Every finding on record at Bethany on University

Based on observation, record review, review of facility policy, and staff interviews, the facility failed to follow infection control standards for 3 of 8 sampled residents (Residents #11, #94, and #118) on enhanced barrier precautions (EBP). Failure to follow infection control practices has the potential to spread infection throughout the facility. Findings Include: Review of the facility policy titled, Hand Hygiene occurred on 02/12/26. This policy revised February 2021, stated, . Hand Hygiene Table . after removing personal protective equipment (PPE), including gloves . [cleanse hands with] Either Soap and Water or Alcohol Based Hand Rub . Review of the facility policy titled, Infection Control - Enhanced Barrier Precautions occurred on 02/12/26. This policy revised May 2025, stated, . Enhanced Barrier Precautions (EBP) . infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves use during high contact resident care activities. High-contact resident care activities include: . Device care . central lines, urinary catheters . -Review of Resident 11's medical record occurred on all days of survey. The current care plan stated, . [Resident #11] on Enhanced Barrier Precautions for Catheter Use . Observation on 02/11/26 at 1:00 p.m. showed an EBP sign on Resident 11's door, a certified nurse aide (CNA) (#2) changed the resident's catheter drainage bag change without applying a PPE gown. The CNA (#2) then applied a gown and stated she normally would have put one on before doing cares. The CNA (#2) completed the cares, removed the gown and gloves and without performing hand hygiene, exited the room.The CNA (#2) failed to apply a gown prior to beginning catheter drainage bag change and perform hand hygiene after removing the soiled gown and gloves. -Review of Resident #94's medical record occurred on all days of survey. The current care plan stated, . is on Enhanced Barrier Precautions for wound drain. Observation on 02/09/26 at 8:48 a.m. showed an EBP sign on Resident #94's door frame and a CNA (#4) in the resident's room with gloves on. The CNA (#4) applied heel boots to Resident #94's feet and adjusted the resident's bedding. The CNA removed her gloves, performed hand hygiene and exited the room. The CNA (#4) failed to apply a gown prior to doing close contact cares. Observation on 02/10/26 at 3:18 p.m. showed a CNA (#5) applied a gown and gloves to complete incontinence cares for Resident #94. After completing perineal care, the CNA (#5) removed the soiled gloves, and without performing hand hygiene, applied clean gloves and barrier cream to the buttocks area. The CNA removed the soiled gloves and without performing hand hygiene, applied clean gloves, placed a brief under the resident, and applied barrier cream to the perineal area. The CNA removed the soiled gloves and without performing hand hygiene, applied clean gloves, adjusted the brief, and the resident's bedding, and placed the call light within the resident's reach. The CNA (#5) failed to perform hand hygiene after removing the soiled gloves and before applying the clean gloves. - Review of Resident #118's record occurred on all days of survey. The current care plan stated, . on Enhanced Barrier Precautions for wounds and PICC [peripheral intravenous central catheter] line. Observation on 02/09/26 at 1:24 p.m. showed an EBP sign on Resident #118's door. A nurse (#1) entered Resident #118's room, performed hand hygiene, moved the bedside table next to the bed, and retrieved gloves from his/her pants pocket. The nurse placed the gloves, laboratory tubes, and sterile syringes onto the bedside table without cleaning the surface or placing a barrier. The nurse performed hand hygiene, applied gloves and without applying a gown, cleansed the PICC line port with alcohol, flushed the line, and withdrew blood twice from the port. The nurse (#1) failed to properly clean the bedside table, place a protective barrier, and apply appropriate PPE prior to obtaining a laboratory blood draw and administering intravenous medication. Additionally, the nurse (#1) failed to clean the bedside table after completing the blood draws and medication administration. During an interview on the afternoon of 02/12/26, an administrative nurse (#3) confirmed she expected staff to wear proper PPE when performing high-contact resident care activities and perform hand hygiene after removing gloves and before applying clean gloves.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the State Long Term Care Ombudsman a written notice of transfer/discharge for 1 of 5 closed records (Resident #177) reviewed for discharge. Failure to notify the State Ombudsman of resident discharges does not allow the State Ombudsman to advocate for the resident and/or their representative regarding their options and rights. Findings include:Review of the facility policy titled Transfer And Discharge Policy occurred on 02/12/26. This policy, dated February 2020, stated, . Contents of the notice must include: The reason for transfer or discharge; The effective date of transfer or discharge; . A copy of the notice shall be provided to a representative of the Office of the State Long-Term Care Ombudsman. Review of Resident #177's medical record occurred on 02/12/26 and identified a discharge from the facility on 11/24/25. The record lacked evidence the facility notified the State Ombudsman of the discharge. During an interview on 02/12/26 at 10:57 a.m. an administrative staff member (#6) confirmed the facility failed to notify the State Ombudsmen of Resident #177's discharge.

Based on record review and review of facility policy the facility failed to provide the resident or resident representative with written discharge instructions for 1 of 2 sampled residents (Resident #190) who were discharged . Failure to provide written discharge instructions to residents leaving the facility may affect the continued health and safety of the residents discharged to the community.Findings include:Review of the facility policy titled TRANSFER AND DISCHARGE POLICY (including AMA [against medical advice) occurred on 02/12/26. This policy, revised February 2020, stated, . For a community discharge, a discharge summary and plan of care should be prepared for the resident.Review of Resident #190's medical record occurred on 02/12/26 and identified a discharge from the facility on 01/09/26. The record lacked evidence the facility provided written discharge instructions to the resident or the resident representative.

Based on record review, review of professional reference, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 sampled resident (Resident #1). Failure to follow physician's orders may result in adverse health consequences and/or delayed treatment for the resident. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, . It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #1's medical record occurred on 06/04/25 and identified a surgical procedure scheduled on 05/22/25. Preoperative orders, dated 05/12/25, stated, . Warfarin (Coumadin) [a blood thinner] -contact Coumadin Clinic or prescribing provider [about medication hold time before surgery]. A progress note, dated 05/16/25 at 7:03 p.m., stated, . Hold Coumadin (Jantoven) 5/16/25 until procedure done [05/22/25]. Review of Resident #1's May 2025 Medication Administration Record (MAR) identified the resident received coumadin on 05/17/25 and 05/18/25. During an interview on 06/04/25, an administrative nurse (#1) confirmed staff failed to hold when the coumadin not held as the physician ordered.

Based on record review and review of professional reference, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #3) reviewed for pre-operative medication orders. Failure to hold scheduled medications prior to surgery according to physician's orders may result in adverse outcomes for the resident. 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 and medications ordered by the physician or primary care provider. It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Clarification from any other source is unacceptable and regarded as a departure from competent nursing practice. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #3's medical record (electronic and paper) occurred on 01/29/25. Physician's orders in the paper medical record stated, okay to take day of surgery [11/25/24]: Tylenol [pain medication], combivent respimat [inhaler medication for the lungs], amlodipine [blood pressure medication], symbicort [inhaler medication for the lungs], cymbalta [antidepressant medication], gabapentin [medication used to treat pain and seizures], levothyroxine [thyroid medication], metoprolol [blood pressure medication], oxycodone [pain medication], prednisone [steroid medication], simvastatin [cholesterol lowering medication]. Hold all others morning of surgery. Review of Resident #3's medication administration record (MAR) showed facility staff administered the medications the physician identified as ok to take. In addition, facility staff administered furosemide (diuretic medication), Calcium plus Vitamin D (mineral and vitamin medication), Cholecalciferol (vitamin D medication), and Acidophilus (probiotic medication) on the morning of 11/25/24. Facility staff failed to follow the physician's order to hold all other medications on the morning of 11/25/24. 19410

Based on observation, record review, review of professional reference, and resident and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 8 sampled residents (Resident #34, #88, and #139) receiving treatment for a wound or pressure ulcer. Failure to practice infection control standards related to enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the Centers for Disease Control document titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 06/28/24, stated, . Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). In the guidance, wound care is included as a high-contact resident care activity and is generally defined as the care of any skin opening requiring a dressing. However, the intent of Enhanced Barrier Precautions is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. This generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, and chronic venous stasis ulcers. - Review of Resident #34's medical record occurred on all days of survey. A physician's order, dated 09/19/24, identified the onset of an open unstageable pressure ulcer (PU) to the coccyx. The care plan stated, . [resident] is at risk for developing a pressure ulcer due to: malnutrition, moisture, decreased activity, decreased mobility, nutrition, friction/sheer and/or history of pressure injury. [resident] has a unstageable PU to coccyx. Observation on 10/23/24 at 9:27 a.m., failed to show a sign for EBP on Resident #34's door or in her room. A staff nurse (#4) entered Resident #34's room and failed to don a gown before performing a dressing change on an open/draining wound. Observation on 10/23/24 at 9:47 a.m., failed to show a sign for EBP on Resident #34's door or in her room. Two certified nurse aides (CNAs) (#5 and #6) entered Resident #34's room and failed to don a gown before performing cares and transfering the resident to and from the toilet. During an interview on 10/23/24 at 3:29 p.m., a managerial staff member (#7) stated, We have not used EBP for newer wounds. 45873 - Review of resident #88's medical record occurred on all days of survey and showed diagnoses of non-pressure chronic ulcer of the left lower leg, right heel, right midfoot and other part of right foot with fat layer exposed present on admission. Physician's orders stated, . L) [left] anterior lower leg, L) lateral foot, R) [right] heel, R) medial foot, R) third toe, and any other open wound to BLE [bilateral (both) lower extremities (legs)]: Cleanse with soap and water each dressing change. Apply skin prep [a moisture barrier]. Allow to dry. Then cover with dry gauze. Then apply tubigrip [a type of covering] from toes to knees bil [bilateral] for light compression. Change dressing BID [two times a day] and PRN [as needed]. Should gauze stick upon removal simply get gauze wet for easy removal. The current care plan stated, [Resident] has several arterial ulcers to bilateral lower extremities. Observation on 10/22/24 at 8:57 a.m., failed to show a sign for EBP on Resident #88's door or in her room. A staff nurse (#8) entered room, performed hand hygiene, applied gloves, and applied wet towels to the resident's lower legs to moisten the old dressing. After removing the outer dressing, gauze pads stuck to the wound on the left leg requiring further moistening. After removing the dressing, the staff nurse (#8) proceeded with the dressing change. Staff nurse (#8) failed to don a gown before performing a dressing change on an open/weeping wound. 28398 - During an interview on 10/22/24 at 9:14 a.m., Resident #139 stated she came to the nursing facility from the hospital about a month ago with a wound on her right lower abdomen, which the doctor debrided as the wound had an infection. The resident stated the nurses here wear gloves to pack the open wound, but not a gown, during the twice daily dressing change. Observation throughout the survey failed to show a sign for EBP on Resident #139's door or in her room. Review of Resident #139's medical record occurred on all days of survey. Diagnoses included necrotic anterior abdominal wall wound, status post debridement and partial panniculectomy [surgery to remove excess skin/fat from the lower abdomen]. The care plan and activities of daily living (ADL) information sheet lacked inclusion of EBP. Nurses' notes stated the following: * 09/18/2024 at 11:54 a.m., . Reason for admission (diagnosis): Necretic [sic] anterior abdominal wound . Has JP [Jackson Pratt surgical suction device] drain for abodminal [sic] wound on right lower abdomen . * 09/27/2024 at 5:22 p.m., . Removed j/p drain today. Sutures and every other staple removed at right side abdominal. Continue to cover incision with dsg [dressing]. * 10/07/2024 at 8:14 a.m., . JP drain removed. Sutures removed at right side abdominal. 11 staples at right side abdominal wound. Abdomen- Pack with Vashe [type of wound cleanser] moistened Kerlix [type of gauze dressing] (single piece) pack twice per day, followed by Abd [Abdominal pad - thick absorbent pad] dressing. A weekly skin assessment, dated 10/23/24 at 6:55 a.m., identified a moderate amount of serosanguineous (pink to pale red fluid) wound drainage in the surgical right flank wound. During an interview on 10/24/24 at 10:28 a.m., a nurse manager (#9) stated Resident #139 only had a surgical wound with no infection and was not on precautions, so we do not wear gowns while changing the dressing.

Based on observation, record review, review of the North Dakota Resident Rights Resident Guide, and resident, staff, and family interviews, the facility failed to respect the resident right to have visitors of their choosing and at the time of their choosing for 1 of 1 sampled resident (Resident #136) and 1 supplemental resident (Resident #96), a married couple whose visitation was discontinued due to behaviors and ended in one resident transferred to another facility. Failure to ensure visitation rights are respected may have been the cause and/or increase of behaviors and/or emotional distress, which negatively impacted the psychosocial well-being of both residents. Findings include: Review of the North Dakota Long Term Care Ombudsman Program Resident's Rights Guide, dated 08/01/19, stated, . You have the right to visitors . with people of your choosing . - During an interview on 10/23/23 at 1:15 p.m., Resident #136 voiced concerns her husband, (who resides at the facility on another unit) has not been allowed to visit her and stated, . I just [NAME] for him. I just want to see my husband. They took my phone away a couple days ago so now I can't even call [Resident #96], or my sister or my son who both live out of the state. Review of Resident #136's medical record occurred on all days of survey and included a diagnosis of dementia. The Minimum Data Set (MDS), dated [DATE], identified a brief interview for mental status (BIMS) score of 11 (indicating moderate cognitive impairment). Resident #136's progress notes included the following: * 10/03/23 at 10:15 a.m. Resident was observed expression [sic] verbal aggression to staff members during an unexpected visit with her husband. Upon receipt of medications administered to the resident, she responded. 'do not talk to my husband, you're just going to take him away, I do not want your help, I don't even want you to look at him, just go away!' . Resident was observed telling her husband, 'Don't go with her [Resident #96]! She only wants to keep us apart! Don't listen to her!!' The husband had willingly began to leave at this point, even though the resident had a hold of his arm with her hand, and with encouragement from staff, was able to equip his walker and be successfully escorted to the wing which he resides. Upon return, our resident presented with irritability, yelling at another resident to stop something across the room . * 10/12/23 at 3:37 p.m. SS [social service worker] also informed [daughter's name] of the repetitive phone calls [Resident #136's] had been making to the facility's [sic] nurses stations, and explained the necessity to have these lines available for incoming/outgoing calls. [daughter's name] stated, 'My only worry with removing mom's phone is that she won't be able to connect with her sister.' SS assured [daughter's name] that each unit has a cordless phone that can be used for [resident's name] to visit with her sister, and FaceTime can also be initiated. * 10/14/23 at 6:53 p.m. Resident received a visit from her husband at 1800 [6:00 p.m.], which is outside of the agreed scheduled times. Husband requested to have his wife accompany him outside of the unit to another floor in which an activity was occurring (BINGO). Husband was soon accompanied by his primary CNA [certified nurse aide] who attempted to reason and convince husband and that he was not allowed to visit his wife during this time, nor was he allowed to remove her from the unit. Husband began to exhibit frustration with the situation, in which the [floor Resident #136 resided on] nurse intervened to briefly explain that d/t [due to] policy and the program in place for his wife and her safety, she would not be able to accompany him to BINGO. [Resident #136] was present during the discussion and was peaceful and compliant, reminding [husband] that she would not be allowed to leave. Staff nurse offered to allow [husband] to remain on the unit and participate in the activity occurring where his wife lives, but [husband] left, visibly upset, without aggression and outburst. staff assisted [Resident #136] with phone calls to [husband] later and throughout the evening, in which he even returned briefly to deliver her a cookie and report that he had won multiple games of BINGO, then proceeded to peacefully return to his room . * 10/16/23 at 11:23 a.m. [The residents' daughter] returned SS's call at this time, and participated in conversation held with SS and UM [unit manager] for both [Resident #136] and her husband, [Resident #96]. IDT [Interdisciplinary Team] on the call explained the efforts that have been put forth to allow meaningful visits between [Resident #136] and her husband. Further explanation was provided on some of the behavioral symptoms that have been displayed during these visits, and the possibility that potential emotional abuse may be present. Potential discharge planning was discussed at this time. * 10/16/23 at 5:41 p.m. resident became upset when husband went to go back to his unit and grabbed his arm and left a red mark . redirected educated and [sic] visiting hours . husband did leave unit and go to his unit . * 10/17/23 at 9:12 a.m. SS stopped by to check in with [resident] at this time. When SS approached [resident], she was dialing a number on the phone. SS informed [resident] that her husband had just sat down to eat breakfast. SS assured [resident] that staff will assist [husband] back to his room to call her when he is through with his meal. [resident] asked SS, 'well what am I supposed to do then just sit here and wait?' SS inquired about [residents] interests/hobbies, and asked what she would like to do while she waited for her husbands call. [resident] responded it really doesn't matter, I will just wait for [husband's] call. * 10/18/23 10:47 a.m. Note Text: Resident received a phone call from her son via the nursing station. Son [son's name] inquired upon whether resident's phone had been removed from her room and why, in which nursing staff replied generically, 'I will have to inquire within the notes we have butshe [sic] does not currently have a telephone in her room, it might be getting repaired.' Son requested to speak to resident, nursing staff obliged, but remained near to observe the communication between resident and family member, and the behavioral effect on resident. Resident was observed repeating 'I will continue to behave but [husband] is being a bad boy, not following the rules. I am following the rules, but [husband] must not want to comply with the rules!' The phone call appeared to disrupt resident's mood, as she became persistent about contacting her husband, while stating, 'this isn't fair, I haven't done anything wrong!' After a brief conversation with the nurse on staff, who attempted to reassure the resident kindly, and gently, that the staff members are available to provide support in ways that maintain her safety and comfort, they are not provided information as to why the situation is currently, nor are they able to provide resources that give her increased contact with her husband. Redirection and compassion was provided frequently throughout the conversation, but was unwelcomed by the resident, as it was stated by the resident that staff response was 'not what she wanted to hear' adding that 'this is all just a joke' to [everyone]. * 10/18/23 at 4:04 p.m. SS and UM placed a call to [daughter], to discuss discontinuing [Resident #136] phone service at this time, due to frequency of calls placed to the facility's nurses stations. as well as [Resident #136] fixation on the phone. SS assured [daughter] that a weekly FaceTime call can be initiated for [Resident #136] to connect with her sister. * 10/20/23 at 1:02 p.m. SS and UM visited with [Resident #136's] daughter [daughter's name], and son, [son's name] to provide update on previous conversations held with [daughter]. IDT members reiterated staff's efforts to allow meaningful visits between [Resident #136] and her husband. SS informed [son] of behavioral symptoms that have been displayed during these visits, including yelling at each other, as well as arguing with each other, staff and other residents. SS discussed instances where potential physical abuse was also present, as well the events that take place when staff attempt to assist [husband] off of the unit. Potential discharge planning was further discussed at this time. Both [daughter] and [son] stated, We would hate to see mom and dad in separate facilities. *10/21/23 at 5:30 p.m. resident had a zoom call with husband and they talked for about an hour, after getting done she started asking when she could see him in person, why are we keeping him away, I just want to see him in person make sure he is alive. * 10/23/23 at 3:36 p.m. [Resident #136] was on a phone call with her husband. [Resident #136] started to become very agitated and started yelling at her husband. Calling him 'Stupid' . Name of Representative notified: [Daughter]- stated she would still like them to have phone calls . *10/24/23 at 1:22 p.m. Resident was anxious about how her husband was doing and she wanted to call him. After calling him she was still nervous so nursing staff checked in with her husband and updated [Resident #136]. [Resident #136] was able to relax and participated in group exercise and lunch with no further issues. * 10/25/23 at 6:13 p.m. Resident told staff that she 'is grieving for [husband] and I am at the end of my rope!' Resident is upset about her husband and when talking to her daughter she stated, 'I don't think [husband] loves me and I have never been verbally abusive to [husband]. We never fight!' Resident is upset and tearful when talking with daughter. - Observation on 10/25/23 at 4:54 p.m. showed Resident #96, a social service designee (#4), and a CNA (#6) stood outside of the door to the memory care unit where Resident #96's wife (Resident #136) resides. The CNA (#6) stated, The door is locked [Resident #96] we've tried it a hundred times already. We can't get back there. The social service designee (#4) stated, [Resident #96] there is no visitation on that unit now. We can't go back there. The resident remained calm and spoke in a soft voice with head held down. His body language suggested potential sadness/disappointment related to not being allowed to visit his wife. At 4:58 p.m., a licensed social worker (LBSW) (#5) arrived and attempted to remove Resident #96 from the doorway telling him he could not visit his wife. The resident had a cupcake on his walker he wanted to give to his wife. When the surveyor asked the staff members (#4, #5, and #6) why the resident couldn't visit his wife, the staff members stated they did not know and would have to get back to the surveyor with the information. At 5:04 p.m., Resident #96 stated to the surveyor, They [staff] tell me I can't see my wife, and she's never done anything wrong. We've been married over [AGE] years, and we both love each other very much, and I'm proud of that. At 5:08 p.m., the social services designee (#4) reassured the resident she would personally take him to see his wife (Resident #136) after supper. During this conversation the resident showed increasing signs of frustration/anxiety, but reluctantly agreed to go to a private area and sit down. Review of Resident #96's medical record occurred on 10/26/23. The MDS, dated [DATE], identified a BIMS score of 15 (indicating cognitively intact). Resident #96's progress notes included the following: * 09/01/23 at 3:28 p.m. Social Services found resident in his room attempting to cut off his wander guard with a nail clipper. resident was noted saying 'I want to go visit my wife and the policy of the place doenst [sic] let me'. * 09/11/23 at 10:18 p.m. [Resident #96] visited wife outside of care planned timeframe and interrupted cares as reported by community life aide . Staff assisted [Resident #96] from the unit, to which he reportedly resisted by yelling at staff. * 10/04/23 at 2:20 p.m. SS spent time visiting with [Resident #96] in regards to his wife's placement on the memory care unit. (20 minute conversation). resident voiced he would like for his wife to be moved off of the memory and stated, 'I had no idea she was in a locked ward. She really doesn't need all of that.' SS provide reassurance to [Resident #96], and explained that his wife's placement is appropriate to best meet her needs. * 10/10/23 at 8:30 p.m. Patient went to visit his wife on separate floor within SNF [skilled nursing facility] and refused to leave when patients were being prepared for bed. Patient had to be told several times by charge on floor [unit's name] that he needed to return to his home floor. * 10/11/23 at 6:57 p.m. Charge Nurse was requested to separate floor [unit's name] to assist with escorting resident off unit, due to staff preparing for bed. Charge Nurse required therapeutic talk to console resident as he was attempting to remove another resident (wife) from [unit's name]. Charge Nurse additionally explained resident could visit with wife in the morning 10/12/23 and also provided that residents can speak to each other through via telephone. Resident although reluctant at first did comply. * 10/16/23 at 4:44 p.m. SS and UM for [Resident #96] and his wife called daughter [daughters name] at this time and date. IDT members on the call explained the efforts that have been put forth to allow meaningful visits between [Resident #96] and his wife. Further explanation was provided on some of the behavioral symptoms that have been displayed during these visits, and the possibility of that potential emotional abuse may be present. Potential discharge planning was discussed at this time. * 10/16/23 at 4:57 p.m. Visitations between [Resident #96] and his wife suspended as a behavior intervention . [Daughter] thanked writer for call and SS for update and expressed understanding. * 10/24/23 at 5:24 p.m. SS placed call to [daughter] to review placement preferences. [Daughter] voiced preference for VA (Veteran's affair) contracted facilities. * 10/25/23 at 5:55 p.m. SS placed call to [daughter] regarding transfer to [facility name]. [Daughter] voiced understanding of the room move. The medical records for Resident #96 and Resident #136 showed two progress notes regarding physical abuse: - 03/15/23 (Resident #136 scratched Resident #96) - 10/16/23 (Resident #136 grabbed Resident #96's arm during a visit leaving a red mark on Resident #96's wrist) documented potential emotional abuse in each medical record. After the 10/16/23 incident the medical record showed an order for a psychiatric referral on 10/25/23, and the initiation of a medication for mood on 10/19/23 for Resident #136. - Instances of verbal abuse between the residents were noted with documentation of redirected/reapproached by staff with family in agreement of interventions. During an interview on 10/25/23 at 5:09 p.m., a LBSW (#9) verified visitation between the couple had stopped last week due to concerns of emotional abuse during the residents' in-person visits. Prior to the stop of visits facility staff had set up scheduled visits three times a day. One incident occurred when Resident #136 grabbed onto Resident 96's arm and didn't want to let go. Also, Resident #96 would become upset when Resident #136 would not remember things. The LBSW denied the facility initiated the no visitation between the couple and stated, The residents' family suggested no visitation. During an interview on 10/25/23 at 5:34 p.m., an administrative staff member (#13) denied the facility initiated the no visitation between the couple and stated the residents' family suggested no visitation. The staff member identified all the documentation for [Resident #96 and Resident #136] is noted in progress notes, and offered no further documentation to the survey team. During an interview on 10/26/23 at 11:13 a.m., two administrative staff members (#7 and #8) stated the family had suggested visitation stop between Resident #96 and Resident #136 to keep them safe, stating Resident #96 has been physical. During a phone interview on 10/26/23 at 11:37 a.m., Resident #96 and Resident #136's daughter (Power of Attorney) stated, I did not suggest they stop visitations. Our [her and brother's] hope would be for them to be in the same building and see each other at least occasionally. When asked if she was aware of a possible discharge for her dad [Resident #96] the daughter stated, Yes, they have discussed moving him [dad] to [another facility] with me because dad figured out the code to the memory care unit where mom is. The daughter went on to say the facility had suggested supervised visits only when the family is present, however, the daughter stated that was not possible for her to be present at the facility to meet all the visitation needs of her mom and dad. This interview contradicted staff interviews regarding who initiated no visitation between Resident #96 and Resident #136. The facility failed to ensure continued alternative options/interventions were offered for visitation to maintain the residents' personal relationship and the family's verbalized hopes for their parents to remain in the same building. The facility action to discharge Resident #96 (family agreed to facility-initiated transfer/discharge) further limited the right to reasonable access for visitation.

Based on observation, record review, and review of facility policy, the facility failed to ensure accurate labeling of medications for 1 of 3 residents (Resident #36) observed for insulin administration. Failure to correctly label medications to match the current physician orders increased the risk of residents receiving an inaccurate dose of insulin and placed the resident at risk for an adverse reaction (a blood sugar too high or too low). Findings include: Review of the facility policy titled MEDICATION LABELING occurred on 10/26/23. This policy, revised February 2019, stated, . All resident medications regardless of source shall be properly labeled as follows . directions for use . strength . quantity . If necessary, a 'signal' type label shall be placed on the medication indicating that there has been a change order affecting the administration of the medication and that the nurse should turn to the resident's health record for correct information. Review of Resident #36's medical record occurred on all days of survey. A physician's order, dated 04/17/23, stated, NovoLOG Injection Solution (Insulin Aspart) Inject as per sliding scale: if 131 - 180 = 4 units; 181 - 240 = 6 units; 241 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 14 units; 401 - 500 = 16 units, subcutaneously before meals . Observation on 10/25/23 at 9:31 a.m. showed the label on Resident #36's Novolog insulin read 21 units in AM [morning]. 16 units twice a day. When asked about the discrepancy between the label and the physician's order, the medication aide (#10) stated, I always use what it says [referring to the electronic medication administration record (MAR)]. Resident #36's pen lacked a signal type label instructing staff to refer to the MAR for dosing instructions.

Based on record review and staff interview, the facility failed to provide the resident or resident's representative and/or the State Long Term Care Ombudsman with the written notice of transfer or discharge for 1 of 2 closed records (Resident #161) and 1 of 1 supplemental resident (Resident #96) discharged to another facility. Failure to provide the resident and/or resident's family member/legal representative a written notice of transfer or discharge, including the destination and reason for the transfer and the residents' right to appeal the action does not allow the resident and/or representative to make an informed decision regarding their rights or inform the Ombudsman of the discharge. Findings include: - Review of Resident #161's medical record occurred on 10/26/23. The record identified the facility discharged the resident to another facility on 09/12/23. The medical record lacked evidence the facility provided a written notice of discharge to the resident or their representative and the Ombudsman. - Review of Resident #96's medical record occurred on all days of survey. The record identified the facility discharged the resident to another facility on 10/26/23. The medical record lacked evidence the facility provided a written notice of discharge to the resident or their representative and the Ombudsman. During an interview on 10/26/23 at 12:40 p.m., an administrative staff member (#1) confirmed the facility failed to provide a notice of transfer or discharge.

Based on record review and staff and family interviews, the facility failed to ensure proper transfer/discharge and documentation processes were followed for 1 of 1 supplemental resident (Resident #96) and 1 of 2 closed records (Resident #161) discharged to another facility. Failure to complete the required facility and physician documentation did not show an appropriate reason the residents were unable to remain in the facility. Findings Include: - Review of Resident #96's medical record occurred on 10/26/23 and included the following progress notes: * 10/16/23 at 4:44 p.m. SS [social services] and UM [unit manager] for [Resident #96] and his wife called daughter [daughter's name] at this time and date. IDT [Interdisciplinary Team] members on the call explained the efforts that have been put forth to allow meaningful visits between [Resident #96] and his wife. Further explanation was provided on some of the behavioral symptoms that have been displayed during these visits, and the possibility of that potential emotional abuse may be present. Potential discharge planning was discussed at this time. * 10/24/23 at 5:24 p.m. SS [Social Services] placed call to [daughter] to review placement preferences. [Daughter voiced preference for VA (Veteran's Affairs) contracted facilities in the [city names] area. * 10/25/23 at 5:55 p.m. SS placed call to [daughter] regarding transfer to [facility name]. [Daughter] voiced understanding of the room move. During a phone interview on 10/26/23 at 11:37 a.m. with Resident #96's daughter (Power of Attorney) when asked if she was aware of a possible discharge for her dad [Resident #96] the daughter stated, . Yes, they have discussed moving him [dad] to [another facility name] with me, because dad figured out the code to the memory care unit where mom is. The medical record lacked the required facility and physician documentation for the reason of Resident #96's facility-initiated transfer/discharge to another facility. - Review of Resident #161's medical record occurred on 10/26/23 and progress notes included the following: * 08/24/23 at 2:26 p.m. IDT Discussed plan of care directed to having [Resident #161] be short stay, and to discharge back to ALF [Assisted Living Facility] setting, IDT further discussed discharge planning as well as discharge timelines, and services to be set up after discharge, family was agreeable to plan of care. * 08/29/23 at 3:37 p.m. MDS [Minimum Data Set] Summary . working with therapy at this time and improvements are anticipated. * 09/05/23 at 3:14 p.m. Family Communication Late Entry: Data: [Resident #161's] daughter . requested to meet with SS to discuss potential discharge options. Information on HH [Home Health] was provided, and placement options of SNF [Skilled Nursing Facility], ALF, and enhanced ALF were discussed. Discharge needs and potential will be monitored ongoing. * 09/12/23 12:44 p.m. Discharge Late Entry: Discharge to: [Facility Name]. During an interview on 10/26/23 at 12:00 p.m., a supervisory staff member (#14) identified the facility's admission agreement stated the Transitional Care Unit (TCU) was for short stay and if extended care was needed a transfer to the 42nd campus would be completed. The family was notified prior to transfer/discharge by phone on 09/12/23. The medical record lacked the required facility and physician documentation for the reason of Resident #161's facility-initiated transfer/discharge to another facility. Refer to F563

Based on complainant information, record review, facility investigation, review of facility policy, and staff interview, the facility failed to report to the State Survey Agency a potential incident of abuse for 1 of 2 closed record residents (Resident #1). Failure to report the allegation of abuse to the State Agency places all residents at risk of potential abuse. Findings include: Review of complaint information identified a staff member grabbed Resident #1's arms, shook the resident, ripped the resident's blankets back, yelled at the resident for having a bowel movement in his brief, and stated the resident had a cut on his temple and bruising on his face. Review of the facility policy titled REPORTING ALLEGED ABUSE AND NEGLECT VIOLATIONS occurred on 02/21/23. This policy, dated January 2020, stated, . When an alleged violation is suspected, the Licensed Nurse should . Initiate an investigation immediately. Remove the employee from resident care areas immediately. Contact the State Agency and the local Ombudsman office to report the alleged abuse. Review of Resident #1's medical record occurred on 02/21/23. The admission Minimum Data Set (MDS), dated [DATE], identified the resident had a Brief Mental Status Interview (BIMS) of 14 indicating intact cognition. The medical record lacked documentation and assessment of the cut and bruising identified by the complainant. The facility's internal investigation, initiated on 01/11/23, stated, When talking with [Resident #1] and his daughter [daughter's name] in person, [daughter's name] reported that Resident #1 told his grandson about his concerns on Sunday, 01/08/23, but nobody in the family had relayed this information to any Bethany staff member. During interview with Resident #1 and [daughter's name], daughter [daughter's name] stated everyone at Bethany has been great, except for this one individual. Review of the facility's internal investigation, also identified interviews with staff and Resident #1, the reassignment of a staff member, and follow up with the resident's daughter on 01/16/23. The facility failed to report the incident to the State Survey Agency as possible abuse. On the afternoon of 02/21/23, two administrative nurses (#1 and #2) confirmed the facility did not report the allegation to the State Survey Agency.

Based on record review, review of professional reference, facility policy review, and information received from the complainant, the facility failed to ensure residents remained free from significant medication errors for 1 of 4 closed record reviewed (Resident #159). Failure to ensure professional standards of medication administration resulted in Resident #159 receiving a double dose of [MEDICATION(S)] (a blood thinner) and may have resulted in negative health outcomes. Findings include: Review of the facility policy titled Order Processing occurred on 09/29/22. This policy, revised August 2019, stated, . Obtain order by calling prescriber . Write order on telephone order from [sic] exactly as prescribed by physician . Transcribe order on Physician's Order Sheet in chart . Enter into Point Click Care [electronic medical record] . Transcribe the new order into the Physician's Orders and Notes in the chart. Berman, Snyder, and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., New Jersey, page 63, stated, . Carrying Out a Physician's Orders . Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Information received from the complainant identified staff administered an extra dose of [MEDICATION(S)] to Resident #159. Review of Resident #159's medical record occurred on September 28-29, 2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses' Notes identified the following: *07/29/22 at 10:23 a.m.: . [MEDICATION(S)] 2 mg [milligrams] on MWF [Monday, Wednesday, Friday] [MEDICATION(S)] 3 mg all other days . Recheck INR [international normalized ratio, a test used to determine the blood's clotting ability] on 8/5/22 . *08/05/22 at 10:53 a.m.: . [MEDICATION(S)] 2 mg every Monday, Wednesday, and Friday. [MEDICATION(S)] 3 mg all other day [sic]. INR recheck on 8/12/22 . *08/07/22 at 11:27 a.m.: . IV [intravenous]/Vascular Access Assessment . [CONDITION(S)] access . intacted [sic]. small amount of dried blood noted under dressing. *08/07/22 at 5:37 p.m.: . Order: Hold [MEDICATION(S)] dose for tomorrow 8/8/22. Reason for Order: hold . The medical record lacked a reason/indication to hold the [MEDICATION(S)] dose. Review of Resident #159's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date for this order was 07/30/22, with an end date of 08/07/22. The record identified staff drew an INR on 08/05/22, and the [MEDICATION(S)] order remained at 3 mg on Tuesday, Thursday, Saturday, and Sunday. The start date for the order identified 08/06/22 with an end date of 08/09/22. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A medication error report (not part of the medical record), completed on 08/07/22, identified the following: . Description of the incident: Duplicate order, previous order not deleted. Extra dose given on 8/6/22 . The report also identified an INR of 3 on 08/07/22 (therapeutic range 2-3). Resident #159's medical record lacked evidence of a physician's order for the INR draw, and failed to include the result of the INR drawn by staff.

Based on observation, record review, review of a professional reference, and staff interview, the facility failed to ensure resident safety for 1 of 2 locked memory care units (Third floor Willow) with unsecured electrical cords. Failure to secure electrical cords has the potential to affect 28 residents on the unit at risk for injury. Findings include: The facility failed to provide a copy of their policy addressing potential fall hazards for residents as requested. Kozier and Erb's Fundamental of Nursing Concepts, Process, and Practice, 11th edition, 2020, page 703, stated, . causes of falls . presence of electrical cords unsecured . people with impaired cognition . vision deficits . are at risks for falls . - Observations of the secured dementia unit on the afternoon of 08/02/21 showed the following: * Four portable air conditioning units stood in areas where wandering residents typically walk. Each unit was approximately three feet tall, on wheels, with an electrical cord approximately six feet in length lying directly on the floor. Facility staff failed to secure the cords along the wall or floor. * Resident #95 stepped around an unsecured air conditioner electrical cord as he walked down the hallway. Review of Resident #95's medical record identified diagnoses of dementia, [CONDITION(S)], gait disturbance, wanderer, and at risk for falls. During an interview on 08/03/21 at 9:06 a.m., a maintenance staff member (#9), reported staff used the portable air conditioning units on the 3rd floor memory care area since June or July to keep the unit cool. During an interview on 08/05/21 at 11:10 a.m., a managerial nurse (#8) reported if they see long, unsecured electrical cords they try to tuck the cords behind the portable air conditioning units.

Based on observation, policy review, and staff interview, the facility failed to assure safe and secure storage of medications for 1 of 2 medication carts (East cart) on Maplewood Lane. Failure to store all medications securely may result in unauthorized access to medications. Finding include: Review of the facility policy titled Pharmacy-Storage of Medications occurred on 8/05/21. The undated policy stated . Medication rooms, carts, cabinets, and medication supplies are locked or attended by persons with authorized access . Observation on 08/02/21 at 5:30 p.m. showed an unlocked/unattended medication cart in the hallway of Maplewood Lane while nursing staff were in the dining room assisting residents. During an interview on 8/02/21 at 5:38 p.m., an administrative nurse (#2) locked the medication cart and stated she would remind staff to lock the cart.

Based on record review, review of professional reference, review of facility protocol, and staff interview, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 1 of 3 residents' (Resident #160) closed records. Failure to ensure facility staff record assessments completely and accurately for residents who die has the potential for all residents to lack documentation of care provided at the time of death. Findings include: Kozier & Erb's Fundamental of Nursing Concepts, Process, and Practice, 10th edition, 2016, pages ,d+[DATE], stated, Notations on records must be accurate and correct. Accurate notations consists of facts or observations rather than opinions and interpretations. Document events in the order in which they occur; for example, record assessments then the nursing interventions and then the client's responses. Record only information that pertains to the clients health problems and care. Do . Chart a change in a clients condition and show that follow-up actions were taken. Review of Resident #160's closed record for occurred on [DATE]. The record showed documentation of a dental appointment on [DATE] at 3:50 p.m. The next note, dated [DATE] at 10:17 a.m., identified management staff contacted the family to give condolences on Resident #160's death. Resident #160's medical record lacked an assessment related to Resident #160's change in condition, and lacked communication with the practitioner prior to death. During an interview on [DATE] at 10:14 a.m., management staff (#3), identified the resident died unexpectedly. The manager (#3) stated the nurse went in on rounds, noted Resident #160 to have labored breathing, called the practitioner, the practitioner directed the nurse to call the family and follow their directions. The family said to keep her at the facility and they would come right up. The manager (#3) stated the family arrived in time to be with Resident #160 when she died . Facility staff failed to document the information surrounding Resident #160's death as stated by the manager (#3).

Based on observation, record review, and staff interview, the facility failed to ensure appropriate care and services to manage symptoms of [CONDITION(S)] (CHF) for 1 of 10 sampled residents (Resident #51) with orders for compression stockings. Failure to ensure timely and consistent implementation may result in worsening symptoms of CHF. Findings include: Review of Resident #51's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A provider notification tool, dated 07/10/21, stated, . Reason for update . Heart failure symptoms . CHF assessment . Resident has weight gain of 7 lbs [pounds] in one day. He has +3 pitting [CONDITION(S)] to RLE and trace [CONDITION(S)] to LLE [left lower extremity]. He has crackles present in his R lower base of lung. He denies SOB [shortness of breath]. On call provider ordered 40 mg [milligrams] [MEDICATION(S)] [a diuretic] one time only PO [by mouth] for [CONDITION(S)] and weight gain. A nurse's note, dated 7/13/21, stated, . Physician Update . NP [nurse practitioner] was updated on +3 pitting [CONDITION(S)] to RLE and wt. [weight] gain. Response: New orders for [MEDICATION(S)] 30 mg PO daily and compression stocking to RLE, on in AM [morning] off at HS [night]. Observation on 08/03/21 at 10:08 a.m. showed Resident #51 in his room without compression stockings in place. Two certified nursing assistants (CNAs) (#4 and #5) assisted Resident #51 to stand from his electric wheelchair and pivot to a chair scale. The CNAs stated they weigh Resident #51 daily, and identified a current weight of 238.5 pounds (a seven pound increase in 24 hours). The CNAs called a nurse (#6) into the room to assess the resident. The nurse stated Resident #51 had more [CONDITION(S)] than yesterday, and she would notify the provider. The nurse also stated they were waiting on some compression socks from the VA (Veteran's Administration), and the unit manager (#3) called to check on the socks. Observation on 08/04/21 at 5:39 p.m. showed Resident #51 in his room with bilateral knee high compression socks in place. The resident identified he received the socks yesterday. Nurses' identified the following: *08/03/21 at 10:59 a.m.: . Physician Update . UM [unit manager] called [nurse manager] from the VA to get a status on [Resident #51's] compression stockings . Response: Pending callback. VM [voicemail] left . Resident Representative Communication (Include name, time, method of update): *08/03/21 at 1:20 p.m.: . UM called [VA nurse manager] back and stockings have arrived . *08/03/21 at 3:11 p.m.: . Order: hold compression stockings until received . Reason for Order: did not have stockings from VA but they did arrive today . During interviews on 08/05/21 at 8:34 a.m. and 12:25 p.m., a nurse manager from the VA (#7) stated she received an email from the nurse manager at the facility on 08/03/21 at 10:42 a.m., requesting compression stockings. The email did not have an order attached, and she replied to the email, stating she needed an order. At this time, the facility had not sent the order. The nurse manager (#7) did not have any notification prior to this regarding Resident #51's compression stockings. During an interview on 08/05/21 at 12:08 p.m., a nurse manager identified the compression stockings Resident #51 currently wore came from the facility's central supply.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 33 sampled residents (Resident #117). 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: The Long-Term Care Facility RAI User's Manual, revised October 2019, page N-3 states, . Enter in Item N0350B, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that the physician (nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders. Review of Resident #117's medical record identified a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS, dated [DATE] identified N0350B coded for a change in insulin orders in the last 7 days. Review of the resident's medical identified no order changes for insulin in the last 7 days. During an interview on 08/04/21 at 8:52 a.m., an MDS coordinator (#1) confirmed facility staff incorrectly coded the MDS related to insulin changes.

Based on information provided by the complainant, record review, review of the facility's investigation, facility policy review, and staff interview, the facility failed to implement policies related to the investigation and reporting of abuse/neglect for 1 of 1 sampled resident (Resident #1) with an injury of unknown origin. Failure to recognize an injury of unknown origin as potential abuse/neglect and implement their investigation/reporting policy placed all residents at risk for abuse/neglect and possible injury. Findings include: Information provided by the complainant identified the resident had a fractured right arm, and the facility failed to thoroughly investigate the incident. Review of the facility policy titled Reporting Alleged Abuse and Neglect Violations occurred on 01/12/21. This policy, dated January 2020, stated, . The facility must ensure: 1. All alleged violations involving abuse, neglect, exploitation or mistreatment must be reported immediately. This includes injury of unknown source . 2. If the alleged violation involves abuse or results in serious bodily injury it must be reported immediately but no later than 2 hours after the allegation is made. 4. The alleged violations must be reported to . other officials (including to the state survey agency .) . Injuries of unknown source: Includes circumstances when both of the following conditions are met: 1. The source of the injury: a. was not observed by any person or b. could not explained by the resident; and 2. The injury is suspicious because of: a. the extent of the injury . Response and Reporting of Alleged Violations: Anyone in the facility can report an alleged violation. When an alleged violation is suspected, the Licensed Nurse should: 1. Respond to the needs of the resident and protect them from further incident. 3. Initiate an investigation immediately. 5. Obtain statements from direct care staff . 7. Contact the State Agency and the local Ombudsman office to report the alleged abuse.10. Complete thorough documentation of the investigation. The President/CEO or other designated persons will confirm the report was received, and report the results of the investigation, when final, as required by state agencies. Review of Resident #1's medical record occurred on 01/12/21. [DIAGNOSES REDACTED]. Resident #1's nurses' notes identified the following: *01/03/21 at 11:02 a.m.: . Behaviors Late Entry: . (Resident #1) was assisted by staff for cares. She was very agitated. she hit staff and stated get out from my home otherwise i (sic) will call (the) cops, I need to call my lawyer. When staff attempted to change her brief, (Resident #1) went to grab staff hand and grab her own hand and had skin tear. she also hit her hand on the side rail of bed and had bruises. band-aid applied to skin tear . *01/03/21 at 11:52 a.m.: . (Resident #1) had a Provider Notification completed due to: skin concern; skin tear to L) (left) forearm, scratch to R) (right) forearm history of skin integrity issues, fragile skin. unable to describe 1.skin tear measuring 7 cm (centimeters) x 3 cm to L)forearm, steri-strip was applied. 2.scratch to R)Forearm measuring 2 cm x 3 cm. band-aid was applied. 3.scattered bruises to R)upper extremity. 4.scattered bruises to L)upper extremity. *01/04/21 at 8:37 p.m.: . CL (community life) went to calm her down and fibbed to resident that (Resident #1's daughter) will be there soon to fix her arm. Resident showed photos of her flowers and talked about her Christmas tree. Resident is a lot more calm if she is alone in the Day room. CL redirected to look out at the parking lot to watch for her family's car. This was the only progress note recorded on 01/04/21. *01/05/21 at 8:44 a.m.: . (Resident #1) had a Provider Notification completed due to: Pain and swelling to R) wrist/forearm . Pain is described as throbbing and area is tender to touch. Decreased ROM (range of motion) to right wrist and hand . *01/05/21 at 4:40 p.m.: . (Resident #1) was anxious and fearful for scheduled x-ray - unable to obtain imaging . (Resident #1) reports pain to R) wrist . PRN (as needed) [MEDICATION NAME] (an anti-anxiety medication) utilized, re-approach . Effective; (Resident #1) allowed for x-ray to be completed . Is representative aware of behavior? : Aware - present during x-ray . *01/05/21 at 6:22 p.m.: . (Resident #1) had a Provider Notification completed due to: xray results . The X-ray report identified an impacted [MEDICAL CONDITION] ulnar (arm bone) diaphysis (central part of a long bone). A provider note from Resident #1's orthopedic clinic visit on 01/06/21, identified, . Yesterday she (Resident #1's daughter) received a call from Bethany that the patient seemed to have a fair amount of bruising and swelling to her right forearm. She was subsequently x-rayed there and discovered to have a fracture. They present today for further evaluation and management. It is not entirely clear how this fracture occurred or when it occurred, though it is believed to have occurred approximately 2 days ago. On 01/12/21 at 2:58 p.m., the survey team requested a copy of the facility's completed investigation regarding Resident #1's fracture from an administrative nurse (#1). The facility provided the investigation at 4:10 p.m., which identified the following: . Summary of Incident: Incident occurred on 1/3/21 at approximately 10:45 AM . On 1/3/21(Registered Nurse {RN}) called (Nurse Manager) on-call (RN name) to notify of (Resident #1) was having behaviors during cares with aggression towards staff member. (Resident #1) obtained skin integrity injury- 1. Skin tear measuring 7 cm x 3 cm to L) forearm . 2. Scratch to R) Forearm measuring 2 cm x 3 cm . 3. Scattered bruises to R) upper extremity . 4. Scattered bruises to L) upper extremity . Root Cause Analysis: (Resident #1) often has behaviors and refuses cares often. She often flails her arms which results in hitting side rails or inanimate objects and throws items at staff with little to no notice. Action Plan: . On 1/3/21 Reviewed Abuse and Neglect Memo, CP (care plan), ADL (activities of daily living), and policy with DON (director of nursing)/nurse manager on call at 42nd campus at this time abuse and neglect was not suspected. A second section of the same investigation identified the following: . Summary of Incident: 1/5/21 (8:44 a.m.) Swelling and bruising to R) Wrist noted provider notified. (Provider name) rounded in facility on (Resident #1) 1/5/21 around (9:30 a.m.) order for XRAY received. 1/5/21 at (11:00 a.m.) XRAY attempted - (Resident #1) was agitated and refused XRAY. Family updated on refusal at (11:10 a.m.). 1/5/21 at (4:40 p.m.) X-RAY completed. Family present and [MEDICATION NAME] PRN utilized. XRAY findings received 1/5/21 at about (6:00 p.m.) to (RN on-call manager). Impacted [MEDICAL CONDITION] ulnar diaphysis . On-call provider (provider name) notified of results on 1/5/21 at (6:22 p.m.) . 1/6/21 (Resident #1) went to Ortho walk-in for further assessment regarding XRAY results. Root Cause Analysis: (Resident #1) is independent with FWW (front-wheeled walker) . often has behaviors . DX (diagnosis) of [MEDICAL CONDITION] . Action Plan: Update ADL (activities of daily living) and CP (care plan) . Continue orders as prescribed to heal R) wrist . Additional ongoing education to staff on behavior interventions/care giver stress . The investigation included interviews with direct care staff, the first of which occurred on 01/06/21 at 9:40 a.m. (over 15 hours after receiving the XRAY results which identified a fractured arm). The investigation failed to include immediate actions taken by staff after discovery of a serious injury of unknown origin (i.e., protecting the resident from further incident, interviews with staff). The interviews completed lacked any mention of or questions related to Resident #1's fracture. The investigation also failed to include a conclusion regarding suspected abuse/neglect related to the fractured arm. The facility declined to provide further documentation related to the investigation of Resident #1's fracture and stated some documents are internal. On the afternoon of 01/12/21, an administrative nurse (#2) confirmed the facility did not report the above incident to the state survey agency. Resident #1's history of aggression with cares and combative behavior, in addition to her severely impaired memory/cognitive status, placed her at increased risk for abuse from staff and other residents. The facility failed to recognize Resident #1's fractured arm as an injury of unknown origin and potential abuse, and promptly implement their policy regarding investigation and reporting of the incident. These failures placed Resident #1 (and other residents with behaviors/dementia) at risk for abuse and injury.

Based on information received from the complainant, observation, record review, and staff interview, the facility failed to ensure the resident received activities of daily living (ADL) assistance necessary to maintain good nutrition for 1 of 1 sampled resident (Resident #2) who required assistance with eating. Failure to cue, set up and/or assist a resident who required assistance may result in decreased intake and/or unwanted weight loss. Findings include: Information received by the complainant identified concerns with dining assistance and meal set up. Upon request the facility failed to provide a policy regarding dining assistance. Review of Resident #2's medical record occurred on 01/12/21 and included the [DIAGNOSES REDACTED]. Occasionally able to feed self with adaptive equipment but benefits largely from assistance to promote intake . A significant change Minimum Data Set (MDS), dated [DATE], identified the resident required extensive assist with eating. A progress note, dated 12/29/20, identified, Sig (significant) Change MDS completed d/t (due to) admission to Hospice. Extensive assist x 1 for eating. Observations on 01/12/21 showed the following: * 11:35 a.m., Resident #2 rested in her bed with a lunch tray (uncovered) untouched in front of her. * 11:38 a.m., an unidentified certified nursing assistant (CNA), entered the resident's room and shut the door. * 11:46 a.m., the unidentified CNA came out of the resident's room, leaving the door open. * 11:47 a.m., the resident remained in the bed with meal untouched and uncovered. * 11:58 a.m., the CNA (#3) fed the resident at her bedside (20 minutes after meal delivery). An interview with the CNA (#3) verified the resident requires assistance with meals and staff are to assist residents immediately once tray is delivered. During an interview on 01/12/21 at 3:25 p.m., a dietary supervisor (#4) stated staff are to assist those residents that need set up/assistance immediately upon bringing the tray to the resident's room.

Based on observations, interviews, and record reviews, the facility failed to ensure that sanitary processes were followed in the preparation and/or serving of residents' food. Specifically, the facility failed to ensure that dishes and utensils were sanitized. These failures place residents, and staff and visitors who eat at the facility, at risk of acquiring infectious diseases. Findings include: Observation on 10/30/2020 at 8:25 AM during a tour of the kitchen with the Director of Dining and Nutritional Services (DNS), the dishwashing machine was verified to be a high temp machine. Reviewed the temperature logs for September and October and noted no dishwasher temperatures recorded for the following days and times: September 2, no temperature recorded for 4 PM September 3, no temperature recorded for 4 PM September 4, no temperature recorded for 4 PM September 7, no temperature recorded for 4 PM September 8, no temperature recorded for 4 PM September 17, no temperature recorded for 4 PM September 21, no temperature recorded for 4 PM September 26, no temperature recorded for 4 PM September 27, no temperature recorded for 4 PM September 28, no temperature recorded for 4 PM October 5, no temperature was recorded at 4 PM. October 12, no temperature recorded at 4 PM. October 19, no temperature recorded at 4 PM. October 20, no temperature recorded at 7:30 AM or 4 PM October 21, no temperature recorded at 7:30 AM or 4 PM October 22, no temperature recorded for 4 PM. October 23, no temperature was recorded for 4 PM October 26, no temperature recorded for 4 PM October 27, no temperature was recorded for 7:30 AM or 4 PM. October 28, no temperature was recorded for 4 PM. Upon reviewing the surveillance given for monitoring the sanitization of cookware, dishware, and utensils, there were several days in which the facility failed to record the dishwasher machine's temperature. A subsequent interview with the DNS, when shared observations, stated, that they (Dietary Staff) should record the temperature twice a day. Record review of policy titled, Procedure for using the dish temp disk thermometer for the dish machine, dated 9/15/19, Under the heading, reads Note: The temperature is to be taken and recorded during each shift at 7:30 AM and 4:30 PM EVERY DAY. Interview with DNS on 11/3/2020 at 10:23 AM, when asked what steps are being taken to ensure staff is recording temperatures per policy, the DNS says every day we have huddles and we are now educating staff to record the temperature on the dishwasher. The DNS further stated, there are changes in the department and states, I'm new to this role, things have gotten missed. When asked is there an internal log that records dishwasher temperatures, the DNS states, No, our machine does alarm if it is too low, but we rely on people (staff) recording those temperatures. Further states, Since the survey, I have educated individuals (staff) on the recording of the temperature and will send out emails. Interview with Nursing Home Administrator (NHA) on 11/3/20 at 10:30 AM, when shared findings of the facility not recording the dishwasher temperatures, the NHA acknowledged.