Resident #14's oxygen tubing from the room concentrator to the portable unit and touched the nasal cannulas as she applied the tubing to the resident. The CNA (#6) donned gloves, stripped the linen from the bed, put linen in a plastic bag, removed her gloves, failed to perform hand hygiene and exited the room. DISINFECTING LIFTS Review of the facility policy titled Resident Care Equipment occurred on 09/07/23. This policy, dated July 2017, stated, . Associates will disinfect reusable equipment between resident uses using EPA approved disinfectant. Observation on 09/05/23 showed staff completed resident transfers with mechanical lifts and failed to disinfect the lifts after or between each resident use as follows: * At 12:49 p.m., Resident #1 full body transfer lift. * At 1:15 p.m. and 4:11 p.m., Resident #12 sit-to-stand transfer lift. * At 2:31 p.m., Resident #47 sit-to-stand transfer lift. * At 3:03 p.m., Resident #39 sit-to-stand transfer lift. During an interview on 09/07/23 at 10:25 a.m., two administrative staff members (#1 and #10) stated, Our expectation of our staff regarding hand hygiene is to follow the Hand Hygiene policy. They further stated, Our expectation of our staff regarding disinfecting mechanical lifts is to follow the policy. Staff are to clean the lifts between and after each resident use. 46477

Based on observation, record review, review of facility policy, staff and resident interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 1 supplemental resident (Resident #2) with medications observed in the room. Failure to determine whether SAM is a safe practice has the potential to limit a resident's right to SAM or result in a medication error and/or harm to a resident. Findings include: Review of the facility policy titled Self-Administration of Medication occurred on 09/07/23. This policy, dated 2020, stated, . 1. The nursing associates will assess each resident's mental and physical abilities. Assessment is documented in the EHR [Electronic Health Record]. 3. If it is determined a resident cannot safely administer medications, the nursing associates will administer the medication. Observations during medication administration on 09/05/23 at 4:11 p.m., showed a bottle of Refresh Plus (Sterile eye drops) located in Resident #2's room. When asked, Resident #2 stated, I'm allowed to use them and do them by myself whenever I need them. Review of Resident #2's medical record occurred on 09/05/23. The record showed a SAM assessment on 06/29/21 documented in the EHR indicated Resident #2 cannot safely self-administer medications. During an interview on 09/07/23 at 8:14 a.m., an administrative staff member (#1) confirmed Resident #2 is not appropriate for SAM.

Based on record review, review of professional reference, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 3 sampled residents (Resident #13) with an indwelling catheter. Failure to follow physician's orders for residents with indwelling catheters may result in delayed treatment, pain and/or worsening of resident's condition. Findings include: [NAME], [NAME], and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., page 63, states, . Carrying Out a Physician's Orders . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #13's medical record occurred on all days of survey. Diagnoses included neuromuscular dysfunction of bladder and urinary retention. A physician order signed on 02/23/22, stated, Next appointment 1 [one] year. The medical record lacked evidence of a follow up physician visit. During an interview on 09/07/23 at 10:03 a.m., an administrative staff member (#1) confirmed the facility failed to make the follow-up appointment as ordered.

Based on observation, record review, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 4 sampled residents (Resident #13) observed during a pivot transfer. Failure to provide adequate assistance and use the assistive devices properly during transfers placed the residents at risk for accidents, falls, or injuries. Findings include: The facility failed to provide a copy of their policy addressing transfers. Review of Resident #13's medical record occurred on all days of survey and included diagnoses of multiple sclerosis and incomplete paraplegia. The current care plan stated, . I do need assistance with mobility due to weakness, unsteadiness, and diagnosis of multiple sclerosis and paraplegia. A1 [assist of one] to stand pivot transfer with FWW [front wheeled walker] and gait belt . During an observation on 09/06/23 at 8:29 a.m., a certified nurse aide (CNA) (#5) stood at the end of Resident 13's bed while the resident slid himself to the edge of the bed, stood, swung his hips towards the wheelchair, and landed roughly and misaligned into the wheelchair. The CNA (#5) failed to assist the resident with the transfer by using the walker and applying a gait belt. During an interview on 09/07/23 at 10:01 a.m., an administrative nurse (#1) confirmed Resident #13 transferred incorrectly and stated she expected staff to follow the resident's care plan.

Based on facility policy, record review, and staff interview, the facility failed to ensure a physician's response to changes in resident's weight for 3 of 3 sampled residents (Resident #23, #44, and #45) with significant weight loss. Failure to ensure the physician responded in a timely manner may result in a delay of treatment and further weight loss for residents. Findings include: Review of the facility policy titled Weight Monitoring and Documentation occurred on 09/07/23. This policy, dated August 2019, stated, . 7. Resident's weights are tracked monthly through an established monitoring system to ensure that significant changes are identified and addressed . 10. The physician . will be notified on any significant weight change. - Review of Resident #23's medical record occurred on all days of survey. Diagnoses included diabetes mellitus, diverticulosis, Parkinson's, and dementia. The current care plan stated, . I'm at risk for weight changes/nutritional deficiency due to dx Dementia, Diabetes and Diverticulosis. Assist me with meals. Review of dietary progress notes identified the following: 08/22/23 at 4:41 p.m., Nutrition: Weight-119.8# [pounds] (8/22). Weight has been decreasing over the past several months with a weight loss of 11# noted from 3 months ago. Review of the physician progress notes from February 2023 through August 2023 lacked evidence the physician acknowledged or addressd Resident #23's significant weight loss. - Review of Resident #44's medical record occurred on all days of survey. Diagnoses included diabetes mellitus and hypothyroidism. The current care plan stated, . I'm at risk for weight changes/nutritional deficiency due to dx's[diagnoses] of type II [two] diabetes mellitus, hypertension and hypothyroidism. I may be forgetful and confused at times . A dietary progress note dated, 03/17/23 at 11:35 a.m., stated, .Weights: 179.8# (3/16), 187.2# (2/19), 203#(12/14), 220.6# (9/14). Neighbor continues to lose weight with significant weight loss of 40.8# (18%) noted in the past 6 months. Review of physician progress notes from October 2022 through September 6, 2023 lacked evidence the physician acknowledged or addressed Resident #44's significant weight loss. - Review of Resident #45's medical record occurred on all days of survey. Diagnoses included dementia and macular degeneration. The current care plan stated, . I'm at risk for weight changes/nutritional deficiency due to Dementia. A dietary progress note, dated 05/30/23 at 3:50 p.m., stated, . Weights: 82# (5/29), 86.1# (4/30), 84.8# (3/5), 92.2# (12/1). Significant weight loss of 10.2# (11%) noted in the past 6 months. Review of physician progress notes from January through July 2023 lacked evidence the physician acknowledged or addressed Resident #45's significant weight loss. During an interview on 09/07/23 at 9:25 a.m., an administrative nurse (#1) confirmed the physician progress notes lacked evidence the physician acknowledged or addressed the significant weight loss for Resident #23, #44, and #45.

Based on information provided by the complainant, policy review, and staff interview, the facility failed to report an abuse allegation to the State Survey Agency within two hours and the results of the investigation within five working days for 1 of 1 sampled resident (Resident #1) who alleged they were sexually assaulted. Failure to report an abuse allegation and the results of the facility's investigation to the State Survey Agency placed all residents at risk for possible abuse. Findings include: The complainant reported Resident #1 hollered he tried to rape me in the dining room in front of other residents, staff members, and visitors on 03/19/23. When questioned, Resident #1 gave a vague description of one of the staff members as the alleged perpetrator. The complainant alleged the facility failed to report and investigate the allegation. Review of the facility policy titled Abuse Prevention Plan occurred on 04/03/23. This policy, dated 2017, stated, . Possible Incidents Which Need Investigation . Any person with the knowledge or suspicion of suspected abuse . must report immediately, without fear of reprisal and/or retaliation. If the event that caused the suspicion involves abuse . the individual is required to report the suspicion to the state immediately, but not later than 2 hours after forming the suspicion. Within five working days . the Director of Nursing, Director of Social Services, or their designee will electronically submit the facility's investigative report to the appropriate state agency. 'Sexual abuse': non-consensual sexual contact of any type with a resident . When asked questions pertaining to the facility's reporting process, staff interviews on 03/30/23 identified the following: * At 2:18 p.m., a social services staff member (#2) indicated, A concern is reported to the charge nurse who passes it on to me. We do not have a form for a concern [abuse allegation]. Sometimes we use a behavior sheet. The form goes to the charge nurse who signs it, showing they received it. The forms are filed in one of two boxes, in my office or on the unit. * At 2:25 p.m., a CNA (certified nursing assistant) (#3) stated, We fill out a behavior form and let the charge nurse know. It [the form] goes in the social worker's box. I gave the sheet [regarding Resident #1's allegation] to [the nurse]. It was during change of shift. * At 4:05 p.m., the social services staff member (#2) stated, They called me on the 19th [of March - the day Resident #1 made the allegation] about this. The charge nurse had assessed her. There was nothing [no visible injuries], no bruises. If the nurse said she saw something [an injury], then I would have reported it. Review of State Agency records lacked evidence the facility reported Resident #1's sexual assault allegation. Facility staff failed to report Resident #1's assault allegation within two hours and failed to report the results of their investigation within five working days of the incident. Refer to F610.

Based on information provided by the complainant, record review, policy review, and staff interview, the facility failed to thoroughly investigate an abuse allegation for 1 of 1 sampled resident (Resident #1) who alleged they were sexually assaulted. Failure to thoroughly investigate all abuse allegations, ensure residents are protected, and implement safety measures during the investigation placed all residents at risk for possible abuse. Findings include: The complainant reported Resident #1 hollered he tried to rape me in the dining room in front of other residents, staff members, and visitors on 03/19/23. When questioned, Resident #1 gave a vague description of one of the staff members as the alleged perpetrator. The complainant alleged the facility failed to report and investigate the allegation. Review of the facility policy titled Abuse Prevention Plan occurred on 04/03/23. This policy, dated 2017, stated, . All . allegations of abuse . will be thoroughly investigated by the Director of Social Services, Director of Nursing, or their appropriate designees. All events will be investigated whether they cause injury or harm or no injury or harm. Measures will be taken to identify the source of the alleged abuse and prevent future incidents. Identify and interview all who might have knowledge of the incident including the alleged victim, perpetrator . or others who may have had related contact with the alleged perpetrator, related to the incident in question. The focus of the investigation is to determine the extent, cause and future prevention with thorough documentation of the investigative process completed . safety measures may include . Responding immediately to protect the resident or alleged victim from further abuse . Examining the alleged victim for any sign of injury, including a physical examination . Providing increased staff supervision of resident, as needed . Providing alternate caregiver(s) to the resident, as appropriate. 'Sexual abuse': non-consensual sexual contact of any type with a resident . Review of Resident #1's medical record occurred on 03/30/23. Diagnoses included anxiety, dementia, depression, and psychotic disorder with hallucinations. A social services assessment, dated 02/20/23, identified, . [Resident #1] . scored 3 on the BIMS [Brief Interview for Mental Status] indicating . severe impairment. When asked questions pertaining to the facility's abuse investigation process, staff interviews on 03/30/23 identified the following: * At 2:18 p.m., a social services staff member (#2) indicated, A concern is reported to the charge nurse who passes it on to me. She enters a progress note. The forms [behavior tracking sheets] are filed in one of two boxes, in my office or on the unit. ITD [the interdisciplinary team] then reviews the incident and will update the care plan if needed. * At 2:25 p.m., a CNA (certified nursing assistant) (#3) stated, I put in a behavior form [regarding Resident #1 on 03/19/23]. She [Resident #1] told me, 'A . guy came in and took my clothes off, took his clothes off, and was about to do something bad to me, when the door suddenly opened, and he ran out.' Another . CNA walked into the room with another resident. I [CNA #3] asked her [Resident #1] if that was him [alleged perpetrator] and she said, 'No, it was the meaner looking one.' This was not typical behavior for her. I gave the sheet to [the nurse]. It was during change of shift. On 03/30/23 at 3:50 p.m., the social services staff member (#2) located and provided copies of the behavior tracking forms submitted by three CNAs (#3, #6, and #7) on 03/19/23 addressing Resident #1's assault allegation. The forms identified the following: * CNA (#6) stated, [CNA #7] brought [Resident #1] into [sic] dining room to her table. She [Resident #1] said to me as I approached in a loud voice 'he tried to rape me .' I asked 'rip' you [sic] she screamed, banged her fist on the table [sic] yelled 'no, rape me.' I said who him pointing to [CNA#7] she said 'no the other [male]' then repeated pointing at [CNA #7] 'not him the other [male] he's not here.' * CNA (#7) stated, . I asked her [Resident #1] can I put your feet back from [sic] the padel [sic]. After that she started [sic] agitate [sic]. Getting her close to dinner table, [CNA #6] stopped by and asked her if everything [sic] okay. [Resident #1] said he rap [sic] me. [CNA #6] ask [sic] again is [CNA #7] and she said no. * CNA (#3) stated, I was approached by Culinary staff that [Resident #1] was upset and to please come talk to her. I approached the neighbor [Resident #1] slowly and kneeled down beside her. I asked her if she was okay and she said I guess I have to be. I then asked what happened she said a . man ripped her clothes off and took his clothes off and was trying to do bad things to her, the door opened and he [ran out] . On 03/30/23 at 4:05 p.m., when asked questions pertaining to the steps taken after the allegation was reported to the nurse, the social services staff member (#2) stated, They [the nurse] called me on the 19th [03/19/23] about this. The charge nurse had assessed [Resident #1]. There was nothing [no visible injuries], no bruises. [Resident #1] is always making claims. She tells wild stories. Ever since her [femur] surgery, she has been declining and hallucinating. She is not a valid witness. If the nurse said she saw something [an injury], then I would have reported it. When I talked to her on the 20th, [Resident #1] wasn't saying this [assault allegation]. When asked if it was typical for Resident #1 to make assault accusations, an administrative staff member (#5) and the social services staff member (#2) responded, No. On the afternoon of 03/30/23, the social services staff member (#2) indicated she interviewed Resident #1 on 03/20/23 and provided a copy of her handwritten notes. She documented that the resident used nonsensical speech, talked about cats and dogs, appeared unafraid, and did not mention men. The medical record lacked evidence the nurse examined Resident #1 for any sign of injury as per facility policy. On 03/31/23 at 11:00 a.m., the administrative staff member (#5) confirmed the nurse failed to document the results of Resident #1's physical examination. Per facility policy, the facility failed to: * thoroughly investigate an allegation of sexual assault, whether there was evidence of an injury or not, * examine the alleged victim for any sign of injury and document the results of the exam in the resident's medical record, * identify and interview everyone who had knowledge of the incident, * take measures to identify the source of the alleged abuse, * provide increased supervision for the alleged victim and/or provide alternate caregivers as deemed appropriate, and * ensure thorough documentation of their investigation process. Refer to F609.

Based on observation, record review, and review of the facility policy, the facility failed to develop a comprehensive care plan for 4 of 16 sampled residents (Resident #6, #44, #47, and #201). Failure to develop a comprehensive care plan limited staffs' ability to communicate needs and ensure the continuity of care. Findings Include: Review of the facility policy titled Comprehensive Assessments and Care Planning occurred on 07/27/22. This policy, revised 07/02/18, stated, . provide a comprehensive person-centered interdiciplinary care assessment of the resident's condition . A facility should use the results of the assessment to develop, review and revise the resident's person-centered comprehensive care plan. Asssessment process must include direct observation . Review of the facility policy titled, BHS [Benedictine Health System] Restorative Therapy Program occurred on 07/27/22. This policy, dated 2017, stated, . The Registered Nurse will document in Matrix Care the individualized program including . Care plan problem, goal, and approaches. - Review of Resident #6's medical record occurred on all days of survey. A Restorative Care Communication Form, dated 04/05/22, identified a restorative program for passive range of motion (PROM) to the resident's left upper extremity three times a week. The current care plan failed to include restorative therapy for PROM. - Review of Resident #44's medical record occurred on all days of survey. A Restorative Care Communication Form, dated 05/25/22, identified a restorative program for PROM to the resident's lower extremities three times a week. The current care plan failed to include restorative therapy for PROM. - Review of Resident #47's medical record occurred on all days of survey. A Restorative care Communication Form, dated 05/09/22, identified a restorative program for PROM to the resident's upper and lower extremities three times a week. The current care plan failed to include restorative therapy for PROM. - Observation on 07/24/22 at 3:31 p.m., showed Resident #201 lying in bed while two certified nursing assistants (CNAs) (#9) and (#10) provided perineal cares. Observation showed two [MEDICATION(S)] Border (an adhesive foam dressing) on the resident's coccyx/upper right buttock area. The CNA (#10) removed the soiled [MEDICATION(S)] Border, revealing an open area with a pink wound bed. Review of Resident #201's medical record occurred all days of survey. A nursing progress note, dated 06/28/22 at 5:52 p.m., stated, Neighbor arrived in the facility around 3 in the afternoon. Skin inspection done, noted to have Stage 2 wound on right buttocks near coccyx measuring 3.5cm [centimeter] in length x 4.5cm [in] width. Wound is pinkish and appears healthy. Resident #201's care plan failed to address the current pressure ulcer.

Based on observation, record review, review of facility policy, and staff and resident interviews, the facility failed to provide the care and services necessary to maintain or improve the resident's ability to perform activities of daily living (ADLs) for 4 of 4 sampled resident (Resident #6, #25, #44, #47) with a restorative therapy program in place. Failure of staff to ambulate a resident and complete range of motion (ROM) exercises may result in decreased mobility and contractures. Findings include: Review of the facility policy titled . Restorative Program, occurred on 07/26/22. This policy dated July 2017, stated, . To provide a basic outline and guidance for implementation and tracking of restorative programs established so that each resident can attain and maintain highest physical, mental and psychosocial well-being. Restorative nursing care promotes resident's highest level of independence in each of the following areas: . Range of Motion . Ambulation . The Registered Nurse in collaboration with the therapist(s) will design the individualized restorative program for the resident. - Review of Resident #6's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS) dated [DATE] identified upper extremity impairment to one side and bilateral impairment to the lower extremities. The Restorative Care Communication Form, dated 04/05/22, identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/25/22 at 4:32 p.m., Resident #6 stated he had not received restorative therapy for several weeks Review of the restorative charting June 1-July 24, 2022 showed Resident #6 received restorative therapy 5 times. - Review of Resident #25's medical record occurred on all days of survey. The Restorative Care Communication Form, dated 09/15/21, identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] decreased mobility, and a walk to dine program daily with assist of one and front wheeled walker with the wheel chair to follow. Observations included the following: * 07/25/22 at 4:33 p.m.: a certified nurse assistant (CNA) (#9) assisted Resident #25 to stand-pivot from the bed to the wheelchair utilizing a gait belt. Resident #25 had difficulty moving her feet. The CNA (#9) failed to ambulate the resident to the supper meal. * 07/25/22 at 4:42 p.m.: Resident #25 self-propelled her wheelchair into the dining room. * 07/26/22 at 11:24 a.m.: Resident #25 self-propelled her wheelchair into the dining room. * 07/26/22 at 4:28 p.m.: Resident #25 self-propelled her wheelchair into the dining room. Staff failed to ambulate Resident #25 to meals as per her restorative program. Review of the restorative charting for Resident #25 identified the resident received walk-to-dine assistance 6 out of 27 days in July. - Review of Resident #44's medical record occurred on all days of survey. The Restorative Care Communication Form, dated 05/25/22, identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/24/22 at 2:03 p.m., Resident #44 stated his legs were tightening at night, and reported he had not received restorative therapy for about 2 weeks. A nursing progress note dated 07/19/22 at 2:49 p.m., stated, Annual MDS completed. Neighbor is alert and oriented. He is on an RC [restorative care] PROM [passive range of motion] program and utilizes the stander [a device to assist with standing]. Review of the restorative charting for June 1-July 24, 2022 showed Resident #44 received restorative therapy 7 times. - Review of Resident #47's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified an upper extremity impairment to one side and bilateral impairment to the lower extremities. The Restorative Care Communication Form, dated 05/09/22, identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Frequency identified as three times a week. During an interview on 07/26/22 at 2:36 p.m., Resident #47 stated she experiences knee pain when lying on her right side an reported she had not received restorative therapy for some time. Review of the restorative charting for June 1-July 24, 2022 identified Resident #47 received restorative therapy 6 times. During an interview on 07/25/22 at 10:51 a.m., an occupational therapist (#1) and a physical therapist (#8) stated the facility had been without a restorative certified nursing assistant for at least two weeks and admitted no one is currently completing the residents restorative therapy programs.

Based on observation, review of professional reference, and staff interview, the facility failed to promote privacy and confidentiality of medication administration records (MAR) on 2 of 2 days observed for medication administration. Failure to close the MAR may result in unauthorized viewing of resident records by other residents, unlicensed staff and/or visitors. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 234, stated, . ensure the privacy and confidentiality of client information stored in computers. Do not leave client information displayed on the monitor where others may see it. Observation during medication administration showed the medication cart unattended with a resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] * 07/24/22 at 4:10 p.m. to 4:15 p.m. * 07/25/22 at 11:15 a.m. to 11:26 a.m. During an interview on 07/26/22 at 8:26 a.m., an administrative staff member (#7) stated she expected staff to lock the computer screen whenever they leave the medication cart.

Based on record review, review of facility policy, and staff interview, the facility failed to provide care in accordance with professional standards for 1 of 17 sampled residents (Resident #19) and 1 closed record (#52) with a history of falls. Failure to complete neurological assessments following an unwitnessed fall or a fall with a head injury has the potential to delay identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Review of the facility policy titled Neurological Assessment occurred on 07/27/22. This policy, dated 2018, stated, . a neurological observation and assessment is completed . following an unwitnessed fall and/or subsequent to a fall with a suspected head injury. - Review of Resident #19's medical record occurred all days of survey. The care plan, dated 04/26/22, stated, . I have times of confusion and forgetfulness and may show fluctuations in cognition due to dx [diagnosis] of [CONDITION(S)] [abnormal brain function] and dementia. The progress notes identified the following: * 05/01/22 at 3:00 a.m., Neighbor was noted on the fall [sic] by her bed. She could not state how she fell . * 05/09/22 at 9:00 a.m., Neighbor was witnessed on the floor in her room by the activity staff this morning around 8:30am. She was leaning on her L [left] side between the foot pedal of her W/C [wheelchair], her left leg was flexed under her R [right] leg. Neighbor was conversant and was sleepy. * 05/23/22 at 4:18 p.m., At [7:15 a.m.], [Resident] was found on the floor beside her bed. CNA heard her calling for help. She was lying on her right side. Her feet were towards the head of the bed. She said that she did not hit her head . Review of Resident #19's medical record showed facility staff failed to complete neurological assessments on all three occasions per facility policy. - Review of Resident #52's medical record occurred on 07/27/22. The care plan, dated 04/02/22, identified, . I do need assistance with mobility due to weakness, unsteadiness, dx Pneumocephalus [presence of air or gas in the cranial cavity and can be associated with head trauma] and hx [history] dizziness with falls . The progress notes identified the following: * 01/21/2022 at 1:34 p.m., . At 10:00AM neighbor was witnessed on the floor in her bedroom. She was sitting between her recliner and Tv stand. Neighbor states that she slide [sic] down from her chair. * 02/19/2022 at 6:40 p.m., . Neighbor was witnessed on the floor in her room around 6:04pm, culinary staff found her sitting upright on the floor beside her night stand . * 04/15/2022 at 5:42 p.m., . Neighbor was witnessed on the floor in her room by the culinary staff this afternoon around 15:05 [3:05 p.m.]. She was laying on her back between her bed and recliner . Review of Resident #52's medical record showed facility staff failed to complete neurological assessments on all three occasions per facility policy. During an interview on 07/27/22 at 10:45 a.m., an administrative nurse (#7) stated she expects staff to perform neurological assessments with each unwitnessed fall.

Based on record review, policy review, and staff interview, the facility failed to notify the physician of a deterioration in skin condition for 1 of 3 sampled residents (Resident #5) with a pressure ulcer. Failure to notify the physician of a deterioration in skin condition resulted in complications to the resident and prevented the physician from evaluating the effectiveness of the current treatment plan. Findings include: Review of the facility policy titled Prevention and treatment of [REDACTED]. This policy, dated September 2018, stated, . 10. Weekly the licensed nurse will . and examine the wound bed and surrounding skin. If wound bed has deteriorated; notify provider. 11. Notify the attending provider, . if the pressure injury has not shown progress in 2 weeks and/or is deteriorating unexpectedly. Review of Resident #5's medical record occurred 1/13/21, and showed [DIAGNOSES REDACTED]. Review of progress notes showed: *10/09/20 2:57 p.m., . 3 cm x 2 cm .stage: stage II. *10/19/20 2:40 p.m., . 6 cm x 6 cm . exudate amount: light . exudate color: bloody . stage: stage II . skin surrounding wound: [DIAGNOSES REDACTED] (redness)/blanchable . wound healing status: declining . *10/28/20 9:33 p.m., . 11 cm x 8 cm. Wound bed composed of 70% pink in color and 30% colored purple which is located in the middle. Surrounding area of the wound is color red warm to touch and no drainage. [MEDICATION NAME] paint applied. Condition relayed to night nurse. *11/16/20 4:19 p.m., . 11 cm x 7 cm . exudate amount: light . exudate color: serous (clear, amber, thin and watery) . tissue type: slough . *12/21/20 1:44 p.m., . 12 cm x 11.5 cm . exudate amount: none . *12/28/20 3:48 p.m., Called (power of attorney) and informed of status of wound on coccyx and starting on abx (antibiotic), wound cultures and consult to wound specialist. *12/29/20 2:43 p.m., (Physician's Assistant) called to report that Resident #5 is growing in (his/her) wound culture and would like to send (him/her) to hospital for further evaluation and treatment. POA (name) notified and is in agreement to the plan. *12/30/20 4:24 p.m., (Nurse Practitioner) with order to continue follow up with (wound nurse practitioner), consult general surgery for [REDACTED]. They will determine if palastic (sic) surgery is needed. Cancel plastic surgery for [REDACTED]. To start antibiotic(s) [MEDICATION NAME] 500mg TID PO (per oral) x 10 days, [MEDICATION NAME] 100mg cap PO BID x 10 days, [MEDICATION NAME] 875/175 (mg) PO BID x 10 days, DC (discontinue) Keflex. Floragen ([MEDICATION NAME]) 1 PO BID x 30 days. *1/04/21 2:06 p.m., Wound bed on coccyx area measures 12 cm x 15 cm. 1.3 cm undermining Bed is 100% necrotic slough. No drainage. With foul smell. Surrounding area is red/purple in color. Review of the medical record showed the facility failed to notify Resident #5's physician of the deterioration of the pressure ulcer. During an interview on 1/13/21 at 1:48 p.m., a provider (#2) stated, Miscommunication on multiple levels between the providers and the facility resulted in probable delay in treatment. During an interview on 1/13/21 at 3:00 p.m., an administrative nurse (#1) agreed the facility failed to notify the provider of the deterioration in Resident #5's pressure ulcer.

Based on record review, review of facility policy, and staff interview, the facility failed to provide appropriate treatment and services to prevent the deterioration of pressure ulcer for 1 of 3 sampled residents (Resident #5) with pressure ulcers. Failure to implement interventions as ordered, and ensure adequate monitoring/assessment resulted in the delayed treatment/deterioration of Resident #5's pressure ulcer. Findings include: Review of the facility policy titled Prevention and treatment of [REDACTED]. This policy, dated September 2018, stated, . Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care. 10. Weekly the licensed nurse will stage, measure, and examine the wound bed and surrounding skin. If wound bed has deteriorated; notify provider. 11. Notify the attending provider . if the pressure injury has not shown progress in 2 weeks and/or is deteriorating unexpectedly. Re-evaluated plan of care as appropriate. 12. Documentation reflects areas as addressed above. Review of Resident #5's medical record occurred on 1/13/21 and showed medical [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], showed extensive assist of two staff members for bed mobility and toileting, total dependence for transfers, one stage 2 pressure ulcer, one venous or arterial ulcer, and moisture associated damage to the skin. The current care plan, updated 10/14/20, identified Problem Skin: I am at risk for skin breakdown due to immobility, catheter/ostomy use, dx's (diagnoses) of Diabetes, MS, CP and leaking catheter. I have a non-pressure chronic ulcer on my left ankle. Long Term Goal: My skin will remain intact. Any skin alterations I develop will heal without complications. Approach: Prevalon boots bilaterally. Individual skin interventions: air mattress, ROHO (brand name) cushion in w/c (wheelchair), reposition regularly in chair, encourage to lay down in bed in afternoon, treat skin issues as ordered. Keep skin clean and dry. Avoid shearing/friction with positioning, transfers. Provide peri care after each episode that I have leakage from Foley catheter. The certified nursing assistant care card showed the following, Keep in bed with HOB (head of bed) elevated for meals only. Reposition Q (every) 2 hours. The facility failed to care plan the sacral ulcer and update the care plan as interventions changed. The facility failed to provide repositioning logs when asked. Review of progress notes/wound management/referral forms showed the following: *10/09/20 2:57 p.m., . 3 cm x 2 cm . exudate (drainage) amount: none . stage: stage II . skin surrounding wound: [DIAGNOSES REDACTED] (redness)/blanchable . wound healing status: stable . comments: continue Q2 (every 2) hour turn and using [MEDICATION NAME] paint (skin treatment). *10/19/20 2:40 p.m., . 6 cm x 6 cm . exudate amount: light . exudate color: bloody . stage: stage II . skin surrounding wound: [DIAGNOSES REDACTED] (redness)/blanchable . wound healing status: declining . The facility failed to measure and document the condition of the ulcer for 10 days. The facility failed to notify the physician with the deterioration of the ulcer. *10/28/20 9:33 p.m., . 11 cm x 8 cm. Wound bed composed of 70% pink in color and 30% colored purple which is located in the middle. Surrounding area of the wound is color red warm to touch and no drainage. [MEDICATION NAME] paint applied. Condition relayed to night nurse. The facility again failed to notify the provider of the deterioration of the pressure ulcer. Review of the referral form from Resident #5's appointment at (Name) Wound Clinic on 11/04/20 stated: . Do not position Resident #5 on left side to prevent ongoing pressure, consult dietician, PT/OT (physical therapy/occupational therapy) to evaluate chair cushion. Noticed sacral ulcer, who is managing this? Consider [MEDICATION NAME] & [MEDICATION NAME] border (wound treatment & dressing) and change every other day. *11/16/20 4:19 p.m., . 11 cm x 7 cm . exudate amount: light . exudate color: serous (clear, amber, thin and watery) . tissue type: slough . Percent of wound covered by granulation tissue: 25 . percent of wound covered by slough tissue: 75. skin surrounding wound: [DIAGNOSES REDACTED] (redness)/blanchable . wound healing status: stable .comments: area is macerate with serous drainage, slough and granulated tissue present. Surrounding tissue is intact and blanchable. No s/s (signs/symptoms) of infection. No pain or odor. Continue [MEDICATION NAME] to wound and Q2 hour turning. 12/19/20 Dietary note: 2nd Qtr (second quarter) Nutrition assessments meds added are [MEDICATION NAME] 40 mg (milligrams), [MEDICATION NAME] BID (twice a day) 19U (units), [MEDICATION NAME] 3U TID (three times a day), plus s/s Vit (vitamin) C, Vit D, Zinc Coccyx ulcer, ADA (American Diabetic Association) diet with 76% ave (average) intake 166 lbs (pounds) (11/10/2020). Adding protein scheduled ONS (oral nutritional supplement) to promote wound healing. The facility failed to follow the physician order for [REDACTED]. *12/21/20 1:44 p.m., . 12 cm x 11.5 cm . exudate amount: none . *12/30/20 4:24 p.m., (Nurse Practitioner) with order to continue follow up with (wound nurse practitioner), consult general surgery for [REDACTED]. They will determine if palastic (sic) surgery is needed. Cancel plastic surgery for [REDACTED]. To start antibiotic(s) [MEDICATION NAME] 500mg TID PO (per oral) x 10 days, [MEDICATION NAME] 100mg cap PO BID x 10 days, [MEDICATION NAME] 875/175 (mg) PO BID x 10 days, DC (discontinue) Keflex. Floragen ([MEDICATION NAME]) 1 PO BID x 30 days. *01/04/21 2:06 p.m., Wound bed on coccyx area measures 12 cm x 15 cm. 1.3 cm undermining Bed is 100% necrotic slough. No drainage. With foul smell. Surrounding area is red/purple in color. *01/05/21 9:06 a.m., (POA) informed that neighbor would be sent to (Hospital Name) this am per (PA) orders. *01/05/21 Resident transferred to (Name) Hospital in Bismarck. During an interview, on 1/13/21 at 3:00 p.m., an administrative nurse (#1) agreed the facility failed to measure, stage, and document Resident #5's pressure ulcer per facility policy. The administrative nurse (#1) agreed the facility failed to inform the physician of the deterioration of Resident #5's pressure ulcer. The facility failed to provide consistent monitoring of Resident #5's sacral pressure ulcer, including staging and measuring of the area which limited the facility's ability to identify worsening of the sacral pressure ulcer, as well as contact the physician when the facility noted deterioration of Resident #5's sacral pressure ulcer. The facility also failed to care plan and update interventions for healing of Resident #5's sacral pressure ulcer. These failures led to the deterioration and increase in the size and depth of the pressure ulcer leading to the need for further treatment, care and hospitalization of resident #5.

BURNS 1. Based on record review and staff interview, the facility failed to ensure residents received adequate supervision and assistance devices to prevent burns from hot liquids for 2 of 2 sampled residents (Resident #9 and Resident #13 - closed record). Failure to provide adequate supervision and/or appropriate drinking devices and monitor the temperature of the coffee dispensing machines resulted in Resident #13's burn, may have contributed to Resident #9's burn, and may result in additional or new burns to residents who drink hot liquids. Findings include: Review of Resident #13's closed medical record occurred on 05/29/14. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and eating with extensive assistance of one person. Resident #13's current care plan stated, ". . . Problem: Communication: I have trouble communicating my needs at times due to my Alzheimer's. . . . Approach: (dated 05/01/12) . . . I do need you to anticipate my needs. . . . Problem: Culinary - I need some help at meals. . . . Approach: (dated 12/15/10) Bring my meals to the table for me. set up my meal. encourage me to eat. Offer cueing and supervision. . . ." This conflicts with Resident #13's MDS, dated [DATE], which indicated the resident required extensive assistance of one person to eat. Review of Resident #13's progress notes stated the following: * 11/14/13 at 9:21 a.m. - "Neighbor spilled coffee on her lap. Bright pink skin noted to inner thighs and back of thighs. Small flat blisters noted to back of left thigh and inner right thigh. Peri-area was not affected. Area was cooled, then silvadene applied and wounds were dressed. (nurse practitioner name) was notified." * 11/15/13 at 9:23 a.m. - "Coffee burns to thighs continue. Areas on both thighs are blistered with redness around the blisters. Blisters are intact and fluid filled. Both thighs cleansed and silvadene applied and then dressed. Some discomfort noted when dressing were put on . . ." * 11/17/13 at 9:26 a.m. - "Dressings changed to burned thighs bilat. (bilateral) Continue to improve. Minimal serous drainage." * 11/29/13 at 8:56 a.m. - "Dressing changed on both legs. Out of Silvadene so I used Adaptic to cover blisters and covered with Kerlix gauge (sic) to keep covered. Blisters to LFT (left) leg resolving but to the right leg the blister is still draining and yellowish in color." * 12/05/13 at 11:04 a.m. - "Order received from (physician name) on dr. round . . . D/C (discontinue) Silvadene to (right) thigh burn, and cover area with a Tegaderm absorbent dressing to be changed on shower days until healed." * 12/25/13 at 9:20 p.m. - ". . . Tegaderm in place to burn area which is healing extremely slowly. . . ." * 01/01/14 at 10:19 a.m. - " . . . seen on dr. rounds on 01/02/14 by (nurse practitioner name) for concern of leg wound not healing. . . ." * 01/08/14 at 09:10 p.m. - "Changed her dressing to the Right thigh; it continues to be red and sore. Also some small amount of drainage." * 01/23/14 at 1:25 a.m. ". . . Burns are healed on thighs." Review of Resident #13's progress notes from 11/14/13 until 01/23/14 failed to identify the dimensions of the burn. A facility "Event Report" "Skin Integrity Events- Burn Event" dated, 11/14/13 at 9:01 a.m. stated, "Description: coffee burns to thighs . . . Location and size of burn: Inner and back of thighs. Etiology of burn: Moist heat (scald): Hot liquids . . . Classification of burn: Superficial Partial - Thickness- Damage to first and second layer of skin, skin turns white when pressed then returns or red, burn is moist and painful with blistering and swelling. Does resident complain of pain at site? If yes rate the pain on the pain scale from 1-10: yes 8. Interventions: cold - silvadene . . ." A physicians assistant progress note dated, 1/09/14, stated, ". . . Assessment: . . . 3) Burn with scar formation started to the right inner thigh. Plan: . . . If there is drainage or seems to be increasing redness then we will have to have further evaluation if family would like to. . . It is starting to form some scarring to the site . . ." Review of Resident #13's "Investigation Report" dated 11/14/13 at 9 a.m., stated, " . . . Neighbor was eating breakfast in the Dakota DR (dining room). Neighbor requires cues (with) eating. Staff was across table assisting another neighbor. (Resident name) picked up coffee mug (and) it slipped out of her hands onto her lap. . . . neighbor is able to assist herself - requires cues. She loves coffee. Immediate intervention: First aid to burn. IDT (interdisciplinary team) Intervention Plan: Dilute coffee (with a) little cold water, do not fill mug full." This conflicts with Resident #13's MDS, dated [DATE], which indicated the resident required extensive assistance of one person to eat. Resident #13's care plan failed to identify the resident sustained [REDACTED]. On 05/29/14 at 1:15 p.m., a surveyor obtained a temperature reading of 164 degrees Fahrenheit for the coffee dispensed from the machine located in the kitchen of the Dakota dining room. During an interview on the afternoon on 05/29/14, a dietary manager (#13) stated staff does not check the temperature of the coffee and she is aware of two residents that sustained burns in the facility. During an interview on 05/29/14 at 1:40 p.m. an administrative nurse (#1) confirmed the staff did not check the temperature of the coffee after Resident #13 sustained a burn. She also confirmed staff failed to update Resident #13's care plan regarding the burn from the coffee, with the interventions to dilute coffee with cold water and not to fill the mug full. Based on Resident #13's cognitive status, need to anticipate her needs, and need for extensive assistance to eat, failure of the facility to put safety measures in place and/or provide assistance with eating contributed to her burn with hot coffee. - Review of Resident #9's medical record occurred on 05/29/14. [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], indicated intact cognition and eating with supervision and set up help only. The current care plan stated the resident ate independently after set up. A physician order, dated 03/07/14, stated, "Silvadene to burn on 4th finger of right hand BID (twice daily) and cover with bandage." Resident #9's nursing progress notes stated: * 03/07/14 at 12:17 p.m. - "Neighbor states he burned his finger on coffee a few days ago, area blistered and measures 2 CM (centimeter) x (by) 2 CM, did open today and is draining serous drainage. Denies c/o (complaint of) pain or discomfort . . . will dress and apply silvadene BID till (until) healed." * 03/11/14 at 9:37 a.m. - "Quarterly assessment (dietary) . . . He spends a lot of his time in the coffee nook area . . . drinking coffee. . . ." * 03/15/14 at 11:15 a.m. - "Dressing change to RT (right) middle finger . . . Blister gone but skin under blister continues to need care. The wound is red and there is an area 1/2 cm that is opened. . . ." * 03/21/14 at 3:53 p.m. - "Did d/c (discontinue) order for silvadene will just leave open to air, area is healing nicely . . ." The Event Report, with event date 03/05/14 at 12:12 p.m. and completed date 03/07/14, stated, "Description: Coffee burn to fourth finger on right hand . . . Etiology of Burn: Moist Heat (scald): Hot Liquids; Additional Description: area is blistered, but broke open today. White in color; Classification of Burn: Deep Partial Thickness - Deeper skin layers, skin is white with red areas, remains white when pressed and may appear waxy, not painful but sensation of pressure may be present. . . ." The facility failed to update the care plan after Resident #9 burned a finger on a hot coffee cup, with interventions to prevent future burns, including an appropriate drinking device. During an interview on the afternoon of 05/29/14, a dietary manager (#13) stated Resident #9's burn was from the ceramic coffee cup he was holding, not from a spill. Resident #9 was in the hospital at the time of the survey for an unrelated reason and unavailable for observation or interview. SAFE ENVIRONMENT 2. Based on observation and staff interview, the facility failed to maintain an environment free of hazardous chemicals and tools for 2 of 3 (May 27-28, 2014) days of survey. Accessible hazardous chemicals and tools and access to the maintenance room placed cognitively impaired and wandering residents at risk for accidents and injury. Findings include: The facility failed to provide a policy specific to the storage of chemicals and tools when requested. Observation on 05/27/14 at 10:45 a.m. showed a maintenance room at the end of the Dakota unit. The door to this room remained unlocked the entire day. The room contained numerous hazardous chemicals and tools such as a spray bottle of Clorox cleaner, a spray can of battery terminal protection, a box cutter, a screwdriver, a hand drill etc. Observation on 05/28/14 at 08:45 a.m. and 12:25 p.m. identified the same maintenance door unlocked. During an interview on 05/27/14 at 6:10 p.m., an administrative nurse (#1) confirmed the maintenance room contained numerous hazardous chemicals and tools and the door needed to remain locked at all times. Observation in the afternoon on 05/28/14 identified a small screwdriver hanging on the outside of an AVI panel (fire alarm panel) door, in the coffee lounge area. A maintenance supervisor (#10) stated the screwdriver should not be stored on the panel.

SAFE HANDLING OF HOT LIQUIDS: 1. Based on observation, record review, review of facility policy and procedure, review of the facility's Plan of Correction, and staff interview, the facility failed to provide supervision and/or assistive devices necessary to attain the highest degree of safety possible while consuming hot liquids for 2 of 3 sampled residents with concerns regarding hot liquids (Resident #8 - observed handling hot liquids in an unsafe manner) and (Resident #3 - whose husband expressed concerns regarding her safety when consuming hot liquids). Failure to evaluate the residents' ability to handle hot liquids, as identified in the facility's Plan of Correction, placed residents consuming hot liquids at risk of sustaining a burn. On 07/28/14 at 2:30 p.m., the team determined a potential Immediate Jeopardy (IJ) situation existed. The team met with facility administrative staff members (#1, #2, and #3) and requested additional information. After review of the information received, the team contacted the State Agency at 3:55 p.m. regarding the potential IJ. Following further review, the team met with administrative staff members (#1, #2, and #3) at 5:05 p.m. and informed the staff members an IJ situation existed. During that meeting, the facility provided a verbal plan of correction. At 5:42 p.m., the team notified the State Agency of the facility's verbal communication and the team's plan to abate the IJ pending review of a written Plan of Correction. At 6:25 p.m. the facility provided a written Plan of Correction. The team reviewed and accepted the written plan at 6:33 p.m. At 7:00 p.m. the team determined the IJ situation abated, reduced the scope and severity level to "D," and informed the administrative staff members (#1, #2, and #3) of this action. Findings include: The facility's Plan of Correction for the deficiencies cited during the 05/29/14 survey, received on 07/09/14, identified the following corrective actions for F323: "Neighbors will be evaluated for ability to handle hot beverages . . . Staff will be educated on hot beverage safety and offered possible interventions if a neighbor is thought to be unsafe in handling hot beverage . . ." The facility identified 07/15/14 as the compliance date for this deficiency. Review of the policy "Hot Beverages" occurred on 07/28/14. This policy, not dated, stated, "Coffee, or hot water, should be between 150-170 degrees when coming out of liquid coffee machines. Staff observation and assessment of risk will be completed upon admission and periodically. Therapy will screen new neighbors for the need for adaptive equipment. Assessments are completed by various disciplines per IDT (interdisciplinary team) Assessment Guide provided by BHS (Benedictine Health System). The care plan will identify individual interventions needed. Safety interventions should be put into place for those neighbors who may have difficulty with holding a hot cup of coffee or other hot beverage. Examples: *Lid on cup *2 handled cup *Chill cup slightly prior to pouring coffee to drop the temp faster *If neighbor does not mind ice cube in coffee to help cool it *If neighbor does not mind adding cold cream *If neighbor does not mind pre-pouring coffee to allow it to cool *Only pour cup half full or less *Add cool water to coffee to cool it down" During the entrance conference on 07/28/14 at 9:30 a.m., the survey team requested a list of all residents deemed unsafe to handle hot beverages. A dietary staff member (#3) stated the facility did not maintain a list of residents deemed unsafe to handle hot beverages, but stated the facility considered Resident #1 and #3 at higher risk. During interview on 07/28/14 at 11:20 a.m., an administrative dietary staff member (#3) stated she does quarterly mini-nutritional assessments and annual nutritional assessments to determine the resident's ability to feed self. The staff member (#3) stated these nutritional assessments are the assessments the facility has always used and they have not changed the format since the survey completed on 05/29/14. The staff member (#3) stated not all of the residents in the facility have been assessed, but will be assessed when their quarterly assessments are due. - Observation on 07/28/14 at 11:40 a.m. showed Resident #8, drinking from a cup of coffee at the dining room table with no staff members present and steam rising from the cup of coffee. A certified nursing assistant (CNA #8) sat down briefly next to the resident, identified the placement of the food on the resident's plate, and then left. Observation then showed a staff member (#9) sitting across the table from Resident #8 feeding another resident. This staff member stated, "Oh you missed it," to Resident #8 as she attempted to use her fork to pick up a meatball. The staff member (#9) verbalized the location of the meatball on the plate to Resident #8. Observation showed Resident #8 picked up the cup of coffee, drank a few sips, and placed the coffee at the edge of the table. The resident continued to eat her meal with constant cuing as to the location of the food on the plate from the staff member across the table. Another staff member (#10) then sat next to the resident, moved the coffee cup away from the edge of the table, and verbally cued the resident for the remainder of the meal. Observation on 07/28/14 at 5:00 p.m. showed Resident #8 eating her meal in the dining room. A staff member sat across the table from Resident #8 feeding another resident. Observation showed Resident #8 feeding herself, with the edge of her plate approximately one and one-half inch over the edge of the table. Review of Resident #8's medical record occurred on 07/28/14. Medical [DIAGNOSES REDACTED]. Resident #8's quarterly Minimum Data Set, dated dated [DATE], identified moderately impaired vision. Resident #8's current care plan identified "Culinary: I need help with meals because I have trouble seeing. . . . Approach: . . . I can use a plate with a lip as needed. . . . Deliver my meals to me. Help me set up my food and tell me where it is. . . ADLS (activies of daily living): I do need assistance with my ADLS r/t (related to) dementia and impaired vision. . . ." Review of Resident #8's "Mini-Nutritional Assessment," dated 07/16/14 identified, "Quarterly assessment complete. . . . She is able to feed herself, but because of her poor vision, does need some help and supervision from staff. She utilizes a plate with lip to keep her food from falling onto the table or her lap and also is using built up silverware per her families request. (Name of resident) doesn't necessarily use the built up silverware r/t (related to) functional limitation, but rather, it is easier for her to see the dark black handles of the . . . silverware. . . ." The mini-nutritional assessment and the care plan did not address the safety of Resident #8 handling hot liquids. During an interview on the afternoon of 07/28/14, an administrative dietary staff member (#3) stated hot liquids are included in this assessment, but confirmed it is not documented. The facility provided documentation the afternoon of 07/28/14 which identified staff had assessed 33 of the facility's 50 residents using the nutritional assessment form, which does not include documentation of the residents ability to handle hot liquids. - Review of Resident #3's record occurred on 07/28/14. A dietary progress note, dated 06/18/14 at 1:24 p.m., stated, "CNA working with (Resident #3) came to me yesterday and stated taht (sic) (Resident #3's) husband has noticed that (Resident #3) is struggeling (sic) some with her liquids. He is worried that she is a risk for spilling. I had OT (Occupational Therapy) take a quick look at her and they are recommending that she utilize kennedy cups (covered cups ) when she is eating meals. I have notified the Dakotah homakers (sic) and will update her care plan." On the afternoon of 07/28/14, a dietary staff member (#3) stated OT staff document their assessments in a different computer program which can't be accessed by other staff members. The staff member (#3) stated she would attempt to obtain a copy of the assessment completed by OT for Resident #3. During an interview, on 07/28/14 at 5:05 p.m., an OT staff member (#4) provided the assessment completed on 06/18/14. The assessment stated, "Kennedy cups due to (increased) risk for spilling related to decline in medical status - shakey @ (at) times." The record indicated staff failed to assess Resident #3's safety when consuming hot liquids until after the resident's husband expressed his concerns regarding her safety and risk for spilling. During an interview on 07/28/14 at 5:05 p.m., the OT staff member (#4) stated she had completed no assessments for residents other than Resident #3 since the survey. The survey completed on 05/29/14 identified two residents with burns from hot liquids. The facility's Plan of Correction stated the residents would be assessed for their ability to handle hot liquids and identified a completion date of 07/15/14. The facility failed to assess all residents as identified in the Plan of Correction and failed to address each residents ability to safely consume hot liquids. Failure to assess all residents, including their safety regarding hot liquids, placed residents at risk of obtaining a burn. SAFE ENVIRONMENT: 2. Based on observation and staff interview, the facility failed to maintain an environment free of hazardous chemicals on 1 of 1 special care unit (Sunflower). Accessible hazardous chemicals, and scissors; and personal items of residents' living in the secured unit, placed cognitively impaired and wandering residents at risk for accidents and injury and the potential for personal items of residents to become misplaced. Findings include: Observation on 07/28/14 at 10:20 a.m., showed a set of cabinets and drawers located in the dining/day area of the Sunflower unit. The unlocked cabinets and drawers contained the following items: *upper large two door cabinet contained individual bins for residents' eye glasses, and hearing aides; three denture cups containing dentures; a container of Super Sani-cloth germicidal wipes; Saf Clens Derma Wound Cleaner in a spray bottle, and finger nail polish *drawers located on the right side below the cabinets contained a pair of scissors and assorted items for wound care *drawers located on the left side below the cabinets contained assorted electric razors, several finger nail clippers, finger nail polish and finger nail polish remover Observation showed each drawer and cabinet had the ability to be locked. During an interview on 07/28/14 at 10:25 a.m., a certified nursing assistant (CNA) (#7) stated, regarding the cabinets and drawers, "it should all be locked but we have been so busy." Observation on 07/28/14 at 11:35 a.m., showed the same set of cabinets and drawers unlocked, with only the right side bottom two drawers locked, which contained staff items. Observations at 3:30 p.m., showed the cabinet and all the drawers locked. Observations throughout the times listed above showed residents in the area and one resident wandering throughout the unit. During an interview on 07/28/14 at 7:15 p.m., an administrator (#1), stated that area of storage should be locked.

1. Based on observation, record review, review of facility policy, review of a professional reference, and staff interview, facility staff failed to adequately assess the nutritional status, needs and risk factors, and implement appropriate interventions to restore/maintain adequate nutritional status for 3 of 3 sampled residents (Resident #1, #8 and #10) identified with severe weight loss. Failure to monitor residents, implement, and evaluate the nutritional needs of compromised residents, consistent with their comprehensive assessment, resulted in severe weight loss in each of these residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) has outlined the parameters for evaluating significance of unplanned & undesired weight loss: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% Review of the facility policy "WEIGHT MONITORING AND DOCUMENTATION" occurred on 07/13/11. The policy, undated, stated, "Each resident's weight is monitored and fluctuations of (greater than or equal to) 5% in one month, or (greater than or equal to) 7.5% in 3 months, or (greater than or equal to) 10% over the past six months will be assessed and appropriate individualized dietary interventions and documentation will be implemented. The facility must ensure that a resident maintains parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. . . . PROCEDURE . . . a. Nursing staff is to verify the accuracy if the weight change. (sic) Reweighs are recommended for residents with a 5-pound or greater change in weight. b. Dietician/designee will meet with the licensed nursing staff to determine possible causes and intervention for resident (sic) with significant weight loss and well as (sic) for those as risk (sic) for unintended weight loss. * Reassess actual food and fluid intake * Assess potential contributing factors: * Acute illness * Multiple medical problems/diseases * Chewing and/or swallowing difficulties * Change in functional eating ability * Changes in cognition . . . * Medication side effects . . . c. Reassess diet order 8. The dietitian/designee will document progress and assessing weight concerns using the following suggested guidelines: * Current weight * Amount of weight loss or gain * Caloric needs . . . * Diet order including supplement use * Estimation of calories provided including snacks * Estimation of calories actual consumed * Possible reason for weight change * Plan/approach for intervention 9. Dietician/designee will update the care plan. . . ." - Review of Resident #1's medical record occurred on all days of survey. The facility admitted the resident in November of 2010 with [DIAGNOSES REDACTED]. The record identified the resident on a regular diet and no supplements. Review of Resident #1's Minimum Data Set (MDS), completed since admission identified the resident's cognitive function and feeding assistance ability as: * admission MDS, dated [DATE], identified the resident usually understood, usually able to understand others, severe impairment in cognitive function (BIMS score of 5), and required limited assist of one person with eating * quarterly MDS, dated [DATE], identified the resident required extensive assistance from one person with eating * quarterly MDS, dated [DATE], identified the resident usually understood, usually able to understand others, with a short and long term memory problem, moderately impaired in daily decision making, and required limited assist of one person with eating. Review of Resident #1's MDSs, completed since admission, identified the resident experienced severe weight loss over a six month period: * 11/22/10, Admission: Weight 165 pounds (lbs) * 02/14/11, Quarterly: Weight 152 lbs (a severe weight loss of 7.8% over 3 months) * 05/12/11, Quarterly: Weight 144 lbs (a severe weight loss of 12.7% over 6 months) Review of Resident #1's weight records identified these additional weights: * 05/07/11: 144.4 lbs * 05/28/11: 137.4 lbs, a 4.8% weight loss in less than 2 weeks * 06/01/11: 143.2 lbs. The record lacked evidence of a re-weigh as per facility policy. * 06/08/11: 133.0 lbs, a 7.6% weight loss in 1 month The record lacked evidence of weights recorded after this date. Review of Resident #1' s medical record, including physician progress notes [REDACTED]. weight loss. A nutritional status Care Area Assessment (CAA), dated 11/22/10, identified Resident #1 ". . . doesn't have any particular foods she will not eat, but she is not a big eater either. She will occasionally ask for smaller portions. . . . Functional problems that affect ability to eat . . . Inability to perform ADLs (Activities of Daily Living) without significant physical assistance . . . Family wishes for us to continue to encourage her to eat. . . . triggered this CAA . . . currently weighs 162 lbs . . . eats by herself . . . does have congnative (sic) imparements (sic) r/t (related to) [MEDICAL CONDITION] and needs cueing from either her husband . . . or staff to come for meals as well as eat and drink. . . . is not a big eater . . . We will allow her to continue to eat smaller portions when she requests them. We will also continue with the assistance at meals. . . . proceeding with a care plan as we wish to continue with the assistance at meals. . . . needs some cueing and reminders as well as occasional reassurance during meals. We will also allow her to request small portions if she wants." Review of Resident #1's current care plan identified the following problem: * "CULINARY - I have relied on my husband (name) to tell me what to do for many years, now that he is gone, I feel very lost. I need some help at meals. I don't have a big appetite and I don't drink adequately" with goals of "I want my weight to be stable and i don't want to get dehydrated this quarter." Approaches included, "Assist me in making food choices, I am on a regular diet, I am on the hydration list. please watch me for any s/s (signs or symptoms) of dehydration and report them to the nurse right away. You may need to remind me that it is time to eat, or offer me reassurance during meals. Encourage me to eat/drink." The care plan did not identify the problem of weight loss, nor the the areas addressed in the CAA including how to address the resident's individuality of not being a "big eater," offering of small portions, and providing assistance with meals. An admission Nutrition Assessment, completed on 12/02/10, identified Resident #1 with the following: * ". . . enjoys drinking milk, juice and coffee. She is not a big eater. . . . regular diet. . . . Supplements . . . none at this time . . . (estimated calorie needs) 1467 kcal . . . Est Fluid Needs = 1875 ccs (cubic centimeters) . . . No or unknown (weight loss) . . . Eating ability . . . Feeds self after set-up . . . Requires Supervision and/or Cueing . . . Inadequate energy intake evidenced by oral intake of meals and snacks of approximately 50% secondary to lack of interest in food related to dementia . . . staff assist with cueing and assist as necessary to support adequate intake to reduce indidence (sic) of weight loss. regular diet." Dietary progress notes, completed by the dietary manager, stated: * 11/23/10: ". . . new neighbor . . . She is confused so will need . . . cueing to come to meals . . . She is a small eater, and has been eating around 50% at meals so far. Her fluid intake is often less than 1000 cc/day so I have put her on the hydration list. . . ." * 02/15/11: "Quarterly assessment complete. (Resident) doesn't have any oral problems. her (sic) weight is 152 lbs and is down about 12.6 lbs in the past 6 months. She has not been eating a lot at meals and needs a lot of encouragement and cueing to keep eating once her meal has been set up for her. She is on a regular diet. We will continue with our current plan of care." A mini-nutritional assessment, (same date) completed by the dietary manager, indicated the following: no nutritional supplement, no therapeutic diet, weight change greater than a 7.5% (severe weight loss in 3 months), current oral intake fair (50-75%) with meals, moderate loss of appetite, "Feeds Self With Some Difficulty." The assessment failed to identify the need for an evaluation by the dietician or a change in the plan of care. * 02/17/11: ". . . has not been eating breakfast very well. We have tried offering a variety of different things, with little success. She does do somewhat better at lunch and supper, but is still not eating very well then either. We will continue to offer cueing and physical support, when needed." * 04/05/11: "(Resident's) intake continues to be fair at best. She needs a lot of encouragement from staff to eat. breakfast (sic) is her poorest meal. Sometimes we are successful and get her to eat some, sometimes not. I have considered a liquid supplement, but she drinks less than she eats. Her weight has been pretty stable for the past month. I will continue to watch her." * 05/12/11: "Quarterly assessment complete. (Resident) doesn't have any oral problems. . . . weight is 144.4 lbs and has been pretty stable since March, but is still greater that 10% loss over 6 months. She is on a regular diet. She needs a lot of reminders and cueing at meals to get her to eat. She has been eating poorly in the morning - seldome (sic) over 25% at breakfast, about 26-50% at lunch and 51-75% at supper. Her fluid intake continues to be insufficient. She is at risk for dehydration with her current fluid intake. I will continue to monitor her weight and her intake as we would like her weight to remain stable." A mini-nutritional assessment, (same date) completed by the dietary manager, indicated the following: no nutritional supplement, no therapeutic diet, weight change greater than 10% (severe weight loss) in six months, poor to fair oral intake (50-75%), and not meeting her current intake needs. The assessment failed to identify the need for an evaluation by the dietician or a change in the plan of care. * 05/16/11: "(Resident's) weight is 141.8 and is down a few lbs since her last weight on the 4th. I don't see a change in her intake. I will continue to watch her." * 06/08/11: "Last weight was 143.2 lbs and is up a few lbs since her last weight on the 4th. Continue plan of care." * 07/04/11: "(Resident's) appetite has not been good. We have been struggeling (sic) to get her to feed herself, so we have moved her to and (sic) assist table, where she can get some help with meals. Her weight has declined also and is 133 lbs currently (this is the 06/08/11 recorded weight)." Record review identified facility staff documented Resident #1 had four HS snacks given in the 4 week period between June 13 and July 11, and documentation identified "None" on 15 of 28 of those days. Review of care conference notes, dated 02/11/11 and 05/20/11, lacked evidence the interdisciplinary team recognized Resident #1's severe weight loss and informed the resident's physician. During an interview on the morning of 07/13/11, an administrative staff member (#1) stated nursing staff informed the provider/physician on rounds, however could provide no documentation to support Resident #1's physician had been informed of her severe weight loss. Observation on all days of survey identified the following: * On the evening of 07/11/11, Resident #1 sat at a feeding assist table, actively participated in eating, and then received cueing and feeding assistance from a staff member until she ate almost 50% of the evening meal. * On 07/12/11 at 8:20 a.m., one staff nurse (#8) and one certified nursing assistant (CNA) (#9) transferred Resident #1 from her wheelchair to recliner in her room. The staff nurse (#8) stated Resident #1 ate "poorly" for breakfast, and so the staff nurse stated she gave Resident #1 "part of" a health shake for breakfast. Intake records identified Resident #1 consumed 1-25% of breakfast and 60 cubic centimeter (cubic centimeters) of fluid for breakfast. * 07/12/11 at 11:45 a.m., after Resident #1 sat in the recliner since 8:20 a.m., two CNAs (#9 and #10) transferred Resident #1 to her wheelchair, gave her a drink of water which she took a sip, asked her if she was hungry, to which she said "no" and transported Resident #1 to the dining room. * 07/12/11 from 12-12:30 p.m., Resident #1 sat at an assisted table, and fed herself a few bites of her meal. Part way through the meal, a staff member, sitting at the table, provided assistance and cueing. Resident #1 consumed less than 25% of the meal, and documentation stated she consumed 360 cc of fluid. * 07/13/11 at 8:20 a.m., Resident #1 sat alone at a dining room table with her meal which included a cut up pancake, sausage, a glass of juice and a glass of liquid shake. Observation showed the resident had consumed a portion of the pancake and sausage. A staff nurse, while standing at her medication cart, stated, "I am going to come and assist her after awhile." Ten minutes later, a supervisory staff nurse (#1) arrived and started assisting Resident #1 to eat. During observation of cares on all days of survey, various staff offered Resident #1 water during cares, and Resident #1 never refused, although she took a small quantity each time. During interview on the morning of 07/12/11, a supervisory dietary staff member (#2) stated the following regarding Resident #1's weight loss: * Resident #1 experienced a severe weight loss since her admission in November * the dietician had not evaluated Resident #1's severe weight loss * no dietary measures have been implemented to offer additional food between meals for Resident #1 * Resident #1 eats breakfast poorly, and she does not get anything offered in the a.m. for additional nourishment after breakfast as she is resting during that time * Resident #1 refuses most liquids, so supplements between meals and/or with med pass have not been attempted * dietary has not attempted to add enhanced (additional calories) to Resident #1's foods * there is, and has not been a written plan developed and implemented to prevent Resident #1's weight loss - Review of Resident #10's record occurred on July 11-12, 2011. Resident #10's medical [DIAGNOSES REDACTED]. Review of Resident #10's MDSs, identified the resident experienced a severe weight loss over a six month period: * 11/02/10, Significant change: Weight 158 lbs * 02/02/11, Quarterly: Weight 138 lbs (a severe weight loss of 12.6% over 3 months). The MDS identified no nutritional approaches in place. * 05/02/11, Quarterly: Weight 129 lbs (a severe weight loss of 18% over 6 months). The MDS identified the resident on a therapeutic diet, and physician ordered supplements on 04/28/11. Review of Resident #10's weight records identified the last recorded weight on 06/10/11 as 129.4 lbs. and no weights after that date. Review of Resident #10' s medical record for the months of December 2010 through April 28, 2011 lacked evidence the facility informed Resident #10's provider of the severe weight loss. A nutritional status CAA, dated 11/03/10, stated ". . . we will care plan to continue w/ (with) hydration list r/t poor fluid intake as well as continued assistance w/ setup at meals . . . She does have some confusion r/t (related to) dementia, and often is living in the past. She may need reminders that it is meal time . . . " Review of Resident #10's current care plan identified the following problem: * "CULINARY - I am sometimes independent at meals, and sometimes need assistance. I am confused, so may need to be reminded to come to them, or be told which meal it is. I occasionally complain that food is hard to chew or swallow. I eat well, but don't like to drink . . . I love ice cream. I don't always eat well, and am at high risk for weight loss." Approaches, with the date implemented, included the following: * 05/01/11: "I may need encouragement at meals to eat." * 05/01/11: "offer me 2 oz (ounces) of 2 cal HN (high nourishment) with med pass." * 11/09/09: "bring my food to my table. You may need to help me set it up. You may need to wake me if I am sleeping, or need to remind me that it is meal time. Watch me to see if I am eating. I may need reminders or cues to eat." * 11/09/09: "I may ask for soft foods if I have trouble chewing or swallowing something, but usually I will eat regular foods." * 11/09/09: "My husband and I used to eat ice cream every night before bed. Please give me ice cream as a bed time (snack) as I still enjoy it." A dietary progress note, dated 11/02/10, stated, ". . . Her weight is 158 lbs and is stable. There is a more recent weight of 150 lbs, but I don't believe it to be correct. I don't have any concerns for her at this time. The dietician will complete the assessment." Review of Resident #10's weight records identified the following weights: * 10/15/10: 158.5 lbs * 10/22/10: 158.2 lbs * 10/29/10: 149.8 lbs, an 8 pound weight loss. The record lacked evidence of a reweigh according to facility policy. * 11/12/10: 147.6 lbs., an 11 pound weight loss or 6.9% weight loss in 1 month * 11/27/10: 142.1 lbs A Nutrition Assessment, completed on 11/16/10, by the dietician, identified the resident's food likes, food and fluid intake at meals, fluid and caloric needs, eating ability and identified the resident on a regular diet, not on a therapeutic diet, on no supplements, and consistency as tolerated diet. The dietician wrote: "Unintended weight loss related to intake inconsistant (sic) with estimated energy requirements evidenced by (greater than) 10 # (lb) weight loss in 1 month and less snacking and smaller portions at meals related to more sleeping and confused at meals. Nutrition Interventions . . . Staff to offer assistance and monitoring at meal time to ensure an adequage (sic) intake. staff to evaluate increased confussion (sic) and or depression as it relates to food intake. Identify food preferences and honor them." Dietary progress notes continued to show Resident #10's weight loss without interventions: * 01/17/11: Weight is 138 lbs . . . continues to eat about half of her food at meals, and is not drinking well. Her weight does however seem to holding (sic) it's own in the upper 130- lb range. She has been neededing (sic) extensive assistance at meals." * 02/01/11: Quarterly assessment complete . . . weight is 138 . . . stable for over a month, but is still triggering a weight loss over 6 months. Her weight 6 months ago was 158 lbs. . . . * 02/17/11: ". . . has been eating about the same. . . she often will yell at staff and bang her cup, or other items on the table to get staff attention. Staff respond to her, but she usually either doesn't want anything, or is not sure what she wants . . . She is seated by the CNAs in the dining room so she can be assisted easier." * 02/22/11: "Weight is 131.4 lbs and has declined since her last weight- which was 137.2 lbs a week ago . . . continues to eat poorly at times . . . I will continue to watch her." * 03/30/11: "Weight has dropped a little again . . . is . . . 129 lbs. . . . has been sleepy at meals. Likely due to medications. However, when her medication is not given, she is very restless and doesn't eat either. She is not a good drinker, and is pretty particular about what she will drink, so it is pretty unlikely that she would accept a liquid supplement. she likes ice cream, but even has not been eating that well lately. We will continue to offer her encouragement and cueing. I will continue to monitor her." * 04/05/11: ". . . weight is down again. 127.5 lbs. . . . I will talk with the RN (registered nurse) coordinators to see if there would be a possibility of adding something between meals or with med pass." * 05/01/11: "Quarterly assessment . . . recently started giving her 2 cal HN with med pass- 2 oz. . . ." Review of care conference notes, dated 02/02/11 and 05/11/11, lacked evidence the interdisciplinary team developed measures to address Resident #10's severe weight loss, or informed the resident's physician of the severe weight loss. Observation on all days of survey showed Resident #10 sat at a table where staff did not provide feeding assistance during meal time unless they moved from an adjacent feeding assist table. During interview on the morning of 07/13/11, a supervisory dietary staff member (#2) stated the following regarding Resident #10's weight loss: * Resident #10 experienced a severe weight loss between November 2010 and May 2011 * Resident #10's weight loss was not a planned weight loss * Resident #10 sat at an assist table "for a period of time", but has not always * Resident #10's care plan did not reflect changes in care to address the weight loss The facility failed to develop, implement and evaluate interventions to address Resident #1's and #10's decreased food intake and severe weight loss. The facility failed to develop an interdisciplinary team approach to Resident #1's and #10's weight loss. The facility failed to closely monitor these resident's meal intake records, including HS snacks. The facility failed to provide both residents consistent meal time assistance, and closely monitor both resident's weights. - Review of Resident #8's medical record occurred on all days of survey. The facility admitted the resident in March of 2011 with [DIAGNOSES REDACTED]. A clinic progress note, dated 04/06/11, stated ". . . ASSESSMENT: 1. Dysphagia. 2. Meal-related abdominal pain. PLAN: At this time I discussed proceeding with an upper endoscopy both to investigate her difficulty swallowing as well as her abdominal discomfort. . . ." The medical record identified the resident had a endoscopy and dilation of the esophagus on 04/29/11. Review of Resident #8's record occurred on all days of survey. Resident #8's weight records identified the following weights recorded since admission: * 03/16/11: 125.4 pounds (lbs) (recorded on the resident's admission MDS) * 04/05/11: 122 lbs * 04/27/11: 120 lbs * 05/04/11: 116.4 lbs * 05/11/11: 117.0 lbs * 05/18/11: 111.8 lbs * 05/25/11: 115 lbs * 06/01/11: 119.4 lbs (recorded on the resident's 06/06/11 quarterly MDS) * 06/08/11: 115.4 lbs; a 10 lb wt loss (a severe weight loss of 7.9% in less than 3 months) Review of Resident #8's medical record, including physician progress notes [REDACTED]. weight loss. A nutritional status CAA, dated 03/17/11, identified Resident #8 with dysphagia and able to tolerate a regular diet and able to eat independently. The CAA stated the resident made her own food choices and was able to make independent choices regarding her health. The CAA stated, "We will care plan for (Resident #8) to have her meals delivered to her. We will follow her wishes as best as we can in allowing her to sleep in, and eat a late breakfast. We will also avoid foods that cause irritation to her diverticulitis." Review of Resident #8's current care plan stated: * "CULINARY - I don't have a big appetite, and don't drink very much. I do have some swallowing problems, but can tolerate regular foods. I should avoid eating foods with seeds or skins. I may need help at meals." The plan identified a goal of "I want to be independent and be served food that does not irritate my digestive tract." Approaches included: "Deliver my food to my table. I may need help with tougher food packets; I am on the hydration list. Please watch me for any signs of dehydration and report them immediately to the nurse; Serve me a regular diet, but avoid seeds and skins." The care plan failed to included delivery of meals to the resident's room, lacked any evidence the resident experienced a severe weight loss, contributing factors, and approaches to address the severe weight loss. The care plan failed to identify the resident has a [DIAGNOSES REDACTED]. A Nutrition Assessment, completed on 03/30/11, by the dietician, identified the resident "likes to sleep in and eat breakfast late. when she does she does not wish to eat lunch. . . . she does not like drinking milk. . . ." The assessment identified the resident "Coughs or chokes during meals or when swallowing medications." Dietary progress notes stated: * 05/16/11: ". . . weight is 117 lbs and is down a few lbs since moved into (facility). This is not suprising (sic) as she likes to skip meals frequently. She often eats breakfast late and then will refuse lunch, but then will eat supper. She does snack some between meals, and does take food from the den frequently. I will continue to watch her as we don't want her skipping meals to hurt her health." * 06/08/11: Quarterly assessment complete . . . dx (diagnosis) of dysphagia. She has not however, had any symptoms of swallowing problems lately. Her weight is 119.4 lbs and is down about 6 lbs in the past quarter, which is not enough to be considered significant, but is up this past month. She continues on a regular diet, but we avoid seeds . . . will skip meals almost daily. . . . does snack on food in her room as well as food that we keep in the den area. She is independent in her mobility and is able to get food on her own. . . ." * 07/04/11: ". . . has been eating around 50-100% at meals. She continues to skip a lot of meals, usually lunch, and sometimes supper. Her weight is 115 lbs and is within a healthy weight range." Observation on all days of survey showed Resident #8 did not attend the open breakfast meal, and did not eat lunch on 07/12/11. During interview on the morning of 07/13/11, a supervisory dietary staff member (#2) stated the following regarding Resident #8's weight loss: * Resident #8 experienced a severe weight loss since admission to the facility * Agreed the facility failed to recognize the severe weight loss * The facility failed to develop and implement measures to prevent the weight loss from occurring * Resident #8's care plan did not reflect changes in care to address the weight loss * Resident #8's weight loss was not a planned weight loss The facility failed to recognize Resident #8's severe weight loss which occurred over a 4 month period. As a result, the facility failed to develop, implement and evaluate interventions to address Resident #8's decreased food intake. During interview on the morning of 07/13/11, two administrative staff members (#1 and #11) stated the facility sit/stand lift scale became inoperable five weeks ago and attempts to repair the scale were unsuccessful. The administrative staff member (#1) stated nursing staff weigh residents weekly so they can tell if the scale is a problem, rather than do reweighs. The administrative staff members (#1 and #11) provided no additional information regarding the weight loss for Resident #1, #8 and #10. 2. Based on record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure the accuracy of resident weights, and failed to ensure weighing of residents occurred, including residents identified with severe weight loss (Resident #1, #8, and #10) due to the lack of a sit/stand lift scale for over a five week period. Failing to ensure staff obtained accurate weights, including reweighs, and failing to obtain weights of residents who experienced unplanned weight loss limits the facility's ability to monitor resident's changing conditions. Findings include: The Centers for Medicare and Medicaid Services (CMS) has outlined the current standards of practice for weighing the resident. Obtaining accurate weights for each resident may be aided by having staff follow a consistent approach to weighing & by using an appropriately calibrated & functioning scale (e.g., wheelchair scale or bed scale). Since weight varies throughout the day, a consistent process & technique (e.g., weighing the resident wearing a similar type of clothing, at approximately the same time of the day, using the same scale, either consistently wearing or not wearing orthotics or prostheses, & verifying scale accuracy) can help make weight comparisons more reliable. Review of the facility policy "WEIGHT MONITORING AND DOCUMENTATION" occurred on 07/13/11. The policy, undated, stated, "Each resident's weight is monitored . . . and documentation will be implemented. The facility must ensure that a resident maintains parameters of nutritional status, such as body weight . . . unless the resident's clinical condition demonstrates that this is not possible. . . . PROCEDURE . . . a. Nursing staff is to verify the accuracy if the weight change. (sic) Reweighs are recommended for residents with a 5-pound or greater change in weight. . . ." A system to verify weights can help to ensure accuracy. Weights obtained in different settings may differ substantially. For example, the last weight obtained in the hospital may differ markedly from the initial weight upon admission to the facility, & is not to be used in lieu of actually weighing the resident. Approaches to improving the accuracy of weights may include reweighing the resident & recording the current weight, reviewing approaches to obtaining & verifying weight, & modifying those approaches as needed. - Review of Resident #1's record occurred on all days of survey. Resident #1's weight records identified the following weights: * 05/07/11: 144.4 lbs * 05/28/11: 137.4 lbs, a 4.8% weight loss in less than 2 weeks. The record lacked evidence of a reweigh. * 06/01/11: 143.2 lbs * 06/08/11: 133.0 lbs, a 7.6% weight loss in 1 month and a 7.1 % loss in one week. The record lacked evidence of a reweigh. The record lacked evidence of weights recorded after this date. - Review of Resident #8's record occurred on all days of survey. Resident #8's weight records identified the following weights recorded since admission: * 03/16/11: 125.4 lbs * 04/05/11: 122 lbs * 04/27/11: 120 lbs * 05/04/11: 116.4 lbs, a weight loss of 4.6 lbs in one week. The record lacked evidence of a reweigh. * 05/11/11: 117.0 lbs * 05/18/11: 111.8 lbs, a weight loss of 6.2 lbs in one week. The record lacked evidence of a reweigh. * 05/25/11: 115 lbs * 06/01/11: 119.4 lbs, a weight gain of 4.4 lbs in one week. The record lacked evidence of a reweigh. * 06/08/11: 115.4 lbs; a 10 lb wt loss (a severe weight loss of 7.9% in less than 3 months) The record lacked evidence of weights recorded after this date. - Review of Resident #10's record identified the resident experienced a severe weight loss over a six month period between November 2010 and May 2011. Review of weight records identified the following: * 10/22/10: 158.2 lbs * 10/29/10: 149.8 lbs, a weight loss of 8.4 lbs. The record lacked evidence of a reweigh. * 11/12/10: 147.6 lbs (next recorded weight after the above weight) * 02/11/11: 137.2 lbs * 02/18/11: 131.4 lbs, a weight loss of 5.8 lbs. The record lacked evidence of a reweigh. * 03/04/11: 132.3 lbs (next recorded weight after the above weight) * 06/10/11: 129.4 lb Resident #10 last logged weight occurred on 06/10/11. The record lacked evidence of weights recorded after this date. During an interview with two administrative staff members (#1 and #11) on the morning of 07/13/11, an administrative staff member (#1) stated nursing staff weigh residents weekly so they can tell if the scale is a problem, rather than do reweighs. The staff members stated the facility sit/stand lift scale became inoperable five weeks ago and attempts to repair the scale were unsuccessful on two occasions. The staff members stated residents requiring weights with the sit/stand scale have not been done since then. The staff member (#11) stated residents determined to need weights could be weighed with the facility Hoye