Every finding on record at Bethel Lutheran Nursing & Rehabilitation Center

1. Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 1 closed record (Resident #85) with an identified breast lump. Failure to ensure follow up on the identified breast abnormality prevented timely treatment interventions.Findings include: Review of the facility policy titled Bethel Lutheran Nursing & [and] Rehabilitation Center-Wound Treatment Management occurred on 04/16/26. This policy, dated February 2026, stated, Procedure . 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the wound care consultant, treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 5. Treatment decisions will be based on: . a. Etiology of the wound: . iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma, calciphylaxis) . c. Location of the wound . 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above.) 3. Changes in the resident's goals and preferences, such as at the end- of-life or in accordance with his/her rights. - Review of Resident #85's medical record occurred on April 15-16, 2026 and identified a breast lump on 10/19/24. The nurse's notes showed the facility notified the provider of the lump on 10/21/24. The resident agreed to have a mammogram. From October 2024 to June 2025, the nurse's notes identified continued presence of a hard lump on the right breast. The record lacked evidence the provider assessed the lump and ordered a mammogram. Further review of Resident's #85 progress notes identified the following: * 07/03/25 at 10:45 p.m., . Scab below the right areola was noted tonight during bath. Area around the right areola still hardened. Resident denies pain or discomfort. No discharges noted to the right nipple. Kept monitored. * 07/07/25 at 9:36 p.m., . Right breast. Hardened around her areola . Scab below the right areola was noted during bath, . * 07/21/25 at 10:55 p.m., . Right breast. Hardened around her areola. Right breast. dry scab with minimal discharge. Length (cm) [centimeter]: 4 Width (cm): 3 Surrounding tissues: Erythema.Skin Issues Note: Bacitracin ointment applied to right breast scab. * 08/04/25 at 10:23 p.m., . Right breast. Hardened around her areola.dry scab with minimal discharge. Deteriorating: wound characteristics deteriorated. Wound acquired in-house. Signs and symptoms of infection: Size has increased. Length (cm): 5 Width (cm): 3.5 Depth (cm): 0 Exudate amount: Light. Exudate type: Purulent: indication of pus, typically thick, yellow, green, tan or brown. slough Surrounding tissue: Erythema. Cleansing solution: Soap & Water. Other additional care: Bacitracin ointment applied. * 08/06/25 at 7:18 a.m., . No improvement in right breast region area measuring 14 cm by 14 cm redness and hardness to the breast with 5 cm by 4 cm scabbed/crusty area to the right of the nipple area no drainage tender to the touch. Resident will be sent to ER [emergency room] to get evaluated. * 08/06/25 at 2:00 p.m., . CNA that went with resident this Am---States that resident was admitted to the hospital for infection and possible breast cancer.Did inform one of the guardians about the admission. * 08/06/25 at 3:36 p.m., . Hospital personal returned my Call--States resident was admitted ---she is on IV [intravenous therapy] antibiotic for breast infection. had a CT [computed tomography]-scan while in ER-the results showing the unlaying breast tissue is cancerous. During an interview on 04/16/26 at 9:38 a.m., three administrative staff members (#1, #2, and #3) confirmed the facility failed to notify the provider of changes in wound characteristics and obtain skin/wound treatment orders. The facility failed to ensure adequate follow-up including timely assessments and treatment options which could have allowed Resident #85 or the resident's guardian to make informed decisions regarding her health care. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the necessary care and services to attain the highest degree of safety with oral intake for 1 of 1 sampled resident (Resident #48) who required diet modifications and specific eating utensils. Failure to ensure staff offered residents food/liquids utilizing the recommended eating utensils resulted in Resident #48 experiencing coughing episodes and may have resulted in aspiratation. Findings include: Review of the facility's policy titled, Thickened Liquids, occurred on 04/16/26. This policy, updated February 2026, stated, . 'Thickened liquids' refer to liquids in which the consistency has been altered to facilitate safe, oral intake. They are ordered as part of treatment for a . clinical condition, such as dysphagia [swallowing disorder] due to a stroke . Review of the facility's policy titled, Therapeutic Diet Orders, occurred on 04/16/26. This policy, dated February 2026, stated, . 'Mechanically Altered Diet' is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include . thickened liquids . Therapeutic diets, including mechanically altered diets . will be based on the resident's individual needs as determined by the resident's assessment. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form . Review of Resident #48's medical record occurred on all days of survey. Diagnoses included cerebrovascular disease, dementia, oropharyngeal (the middle part of the throat) dysphagia (swallowing difficulty), and reflux disease. Resident #48's Speech Therapy Evaluation, dated 04/03/26, identified dysphagia, coughing with thin liquids, and required a mechanically altered diet that included nectar thickened liquids via straw sip. The current physician's orders identified, . nectar thick liquids using straws per SLP [Speech Language Pathologist] . The current care plan stated, . I have . potential nutritional problem . Assist me with meals as needed. Straws with nectar thick liquids per SLP 4/3/26. Adaptive Devices: . straws, and sipper cups with spouts as necessary. The facility failed to remove the sipper cups with spouts from the care plan following the 04/03/26 dysphagia assessment. Observation showed the following: * 04/14/26 at 10:34 a.m., Two certified nurse aides (CNAs) (#13 and #14) completed Resident #48's morning cares. The CNA (#13) offered Resident #48 a drink of nectar thickened water via a glass. Resident #48 took a drink of water and immediately coughed. The CNA (#14) then asked if the water had been offered from a straw. * 04/15/26 at 3:48 p.m., Two CNAs (#8 and #13) completed Resident #48's afternoon cares. Observation showed a mug of non-thickened water in the resident's room. The CNAs (#13) poured water from a mug into a smaller glass, realized the water had not been thickened, and handed the glass to the other CNA (#8) to discard. The CNA (#13) transported Resident #48 to the nurses' station. An unidentified CNA approached Resident #48 and offered her a drink of nectar thickened liquids via a sipper cup. Resident #48 took a drink from the sipper cup (not a straw) and immediately coughed. A nurse (#6) asked Resident #48 if the liquids went down the wrong tube, before checking her lung sounds. During an interview on 04/16/26 at 8:20 a.m., two administrative staff members (#2 and #3) confirmed staff should follow the physician's orders for use of appropriate utensils (straws). The facility failed to ensure staff provided Resident #48 nectar thickened liquids via a straw and update the care plan per the speech therapist's recommendation and physician's order.

Based on observation, record review, review of facility policies, and staff interviews, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity for 2 of 2 sampled residents (Resident #18 and #47) and 2 supplemental residents (Resident #74 and #76) observed during meals and 1 of 1 sampled resident (Resident #56) who requested assistance in their room. Failure to treat residents with dignity and respect has the potential to affect the residents' psychosocial wellbeing and does not enhance their quality of life. Findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, occurred on 04/16/26. This policy, revised 2025, stated, . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Respond to requests for assistance in a timely manner. - Observations during dining showed the following: * 04/14/26 at 8:10 am, A certified nurse aid (CNA) (#12) sat between Resident #18 and Resident #47. The CNA (#12) fed Resident #47 and used the resident's clothing protector to wipe excess food from the corners of her mouth. The CNA (#12) sanitized her hands and then fed Resident #18 and used the resident's clothing protector to wipe excess food from the corners of her mouth. A nurse (#6) administered medications to Resident #47, and used a small, coated spoon to remove excess food from the corners of the resident's mouth. * 04/14/26 at 12:10 a.m., A CNA (#13) fed Resident #18 and used a spoon to remove excess food from the corners of her mouth. * 04/15/26 at 8:14 am, A CNA (#12) sat between Resident #18 and Resident #47. The CNA (#12) fed Resident #47 and used the resident's clothing protector to wipe excess food from the corners of her mouth. A nurse (#6) administered medications to Resident #47, and used a small, coated spoon to removed excess food from the corners of the resident's mouth. During an interview on 04/16/26 at 8:20 a.m., two administrative staff members (#2 and #3) confirmed staff should utilize a napkin to remove excess food from a resident's face. - Review of Resident #56's medical record occurred on all days of survey. The current care plan stated, . I am . unaware of safety needs and history of falls . I need prompt response to all requests for assistance. I exhibit confusion, forgetfulness, agitation and anxiety. I am able to make myself understood . Encourage me to use bell to call for assistance. I need reminders. Observations on 04/13/26 from 4:48 p.m. to 5:25 p.m. (37 minutes), showed Resident #56's room door closed and the resident repeatedly hollered for staff assistance until the surveyor summoned staff assistance. During an interview on 04/15/26 at 2:15 p.m., administrative staff members (#1 and #2) confirmed staff should respond to Resident #56's verbal calls in a timely manner. - Review of Resident #74's medical record occurred on 04/15/26. The current care plan stated, . I have a problem or potential nutritional problem related to Hemiplegia [paralysis of one side of the body] and hemiparesis [weakness or partial paralysis affecting one side of the body] following cerebral infarction [stroke] affecting right dominant side . mild cognitive impairment . dysphagia [difficulty swallowing] . I frequently use my fingers to eat instead of my utensils. Assist me with meals as necessary. Per therapy, I feed myself but require supervision. Adaptive equipment . built up silverware . Observation on 04/15/26 at 11:48 a.m. showed Resident #74 seated in a wheelchair at the dining room table with eyes closed, adaptive silverware on the table out of the resident's reach, and the meal and drinks in front of the resident. At approximately 12:10 p.m., the resident unsuccessfully reached for the glass of apple juice and made repeated attempts to self-feed. The resident again reached for the apple juice, the cup tipped over, and the juice spilled onto the floor. At 12:15 p.m., an unidentified staff member cleaned up the spill, placed a new glass of juice on the table, gave the resident the adaptive silverware, and walked away. The resident attempted to eat the larger pieces of the croissant, but most of the food fell to her lap. The facility staff failed to supervise and offer Resident #74 assistance during the noon meal. - Review of Resident #76's medical record occurred on 04/15/26. The care plan stated, . I have potential nutritional problem r/t [related to] . dysphagia . Assist me with meals as needed. I am able to feed myself with set up assistance and encouragement. At times I may require more assistance. Observation on 04/15/26 at 11:48 p.m. showed Resident #76 seated in a wheelchair at the dining room table drinking liquid from a coffee cup. The resident lifted the cup up in the air and repeatedly stated, Take this. Take this. and almost spilled the liquid. At 12:15 p.m., the resident closed her eyes and lowered her head. The resident's meal appeared barely eaten. The facility staff failed to encourage, cue, and/or assist Resident #76 during the noon meal. During an interview on 04/15/26 at 2:15 p.m., administrative staff members (#1 and #2) confirmed Residents #74 and #76 require supervision and/or encouragement and cueing during meals.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 3 of 6 residents (Resident #3, #12 and #77) observed during medication administration. Four medication errors occurred during staff administration of 27 medications, resulting in a 14 percent error rate. Failure to follow physician's orders and/or pharmacy recommendations may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health.Findings include:Review of the facility policy titled Crushed Medications occurred on 04/16/26. This policy, dated June 2022, stated, . Medications shall be crushed in accordance with standard of practice for safety and accuracy in medication administration. Medications shall be crushed in accordance with physician orders.Review of the facility policy titled Insulin Pen occurred on 04/16/26. This policy, revised March 2026, stated, . Prime the insulin pen. i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger .Information for finasteride, updated 02/01/26, found at https://www.mayoclinic.org/drugs-supplements/finasteride-oral-route/description/drg-20063819 stated, . Finasteride is used to treat men who have symptoms of benign prostatic hyperplasia (BPH) . Swallow the tablet whole. Do not crush, break, or chew it. Prescribing information for levothyroxine (treats thyroid disorders), revised April 2019, found at https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/021116s017lbl.pdf, stated, . 2.1 General Administration Information. Administer Levothyroxine Sodium Tablets as a single daily dose, on an empty stomach, one half to one hour before breakfast.Review of Resident #12's medical record occurred on 04/15/26. Physician's orders identified Finasteride Oral Tablet 5 MG [milligrams] . DO NOT crush or split. and Levothyroxine Oral Tablet 50 MCG [micrograms] . -Observation on 04/15/26 at 8:14 a.m. showed a nurse (#7) prepared Resident #12's medications. The nurse crushed the finasteride and placed it and other medications, including the levothyroxine, in strawberry ice cream, and administered them to the resident.-Observations on 04/15/26 at 11:35 a.m. and 11:47 a.m. showed a nurse (#7) primed Resident #3 and #77's insulin pens at a 45-degree angle.The nurse (#7) failed to follow physician's orders and crushed the finasteride, failed to prime insulin pens with the needle pointing upward, and failed to administer the levothyroxine on an empty stomach. During interviews on 04/15/26 at 10:50 a.m. and 2:15 p.m., administrative staff members (#1 and #2) confirmed staff should not crush finasteride, levothyroxine should be administered on an empty stomach, and insulin pens should be primmed pointing up at a 90-degree angle.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 18 sampled residents (Resident #1, #3, #12, #34, and #56) and 1 supplemental resident (Resident #77) observed during toileting cares and medication preparation and administration. Failure to practice infection control standards related to hand hygiene, glove use, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 04/16/26. This policy, revised September 2025, stated, . implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. employs targeted gown and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g. chronic wounds such as . diabetic foot ulcers .) and/or indwelling medical devices (e.g. urinary catheters .) . High-contact resident care activities include: . Transferring . Changing briefs or assisting with toileting . Device care or use: . urinary catheters . Wound care: any skin opening requiring a dressing. Review of the facility policy titled Personal Protective Equipment occurred on 04/16/26. This undated policy stated, . appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Gloves . Wear gloves when direct contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment is anticipated. Perform hand hygiene before donning gloves and after removal. Review of the facility policy titled Hand Hygiene occurred on 04/16/26. This policy, revised July 2025, stated, . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table . Condition . Between resident contacts . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . Before preparing or handling medications . Before and after handling clean or soiled dressings, linens . When, during resident care, moving from a contaminated body site to a clean body site . Review of the facility policy titled Insulin Pen occurred on 04/16/25. This policy, revised March 2026, stated, . i. Remove the pen cap from the insulin pen. ii. Wipe the rubber seal with an alcohol pad. iii. Screw the pen needle onto the insulin pen. - Review of Resident #1's medical record occurred on all days of survey. The care plan stated, . Enhanced Barrier Precautions Due to indwelling catheter . Staff will wear gown and gloves for dressing . assisting with toileting . Observation on 04/13/26 at 4:02 p.m. showed an EBP sign on Resident #1's door and PPE supplies outside of the room. Two certified nurse aides (CNAs) (#9 and #10) applied PPE, entered the resident's room, and transferred the resident from a wheelchair onto the toilet. The CNA (#9) emptied urine from the resident's foley catheter bag into a urinal. The CNA's completed toileting cares and transferred the resident back into the wheelchair. The CNAs removed their PPE, performed hand hygiene, and the CNA (#10) exited the room. The CNA (#9) failed to apply a gown and gloves, emptied the urine from the urinal into the toilet, performed hand hygiene, applied clean gloves, removed the resident's soiled shirt, applied a clean shirt, and offered the resident water. The CNA (#9) failed to apply a gown and gloves prior to emptying the urine from the urinal into the toilet, failed to wear a gown when changing the resident's shirt, and failed to remove gloves and perform hand hygiene prior to touching the resident's water mug. During an interview on 04/15/26 at 10:50 a.m., administrative staff members (#1 and #2) stated they expect staff to wear a gown and gloves when emptying a urinal. - Review of Resident #3's medical record occurred on all days of survey. Diagnoses included a history of methicillin resistant staphylococcus aureus (MRSA) (a multi-drug resistant infection). Nurses' notes identified a left heel pressure ulcer and two right foot/leg diabetic ulcers. Physician's orders identified daily dressing changes to the areas. Observation of Resident #3 on all days of survey showed no enhanced barrier precautions in place. Observation on 04/13/26 at 4:29 p.m. showed Resident #3 resting in bed. Two CNAs (#5 and #16) performed hand hygiene, applied gloves, and entered the room. The CNAs performed a check and change of the resident's brief and transferred the resident to the wheelchair with a full body mechanical lift. The CNAs failed to wear gowns during Resident #3's cares. During an interview on 04/15/26 at 3:30 p.m., an administrative nurse (#3) confirmed the facility failed to implement EBP for Resident #3. - Review of Resident #12's medical record occurred on all days of survey. The current care plan stated, . Enhanced Barrier Precautions Due to indwelling catheter . Observation on 04/13/26 at 4:03 p.m. showed an EBP sign on the resident's door and PPE supplies outside of the room. A CNA (#5) and a nurse (#4) applied PPE and entered the room. The CNA (#5) completed bowel movement cares, removed the soiled gloves, and without performing hand hygiene or applying clean gloves, moved the sit to stand lift and the garbage can closer to the bed. The CNA (#5) washed her hands and applied clean gloves. The CNA (#5) completed the remaining perineal cares, removed the soiled gloves, and without performing hand hygiene or applying new gloves, assisted the resident to turn, pulled up the resident's pants, placed the package of wipes in the bedside drawer, and performed hand hygiene. Without applying gloves, the CNA moved the sit to stand lift, handed the resident's shoes to the nurse, lowered the bed, and transferred the resident to the wheelchair. The CNA placed the urinary drainage bag under Resident #12's wheelchair in a privacy bag, adjusted the resident's clothing, and straightened the bedding. The nurse (#4) removed the soiled gown and gloves, performed hand hygiene, and exited the room with the sit to stand lift. The CNA emptied the trash, removed the soiled gown, washed her hands and exited the room. The CNA (#5) failed to perform hand hygiene after removing the soiled gloves and before touching other items in the room and failed to wear gloves while performing cares for a resident in EBP. During an interview on 04/16/26 8:40 a.m., a nurse (#3) confirmed she expected staff to wear gloves for the duration of cares provided in EBP, perform hand hygiene after glove removal, and before touching other objects. -Review of Resident #34's medical record occurred on all days of survey. Diagnoses included a pressure ulcer of the sacral region. Physician's orders identified dressing changes every three days and as needed. Observation on 04/14/26 at 10:08 a.m. showed an EBP sign on the resident's door and PPE supplies outside of the room. A nurse (#6) performed hand hygiene, applied a gown, mask, and gloves, and entered the resident's room to complete pressure ulcer cares. A CNA (#8) assisted Resident #34 to roll onto her right side. The nurse removed two soiled dressings and discarded them. Without removing the soiled gloves and performing hand hygiene, the nurse cleansed the left lower buttocks wound with normal saline and a dried with a gauze pad. The nurse applied Anacept (antimicrobial solution) to her gloved finger and rubbed it into the wound and applied Anacept to the wound area to the upper coccyx. The nurse applied Mepilex (foam dressing) to both wound areas, gathered opened packages and discarded them. The nurse removed her gown, gloves, mask, and completed hand hygiene prior to exiting the room. The nurse failed to remove the soiled gloves, perform hand hygiene, and apply new gloves when moving from a dirty to clean task during wound care. - Observation during medication pass showed the following: * 04/15/26 at 8:14 a.m., A nurse (#7) applied gloves and administered Resident #12's oral medications. Without removing the soiled gloves, performing hand hygiene, and applying clean gloves, the nurse administered eye drops. * 04/15/26 at 11:35 a.m. and 11:47 a.m., A nurse (#7) prepared two insulin pens (Resident #3 and #77) and failed to disinfect the rubber stoppers before attaching the needles. During an interview on 04/15/26 at 10:50 a.m., administrative staff members (#1 and #2) stated they expected staff to change gloves between administering oral medications and eye drops and disinfect insulin pen tips before attaching sterile needles.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the physician or resident's representative for 1 of 1 closed records (Resident # 85) reviewed for change in breast tissue. Failure to notify the resident's representative and physician of an identified breast abnormality does not allow the representative or physician to be fully informed of the resident's care, current status, and to make informed decisions regarding medical care. Findings Include:Review of the facility policy titled Change in a Resident's Condition or Status occurred on 04/16/26. This policy, reviewed March 2026, stated, 2. Unless otherwise instructed by the resident. the Neighborhood Nurse Manager (or designee) or Social Worker will notify the resident's next of kin or representative (sponsor) when: . b. There is a significant change in the resident's physical, mental, or psychosocial status. c. There is a need to alter the resident's treatment significantly. -Review of Resident's #85 medical record occurred on April 15-16, 2026 and identified a right breast lump on 10/19/24. Review of Resident's #85 progress notes identified the following: * 07/03/25 at 10:45 p.m., . Scab below the right areola was noted tonight during bath. Area around the right areola still hardened. Resident denies pain or discomfort. No discharges noted to the right nipple. Kept monitored. * 07/07/25 at 9:36 p.m., . Right breast. Hardened around her areola . Scab below the right areola was noted during bath, . * 07/21/25 at 10:55 p.m., . Right breast. Hardened around her areola. Right breast.dry scab with minimal discharge. Length (cm) [centimeter]: 4 Width (cm): 3 Surrounding tissues: Erythema.Skin Issues Note: Bacitracin ointment applied to right breast scab. * 08/04/25 at 10:23 p.m., . Right breast. Hardened around her areola.dry scab with minimal discharge. Deteriorating: wound characteristics deteriorated. Wound acquired in-house. Signs and symptoms of infection: Size has increased. Length (cm): 5 Width (cm): 3.5 Depth (cm): 0 Exudate amount: Light. Exudate type: Purulent: indication of pus, typically thick, yellow, green, tan or brown. slough Surrounding tissue: Erythema. Cleansing solution: Soap & Water. Other additional care: Bacitracin ointment applied. * 08/06/25 at 7:18 a.m., . No improvement in right breast region area measuring 14 cm by 14 cm redness and hardness to the breast with 5 cm by 4 cm scabbed/crusty area to the right of the nipple area no drainage tender to the touch. Resident will be sent to ER [emergency room] to get evaluated. * 08/06/25 at 2:00 p.m., . CNA that went with resident this Am---States that resident was admitted to the hospital for infection and possible breast cancer.Did inform one of the guardians about the admission. * 08/06/25 at 3:36 p.m., . Hospital personal returned my Call--States resident was admitted ---she is on IV [intravenous therapy] antibiotic for breast infection. had a CT [computed tomography]-scan while in ER-the results showing the unlaying breast tissue is cancerous. During an interview on 04/15/26 at 4:53p.m., Administrative staff member (#1) confirmed the resident's the facility did not notify Resident #85's guardian about the breast lump and the provider's recommendation for no further treatment. The facility failed notify Resident #85's guardian about the breast lump and failed to notify the provider when the breast tissue surrounding the lump showed signs of infection and the application of bacitracin on 07/21/25.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #48) reviewed for abuse. Failure to provide the necessary services to protect residents from physical abuse resulted in a bruise to Resident #48's arm. Failure to protect all residents from physical abuse placed all residents at risk for psychosocial harm and/or injury.Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, occurred on 04/16/26. This policy, dated February 2026, stated, . 'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and kicking. 'Sexual Abuse' is non-consensual sexual contact of any type with a resident . The facility will implement policies and procedures to prevent and prohibit all types of abuse. that achieves . the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Review of Resident #48's medical record occurred on all days of survey. Diagnoses included anxiety, dementia with psychotic disturbance, depression, restlessness and agitation. Review of Resident #48's nurse's notes identified the following: * 12/04/25 at 7:12 p.m., Writer was doing evening med pass when writer heard a scream coming from the unit's lounge. Writer ran and saw [CNA's name] in between residents [Resident #48] and [Resident #9]. CNA informed writer that resident was yanked on left wrist and was slapped on left side of face x [times] 2 by [Resident #9]. Noted resident's left cheek was reddish in color on assessment. No noted bruising/redness on resident's left hand. De-escalation done. Cold compress applied on left cheek and left dorsal hand. * 12/05/25 at 10:09 p.m., . CNA notified this nurse that resident [Resident #48] has a 1.5 cm [centimeter] by 1.5 cm bruise to the L [left] inner forearm. Resident is oriented to self only and is unable to verbalize what happened. Resident does not appear to have pain in this area. Review of Resident #9's medical record occurred on all days of survey. Diagnoses included dementia with agitation, depression, irritability/anger, and psychotic disorder with hallucinations. The current physician's orders included Valproic Acid capsule during the day and two capsules at bedtime for a psychotic disorder with hallucinations. The current care plan stated, . I have potential to demonstrate physical and verbal behaviors. I can be started [sic] easily. I at times get frustrated if there are too many people around me . Remove from stressful situation . Resident #9's care plan failed to address his physically aggressive behaviors towards other residents in the facility. During an interview on the morning of 04/16/26, an administrative staff member (#2) confirmed the facility failed to report/thoroughly investigate the incident between Resident #48 and #9.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from restraints for 1 of 1 sampled resident (Resident #9) reviewed for restraints. Failure to ensure staff refrained from using a manual method of restraining a resident placed Resident #9 at risk for increased behaviors, fear, anxiety, and injury.Findings Include:Review of the facility policy titled Use of Physical Restraints occurred on 04/16/26. This policy, dated February 2026, stated, . all residents have the right to be free from any physical restraints . Within 72 hours the interdisciplinary team must be notified of the application of the restraint so that they may complete a follow-up evaluation and determine the need to initiate the non-emergency physical restraint procedure.Review of Resident #9's medical record occurred on all days of survey. Diagnoses include irritability, anger, and dementia with agitation and psychotic disturbances. The current care plan stated, . I have potential to demonstrate physical and verbal behaviors. And at times will refuse cares . Give me as many choices as possible about my care and activities . I at times get frustrated if there are too many people around me . Reapproach .Review of Resident #9's nurse's notes identified the following:* 08/09/25 at 11:00 p.m., . needs brief change . started throwing punches and kicking. Called for assistance. Another RN [registered nurse] and 2 CNAs [certified nurse aides] came and help [sic]. One staff [sic] held his hands and another on hold [sic] his legs. 2 other staff cleaned . * 08/18/25 at 11:55 p.m., . needed to be changed. started to be violent and throwing punches . called CNA to help but resident was even [sic] kicking the staffs [sic]. called another CNA to assist. Writer held resident's arms, 1 CNA held his legs while the other CNA washed . The medical record lacked documentation the staff attempted to reapproach Resident #9 or minimize the number of staff in the room during the above incidents. During an interview on 04/16/26 at 10:12 a.m., an administrative nurse (#1) stated facility staff should not physically restrain residents.The facility failed to ensure Resident #9 remained free from manual restraint use by multiple staff members.

Based on record review, review of facility policy, and staff interview, the facility failed to report incidents of potential abuse to officials including the State Survey Agency (SSA) for 3 of 3 sampled residents (Resident #9, #42, and #48) with allegations of physical or sexual abuse. Failure to report incidents of potential physical or sexual abuse to the State agency placed all residents at risk of abuse, mental and emotional distress, and or physical injury. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, occurred on 04/16/26. This policy, dated February 2026, stated, . The facility will have written procedures that include . Reporting of all alleged violations to the . state agency, adult protective services and to all other required agencies . within specified timeframes . Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse .- Review of Resident #9's medical record occurred on all days of survey. Diagnoses included dementia with agitation, depression, irritability/anger, and psychotic disorder with hallucinations. The current care plan identified, . I have potential to demonstrate physical and verbal behaviors. I can be started [sic] easily. I at times get frustrated if there are too many people around me . Remove from stressful situation . Review of Resident #9's nurse's notes identified the following:* 8/9/25 at 11:00 p.m., . needs brief change . started throwing punches and kicking. Called for assistance. Another RN [registered nurse] and 2 CNAs [certified nurse aides] came and help [sic]. One staff [sic] held his hands and another on hold [sic] his legs. 2 other staff cleaned . * 8/18/25 at 11:55 p.m., . needed to be changed. started to be violent and throwing punches . called CNA to help but resident was even [sic] kicking the staffs [sic]. called another CNA to assist. Writer held resident's arms, 1 CNA held his legs while the other CNA washed . The facility failed to report potential staff-to-resident abuse to the SSA. - Review of Resident #48's medical record occurred on all days of survey. Diagnoses included anxiety, dementia with psychotic disturbance, depression, restlessness and agitation.A nurse's note, dated 12/04/25 at 7:12 p.m., stated, Writer was doing evening med pass when writer heard a scream coming from the unit's lounge. Writer ran and saw [CNA's name] in between residents [Resident #48] and [Resident #9]. CNA informed writer that resident was yanked on left wrist and was slapped on left side of face x [times] 2 by [Resident #9]. Noted resident's left cheek was reddish in color on assessment. No noted bruising/redness on resident's left hand. De-escalation done. Cold compress applied on left cheek and left dorsal hand. Family informed, physician fax form prepared, DON [director of nursing] and nurse managers notified. The facility failed to report resident-to-resident abuse to the SSA. - Review of Resident #42's medical record occurred on all days of survey. Diagnoses included dementia, anxiety, restlessness, agitation, and hallucinations. A nurse's note, dated 11/19/2025 at 7:00 p.m., stated, Resident [Resident #42] was on her wheelchair and on her way back to her room when she passed by a male resident and touched his shoulder. Male resident grabbed her breast and she just laughed. Took resident back to her room. The facility failed to report potential resident-to-resident abuse to the SSA. During an interview on the morning of 04/16/26, two administrative staff members (#1 and #2) confirmed the facility failed to report the incidents identified above to the SSA.

Based on record review, review of facility policy, and staff interview, the facility failed to thoroughly investigate alleged violations of possible abuse for 3 of 3 sampled residents (Resident #9, #42, and #48) subjected to physical abuse, sexual abuse, and restraint use. Failure to thoroughly investigate allegations of abuse, implement corrective actions, and evaluate the effectiveness of those actions, placed all residents at risk of abuse, mental/emotional distress, and physical injury.Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, occurred on 04/16/26. This policy, dated February 2026, stated, . An immediate investigation is warranted when suspicion of abuse . or reports of abuse . occur. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following . analyzing the occurrence(s) to determine why abuse . occurred, and what changes are needed to prevent further occurrences. Defining how care provision will be changed and/or improved to protect residents receiving services .- Review of Resident #9's medical record occurred on all days of survey. Diagnoses included dementia with agitation, depression, irritability/anger, and psychotic disorder with hallucinations. The current care plan identified, . I have potential to demonstrate physical and verbal behaviors. I can be started [sic] easily. I at times get frustrated if there are too many people around me . Remove from stressful situation . Review of Resident #9's nurse's notes identified the following:* 8/9/25 at 11:00 p.m., . needs brief change . started throwing punches and kicking. Called for assistance. Another RN [registered nurse] and 2 CNAs [certified nurse aides] came and help [sic]. One staff [sic] held his hands and another on hold [sic] his legs. 2 other staff cleaned . * 8/18/25 at 11:55 p.m., . needed to be changed. started to be violent and throwing punches . called CNA to help but resident was even [sic] kicking the staffs [sic]. called another CNA to assist. Writer held resident's arms, 1 CNA held his legs while the other CNA washed . The facility failed to investigate the potential abuse to Resident #9 by staff, - Review of Resident #48's medical record occurred on all days of survey. Diagnoses included anxiety, dementia with psychotic disturbance, depression, restlessness and agitation.A nurse's note, dated 12/04/25 at 7:12 p.m., stated, Writer was doing evening med pass when writer heard a scream coming from the unit's lounge. Writer ran and saw [CNA's name] in between residents [Resident #48] and [Resident #9]. CNA informed writer that resident was yanked on left wrist and was slapped on left side of face x [times] 2 by [Resident #9]. Noted resident's left cheek was reddish in color on assessment. No noted bruising/redness on resident's left hand. De-escalation done. Cold compress applied on left cheek and left dorsal hand. Family informed, physician fax form prepared, DON [director of nursing] and nurse managers notified. The facility failed to investigate the incident of resident-to-resident abuse. - Review of Resident #42's medical record occurred on all days of survey. Diagnoses included dementia, anxiety, restlessness, agitation, and hallucinations. A nurse's note, dated 11/19/2025 at 7:00 p.m., stated, Resident [Resident #42] was on her wheelchair and on her way back to her room when she passed by a male resident and touched his shoulder. Male resident grabbed her breast and she just laughed. Took resident back to her room. The facility failed to investigate the potential incident of resident-to-resident abuse. During an interview on the morning of 04/16/26, two administrative staff members (#1 and #2) confirmed the facility failed to investigate the incidents identified above.

Based on record review and staff interview, the facility failed to provide the State Long Term Care Ombudsman with a written notice of discharge for 1 of 1 closed record (Resident #81) reviewed for facility discharge. Failure to notify the State Ombudsman does not provide residents with access to an advocate who can inform them of their options and rights, and to provide them with protection from being discharged inappropriately.Findings include: Review of Resident #81's medical record occurred on 04/14/26. A progress note dated 02/12/26 at 2:17 p.m., stated, Resident seen for rounds today . will be discharging home on 2/18/26 as therapy complete. The record failed to include evidence the facility notified the State Ombudsman of the discharge. During an interview on 04/14/2026 at 3:35 p.m. an administrative staff member (#2) confirmed Resident #81's medical record lacked the required notification to the State Ombudsman.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 1 of 18 sampled residents (Resident #9). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility's policy titled Comprehensive Care Plans occurred on 04/16/26. This policy, dated March 2026, stated, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. Review of Resident #48's medical record occurred on all days of survey. A nurse's note, dated 12/04/25 at 7:12 p.m., stated, Writer was doing evening med pass when writer heard a scream coming from the unit's lounge. Writer ran and saw [CNA's name] in between residents [Resident #48] and [Resident #9]. CNA informed writer that resident was yanked on left wrist and was slapped on left side of face x [times] 2 by [Resident #9]. Noted resident's left cheek was reddish in color on assessment. No noted bruising/redness on resident's left hand. De-escalation done. Cold compress applied on left cheek and left dorsal hand. Family informed, physician fax form prepared, DON [director of nursing] and nurse managers notified. - Review of Resident #9's medical record occurred on all days of survey. Diagnoses included dementia with agitation, depression, irritability/anger, and psychotic disorder with hallucinations. The current care plan identified, . I have potential to demonstrate physical and verbal behaviors. I can be started [sic] easily. I at times get frustrated if there are too many people around me . Remove from stressful situation . Review of Resident #9's nurse's notes identified the following:* 8/9/25 at 11:00 p.m., . needs brief change . started throwing punches and kicking. Called for assistance. Another RN [registered nurse] and 2 CNAs [certified nurse aides] came and help [sic]. One staff [sic] held his hands and another on hold [sic] his legs. 2 other staff cleaned . * 8/18/25 at 11:55 p.m., . needed to be changed. started to be violent and throwing punches . called CNA to help but resident was even [sic] kicking the staffs [sic]. called another CNA to assist. Writer held resident's arms, 1 CNA held his legs while the other CNA washed . The facility failed to update Resident #9's care plan following the incidents identified above. During an interview on the morning of 04/16/26, two administrative staff members (#1 and #2) confirmed the facility failed to update Resident #9's care plan following the incidents.

Based on observation, record review, review of facility policy, review of manufacturer's instruction manual, and staff interview, the facility failed to ensure staff used a mechanical lift appropriately for 1 of 4 sampled residents (Resident #48) observed during sit-to-stand lift transfers. Failure to ensure staff used the mechanical lift according to manufacturer's instructions placed Resident #48 at risk for pain/discomfort and/or injury. Findings include: Review of the facility's policy titled, Safe Resident Handling/Transfers, occurred on 04/16/26. This policy, reviewed February 2026, stated, . All residents require safe handling when transferred to prevent or minimize the risk for injury . Staff will perform mechanical lifts/transfers according to the manufacturer's instructions . The facility provided a copy of the manufacturer's instructions for the Easy Way sit-to-stand lift. Review of the instructions occurred on 04/16/26. The instructions stated, . Raise the patient's arms on the outside of the harness and have them place their hands on the padded handles. As the patient is being raised, simultaneously tighten the safety strap buckled around their torso. Stop lifting when the patient is in a standing position. With the patient in a standing position, transfer the patient to the desired location. Review of Resident #48's medical record occurred on all days of survey. Medical diagnoses included dementia, disc degeneration; cervical, lumbar, and thoracic regions, and extremity pain. The current care plan stated, . I have an ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to] Dementia . TRANSFER: PAL [sit-to-stand] lift and assist of 2 . I have history of chronic pain and history of fractures . Monitor . complications related to arthritis: Joint pain; Joint stiffness . Swelling . Observations showed the following:* 04/14/26 at 10:34 a.m., two certified nurse aides (CNAs) (#13 and #14) transferred Resident #48 from the bed to the toilet with a sit-to-stand lift. When the CNAs raised the lift, the resident failed to bear weight, remained in a seated position, and hung from the harness. The harness straps pulled upward into Resident #48's axillae (armpits), rolled/pinched the skin above the sling strap, and raised her shoulders. The resident remained in this position until the CNAs (#13 and #14) lowered her onto the toilet.* 04/15/26 at 3:48 pm, two CNAs (#8 and #13) transferred Resident #48 from the bed to the toilet with a sit-to-stand lift. When the CNAs raised the lift, the resident failed to bear weight, remained in a seated position, and hung from the harness. The harness straps pulled upward into Resident #48's axillae, bunched her shirt sleeves above the sling strap, and raised her shoulders. The resident remained in this position until the CNAs (#8 and #13) lowered her onto the toilet. During an interview on 04/16/26 at 8:20 a.m., two administrative staff members (#2 and #3) confirmed staff should ensure residents can bear weight when utilizing a sit-to-stand lift.

Based on observation, record review, review of facility policy, review of the dialysis communications forms, and resident and staff interview, the facility failed to provide care and services consistent with professional standards of practice for 1 of 1 sampled resident (Resident #63) receiving hemodialysis. Failure to receive dialysis treatment communication on a consistent basis and complete post-dialysis assessments may result in an unidentified change in the resident's condition.Findings include: Review of the facility policy titled Hemodialysis occurred on 04/16/26. This policy, dated 2025, stated, . The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include . Ongoing assessment and oversight of the resident before, during and after dialysis treatment . Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. Review of Resident #63's medical record occurred on all days of survey. A hospital discharge order, dated 04/02/26, stated, . Continue dialysis 3 times per week . A physician's order, dated 03/10/26, stated, Assess AV [arteriovenous] fistula [dialysis access site] to right forearm, appearance, bruit, and thrill. two times a day . Observation on 04/14/26 at 8:01 a.m. showed a fistula to Resident #63's right forearm. The resident confirmed dialysis treatments three times a week on Mondays, Wednesdays, and Fridays. Review of Resident #63's dialysis communication forms, dated 03/13/26 through 04/13/26 (12 visits), showed 5 of the 12 forms failed to include the dialysis centers pre and/or post dialysis information. Review of the resident's treatment administration records (TARs) and nurses' notes from 03/13/26 through 04/13/26 lacked documentation of the facility's post-dialysis/fistula site assessments for 12 of the 12 visits. During an interview on 04/14/26 at 5:14 p.m., two administrative staff members (#1 and #2) confirmed nursing staff failed to ensure the dialysis center completed the communication forms or the facility nursing staff called the center to obtain a report on the resident's status. The administrative staff members also stated nursing staff failed to complete and document post dialysis/fistula assessments after the resident returned to the facility on all 12 visits.

Based on observation, review of professional reference, and staff interview, the facility failed to ensure medication labels matched provider's orders for 1 of 2 residents (Resident #3) observed for insulin administration. Failure to ensure medication labels matched the provider's orders placed the resident at risk for medication errors.Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 838, stated, . Obtain the appropriate medication. Compare the label of the medication container or unit-dose package against the order on the MAR [medication administration record] or computer printout. Rationale: This is a safety check to ensure that the right medication is given. If these are not identical, recheck the prescriber's written order in the client's chart. If there is still a discrepancy, check with the pharmacist. Prepare the medication. While preparing the medication, recheck each prepared drug and container with the MAR again. Rationale: This second safety check reduces the chance of error.Review of Resident #3's medical record occurred on 04/15/26. A physician's order, dated 11/27/24, identified to administer Novolog insulin sliding scale in addition to the scheduled insulin before meals and at bedtime as follows: with a blood sugar reading of 150 - 199 administer 1 additional unit of insulin; 200 - 299 = 3 units; 300 - 399 = 5 units; 400 - 500 = 7 units; greater than 500, call the provider. Observation on 04/15/26 at 11:47 a.m. showed a nurse (#7) prepared Resident #3's Novolog sliding scale. The label on the pen showed 0 - 199 = 0 units; 200 - 299 = 2 units; 300 - 399 = 4 units; 400 - 500 = 6 units; greater than 500, call the provider.The facility failed to ensure the label on the insulin pen and the provider's order matched. During an interview on 04/15/26 at 2:15 p.m., administrative staff members (#1 and #2) confirmed the label on the insulin pen and the provider's orders did not match.

Based on record review, review of facility policy, and resident and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 3 of 18 sampled residents (Residents #50, #55, and #63) and 1 supplemental resident (Resident #81). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 02/05/25. This undated policy stated, . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS [Minimum Data Set] assessment, and PRN [as needed] when changes in the resident condition dictates. - During an interview on 02/03/25 at 3:59 p.m., Resident #50 stated she had pain to both knees. Review of Resident #50's medical record occurred on all days of survey and identified a diagnosis of right and left knee pain with a physician's order, dated 06/11/23, for Biofreeze (topically pain reliever) gel two times a day for bilateral knee pain. The current care plan failed to address Resident #50's bilateral knee pain. - Review of Resident #55's medical record occurred on all days of survey with a physician's orders, dated 12/05/24 and 01/03/25, stated, . Regular. diet Pureed texture, Honey consistency, Small bites with spoon for Mod [moderate]-severe pharyngeal-esophageal dysphagia [swallowing difficulty] . Vanilla Boost+/Ensure [a high calorie nutritional drink] . Magic Cup [a high calorie protein ice cream] one time a day Alternate w [with]/pudding. The care plan failed to address the changes made to Resident #55's diet. - Review of Resident #63's medical record occurred on all days of survey and identified a diagnosis of diabetes. The current physician's orders included an order for insulin at bedtime. The care plan failed to address the resident's use of insulin and the signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). - Review of Resident #81's medical record occurred on all days of survey and identified a diagnosis of insomnia. Physician's orders included Ambien (hypnotic) at bedtime for insomnia, initiated 11/21/24. The current care plan failed to address the resident's insomnia and use of a hypnotic medication. During an interview on 02/05/25 at 3:21 p.m., an administrative nurse (#1) stated the care plans are reviewed and updated prior to the resident's care conference, with the minimum data set (MDS), and with any daily care changes. 42397 46964

Based on record review, policy review, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 2 of 18 sampled residents (Resident #78 and Resident #285) reviewed for advanced directives. Failure to ensure all methods of communication and/or documentation of code status accurately reflected the resident/resident representative wishes has the potential to limit access to life-sustaining services or unwanted treatment. Findings include: Review of the facility policy titled Advanced Directives occurred [DATE]. This policy, revised [DATE], stated, . In view of its [sic] mission to respect the life and dignity of each person, Bethel Lutheran Nursing & [and] Rehabilitation Center recognizes that every competent adult has the right and responsibility to control the decisions relating to their own health care. Bethel Lutheran Nursing & Rehabilitation Center is transitioning forward using the North Dakota POLST (Physician Order for Life sustaining Treatment). Review of the facility policy titled CPR Directive . occurred [DATE]. This policy, revised [DATE], stated, . will inform residents and/or significant others about the choices available regarding cardiopulmonary resuscitation. The code level will be scanned and entered on the physician order sheet. During an interview on [DATE] at 8:49 a.m., a nurse (#2) stated she would look on the resident profile in the electronic health record (EHR) for a resident's code status. - Review of Resident #78's medical record occurred on all days of survey. A POLST form, dated [DATE], indicated Full Code. The EHR lacked a physician's order for a code level status and failed to display the resident's code status in an area direct care staff would access prior to providing life sustaining treatment. - Review of Resident #285's medical record occurred on all days of survey. A POLST form, dated [DATE], stated DNR [do not resuscitate]/Limited interventions. The EHR lacked a physician's order for a code level status and failed to display the resident's code status in an area direct care staff would access prior to providing unwanted treatment. During an interview on [DATE] at 4:05 p.m., an administrative nurse (#1) confirmed the EHR lacked a physician's order which triggers the code status to display in the resident's profile, agreed she expected the resident's code status to be displayed in the resident profile of the EHR, and confirmed Resident #78 and #285's EHR profiles lacked a code status.

Based on record review, review of facility investigation, review of the facility policies, and staff interviews, the facility failed to ensure adequate supervision and assistance for 1 of 3 sampled residents (Resident #3) who required staff assistance and sit to stand mechanical lift transfers. Failure to provide adequate assistance as care planned for transfers may have resulted in Resident #3's fracture and placed all residents requiring assistance for transfers at risk for injuries. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 02/07/24. This undated policy, stated, . It is the policy of [Facility Name] to develop and implement a comprehensive person-centered care plan for each resident, . to meet a resident's medical, nursing, and mental . needs . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. f. Resident specific interventions that reflect the resident's needs . 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the facility policy titled Nursing Practice Guidelines - Nursing Service Department occurred on 02/07/24. This undated policy, stated, . II. Activity of each resident will be maintained at a maximal level. a. Ambulation of residents will be carried out: 1. According to individual needs . 2. Using proper . transfer techniques. 3. Assisting residents to use adaptive equipment . XI. Other Therapy. a. Provisions should be made to insure [sic] safe and proper therapeutic use of equipment such as: mechanical lifts . Review of Resident #3's medical record occurred on 02/06/24. The current care plan stated, .TRANSFER: PAL [mechanical sit to stand lift] LIFT TRANSFER . revision on 01/25/24 . A nursing progress note, dated 02/01/24 at 4:20 a.m., stated, . PAL lift in the bathroom during transfer with 2 assist . Once toileting complete she was being lifted in PAL lift and she removed her left hand from the left handle. She was easily redirected by staff to place hand back to handle, removed x2 [two times] during transfer. Yelling out with transfer and nothing heard or seen by staff during transfer . CNA [certified nurse aide] [name] noticed that left hand was uneven and called the nurse. Upon assessment, noted resident in pain upon movement of left arm. Pain scale 10/10 upon movement. Limited ROM [range of motion] left arm. Noted swelling on left upper arm. Left arm looks uneven. Informed on-call [administrative nurse] . Informed on-call doctor . and got an order to send resident to ED [emergency department] for evaluation . Transferred resident to her wheelchair using hoyer [full body mechanical lift] with 4 assist. Maintained support on left arm. Resident was brought to ED per wheelchair in stable condition with arm sling on left arm, accompanied by CNA . An emergency room physician's progress note, dated 02/01/24 at 5:38 a.m., stated . presents to emergency department with left arm deformity . Very obvious fracture on her x-ray . Review of the facility's investigation of the incident identified the following: * Resident #3's care plan revised for transfers on 01/25/24 * The change was communicated through report and placed in the communication book * The facility staff failed to update the CNA paper assignment sheet with the change in Resident #3's transfer status * The facility conducted interviews with staff working 01/31/24 and 02/01/24 The facility's investigation report stated, . It was noted in [CNA #2's name] statement she had transferred the resident earlier in the evening in the shower room bathroom with assist of 1, gait belt, and grab bar. Then got the resident toileted and ready for bed, placed back to the lounge for a bit . she used a two person PAL lift assist to transfer the resident to bed at bedtime, but did the transfer herself in the shower room to assist the resident with toileting and bedtime cares. In review of all information, it is likely the injury was more likely to have occurred during that assist of 1 transfer in the shower room bathroom with the resident standing with the grab bar, turning and putting herself backwards to the toilet by still holding the grab bar to her right. Placing that left arm in a twisted, akward [sic] position, across her body, with the weight of her body going back and down. During an interview on 02/06/24 at 1:39 p.m., the CNA (#2) confirmed she transferred Resident #3 with a gait belt and assist of 1 on the evening of 01/31/24. She stated she was unaware of the care plan change for Resident #3 to PAL lift for all transfers, did not review care plans on a routine basis, and relied on the paper CNA assignment sheet for transfer status. During an interview on 02/06/24 at 2:45 p.m., an administrative nurse (#1) stated she expected staff to be aware of resident care plans and changes to them. She confirmed the facility staff failed to update the paper CNA assignment sheet with the change to Resident #3's transfer status, and the CNA (#2) failed to follow Resident #3's care plan for transfers that likely resulted in Resident #3 sustaining a fractured left arm.

Based on observation, and review of facility policy, the facility failed to ensure safe and secure storage of narcotic medications for 2 of 4 medication carts (Harmony and Wheatland Units). Failure to store medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Controlled Medication Storage occurred on 12/06/23. This policy, dated August 2022, stated, . B. Scheduled II medications are stored in a separate area under double lock. Observation on 12/05/23 at 8:22 a.m. showed a staff nurse (#4) assigned to the medication cart for the Harmony Unit showed narcotics/controlled medications (Schedule II-V), located in the bottom left-hand drawer not double locked. Observation on 12/05/23 at 4:10 p.m. showed a staff nurse (#5) assigned to the medication cart for the Wheatland Unit showed narcotics/controlled medications (Schedule II-V), located in the bottom left-hand drawer not double locked.

Based on record review and staff interview, the facility failed to provide a bed hold notice to 2 of 5 sampled residents (Residents #15 and #79) reviewed with a hospital transfer. Failure to provide a bed hold notice does not allow the residents and/or their representatives to make an informed decision regarding their rights. Findings include: - Review of Resident #15's medical record occurred on all days of survey and identified a transfer to the hospital on 03/07/23. The record lacked a bed hold notice for the hospital transfer. - Review of Resident #79's medical record occurred on all days of survey and identified a transfer to the hospital on 10/12/23. The record lacked a bed hold notice for the hospital transfer. During an interview on 12/07/23 at 9:05 a.m., an administrative staff member (#2) confirmed Resident #15 and #79's medical records lacked a copy of the bed hold notices.

Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASRR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 2 of 4 sampled residents (Resident #2 and Resident #63) reviewed for PASRR. Failure to complete a change in status assessment for a newly diagnosed mental illness may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASRR Provider Manual, revised December 2020, page 13, states, . Change in Status Process: Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC [mental illness, intellectual disability, and conditions related to intellectual disability (referred to in regulatory language as related conditions or RC)] was not identified at the Level I screen process, and that condition later emerged or was discovered. - Review of Resident #2's medical record occurred on all days of survey. The record showed an initial PASRR completed on 03/30/01. The resident's diagnosis list identified a new diagnosis of psychotic disorder with delusions due to known physiological condition, dated 08/14/20. The record lacked evidence the facility completed a Level I screening/change in status assessment with the new diagnosis. During an interview on 12/06/23 at 4:00 p.m., an administrative staff member (#2) confirmed the facility failed to submit another PASRR for Resident #2 following the new diagnosis. 40488 - Review of Resident #63's medical record occurred on all days of survey and identified a Level I PASARR completed on 05/27/22. The record showed Resident #63 received a new diagnosis of psychotic disorder with hallucinations on 08/15/23. The record lacked evidence the facility completed an updated Level I screening/change in status assessment with the new diagnosis. During an interview on 12/06/23 at 5:16 p.m., an administrative staff member (#2) confirmed the facility failed to submit another PASRR for Resident #63 following the new diagnosis.

Based on observation, review of facility policy, review of manufacturer's guidelines, review of professional reference, and staff interview, the facility failed failure to ensure sanitization of dishware (utensils, dishes, pots/pan) used to serve residents, staff, and visitors in 1 of 1 kitchen. Failure to ensure the mechanical dishwashing machine maintains the correct hot water temperature required by manufacturer's directions to destroy pathogens may result in the spread of illness and/or foodborne illness to residents, visitors, or staff During the on-site recertification survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on 11/16/22 at 9:50 a.m. The IJ potential resulted from observation of the dishwashing machine temperatures not being maintained at the manufacturer's recommendations. This finding placed residents in immediate danger due to the potential of spread of illness and/or foodborne illnesses from improper sanitization. * 11/16/22 at 10:02 a.m. - The survey team notified the director of nursing and dietary management of the IJ situation and requested they develop a plan for removal of the immediate jeopardy. * 11/16/22 at 10:10 a.m. During an interview with a dietary director (#6) she stated, Unfortunately our machine temperatures may have been wrong for some time. * 11/16/22 at 10:15 a.m. The survey team contacted the State Survey Agency (SSA) to report the findings and to discuss IJ. * 11/16/22 at 10:26 a.m. An administrative nurse (#8) verified the facility did not have any gastrointestinal illnesses in the facility. * 11/16/22 at 10:45 a.m. The facility submitted a written immediate action plan. * 11/16/22 at 5:05 p.m. - The facility provided a revised written plan of correction for the IJ. * 11/16/22 at 5:30 p.m. - The survey team reviewed and accepted the facility's version of the written plan of correction for the IJ. * 11/16/22 at 5:35 p.m. - The survey team removed and reduced the IJ situation from a scope/severity of L to a scope and severity of F. * 11/16/22 at 5:40 p.m. - The SSA notified the Centers for Medicare and Medicaid Services location of the immediate jeopardy was removed. Findings include: The FDA Food Code 2017 Annex 3 - Public Health Reasons, page 506, stated, 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. The temperature of hot water delivered from a warewasher sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits . to ensure surfaces of multi-use utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least . 160 degrees F [Fahrenheit] as measured by an irreversible registering temperature measuring device to affect sanitization. Manufacturer's guidelines (page 24) for dishwashing machine model CLCS66eN states . Minimum Temperatures Using High-Temperature Sanitizing for wash tank is 160 degrees Fahrenheit and for final rinse is 180 degrees Fahrenheit. Review of the facility policy titled, Cleaning Dishes/Dish Machine occurred on 11/16/22, and stated .Check the dish machine gauges throughout the cycle to assure proper temperatures. Observations of the mechanical dishwasher currently in use in the main kitchen showed the following: * 11/16/22 at 9:25 a.m., Upon the completion of the rinse cycle, the plate simulator (a type of irreversible temperature registering device) indicated a food-contact surface temperature of 152.4 degrees F (Fahrenheit). The temperature display on the outside of the dishwasher showed 157 degrees F during the wash cycle and 128 F during the rinse cycle. * 11/16/22 at 9:35 a.m., wash temperature 155 degrees F and rinse temperature 135 degrees F; and plate simulator 152.4 degrees F. * 11/16/22 at 9:51 p.m., wash temperature 155 F and rinse temperature 135 degrees F; plate simulator 152.5 degrees F. The facility's plate simulator registered 153.3 degrees F. During an interview on 11/16/22 at 10:00 a.m., an administrative staff (#4) and two dietary administrative staff (#6 and #7) agreed the dishwasher temperatures were a concern and the facility immediately implemented to paper and plasticware and the three-compartment sink method for dishwashing, rinsing, and sanitizing until the facility could resolve the issue. An administrative staff member (#7) demonstrated the correct use of the three-compartment sink method.

FALLS 1. Based on record review and staff interview, the facility failed to ensure necessary assistance and supervision to prevent accidents for 2 of 3 sampled residents (Resident #2 and #5) who experienced a fall with major injury. Failure to provide assistance with ambulation and bed mobility resulted in a hip fracture (Resident #5) and a head injury (Resident #2). Findings include: - Review of Resident #2's medical record occurred on August 19-21, 2014. [DIAGNOSES REDACTED]. The MDS in effect at the time of the fall, dated 02/25/14, identified extensive assistance from two or more people for bed mobility. Resident #2's care plan in effect at the time of the fall, dated 06/14/13, stated, ". . . I have an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Stroke, Dementia, Limited ROM (range of motion), Aggressive Behaviour (sic), [DIAGNOSES REDACTED], Limited Mobility, Pain . . . BED MOBILITY: I require 2 staff participation to reposition and turn in bed. . . ." Nurses' notes stated the following: *05/09/14 at 8:00 p.m.: ". . . CNA (certified nursing assistant) (name) approached Nurse (name) in hallway and summoned her to (Resident #2) room. Resident fell off the bed during PM (evening) care and sustained a laceration to back of head. Area to head is actively bleeding. Blood noted in corner of room on the floor. . . . Open skin noted. Unable to assess size due to matted hair. . . ." *05/09/14 at 8:05 p.m.: ". . . Call made to (hospital name) for transport for evaluation and treatment . . ." *05/09/14 at 11:45 p.m.: ". . . Resident arrived at bethel via wheelchair. . . . Dressing to site. 7 Staples in place. . . ." During an interview on the afternoon of 08/18/14, a supervisory nurse (#9) stated there were supposed to be 2 staff assisting Resident #2 while she was in bed, and the CNA did not follow the care plan. Failure to provide assistance with cares according to the care plan resulted in Resident #2's fall from bed with a head injury that required staples to repair. - Review of Resident #5's medical record occurred on August 19-21, 2014. [DIAGNOSES REDACTED]. The MDS in effect at the time of the fall, dated 04/05/14, identified extensive assistance from two or more people for walking in corridors. Resident #5's care plan in effect at the time of the fall, dated 11/08/13, stated, ". . . Ambulate with walker assist of one with gait belt. . . . I am High risk for falls r/t (related to) Unaware of safety needs, Confusion, Psychoactive drug use, Wandering. Actual falls. . ." Nurses' notes stated the following: *06/13/14 at 10:00 a.m.: "this nurse saw CNA walking with resident to table. (The CNA was walked beside the resident without using a gait belt). Resident stumbled CNA tried to reach unable to resident went down on right knee then to side then to back. . . after assessment done this nurse and two CNAs assisted the resident to sit up and applies (sic) a gait belt . . . my knees are bothering me icy hot applied and resident into wheelchair. . . Interventions: Stay at side for entire transfer." *06/13/14 at 1:00 p.m.: "resident no longer baring (sic) weight to right side needing two people to transfer called daughter and would like her checked out called dr (doctor) on call . . . ok to send to for evaluation." *06/13/14 at 8:00 p.m. (late entry): ". . . resident admitted with Right Hip fracture. Will have surgical repair in AM (morning) if no changes." During an interview on 08/20/14 at 2:30 p.m., a supervisory nurse (#10) stated according to Resident #5's care plan at the time of the fall, the resident should have been wearing a gait belt and a CNA assisting her. Failure to provide assistance with ambulation according to the care plan resulted in Resident #5's fall sustaining a broken hip that required surgical intervention. HAZARDOUS CHEMICALS 2. Based on observation, review of Material Data Safety Sheets (MSDS), and staff interview, the facility failed to ensure an environment free from hazardous chemicals in 2 of 5 resident care areas (3rd floor Towers and Special Care Unit). Accessible hazardous chemicals place cognitively impaired and wandering residents at risk for accidents/injury. Findings include: Observation on 08/20/14 at approximately 1:30 p.m. showed a spray bottle of Virex 256 One Step disinfectant cleaner and deodorant in an unlocked cupboard in the nurses' station. Observation showed the door to the nurses' station was open and unlocked and no staff members were present. Observation in the Special Care Unit on 08/20/14 at approximately 2:00 p.m. showed chemicals in an open and unlocked cabinet in the bath house. The door to the bath house was also open and unlocked with no staff present. The chemicals included: *Virex 256 One Step disinfectant cleaner and deodorant - 3 bottles *Diversey Good Sense odor counteractant - 1 spray bottle *Apollo Turbo Clean pre-disinfectant chelating detergent - 1 gallon *Ecolab Pantastic Concentrated Pot and Pan Cleaner detergent - 1 gallon MSDS's showed the following warnings: *Virex: "Danger. Corrosive. Causes skin and eye burns. Harmful or fatal if swallowed. Combustible liquid and vapor." *Apollo: "Mild irritation of sensitive skin and mucus membranes." *Ecolab: "May cause eye and skin irritation. Avoid contact with eyes, skin, and clothing." During an interview on the morning of 08/21/14, a supervisory nurse (#3) stated staff should keep cleaning chemicals in locked cupboards/cabinets.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 09/15/11. 1. Based on record review, staff interview, and review of facility policy and procedure, the facility failed to provide the necessary care and services to ensure treatment for 1 of 1 sampled resident (Resident #11) who experienced unresolved pain following a fall. Failure to promptly complete a comprehensive pain assessment, implement interventions, and evaluate the effectiveness of the interventions related to pain management resulted in Resident #11 experiencing avoidable pain. Findings include: Review of the facility policy titled "Pain Assessment" occurred on 08/30/12. This policy, updated April 2012, stated, ". . . Policy Statement Bethel Lutheran & Nursing Rehabilitation Center attempts to reduce pain and suffering for all residents in our facility by identifying those residents who are experiencing pain by implementation of appropriate pain assessment and management protocols. . . . Policy . . . Implementation . . . 2. Conditions/[DIAGNOSES REDACTED]. . . g. Falls . . ." Review of Resident #11's medical record occurred on August 27-30, 2012 and identified [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as cognitively intact, and having experienced almost constant moderate pain and received scheduled pain medications. The current care plan stated the following, ". . . Problem: . . . Chronic low back pain . . . Approaches: . . . Assess characteristics of pain . . . Offer [MEDICATION NAME] Q (every) 4-6 hours PRN (as needed) as per physician orders, Nonpharmacologic methods to reduce pain. a. Back Rubs. b. Repositioning. c. Diversional Activity . . . d. Application of warm or cold packs. e. Assist with activities of daily living as needed . . . f. Deep breathing." Review of the interdisciplinary progress notes identified the following: * 07/14/12 at 6:50 p.m., "Found on floor by aide. Resident was falling as aide passed her doorway but could not break her fall. . . . c/o (complained of) pain at level '6' in right buttock. No c/o pain with ROM (range of motion). Assisted back to bed. Evening medications administered. including [MEDICATION NAME] (for anxiety) and [MEDICATION NAME] (for pain). Instructed to breath slowly in and out to calm anxiousness." * 07/15/12 at 4:20 a.m., "Still complaining of pain in (L) (left) buttock - lower back area. [MEDICATION NAME] x (times) 1 plus warm packs to affected area. . . ." * 07/15/12 at 5:30 p.m., "Medicated x 2 for c/o lower back pain." * 07/16/12 at 4:15 a.m., "Medicated x 2 for lower back pain." * 07/18/12 at 4:00 p.m., "Called over to clinic x 3 to talk to (Physician's) nurse about her pain - appointment need or x-ray) with no return call back - medicated x 2 with [MEDICATION NAME] - resident (up) walking with walker per (one) assistance - appetite poor - refused to come out of room . . ." * 07/22/12 ". . . much encouragement need (sic) to come out of room - continues to use pain rx (prescribed medications) routinely. . . ." * 07/25/12 at 11:00 a.m., "Resident continues with lower back pain - wants x-ray - no response from (Physician) last week - today he is out of the office - called the nurses (sic) manager . . . to get orders for x-ray this (after)noon (at) (Hospital Name) - she states she will see what she can do and get back to me . . ." * 07/25/12 at 1:00 p.m., "nurse manager returned call and set up appointment for resident with (Physician) this (after)noon . . . " * 07/25/12 at 4:45 p.m., "returned from the clinic - (increased) her pain patch - new script sent to Pharmacy . . ." * 07/25/12 at 5:30 p.m., "Resident states that she had x-ray's with no fracture . . ." * 07/25/12 at 10:30 p.m., "(Increased) dose of [MEDICATION NAME] applied at 7:00 p.m., c/o low back pain. rate 8/10. . . ." The "Comprehensive Pain Assessment Form," dated 07/25/12, identified Resident #11 experienced intermittent, stabbing/shooting pain with movement and/or coughing. She rated the intensity of her pain as being an 8 on a 10 point scale. The "Clinic Appointment Sheet," dated 07/25/12, stated, "07/14/12 fell in room . . . resident has (sic) complaining of lower back pain - unable to get app (appointment) - or x-ray for resident --- Resident loves pain meds (medications) . . . and likes the attention . . ." The radiology report, dated 07/25/12, identified "Diffuse osteopenia is seen. Multiple levels of superior and inferior endplate compression fractures are seen throughout the lower [MEDICATION NAME] spine and throughout the lumbar spine sparing L5. No subluxation is identified. . . ." The PRN Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. From July 15-25, 2012, the PRN MAR indicated [REDACTED]. Resident #11 rated her pain between 4-8 on a 10 point scale. Review of Resident #11's medical record identified the following: * [MEDICATION NAME] 5/325 mg (milligrams) 1 tablet every night and 1-2 tablets every 4 hours prn for pain (Ordered 04/30/12) * [MEDICATION NAME] Patch 25 mcq/hr (micrograms/hour) for pain (Ordered 04/30/12 - increased to 25 mcq/hr on 07/25/12) During interview on the morning of 08/30/12, two administrative nursing staff members (#2 and #3) confirmed facility staff failed to promptly address the resident's unresolved pain. Resident #11's record showed no evidence of a pain assessment completed until 11 days after her fall, no evidence the facility followed up when the physician's nurse failed to return calls on 07/18/12 and no evidence the x-ray was completed until the resident requested to have one done. Failure of facility staff to adequately assess and intervene delayed the provision of additional pain medication until 11 days after the fall/fractures occurred and resulted in Resident #11 experiencing unrelieved pain without appropriate management. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 09/15/11. 2. Based on observation, record review, and review of professional literature, the facility failed to ensure 1 of 1 supplemental resident (Resident #26) with a history of aspiration pneumonia, received the care and services necessary to attain the highest degree of safety possible while being fed in the dining room. Failure to adequately assess and provide services based on the assessment has the potential to affect the resident's overall swallow safety, putting him at greater risk of aspiration and limiting his nutritional intake. Findings include: Nancy B. Swigert, The Source for Dysphagia: Third Edition, LinguiSystems, Inc, pages 9-16 stated a sign of oral phase dysphagia (difficulty swallowing) include pocketing of food; while signs of pharyngeal dysphagia include coughing or choking during a meal or a wet, gurgly vocal quality. Review of Resident #26's medical record occurred on 08/30/12. Medical [DIAGNOSES REDACTED]. Resident #26's significant change Minimal Data Set ((MDS) dated [DATE], identified the resident as rarely/never understood; requires extensive assistance with bed mobility and transfers; total assistance with locomotion, dressing, eating, and toilet use; and swallowing disorders of a loss of liquid/solids when eating or drinking and coughing/choking during meals or when swallowing medications. Resident #26's current care plan, dated 08/20/12, identified a problem of "Nutrition and Hydration . . . " and interventions including ". . . Assist resident with Liberal ADA (American Dietetic Association), Puree, Small Portion Diet Nectar-Thick Liquids . . . ." Resident #26's Interdisciplinary Progress Notes (IPNs) from July -August 2012 stated: *07/08/12 at 5:30 p.m. - "Noted patient shivering. Took vitals. T (temperature) 100.1 (degrees Fahrenheit) . . . O2 (oxygen) sat (saturation) 82% . . . ." The facility notified the physician and transferred Resident #26 to the emergency department (ED). Resident #26 returned from the ED with orders for an oral antibiotic and oxygen to maintain adequate saturation. Resident #26 continued on pureed diet and thickened liquids. *07/12/12 at 4:30 a.m. - "Resident had coughing spell which increased to small emisis (sic) at supper . . . ." *07/12/12 at 2:00 p.m. - "Resident continues on [MEDICATION NAME] (an oral antibiotic) for aspiration PNE (pneumonia) . . . ." *07/23/12 at 1:25 p.m. - ". . . Resident also noted to have loose wet cough. Lungs noted to have rubs (and) rhonchi throughout. Cont (continue) to monitor for any (changes) in condition." *07/24/12 at 9:35 a.m. - "Received fax from (name of doctor) re: (regarding) cough (and) Hospice . . . ." 07/25/12 at 9:20 a.m. - "Resident continues to have coarse rhonchi to (bilateral) (upper) lung fields (with) diminished bases . . . Noted loose wet cough continuing . . . ." *08/26/12 at 4:00 p.m. - " . . . Noted (increased) coughing and crackles throughout all lung fields . . . ." Observation of Resident #26 in the Harmony Dining Room on 08/30/12 at 8:40 a.m. showed the resident seated in a high-back wheelchair with his neck hyper-extended and a pillow positioned behind his neck. A certified nurse aide (#8) fed Resident #26 approximately three spoonfuls of thickened cream of wheat hot cereal. Resident #26 failed to immediately swallow and held the food in his mouth. The CNA (#8) failed to provide verbal cueing or reposition the resident's neck to encourage him to swallow. Observation revealed Resident #26 displayed wet and raspy respirations. After a couple of minutes, the resident swallowed the food. The CNA (#8) continued to provide food to Resident #26. Observation showed Resident #26 coughed throughout the breakfast meal. After approximately fifteen minutes, an unidentified staff nurse entered the DR, observed Resident #26 coughing, and showed the CNA how to reposition Resident #26's neck (tuck the resident's chin to his chest) to facilitate his ability to swallow. Facility staff providing meal assistance to Resident #26 failed to immediately identify signs/symptoms of aspiration and implement interventions to prevent aspiration or stop feeding the resident. 3. Based on record review, policy and procedure review, review of professional literature, and staff interview, the facility failed to implement interventions to ensure 1 of 1 sampled resident (Resident #5) maintained normal bowel elimination patterns to prevent constipation/fecal impaction. Failure to conduct a comprehensive assessment and implement approaches/interventions for constipation resulted in Resident #5 requiring manual extraction of stool. Manual extraction of stool has the potential to cause the resident great discomfort and irritation of the rectal mucosa. Findings include: Berman, Snyder, Kozier, Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 9th edition, Pearson Education, Inc., New Jersey, pages 1349-1350, stated, "Constipation may be defined as fewer than three bowel movements per week. This infers the passage of dry, hard stool or the passage of no stool. . . . It is important to define constipation in relation to the person's regular elimination pattern. Some people normally defecate only a few times a week; other people defecate more than once a day . . . Many causes and factors contribute to constipation. Among them are the following: Insufficient fiber intake, Insufficient fluid intake, Insufficient activity . . . Emotional disturbances such as depression or mental confusion . . . Medications such as opioids (for pain). . . ." Review of the facility policy titled "Nursing Care Protocols" occurred on 08/30/12. This policy dated, March 2001, stated, "The following guidelines will be utilized to attend to resident needs that arise on an intermittent basis . . . III. GI System Protocol: as determined by assessment . . . e. May receive a high fiber supplement . . . IX. Elimination. a. Adequacy of bowel elimination should be assessed and maintained by: . . . 1. Checking and recording BM (bowel movements) daily. 2. Giving enemas, laxatives, and suppositories when ordered and indicated. 3. Encouraging fluids and activity and change in diet, if appropriate . . . ." Review of Resident #5's medical record occurred on August 27-30, 2012 and identified [DIAGNOSES REDACTED]. Resident #5 sustained a fractured right hip following a fall in April 2012. A significant change Minimum Data Set (MDS), dated [DATE], identified the resident displayed severe cognitive impairment and required extensive two-person physical assistance with bed mobility, transfer, ambulation, dressing, toilet use, and personal hygiene, continent of bladder and bowel, and utilizing scheduled and as needed pain medications. Resident #5's medications include: * [MEDICATION NAME] (an opioid [MEDICATION NAME] pain medication applied to the skin to manage moderate to severe chronic pain for individuals who require around-the-clock dosing) patch 25 micrograms every 72 hours. * Tylenol (also known as [MEDICATION NAME], an over-the-counter (OTC) pain medication), 650 milligrams (mg) three times a day. * [MEDICATION NAME] (an opioid [MEDICATION NAME] pain medication used to manage moderate to severe pain). Resident #5's medication regime failed to include any routine oral laxative medication. One of the side effects of all of these medications is constipation. Resident #5's July Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An Interdisciplinary Progress Note, (written by a staff nurse (#7)) on 07/25/12 at 7:00 p.m., stated "Resident denies having pain. Was constipated today and impacted. Gave MOM (Milk of Magnesia) and it didn't help. Helped (with) her impaction and also did a Fleets enema. Able to have a bowel movement (times) 2 . . . ." During an interview on 08/29/12 at 1:55 p.m., a staff nurse (#7) stated she "helped" Resident #5 by manually removing hard stool from Resident #5's rectum. This staff nurse stated she failed to inform Resident #5's physician and/or dietary department of the resident's constipation problem. Review of Resident #5's care plan, dated 07/05/12, failed to identify a problem of constipation or any dietary approaches or medications to prevent additional episodes of constipation. During interview on the morning of 08/30/12, an administrative nurse (#3) confirmed Resident #5's current care plan lacked specific dietary interventions following the resident's episode of fecal impaction. Failure of facility staff to complete a comprehensive assessment, inform the physician and dietary staff of Resident #5's constipation problem, and implement both pharmacological and non-pharmacological interventions placed this resident at risk for repeat manual assistance to extract stool. 4. Based on record review, review of facility policy, and staff interview, the facility failed to ensure 3 of 5 sampled insulin dependent diabetic residents (Resident #6, #17, and #18) received the necessary care and services regarding blood sugar (BS) monitoring and/or insulin administration. Failure to monitor residents' BS levels and/or administer insulin placed the residents at risk of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] (low and high blood sugar), and including coma and death. Findings include: Review of the facility policy titled "Medication Monitoring" occurred on 08/30/12. This policy, dated February 2006, stated, ". . . 10. INSULIN AND ORAL HYPOGLYCEMIC MEDICATIONS - Accuchecks as ordered by Physician. Contact physician if two weekly glucose reading are less than 70 or guidelines set by physician. - If resident is fasting and fingerstick glucose is less than 60, hold insulin or oral hypoglycemic and administer after resident has eaten . . ." Review of the facility policy titled "Adult Insulin Supplement ('Sliding Scale')" occurred on 08/30/12. This policy, dated May 2010, identified blood glucose levels with the number of units of insulin to be administered. For a blood glucose reading of "under 80 (milligrams/deciliter (mg/dL))" this policy instructs facility staff to "Follow [DIAGNOSES REDACTED] Policy/(Guidelines)" and for blood glucose reading of "over 400 (mg/dL)" for facility staff to "Call physician." The "[DIAGNOSES REDACTED] Guidelines," stated: "Blood Glucose: under 80 - Action" (for staff to follow) "4-6 ounces concentrated carbohydrate (blood glucose in 1 hr (hour)) 60-70 - Action - 4-6 ounces concentrated carbohydrate* 50-60 - Action - 8 ounces of concentrated carbohydrate* Under 50 - responsive - Give 8 ounces of concentrated carbohydrate* *Recheck glucose in 15-30 minutes and repeat above as necessary. May substitute any juice, milk or glucose gel in place of Gatorade per resident tolerance." Review of the facility policy titled "[MEDICAL CONDITION]/[DIAGNOSES REDACTED]" occurred on 08/30/12. This policy, dated May 2010, stated, "[MEDICAL CONDITION] (abnormally high serum glucose level) . . . Blood sugar: greater that 350. [DIAGNOSES REDACTED] (abnormally low serum glucose level) . . . Blood Sugar: less than 70. Treatment: As per physician order for [REDACTED]. Document any incident of either hyper-or [DIAGNOSES REDACTED] in the clinical record (interdisciplinary progress note or glucose monitoring record . . .)." - Review of Resident #17's medical record occurred on August 29-30, 2012. [DIAGNOSES REDACTED]. sugar level. Resident #17's blood glucose is to be monitored at 7:00 a.m, 11:00 a.m., 5:00 p.m., and 9:00 p.m. Review of Resident #17's glucose monitoring records and medication administration records (MARs) from March 2012 through August 29, 2012 identified the following concerns: * 03/04/12 - no documentation of a blood sugar (BS) level at 9:00 p.m. * 03/06/12 - as above * 03/11/12 - BS at 7:00 a.m. 102 mg/dL; 11:00 a.m. 137 mg/dL; 5:00 p.m. 210 mg/dL; 9:00 p.m. 172 mg/dL. The MAR indicated [REDACTED]. * 05/04/12 - BS at 11:00 a.m. 58 mg/dL; 12:00 p.m. 34 mg/dL; 12:15 p.m 44 mg/dL; 12:30 p.m. 79 mg/dL; 5:00 p.m. 75 mg/dL. The only comment documented on the glucose monitoring record stated, "was given lunch (with) assistance." * 05/27/12 - no documentation of BS level at 9:00 p.m. * 06/05/12 - BS at 11:00 a.m. 68 mg/dL; rechecked (no time indicated) and BS 153 mg/dL. Neither the glucose monitoring record or the progress notes identified the action taken by facility staff related to the resident's low blood glucose level. * 06/27/12 - BS at 9:00 p.m. 49 mg/dL. BS rechecked at 11:00 p.m. and measured 73 mg/dL. Neither the glucose monitoring record or the progress notes identified the action taken by staff related to the resident's low blood glucose level. Facility staff failed to recheck the resident's BS every 15 to 30 minutes as per facility policy. * 08/09/12 - BS at 11:00 a.m. 37 mg/dL and 75 mg/dL at 5:00 p.m. A comment on the glucose monitoring record stated, "Held 17 (5:00 p.m.) insulin. Facility staff failed to document the actions taken related to the resident's BS level at 11:00 a.m. and failed to recheck the resident's BS every 15 to 30 minutes as per facility policy. * 08/14/12 - BS at 9:00 p.m. 200 mg/dL. A comment on the glucose monitoring record stated, "Held HS (bedtime) Insulin." The record failed to identify why the insulin was held. * 08/28/12 - no documentation of BS level at 9:00 p.m. - Review of Resident #18's medical record occurred on August 29-30, 2012. [DIAGNOSES REDACTED]. Resident #18's blood glucose is to be monitored at 7:00 a.m. and 5:00 p.m. Review of Resident #18's glucose monitoring record and MAR from March 2012 through August 29, 2012 identified the following concerns: * 03/20/12 - BS 80 mg/dL at 5:00 p.m. and eight ounces of Gatorade given and no documentation of insulin administered. * 04/11/12 - no BS levels recorded and insulin administered at 7:00 a.m. and 5:00 p.m. * 04/20/12 - no documentation of insulin administered at supper time * 04/21/12 - as above * 04/22/12 - BS 68 mg/dL at 5:00 p.m. and no documentation facility staff followed protocol related to low BS levels * 05/29/12 - no documentation of BS level or insulin administered at 5:00 p.m. * 06/03/12 - no BS level recorded at 5:00 p.m. and insulin administered at 6:00 p.m. * 07/27/12 - BS 87 mg/dL at 5:00 p.m. and no insulin administered * 08/07/12 - no BS documented at 5:00 p.m. * 08/20/12 - as above * 08/22/12 - BS level 59 mg/dL. The record stated the resident's insulin held but failed to identify the actions taken, if any, for the low BS level. During an interview on 08/30/12 at 10:05 a.m. with an administrative nurse (#13), and at 10:50 a.m. with an administrative nurse (#3), both nurses were unable to provide any clarification regarding the above discrepancies documented on Resident #17 and #18's MARs or glucose monitoring records. - Review of Resident #6's medical record occurred on August 27-30, 2012. Current [DIAGNOSES REDACTED]. Resident #6's medical record lacked parameters for blood sugar levels. Review of Resident #6's glucose monitoring records, nurses notes, and MARs from April 2012 through August 29, 2012 identified the following concerns: * 04/05/12 - BS 69 mg/dL at 11:00 a.m., the resident received 6 oz. of Gatorade, no recheck on glucose monitoring record * 04/13/12 - no documentation of BS levels at 7:00 a.m., 11:00 a.m., and 5:00 p.m. * 04/15/12 - no documentation of a BS level at 9:00 p.m. * 05/10/12 - BS 66 mg/dL at 11:00 a.m.; received 6 oz. of Gatorade with an untimed recheck of 114 mg/dL * 05/15/12 - no documentation of a BS level at 11:00 a.m. * 05/17/12 - no documentation the scheduled 5:30 p.m. insulin dose administered * 05/21/12 - no documentation of BS levels at 7:00 a.m., 11:00 a.m., 5:00 p.m., and 9:00 p.m. * 05/23/12 - no documentation of a BS level at 11:00 p.m. * 05/24/12 - no documentation the noon and 5:30 p.m. dose of insulin administered; BS levels at 11:00 a.m. - 341 mg/dL, at 5:00 p.m. - 352 mg/dL, and at 9:00 p.m. - 364 mg/dL * 05/26/12 - no documentation of a BS level at 9:00 p.m. * 05/29/12 - a BS of 66 mg/dL at 7:00 a.m.; received 4 oz. of Gatorade with an untimed recheck of 108 mg/dL * 05/30/12 - no documentation of a BS level at 5:00 p.m. and 9:00 p.m., and no documentation the scheduled 9:30 p.m. insulin dose administered * 06/05/12 - no documentation of a BS level at 7:00 a.m., 11:00 p.m., and 5:00 p.m. * 06/08/12 - no documentation of a BS level at 5:00 p.m. and insulin not signed off at 5:30 p.m. with the BS level at 9:00 p.m. being 322 mg/dL * 06/11/12 - no documentation of BS levels at 11:00 a.m. and 5:00 p.m. * 06/19/12 - BS at 7:00 a.m. 68 mg/dL with untimed recheck of 131; BS at 11:00 a.m. 68 mg/dL with no recheck or documentation related to intervention provided * 06/26/12 - no documentation of a BS level at 5:00 p.m. * 06/29/12 - no documentation of a BS level at 5:00 p.m.; a BS at 9:00 p.m. 398 mg/dL * 07/21/12 - BS levels at 11:00 a.m. 589 mg/dL, at 5:00 p.m. 508 mg/dL, and at 9:00 p.m. 516 mg/dL; a nurses note at 11:00 p.m. stated, "Blood sugar 516 called (physician's name) to give 15 units of humalog. recheck 109." No documentation for the treatment of [REDACTED]. * 08/04/12 - BS at 5:00 p.m. 57 mg/dL, per monitoring record snack given at 4:00 p.m. with an untimed recheck of 137 mg/dL * 08/06/12 - no documentation of a BS level at 11:00 a.m. and 5:00 p.m.; BS at 9:00 p.m. was 511 mg/dL. A nurse's note at 4:00 p.m. stated, "One time sliding scale 15 U (units) see PO (physician's order)." A physician ordered timed at 6:30 p.m. stated, "Chk (check) BS two hours after supper if over 400 give 15 U humalog . . ." The medical record lacked a BS level prior to obtaining a physician order at 6:30 p.m. to give additional insulin and lacked a blood sugar after the additional humalog administered. * 08/16/12 - no documentation of a BS level at 5:00 p.m. * 08/28/12 - BS at 7:00 a.m. 86 mg/dL with juice provided and an untimed recheck of 113 mg/dL, BS at 5:00 p.m. 75 mg/dL with an untimed recheck of 105 mg/dL after intervention provided. During an interview on 08/29/12 at 8:17 a.m., a nurse (#24) stated missing blood glucose checks on the monitoring record can occur when a nurse forgets to write them in or if a resident is off the floor (at meals). This nurse stated insulin should be circled on the MAR indicated [REDACTED] During an interview on 08/30/12 at 9:23 a.m., an administrative nurse (#2) stated staff should recheck blood sugars per policy and should indicate the time a blood sugar level is rechecked. Failure to administer insulin or monitor blood sugar levels placed Resident #6, #17, and #18 and other diabetic residents at risk of illness and complications related to [DIAGNOSES REDACTED] and [MEDICAL CONDITION] and limited the physicians' ability to ensure acceptable quality of care.

Based on record review, review of facility policy and procedure, review of the Emergency Medical Service (EMS) report, review of the investigation completed by the facility, and staff interview, the facility failed to provide the necessary care and services to ensure prompt treatment including indicated transfer to the hospital which resulted in 1 of 2 sampled residents' (Resident #7) not receiving medical treatment in a timely manner for an acute medical event and for 1 of 1 sampled residents recently diagnosed with [REDACTED]. Failure to provide prompt treatment for [REDACTED]. Failure to identify Resident #1's pain; failure to complete the pain screen until ten days after identification of Resident #1's fracture; failure to accurately complete the pain screen; and, failure to complete a comprehensive pain assessment resulted in Resident #1 experiencing pain on 25 of 26 days in [DATE] and delayed the provision of additional pain medication ([MEDICATION NAME]) until two months after the fracture occurred. Findings include: - Review of Resident #7's medical record occurred on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the Patient Care Report obtained from EMS, dated [DATE], identified a "911" call from the facility at 2:44 a.m. The ambulance crew responded to the call at 2:45 a.m. and arrived at the facility at 2:49 a.m. Review of Resident #7's interdisciplinary progress notes, dated [DATE], identified the following: * 1:30 a.m. - "Called to resident's room by aide. Resident had large dark, black brown coffee grounds emesis, Having difficulty breathing BP (blood pressure) ,[DATE] P (pulse) 130 . . . Legs mottled up to the knees. Oxygen put on resident via face mask at 3 LPM (liters per minute). Emesis was coming through the nose as well as the mouth. Attempted to contact local family member and left message on cell phone. Called son in Arizona (emergency contact representative) and he requested she be transported to the hospital . . ." The investigation completed by the facility identified the charge nurse actually didn't contact Resident #7's emergency contact representative until 2:40 a.m. due to inability to locate the facility's long distance telephone code number to place the long distance call. The investigation identified the nurse finally utilized the cell phone of another staff member to contact the emergency contact representative. * 1:45 a.m. - "Orders to transport to hospital obtained via telephone order from on call physician." * 2:15 a.m. - "Called for ambulance . . ." This note conflicts with the Patient Care Report which identified a "911" call at 2:44 a.m. * 2:45 a.m. - "Ambulance crew arrives. Resident had no pulse, no BP, no respirations." The Patient Care report identified the ambulance crew arrived at the facility at 2:49 a.m. * 2:55 a.m. - "Resident expired." The facility waited for one hour and 14 minutes before contacting the ambulance service for transportation to the hospital. The facility had received a physician order [REDACTED]. These actions did not allow Resident #7 the opportunity to receive the necessary care and treatment which may have prevented her death, and did not allow the family the opportunity to arrive to the facility and be with her at the time of her death. Review of the medical record and the investigation report identified discrepancies as to when the family and ambulance were contacted. Refer to F514. - Review of the facility's Pain Screening Form occurred on [DATE]-06, 2012. This form, revised [DATE], stated ". . . Instructions: This is a screening tool to be used for monitoring of residents to identify any pain that may need a more in depth assessment. . . ." This form also included "Parameter, 1. New Pain . . . 4. Routine medications ordered for pain; 5. Frequency of pain; 6. Conditions/[DIAGNOSES REDACTED]. Intensity of pain, Pain Scale (0 to 10, no pain to worst); 8. Observations of pain; Score of 5 or greater indicates comprehensive assessment needed. . . ." Review of Resident #1's medical record occurred on [DATE]-06, 2012. The facility admitted the resident in [DATE]. Current [DIAGNOSES REDACTED]. The quarterly MDSs, dated [DATE] and [DATE], identified severe cognitive impairment, total assistance of two or more persons for transfers, walking did not occur, and the resident experienced moderate pain. Resident #1's medical record included emergency room records from an acute care facility, dated [DATE]. These records included radiology reports which stated "Osteopenia is evident. There is a comminuted fracture at the junction of the diaphysis (shaft of the bone) and distal metaphysis (growth plate at the end of the bone) with fracture fragments in gross anatomic alignment. . . ." The medical record also included ". . . Plan: BK (Below Knee) Non Wt (weight) bearing cast . . . Will reassess in 1 wk (week). Elevate leg. Watch for swelling." Resident #1's care plan, dated [DATE], stated "Problem, Impaired physical mobility . . . Chronic knee pain & (and) Lt. (left) upper extremity . . . pain . . . Complains of general aching most days. (Undated update) Fracture left tibia/fibula. . . . Approaches . . . Monitor for level of pain. PRN (As needed) pain medications ordered. Monitor effectiveness of pain medication. (updated [DATE]) Medicate for pain as needed. . . ." The resident's current care plan, dated [DATE], did not include the update of [DATE]. The facility failed to include care plan approaches regarding Resident #1's pain related to the fracture. Resident #1's physician orders [REDACTED]. *[MEDICATION NAME] Patch (opioid pain reliever) 12 micrograms per hour (mcg/hr), q72h, [DATE]. *Tylenol 500 milligrams (mg), two tablets, two times each day (bid), [DATE]. *Tylenol 500 mg, two tablets, every six hours (q6h), prn, [DATE]. *[MEDICATION NAME] ,[DATE] (5 mg [MEDICATION NAME] (narcotic pain reliever)/500 mg Tylenol), one tablet, q4h, prn, [DATE]. Resident #1's Medication Administration Record (MAR) identified the facility staff provided the following prn medications: *[DATE] - Tylenol - two times. [MEDICATION NAME] - seven times. *[DATE]-04, 2012 - Tylenol - one time. [MEDICATION NAME] - four times. *[DATE]-31, 2012 (after fracture identified) - Tylenol - six times. [MEDICATION NAME] - 27 times, including four times on [DATE] and two times on seven additional days. *February 2012 - Tylenol - four times. [MEDICATION NAME] - 8 times, including two times on [DATE]. *[DATE]-06, 2012 - Tylenol - none [MEDICATION NAME] - two times Resident #1's MAR included the question "What is your pain level today? . . . 0 no pain and 10 worst . . ." two times each day. For the period [DATE]-31, 2012, the resident reported pain at least one time each day, except no pain reported on [DATE], and rated her pain from "3" on several days to "9" on [DATE]. Resident #1's Interdisciplinary Progress Notes included the following: *[DATE] at 10:00 a.m. - "CNA (Certified nursing assistant) hit foot on wall by elevator. ROM (Range of motion) (without) difficulty. Resident moving foot per self freely, no redness or bruising noted." *[DATE] at 11:00 a.m. - "Resident c/o (complains of) (L) (left) shin and lower leg area. Resident examined. Pt. (Patient) unable to move leg, when toes flex or ankle moved pt. c/o severe pain. Swelling noted to ankle et (and) shin area. . . . To E.R. (emergency room ) per w/c (wheelchair)." *[DATE] at 4:00 p.m. - "Returned from appt. (appointment). Cast intact to (L) lower leg. . . . Denies any pain @ (at) this time." *[DATE] at 4:00 p.m. - "Resident moaning. When asked if she was having pain she said yes all over. When asked if her leg hurt she said 'Just all over aching.' Pain pill given. Resident resting in comfort." *[DATE] at 5:00 p.m. - "Visited with resident's daughter, (name) about resident's pain and decrease appetite. Stated mother's always had pain from arthritis. Discussed sending fax to doctor regarding pain. Agreed with this. Told her would revisit when heard from doctor. . . ." The medical record lacked evidence of a response from the physician or revisit with the family member until [DATE]. *[DATE] at 8:15 p.m. - "Medicated for c/o pain 'all over,' yells et screams, wanting to go to bed." *[DATE] at 3:40 p.m. - "Visited with daughter, (name), about mother. Sending fax to (physician) about resident's pain and seeing if there is something that will give better pain control. . . ." *[DATE] at 2:00 p.m. - "Received script (prescription) for [MEDICATION NAME]. . . ." Resident #1's Pain Screening Form, dated [DATE], [DATE], [DATE], and [DATE] each identified ". . . Total Score, 4 . . ." which indicated comprehensive assessments were not needed. The Pain Screening Form, completed on [DATE], ten days after identification of Resident #1's left lower leg fracture on [DATE], failed to identify the following: 1. New Pain - related to the resident's lower leg fracture. 4. Routine medications ordered for pain - identified as effective, although the resident continued to complain of pain. 5. Frequency of pain - identified as less than daily. Resident #1 complained of pain daily between [DATE]-15, 2012. 6. Conditions/[DIAGNOSES REDACTED]. Failed to identify the resident's fracture as a new [DIAGNOSES REDACTED]. 7. Intensity of pain - identified as "0 - no pain." Resident #1 complained of pain daily. 8. Observations of pain - identified as "no observations." Resident #1 complained of pain as noted on the MAR and Interdisciplinary Progress Notes. The facility staff identified Resident #1's severe cognitive impairment and moderate degree of pain before the left leg fracture. Following identification of the fracture, the facility staff failed to identify the resident's increased pain, accurately screen the resident for pain, or monitor the resident for pain. The medical record lacked evidence of discussions with family members or physicians regarding additional pain medications until [DATE]. The medical record lacked information regarding a change in pain medications after the conversation with the family member on [DATE]. The response to this "fax" is unknown. During interview, on [DATE] at 4:00 p.m., an administrative nursing staff member (#6) confirmed the facility staff failed to accurately complete the Pain Screen on [DATE] which resulted in failure to complete a comprehensive pain assessment.