Every finding on record at Eastern Star Home of South Dakota, Inc

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure an environment free from accident hazards by one of one certified nursing assistant (CNA)/bath aide (E) who did not use the required whirlpool chair safety belt while providing a whirlpool bath for one of one sampled resident (1) who subsequently fell out of the whirlpool chair onto the floor, which caused laceration to the resident's forehead that required sutures. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings included:1.Review of the provider's 1/22/26 submitted SD DOH FRI report regarding resident 1 revealed that on 1/21/26 at 11:15 a.m. CNA/bath aide E radioed for immediate staff assistance to the whirlpool room. CNA F, charge nurse/licensed practical nurse (LPN) D, director of nursing (DON) B and Minimum Data Set (MDS) coordinator C immediately responded. Resident 1 was lying on the floor on his left side with his left arm tucked underneath him. CNA/bath aide E was sitting on the floor next to resident 1 applying pressure to his head. Charge nurse/LPN D assessed resident 1 and saw that he had a laceration to his forehead. Resident 1 demonstrated the ability to move both upper and lower extremities, a neurological examination (assessment of the residents brain, spinal cord, and nerve function) was completed, and his vitals ( measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were obtained.CNA/bath aide E stated resident 1 had lost consciousness for less than one minute following the fall from the whirlpool chair. Resident 1 denied experiencing any nausea but reported having a headache. Resident 1 had advanced dementia, but he was able to respond to yes and no questions. The on-call provider was notified and resident 1 was to be transferred to the local hospital. Emergency medical services were called at 11:25 a.m., arrived at the facility at 11:35 a.m., left with resident 1 at 11:40 a.m. Resident 1 returned to the nursing home later that day.As part of the provider's investigation of the incident, CNA/bath aide E was interviewed and stated she was positioned behind resident 1 while attempting to reposition the whirlpool chair wheels to lock them. She raised the chair slightly and resident 1's feet were no longer able to touch the floor. Resident 1 had leaned forward and fell out of the whirlpool chair and onto the floor. CNA/bath aide E attempted to grab resident 1 from behind but was only able to slow his fall. Resident 1 fell on his left side and hit the left side of his forehead on the floor, resulting in the laceration. Resident 1 was not wearing the whirlpool chair safety belt at the time of the fall. CNA/bath aide E was removed from being a designated bath aide following the incident, DON B reviewed the facility's Procedure for Whirlpool Bath Policy. CNA/bath aide E and all bath aides beginning on 1/21/26 and before their next scheduled shift. 2. Review of resident 1's medical record revealed he admitted to the facility on [DATE]. His diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities). His 7/30/25 Brief Interview for Mental Status (BIMS) assessment score was 0, which indicated his cognition was severely impaired. Resident 1 passed away at the facility on 2/26/26.Resident 1's 1/21/26 discharge summary report from the local hospital revealed he received 12 sutures on his left frontal scalp. The sutures were 2.5 cm (centimeter) in length and .25 cm in width. The hospital staff applied bacitracin (an antibiotic ointment) and a sterile gauze dressing to resident 1's sutures and he was to follow up with medical director G at the nursing home in one week for a wound recheck and suture removal.A nursing progress note dated 1/28/26 indicated that medical director G requested resident 1's sutures remain in place for a few additional days. The 1/28/26 progress note indicated that the facility received orders for sutures to be removed on 1/30/26. 3. Phone interview on 5/5/26 at 11:46 a.m. with CNA/bath aide E regarding the above incident resident 1 revealed that she had just raised the whirlpool chair and was attempting to adjust the wheels to lock the chair's brakes when resident 1 leaned forward and fell out of the whirlpool chair and onto the floor hitting his head. CNA/bath aide E noticed he was bleeding and immediately applied pressure to the area with a towel. She stated she called out for help and she charge nurse/LPN D and CNA F were the first to respond. Charge nurse/LPN D replaced the bloody towel with a clean towel and applied pressure to resident 1's head while CNA F obtained the resident's vital signs. CNA/bath aide E stated that another staff member called 911. The staff remained with resident 1 in the whirlpool room until emergency services arrived and transported the resident to the hospital. CNA/bath aide E confirmed that she did not follow the facility's policy requiring the use of the whirlpool chair safety belt and did not use the safety belt with resident 1 at the time of the incident. She was removed from the bath aide work schedule and was had only recently permitted to work was a bath aide shift per work week. 4. Phone interview on 5/5/26 at 12:01 p.m. with charge nurse/LPN D revealed she was the charge nurse on duty on 1/21/26. She did not recall many details from that day; however, she remembered that upon arriving in the whirlpool room and observing resident 1 on the floor, she immediately recognized that emergency medical services needed to be contacted. She also recalled that resident 1 appeared more sluggish than usual following the fall. 5. CNA F was not available for an interview during the time of the survey. 6. Interview on 5/5/26 at 12:20 p.m. with DON B revealed that she was notified by CNA F regarding resident 1's fall in the whirlpool room. DON B stated that when she arrived, she saw charge nurse/LPN D holding resident 1's head and was informed that he fell from the whirlpool chair and MDS coordinator C had contacted emergency medical services. DON B stated resident 1 was alert and moved his upper and lower extremities. She stated that staff remained with resident 1 until emergency medical services arrived. DON B acknowledged that CNA/bath aide E did not follow the facility's Procedure for Whirlpool Bath policy and did not use the whirlpool chair safety belt at the time resident 1's fall. DON B stated resident 1 was declining over the prior few months due to his late-stage dementia. 7. Interview on 5/5/26 at 12:30 p.m. with MDS coordinator C revealed that her office was located next to the whirlpool room. Regarding the above incident involving resident 1 she heard commotion coming from that area and went to check on what was happening. When she entered the whirlpool room, she asked whether emergency medical services needed to be called and was instructed to do so. After contacting emergency medical services, she returned to the whirlpool room to offer any additional assistance while the staff remained with resident 1 until the emergency medical services arrived. 8. Review of the provider's undated Procedure for Whirlpool Bath policy revealed that bath aides were to ensure, With resident properly secured with belting, facing the deck of the rub [tub], raise the transfer to the appropriate height to clear the top of the seat inside the tub, and Keep [the] bath chair belt on until [the] resident is ready to transfer. 9. Review of the provider's undated Bath Aide Responsibilities policy revealed that the bath aides were required to ensure that, All residents will be properly secured with belting. 10. The provider's implemented actions to ensure that the deficient practice does not reoccur were verified on 5/5/26 after record reviews and interviews revealed that the facility had followed its quality assurance and performance improvement (QAPI) process regarding quality of care and all bath aides were education on the Procedure for Whirlpool Bath policy beginning on 1/21/26. If the staff could not attend, they were expected to review the information and acknowledgement sign the sheet before their next scheduled shift. Interviews indicated the staff understood the information provided regarding the use of the whirlpool chair safety belt. Ongoing audits of the whirlpool safety chair belt were conducted and the audits results are planned to be reported to the quality assurance committee at their scheduled monthly meetings for six months for review and recommendations. Based on the above information, the non-compliance at F689 occurred on 1/21/26, and based on the provider's 1/22/26 corrective actions implemented for the deficient practice confirmed on 5/5/26, the non-compliance is considered past non-compliance.

Based on observation, record review, interview, and policy review, the provider failed to ensure two of five sampled residents (25 and 28) who received psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) had an attempted gradual dose reduction (systemic dose reduction over time to determine if the condition could be managed with a lower dose or discontinuation of the medication) (GDR) or documented rationale to support that a GDR was clinically contraindicated (not appropriate based on the resident's condition, potential risks, or adverse effects) for those medications. Findings include: 1. Observation and interview with resident 28 on 8/5/25 at 4:30 p.m. revealed she: *Was in the common area of the facility, seated in a wheelchair with a blanket over her lap. *Was very hard of hearing, but answered simple questions and indicated:-The staff were good to her. -The food was good.-She had no concerns. Review of resident 28's 7/14/25 annual Minimum Data Set (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) (MDS) assessment revealed she: *Had been admitted to the facility on [DATE]. *Had diagnoses of dementia (a group of symptoms affecting memory, thinking, and social abilities), depression, and traumatic brain dysfunction (a disruption in the normal function of the brain caused by an injury that affects how the brain works). *Had moderately impaired cognition, was rarely/never understood, and was unable to complete a cognitive screening. *Exhibited the following mood indicators: little interest in doing things, appearing down or depressed, having little energy, and a poor appetite. *Exhibited the following behaviors: wandering and rejection of care. *Was prescribed psychotropic medications that included an: -Antidepressant medication.-Antipsychotic medication. --The antipsychotic medication had not had a gradual dose reduction (GDR) attempted in the past year. --There was no documentation by the physician to support why a GDR was clinically contraindicated. Minimum Data Set (MDS) coordinator C had signed the assessment as completed on 7/20/25. Review of resident 28's care plan, dated 5/27/25, revealed:*The resident was taking psychotropic medications (antidepressant and antipsychotic) for her depression. -Her care plan goal was to take the lowest therapeutic dose of medication daily.-Her approaches included:--Education was provided to the family and the resident on the risks and benefits of those medications. --Staff were to observe the resident for side effects and report unusual findings to the nurse. --A GDR review was to be completed every six months. Review of resident 28's Pharmacy Recommendation form dated 7/17/25 revealed:*Director of nursing (DON) B had initiated the form and indicated that the resident was currently taking: -The antidepressant medication Sertraline 150 milligrams (mg) daily since 4/15/25 when the dosage had been increased. -The antipsychotic medication Olanzapine 5 mg daily, which had been started in February 2025, and included a request to- - Please advise. *The pharmacy recommendation was to Continue the same dose and was signed 7/22/25 by the provider's consultant pharmacist. *The resident's primary physician had signed the form on 8/5/25 and noted that she agreed with the consultant pharmacist's above plan. *The form had not included a description of the clinical contraindications to completing a GDR for those medications. Interview on 8/6/25 at 6:27 p.m. with administrator A, DON B, and MDS coordinator C regarding resident 28's psychotropic medications revealed:*DON B agreed she had asked regarding the psychotropic medications on the Pharmacy Recommendation form and: -The provider's consultant pharmacist's recommendation indicated no change and not to proceed with a GDR. -The resident's physician had signed the form.*They agreed the physician had not provided a written indication why a GDR would be clinically contraindicated. *Administrator A and DON B agreed that:-The physician should have documented on the form the rationale for the decision to maintain the current medications' dosage and not attempt a GDR. -The consultant pharmacist should have requested the physician to review the resident's psychotropic medications for possible GDRs. Interview on 8/7/25 at 11:47 a.m. with MDS Coordinator C regarding resident 28's psychotropic medications revealed she agreed that: *Resident 28's medical record had no documentation regarding the clinical contraindications of completing a GDR for her psychotropic medications. *Resident 28's physician should have documented the rationale for the decision to maintain the current medications' dosage and not attempt a GDR. *She expected that psychotropic medications were reviewed for possible GDRs every six months. 2. Review of resident 25's 5/26/25 annual MDS assessment revealed she: *Had been admitted to the facility on [DATE]. *Had diagnoses of dementia and anxiety disorder. *Had moderately impaired cognition, was rarely/never understood, and was unable to complete a cognitive screening. *Exhibited the mood indicator of having a poor appetite. *Had not exhibited any behaviors. *Was prescribed psychotropic medications that included an: -Antianxiety medication. -Antipsychotic medication. --The antipsychotic medication had not had a GDR attempted in the past year. --There was no documentation by the physician to support why a GDR was clinically contraindicated. Minimum Data Set (MDS) coordinator C had signed the assessment as completed on 6/1/25. Review of resident 25's care plan, dated 5/27/25, revealed:*The resident was taking psychotropic medications (antianxiety and antipsychotic) for aggression, hallucinations (to see, hear, smell, taste or touch something that is not there), and delusional thinking (false beliefs and distorted views of reality). -Her care plan goal was to take the lowest dose of medication daily.-Her approaches included:--Education was provided to the resident's family and the resident on the risks and benefits of those medications. --Staff were to observe the resident for side effects and report unusual findings to the nurse. --A GDR review was to be completed every six months. Review of resident 25's Pharmacy Recommendation form dated 9/12/24 revealed:*DON B had initiated the form and indicated the resident was currently taking the antianxiety medication Ativan 0.25 mg three times daily since 6/27/23, and included a request to- - Please advise. *The pharmacy recommendation was to Continue the same [dose] and was signed 9/30/24 by the provider's consultant pharmacist. *The resident's primary physician had signed the form on 10/2/24. *The form had not included a description of the clinical contraindications to completing a GDR for that medication. Review of resident 25's Pharmacy Recommendation form dated 1/17/25 revealed:*DON B had initiated the form and indicated the resident was currently taking the antipsychotic medication Risperidone 0.25 mg daily since 3/22/23, and included a request to- - Please advise. *The pharmacy recommendation was No change, continue the same dose and was signed on 1/28/25 by the provider's consultant pharmacist. *The resident's primary physician had signed the form on 1/29/25. *The form had not included a description of the clinical contraindications to completing a GDR for that medication. Review of resident 25's Pharmacy Recommendation form dated 3/20/25 revealed:*DON B had initiated the form and indicated the resident was currently taking the antianxiety medication Ativan 0.25 mg twice daily since 4/18/23, and included a request to- - Please advise. *The pharmacy recommendation was to Continue the same dose and was signed 3/25/25 by the provider's consultant pharmacist. *The resident's primary physician had signed the form but had not indicated the date she had signed it. *The form had not included a description of the clinical contraindications to completing a GDR for that medication. Review of resident 25's Pharmacy Recommendation form dated 6/18/25 revealed:*DON B had initiated the form and indicated the resident was currently taking the antipsychotic medication Risperidone 0.25 mg daily since 3/22/23, and included a request to- - Please advise. *The pharmacy recommendation was to Continue the same dose and was signed 6/23/25 by the provider's consultant pharmacist. *The resident's primary physician had signed the form but had not indicated the date she had signed it. *The form had not included a description of the clinical contraindications to completing a GDR for that medication. Review of the provider's 3/6/19 Gradual Dose Reduction of Psychotropic Drugs policy revealed: *Purpose: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.*Performed By: Nurses and Pharmacist. *For any individual who is receiving a psychotropic medication to treat expressions or indications of distress related to dementia, the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to:- The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility.- The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.

Based on observation, interview, record review, and policy review, the provider failed to maintain the dishwasher wash cycle temperature at a minimum of 120 degrees Fahrenheit per the manufacturer's manual for one of one dishwasher. Failure to ensure that increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the kitchen. Findings include: 1. Observation and interview on 7/17/24 at 10:58 a.m. with cook G in the kitchen revealed: *The wash cycle temperatures on The Dishwashing Machine Temperature log was recorded as follows: -7/13/24 Breakfast 100 degrees Fahrenheit, dinner 112 degrees Fahrenheit, supper 108 degrees Fahrenheit. -7/14/24 Breakfast was left blank, dinner 106 degrees Fahrenheit, supper was left blank. -7/15/24 Breakfast was left blank, and dinner 115 degrees Fahrenheit, supper was left blank. -7/16/24 Breakfast was 108 degrees Fahrenheit, dinner was left blank, and supper was left blank. -7/17/24 Breakfast 105 degrees Fahrenheit. *There were 19 wash, rinse, and chemical sanitation level checks missing out of 49 opportunities. *There had been only 2 wash cycle temperatures recorded at 120 degrees Fahrenheit or higher for July. -One on 7/6/24 for 120 degrees Fahrenheit at dinner and a second on 7/8/24 for 120 degrees Fahrenheit at dinner. *Dishwasher temperatures are completed after each meal. *After the fifth wash cycle the dishwasher wash temperature reached 115 degrees Fahrenheit on the machine's external thermometer. Observation and interview on 7/17/24 at 3:34 p.m. with cook D and dietary aide F in the kitchen revealed: *A dishwasher-safe thermometer runs through the dishwasher multiple times recorded temperatures between 100 and 105 degrees Fahrenheit. *Cook D confirmed that the dishwasher machine's external thermometer read the same temperature as the thermometer that had been sent through the dishwasher with each cycle. *Dietary Aide F stated The wash temperature should be 120 degrees Fahrenheit. *The dishwasher machine had been serviced monthly by the vendor. Interview on 7/17/24 at 3:49 p.m. with administrator A revealed. *There had been no gastrointestinal illness in the past three months. *She expected dietary staff to notify the dietary manager, the maintenance department, or her when the dishwasher had low-temperature readings. *She had not been notified of any dishwasher low-temperature readings. *ECOLAB comes monthly to service the dishwasher. Review of the 2/28/24 Regular Service Call report from ECOLAB revealed: *Wash Temperature: 100 Fahrenheit. *Monitor wash temp for compliance to protect guests, reputations, and machine efficiency. *Wash temp is hitting 100 degrees. Interview on 7/18/24 7:50 at a.m. with administrator A revealed she: *Had spoke with the ECOLAB representative and had been reassured that the dishwasher is sanitizing the dishes with the chemicals. *Was aware that the manufacturer's specification stated that the wash temperature minimum was 120 degrees Fahrenheit. *Expected dietary staff to run the dishwasher until it is temping at 120 degrees before running dishes through. Notice: Notice of immediate jeopardy was given verbally and in writing on 7/18/24 at 9:10 a.m. to administrator A of the immediate jeopardy related to failure to maintain the manufacturer's specification for dishwasher wash temperatures of a minimum of 120 degrees Fahrenheit at F812. She was asked for an immediate removal plan. On 7/18/24: *At 12:19 p.m. the removal was received. *At 12:23 p.m. the removal was accepted. On 7/18/24: *At 1:00 p.m. while on-site the survey team verified the immediacy was removed. Plan: 1. Dietary staff were instructed to use paper plates and bowls and to use the three-compartment sink for cleaning and sanitizing of all utensils/pots/pans, etc. that are not disposable. (7/17/2024 prior to supper meal). 2. Administrator met with Dietary staff on both 7/17/2024 (prior to supper meal) and 7/18/2024 (prior to morning preparation) and reviewed the policy and procedure on the use of the three-compartment sink as well as instructions located above the three-sink area. 3. Administrator spoke with the representative from ECO Lab ([Name]) on 07/17/2024 concerning this noncompliance. Recommendation to install a booster water heater to our current dishwasher unit. (This dishwasher unit is rented and maintained from ECO Lab). 4. Administrator spoke with [Name] ([Name] Heating and Cooling) on 07/17/2024 following the phone call with [Name] from ECO Lab and arranged for a service call to be completed on 07/18/2024 to complete wiring for the installation of the booster water heater. 5. [Name] Heating and Cooling presented to facility at 1020 on 07/18/2024. Conversation was held with [Name] from [Name] Heating and Cooling and [Name] from ECO Lab via phone. [Name] from ECO Lab and [Name] from [Name] Heating and Cooling will be installing the booster water heater on 7/19/2024 in the am. 6. Administrator completed and implemented new Dishwasher Temperature Policy and Low-Temperature Dishwasher Chart on 07/18/2024. 7. Dietary Staff mandatory education will be held on 07/18/2024 to review the Dishwasher Temperature Policy and Procedure as well as the Low-Temperature Dishwasher Chart. 8. Daily audits to ensure compliance with the dishwasher temperature will be completed by this Administrator x 30 days and will report findings to the QAPI Committee. Following 30 days of continuous compliance daily audits will change to weekly audits x 3 months. The continuation of audits will be reviewed monthly during QAPI Committee meetings. The immediate jeopardy was removed on 7/18/24 at 1:00 p.m. after verification that the provider had implemented their removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was F with guidance from the long-term care advisor for the South Dakota Department of Health. Review of the ECOLAB Installation & Operation Manual revealed: *Temperatures: WASH---*F [degrees Fahrenheit] (MINIMUM) 120 Review of the providers November 1, 2017 Cleaning Dishes Policy revealed: *Dishes and cookware will be washed and sanitized after each meal. *Current dishwasher is a chemical sanitizing machine; temperature needs to be between 90 and 110 degrees. PPM [parts per million of chemical sanitizer solution] will be check[ed] using test strips three times daily during heavy use and must read between 50-[and] 100 PPM. *The facility policy did not accurately reflect the manufacturer's specification for maintaining the minimum wash temperature.

Based on observation, interview, and policy review the provider failed to ensure: *One of one sampled resident (10) who was on precautions for Clostridium Difficile (C-Diff) had their room cleaned with bleach by one of one housekeeping staff (K). *Eight of eight sampled residents (1,3,6,19,21,23,27, and 28) had been placed on enhanced barrier precautions (EBP). 1. Observation of resident 10's door to her room revealed there was a red P and a drawered storage container that contained personal protective equipment (PPE). Interview on 7/16/24 at 9:00 a.m. with medication aide/certified nursing assistant (CNA) M regarding precautions for resident 10 revealed she had C-Diff. Interview on 7/16/24 at 9:30 a.m. with housekeeper K regarding the cleaning of resident 10's room revealed she: *Had used Lysol to clean the top of surfaces and sprayed into sinks. *Had used AF79 concentration for cleaning the toilets. *Had pH7 ultra had been used to clean the room floors. *Would have used pH7Q Dual to clean up any bodily fluids. Interview on 7/16/24 at 10:15 a.m. with licensed practical nurse (LPN) L regarding resident 10's C-Diff revealed: *Resident 10 had been taking an antibiotic for her infection, but was not currently taking one. Interview on 7/16/24 at 10:57 a.m. with Minimum Data Set (MDS)/infection preventionist (IP) C regarding the cleaning of a room with a resident on C-Diff precautions revealed: *She was not aware that housekeeping had not cleaned with bleach. *They discuss precautions in the morning meeting. *She had not been aware of the need for enhanced barrier precautions for residents with catheters, indwelling feeding tubes, and open wounds. Interview on 7/16/24 at 11:23 a.m. with housekeeper K regarding education on cleaning resident rooms with C-Diff precautions revealed: *She had not received any education before today on using bleach to clean the rooms. *She had worked here for almost two years. Observation and interview on 7/16/24 at 8:16 a.m. with resident 21 while seated in her recliner revealed she had a catheter due to her not being able to pee. *There had not been any signage on her room to indicate EBP. Interview on 7/16/24 at 10:16 a.m. with LPN L regarding residents with open wounds requiring dressing changes revealed resident 3 had a daily dressing change and resident 27 had dressing changes twice a day. Observation on 7/16/24 at 10:30 a.m. of resident 3 and 27's doors revealed there had not been any signage indicating EBP. Observation on 7/16/24 at 2:14 p.m. of resident 1 while lying in her bed and LPN L administering medication via her feeding tube revealed: *Resident 1 had any signage on her door to indication EBP. *LPN L had worn PPE while administering medication to resident 1. 49958 2. Observation and interview on 7/16/24 at 9:24 a.m. with resident 23 revealed: *She had a urinary catheter and wore a leg bag. *Nursing staff assisted her with her catheter. -She stated, They wear gloves but not a gown. *There had not been any signage on the door that indicated EBP. Observation on 7/16/24 at 10:19 a.m. with resident 19 revealed: *A urinary catheter bag was hung from the night table drawer. *There had not been any signage on the door that indicated EBP. Observation on 7/16/24 at 2:07 p.m. with resident 28 revealed: *A urinary catheter bag in a basin on the floor next to his recliner. *There had not been any signage on the door that indicated EBP. Observation and Interview on 7/16/24 at 2:18 p.m. with resident 6 revealed: *She had seen the physician today for sores, like fever blisters on her right lower leg that were open areas. *She stated that staff had worn gloves but not gowns when they assisted her. *There had not been any signage on the door that indicated EBP. 3. Review of the provider's January 2024 Management of C. [Clostridium] Difficile Infection revealed: *Housekeeping staff shall adhere to standard and contact precautions. *Perform daily cleaning of the resident's room and high touch surfaces using bleach wipes or bleach/water ratio solution (3/4 cups bleach to 1 gallon of water). Review of the provider's July 2023 Indwelling Catheter Care policy revealed: *Implement EBP and apply gloves and gown. Review of the provider's July 2024 Tube Feeding policy revealed: *Implement Enhanced Barrier Precautions.

Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans were revised to reflect the current enhanced barrier precautions (EBP) of eight of twenty sampled residents (1, 3, 6, 19, 21, 23, 27, and 28). Findings include: Refer to F880. Interview on 7/18/24 at 11:34 a.m. with Minimum Data Set (MDS)/infection preventionist (IP) C revealed: *It was her responsibility to complete the care plans. -Care plans were completed on admission, quarterly, and whenever things change. *She expected EBP to have been on the care plans, and a sign to have been on the doors to inform staff of residents with catheters, indwelling feeding tubes, and open wounds. *She confirmed that the care plans had not been updated to indicate EBP for any residents. *She had not been aware that some resident room doors were still not marked with a sign to indicate EBP. Review of residents 1, 3, 6, 19, 21, 23, 27, and 28's care plans revealed: *They had not been revised to indicate the need for EBP. Review of the provider's 10/07/21 Care Planning policy revealed, The facility will notify the resident and/or resident representative in advance of care to be furnished . as well as changes to the plan of care.

Based on interview, record review and policy review the provider failed to ensure residents and/or their representative received a written notice with information regarding the transfer to the hospital and to provide a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for one of one sampled residents (17) reviewed for facility-initiated hospital transfer to the hospital. Findings include: 1. Interview and record review on 4/12/23 at 9:50 a.m with resident 17 revealed she: *Could not remember when she had gone to the hospital. *Was not sure what a bed hold was. *Went to the [name of hospital] on 11/18/22. *Had kidney stones. *Was transferred to [name of hospital] for treatment. 2. Interview on 4/13/23 at 3:14 p.m. with administrator A revealed: *They provide education to the residents about the bed hold policy upon admission. *She confirmed they do not send bed hold information with a resident when they are transferred to a hospital. *The responsible party was notified by phone when a resident was transferred. *They had not notified the ombudsman of transfers or discharges. 3. Review of the Bed Hold Notice Upon Transfer policy dated 3/6/19 revealed: *1. Upon admission, the Eastern Star Home of South Dakota, Inc. will provide to the resident and/or the resident representative written information that specifies: a. If a resident requires transfer to an acute hospital or takes a therapeutic leave, his/her bed at the Eastern Star Home of South Dakota, Inc. may be held indefinitely. b. If a resident has Long-Term Care Insurance these leaves may or may not be covered or be subject to certain stipulations. c. Medicaid allows reserved bed days that the resident is absent from the facility due to an inpatient hospital stay. The resident may be absent from the facility for a maximum of five days. Medicaid also allows for non-medical or therapeutic leave days for a maximum of fifteen consecutive days. d. Conditions upon which the resident would return to the Eastern Star Home of South Dakota, Inc.: i. The resident requires the services which the Eastern Star Home of South Dakota, Inc. offers; ii. The resident is eligible for Medicaid nursing facility services.

Based on observation, interview, record review, and policy review, the provider failed to review and update care plans for 7 of 16 sampled residents (3, 14, 16, 17, 20, 24, 28) to reflect their current needs. Findings Include: 1. Interview on 9/14/21 at 9:19 a.m. with resident 20 revealed she: *admitted recently after breaking her left hip. *Wanted to discharge to a more independent setting when she was stronger. *Had felt depressed due to her move to the nursing home. *Had been taking a blood thinner. Review of resident 20's medical record revealed she: *Was admitted on [DATE]. *Had been diagnosed with: -Fracture of left hip, [CONDITION(S)], congestive heart failure, acute [CONDITION(S)], high blood pressure, high cholesterol, [CONDITION(S)], type II diabetes, depression, and chronic back pain. Review of resident 20's 6/30/21 care plan revealed: *Her care plan had not been reviewed or revised since her admission. *The active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] *It was not individualized and had not reflected her current needs. *There was no mention of discharge plans or her depression diagnosis. 2. Review of resident 17's current care plan as provided by the facility revealed: *The last handwritten date notation in the left margin was 4/19/21. *The following were not updated with the resident's recent decline in her ability to transfer, walk, and eat: -Locomotion/ambulation [mobility/walking] with supervision and walker. -Risk for falls/injury related to seat and bed alarm. Refer to F604, finding 1. -Nutritional status and needs related to a regular diet. Refer to F692, finding 5. *Some items were yellowed out without a date documenting when that was done. 3. Review of resident 28's current care plan as provided by the facility revealed: *Restorative therapy of Nustep bike had stopped but it was listed as an approach. Refer to F604, finding 2. *Some items were yellowed out without a date noting when that was done. 4. Review of resident 6's medical record revealed: *A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Monthly lab orders to monitor for her [MEDICATION(S)] level. Review of her 7/26/21 care plan revealed:*She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . *She was at risk for impaired skin integrity related to her falls. *The care plan had not included the use of an blood thinner and risk of bleeding. 5. Review of resident 14's medical record revealed: *He had been on Aspirin. *He had difficulties with constipation. *Refer to F658, finding 2. Review of resident 14's 6/28/21 care plan revealed: *Aspirin had not been included in his care plan. *Constipation had not been included in his care plan. 6. Review of resident 3's care plan revealed: *Aspirin had not been mentioned on her care plan. *Monitoring for signs or symptoms of bleeding had not been added to her care plan. Review of resident 3's physician documentation revealed she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] 7. Review of resident 16's medical record revealed: *She had chronic peripheral [CONDITION(S)]. *She was supposed to wear Ted hose daily. *She had an order to receive a prn [MEDICATION(S)] dose if she gained more than three pounds in two days. Review of resident 16's care plan revealed: *[CONDITION(S)] had been mentioned on the care plan. *There was no mention of monitoring her weight every two days. -Nor giving her an as needed (prn) dose of [MEDICATION(S)] if she had gained more than three pounds. *Ted hose had not been mentioned. 8. Review of resident 24's medical record revealed: *She had [CONDITION(S)] and [CONDITION(S)]. *She had chronic constipation. Review of resident 24's 6/21/21 care plan revealed: *[CONDITION(S)] and [CONDITION(S)] were not mentioned. *Chronic constipation had not been mentioned. Interview on 9/15/21 at 4:09 p.m. with minimum data set (MDS) and infection control coordinator C revealed she: *Had been in her role for about eight years. *Was responsible for completing the resident care plans. *Completes a baseline care plan within a day or two of admission. *Classified scooped mattresses as pressure reduction devices. *Agreed scooped mattresses were not being used as pressure reduction devices. *Had not included things like constipation or anticoagulants on the care plans. *Agreed it is important for staff to monitor for signs and symptoms of bleeding and constipation. *Stated the care plans were completed on admission, quarterly, and as needed when resident changes occurred. *Was aware resident 20's care plan had not been updated since her admission and it should have been. *Must have missed putting dates on the residents' care plans when changes were made. *Tried to make little changes to the care plans right away. Interview on 9/16/21 at 11:39 a.m. with the director of nursing (DON) B revealed: *Her expectation was the use of a blood thinner should have been added to the care plan to monitor for signs of bleeding. Interview on 9/16/21 at 12:26 p.m. with administrator A revealed she expected: *Care plans to be individualized and updated to reflect the current needs of the residents, and to be completed in a timely manner. *Care plans to include items such as anticoagulants and constipation. Review of the provider's September 2013 Resident Assessment policy revealed: *As part of the assessment process, the functional, medical, mental, nursing, and psychosocial needs of each resident must be evaluated. The assessment process must include participation of the interdisciplinary team, the resident, the resident's family or legal representative .

Based on observation, interview, record review, and policy review the provider failed to ensure: *Residents (3, 10, 14, 15, 16, 17, 24, and 28) who were at nutritional risk received ongoing monitoring of nutrition and assessments. *Residents (3, 14, 15, 24)who had weight fluctuations were re-weighed for accuracy. *One of one sampled resident (1) who received enteral feedings were assessed frequently for nutritional monitoring. Findings include: 1. Observation on 9/14/21 at 12:11 p.m. in the facility's dining room revealed: *Resident 3, 14, 16, and 24 were eating lunch. *Resident 16: -Was being assisted by registered nurse (RN) J. -Was on a pureed diet. -Would spit out food if it was not pureed well enough. -Ate approximately 75 percent of her food. *Resident 3 had been sitting at another table. *Her food had been placed in front of her. *She continued to have her head down and appeared to be sleeping. *After about 15 minutes a staff member came over to resident 3 and began assisting her to eat. *Resident 14 sat at another table with his wife who was a part of the assisted living facility. Review of resident 14's vital flow sheet revealed: *He had many weight fluctuations. *Some of the fluctuations included: -A six-pound weight loss in two days. -A six-pound weight gain in one week. *There had been no re-weights to check the accuracy of the weights. Review of resident 14's Stop and Watch form revealed: *The form had been filled out by nursing staff if they had noticed a change in a resident's status *The forms included: -A description of the change. -The resident's name. -The staff person's name. -The nurse it had been reported to. -The intervention the charge nurse implemented. *He had a stop and watch form filled out for a four-pound weight loss in a three-day period at the end of July 2021. *The intervention for July was that staff would continue to monitor. *He had another stop and watch form filled out in August 2021. *The August entry was for a six-pound weight loss in three days. *The intervention for August was for staff to supervise and assist at meals. Review of resident 14's registered dietician (RD) F notes revealed: *RD F documented dietary assessments on: -11/16/20. -5/25/21. -7/28/21. *RD F documented the following in November 2020: -He had COVID-19 in October 2020. -He had a significant weight loss of 6.1% in 1 month. -They would continue to monitor. *RD F's next dietary assessment in May of 2021 stated: -There had been no significant weight change noted. *RD F's dietary note in July of 2021 stated: -Resident 14's intakes were down from May assessment. -He had not had any significant weight changes. 2. Review of resident 16's vital flow sheet revealed: *She had weighed 172 pounds in January of 2021. *Her last recorded weight was 140 lbs. on 9/14/21. *She had many weight fluctuations that had not been weighed. Review of resident 16's RD assessments revealed: *She had dietician assessments on the following dates: -11/16/20. -5/25/21. -7/25/21. *RD F stated in her November 2020 assessment: -Resident had COVID-19 in October 2020. -Had experienced weight loss which could be related to COVID-19. -She had an 8.2% weight loss in one month. -She had experienced a 6.6% weight loss in six months. -RD F would update the doctor. -She would be continued on her diet which consisted of: --Power protein. --Regular, high potassium diet. *In May 2021 RD F documented: -She was now on a pureed diet. -She was on a regular, high potassium diet. -She had been experiencing chewing and swallowing difficulties. -She had a 10% weight loss in one month. -11.4% weight loss in three months. -12.7% weight loss in six months. -She would update the physician on the weight loss. -She was going to request to liberalize diet and added supplements for wound healing. *In July 2021 RD F documented: -Resident was on a pureed [MEDICATION(S)] diet. -She had been receiving supplements two times per day *She had no other dietician notes. Review of resident 16's stop and watch forms revealed: *She had a stop and watch form completed on 5/11/21 and 5/18/21 for weight loss. *The 5/11/21 form stated: -[ineligible] during last hosp [hospital] stay. *The 5/18/21 form stated: -[certified dietary manager's name], I charted the continued decline. *She had no other stop and watch forms completed for weight loss. 3. Review of resident 3's vital flow sheet revealed: *Some of those weights included: -Eight-pound loss in 10 days. -Five pound gain in four days. -Five and a half loss in three days. *She had weight fluctuations that had not been re-checked. Review of resident 3's stop and watch forms revealed: *She had a stop and watch form completed in February 2021 and July 2021. *Her February note stated: -She was down five pounds. -The charge nurse sent a fax to the doctor. *Her July note stated: -She had lost eight pounds. -The charge nurse had faxed a note to the doctor. Review of resident 3's RD notes revealed: *She had an admission assessment on 2/19/21. *Her next RD assessment was on 8/13/21. *Her admission RD assessment included: -She had a five-pound weight loss since admission. -RD F would continue to monitor. *Her next RD assessment in August 2021 included: -She was on ground meats and supplements three times per day. -Her one-month weight loss and three-month weight loss were both considered significant weight losses. -Her diet would be changed to an [MEDICATION(S)] diet. -She would update the doctor on the weight losses. 4. Review of resident 24's vital flow sheet revealed: *She had been around 170 pounds since April 2021. *She had a weight on: -8/30/21 of 173.5 pounds. -9/3/21 of 170 pounds. -9/6/21 of 172.5 pounds. -9/10/21 of 165.5 pounds -9/13/21 of 160 pounds with a note saying, scale off. *There had been no rechecks documented. Review of resident 24's RD notes revealed: *She had RD assessments completed on 11/16/20 and 8/25/21. *RD F's 11/16/20 note included: -Resident 24 had weight loss but it was probably related to COVID-19. -RD F would update the physician on significant weight loss. -Resident 24 was started on a four-ounce supplement two times per day for weight loss. *RD F's next 8/25/21 note included: -They discontinued the supplement in July due to weight gain. 5. The Nutrition Assessment completed by registered dietitian (RD) F revealed the following weight changes for resident 17: *On 2/8/21, the resident weighed 169.5 lbs. *On 5/3/21, the resident weighed 173.5 lbs. The nutrition diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *On 7/15/21, the resident weighed 155.5 pounds, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *The percent of loss between 7/15/21 and: -2/8/21 was 8.26% -5/3/21 was 10.37% Observations of resident 17 on 9/15/21 in the dining room for breakfast revealed: *At 8:13 a.m., the resident's hands were in her lap with glasses of beverages on the table. *At 8:30 a.m., bowls of hot cereal and pureed fruit were in front of her, but she was not eating. *At 8:40 a.m., registered nurse (RN) G sat down next to the resident and began feeding her. Observation on 9/15/21 at 12:30 p.m. during lunch revealed resident 17 was one of a few residents still seated in the dining room. Her plate of food was still in front of her and over 50% of her food remained on her plate. Review of the minimum data set (MDS) assessments dated 6/7/21 and 7/19/21 revealed: *Weight loss of 5% or more in one month or 10% or more in 6 months were checked. *The resident's weight on the 6/7/21 MDS, coded as a discharge assessment, was 161 *The resident's weight on the 7/19/21 MDS, coded as a significant change assessment, was 153 Review of dietary interdisciplinary notes dated 7/15/21 signed by RD F revealed: *The resident had returned from the hospital following a cholecystectomy procedure. *Currently on a regular diet with cut-up meat. *Eating 61% of meals and 25% of the four-ounce supplement twice a day. *Weight loss is significant, 8.5% in 3 months, and 11.4% in 6 months. *Will request [MEDICATION(S)] diet. Review of Dietitian Recommendation dated 7/15/21 revealed request for [MEDICATION(S)] diet was authorized by the physician and noted by licensed practical nurse (LPN) R on 7/16/21. Review of resident 17's current care plan for nutritional needs with a date of 2/7/21 revealed the following updates: *Risk for weight loss, added on 7/8/21. *Sits at feeder assist table, added on 7/8/21. *[MEDICATION(S)] diet, added on 7/19/21. Review of Care Conference Meeting and Review dated 7/19/21 with notes by the dietary manager/licensed social worker (DM/LSW) D revealed the resident was assisted with meals. A discharge return anticipated MDS assessment dated [DATE] noted a weight of 139. (Calculated against the weight of 161 on 6/7/21, that is a severe loss of 13.7% in three months.) Review of Nurses Notes revealed: *The resident returned from the hospital on 9/8/21. *A speech therapy evaluation on 9/14/21 with a trial of thin liquids, soft solids, and pureed foods. *A recommendation on 9/14/21 for pureed textures and regular/thin liquids. Following resident 17's hospital return on 9/8/21, no changes had been made to the care plan, and: *RD F had not documented dietary notes since 7/15/21. *DM/LSW D had not documented notes since 7/19/21.*. Interviews with the following employees revealed: *Certified nursing assistant (CNA) P reported on 9/15/21 at 1:50 p.m. that there have been problems with the scale used to weigh the residents for about a month. *CNA K, at 2:10 p.m., confirmed the scale has been a problem and maintenance keeps recalibrating. *RD F on 9/16/21 at 10:42 a.m. reported she was not aware of a recent change to pureed diet, and she should have been notified within 24 hours of that change. *The dietary manager/licensed social worker (DM/LSW) D reported at 11:25 a.m.: -She was not involved in the process of changing a resident's diet or food texture. -She had been informed of speech therapy recommendations by the director of nursing (DON) B. -We try different nutritional approaches between assessments but have not documented monthly. 6. The Nutrition Assessment completed by registered dietitian (RD) F revealed the following weight changes for resident 28: *On 12/23/20, the resident weighed 132 lbs. *On 05/10/21, the resident weighed 101 lbs. The nutrition diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *On 6/24/21, the resident weighed 96.5 pounds with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *The percent of loss between 6/24/21 and: -12/23/20 was 26.89% (That is a severe loss in six months.) -5/10/21 was 4.46% Observations of resident 28 on 9/15/21 in the dining room revealed: *At 8:13 a.m., the resident was seated at the table with beverages served. *At 8:30 a.m., she had eaten her breakfast except for her toast. She was setting her coffee cup down on top of a table knife. Interview with her at that time confirmed she had not seen the knife in that spot. *At 12:25 p.m., the resident's plate of food was still on the table and over 50% of her food remained. Review of the minimum data set (MDS) assessments between 3/15/21 and 9/13/21 revealed: *All were checked for weight loss of 5% or more in one month or 10% or more in 6 months. *Weight on the 3/15/21 MDS, coded as a quarterly, was 105 *Weight on the 6/14/21 MDS, coded as a quarterly, was 96 *Weight on the 8/3/21 MDS, coded as a discharge return anticipated, was 85 *Weight on the 9/13/21 MDS, coded as a significant change, was 87s A dietitian recommendation dated 5/10/21 noted significant weight loss times 3 months and requested orders for an [MEDICATION(S)] diet. The physician's authorization was noted by director of nursing (DON) B on 5/11/21. Review of dietary interdisciplinary notes signed by RD F revealed: *A gap of almost 5 months between RD F's admission note of 12/23/20 and her 5/10/21 note. *On 5/10/21: -Resident's intake was noted as 39% of meals and 43% of supplements 1-2 times a day. -Requires plate orientation. -Loss of 9.8% in 3 months is significant. (Loss of greater than 7.5% is considered severe.) -Will request to enrich diet. *On 6/24/21, weight was noted at 96.5 pounds with no other wts [weights] in chart to assess. *On 8/13/21: -Continued on [MEDICATION(S)] diet -Double portions at lunch -Supplements TID [3 times a day] The dietary manager/licensed social worker (DM/LSW) D documented interdisciplinary notes on 6/15/21 and 9/14/21 with similar information as provided by the RD F. Review of resident 28's current care plan for nutritional needs with a date of 1/8/21 revealed the following updates: *Risk for weight loss, added on 6/28/21 *[MEDICATION(S)] diet, added on 5/10/21 *Supplements 3x a day, added on 6/14/21. 2x/day was yellowed out. *Orientate to food - plate - glass - silverware was added on 6/14/21 *Repeated attempts need made to assist with meal, Provide time/space when agitated - attempt at later time, added 7/22/21 Interviews with the following employees revealed: *Certified nursing assistant (CNA) P reported on 9/15/21 at 1:50 p.m. that there have been problems with the scale used to weigh the residents for about a month. *CNA K, at 2:10 p.m., confirmed the scale has been a problem and maintenance keeps recalibrating. *RD F on 9/16/21 at 10:42 a.m. had no explanation for severe weight loss but had been aware of it. 7. Observation on 9/15/21 at 2:00 p.m. of resident 1 during a medication pass revealed she required all medications to be crushed and delivered through an enteral tube. Review of resident 1's reviewed 3/1/21 care plan revealed:*Her enteral feeding tube was to have been used for all nutrition, fluids and medications. *The dietitian was to have reviewed the adequacy of the tube feedings, water flushes, and weights. Review of resident 1's medical record revealed: *Her current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -The tube feeding at 125 milliliters (ml) per hour for twelve hours every day. -Three hundred ml of water three times daily through her tube. -One can of Coke weekly through her tube. *Review of her dietitian's assessments from December 2020 through September 2021 revealed she had been assessed by the dietitian on the following dates: -12/23/20. -1/18/21. -4/7/21. -6/9/21. -7/28/21. -9/1/21. *There were no dietitian entries for February, March, May, and August 2021. Interview on 9/16/21 at 9:30 a.m. with the certified dietary manager (CDM) D regarding resident 1's missing dietitian assessments revealed the CDM stated the dietitian would have to speak for that. Refer to F692, finding 8 regarding RD F's interview on 9/16/21 at 10:42 a.m. Review of the September 2013 Enteral Nutrition Care Policy revealed:*The RD would assess and/or review the nutritional status of residents receiving internal nutrition every month. *The RD would review: -The formula that was being administered. -Weight. -Skin condition. -Labs. -Physical symptoms. -Tolerance to feeding. -Oral/food fluid intakes when applicable. -Check the pump for flow rate. -Assess down times. -Check input/output records. -Check the medication administration records for the amount of feeding administered. 8. Observation on 9/14/21 from 12:00 p.m. to 12:23 p.m. and on 9/15/21 from 12:10 p.m. to 12:40 p.m. of resident 10 during meal time revealed: *Staff were not observed to cue or encourage him to eat or drink. Review of resident 10's medical record revealed: *Admission on 11/25/20. *His brief interview for mental status (BIMS) score of three indicated severe cognitive impairment. *Weight loss since his admission. *Staff were to assist with set up, cueing, and encouragement to eat. Review of resident 10's nutritional assessments from December 2020 through July 2021 revealed he had been assessed on the following dates: -12/23/20 -2/19/21 -5/25/21 -7/15/21 *His initial assessment on 12/23/20 took place a month after he had been admitted to the facility. *The nutrition intervention sections on the 12/23/20, 2/19/21, and 5/25/21 assessments all stated: con't [continue] same. *His 5/25/21 assessment showed a 5.7% weight loss in one month; 14% weight loss in 3 months; and 12.4% weight loss in 6 months indicating significant weight loss. *His 7/15/21 assessment showed 1.8% weight loss for one month; 11.7% weight loss in 3 months; and 12.8% weight loss in 6 months indicating significant weight loss. Resident 10's dietician recommendation sheets revealed: *5/25/21: Diet- [MEDICATION(S)], pureed, supplements TID [three times a day]. -Please note sig [significant] wt [weight] loss. No new recommendations at this time. *7/15/21: Currently on [MEDICATION(S)], pureed diet with mech [mechanical] soft textures for pleasure, Supplements TID [three times a day]. -Please note wt [weight] loss. -Request was made for a speech therapy evaluation to assess diet textures. A speech therapy evaluation was completed for resident 10 on 7/22/21 with an order to change to a mechanical soft diet with chopped meat. *Order comments: May need to pace pt [patient]. Give drink if he has too much food in his mouth. Interview on 9/15/21 at 11:45 a.m. with dietary manager/licensed social worker D revealed: *She was aware resident 10 had lost weight. *She had informed the dietician of his weight loss either by phone or email. -The dietician completed nutritional assessments quarterly and as needed. *Stated those assessments were usually completed a day or two after she informed the dietician of the resident's change. *Resident 10 had a diet change on 4/28/21 for a pureed diet and did not like it. *Resident 10 had tolerated his current diet of mechanical soft with chopped meat better and had started to gain the weight back. *Nursing staff would let her know about weight losses or gains. *Nursing staff would complete a stop and watch form. *She would contact the RD to inform them of the change. *She did not know if the RD would complete more frequent assessments on someone with significant weight losses, the RD had her own schedule. Interview on 9/16/21 at 9:21 a.m. with RN G revealed: *She was familiar with resident 10 and was aware he had significant weight loss. *Staff were expected to cue him to eat. *Since his diet had been changed to mechanical soft with ground meat he had been eating better. *He had not eaten well with pureed meals. *Since the diet change, he had gained some weight back. *A lot of his calories were used by wandering around the facility. Interview on 9/16/21 at 9:23 a.m. with CNA K revealed: *Resident 10 ate better when he ate independently but would accept cues and encouragement to eat. *If staff noticed he was not eating they tried to cue and encourage him. *Since he had a diet change, he had been eating better. Interview on 9/16/21 at 10:42 a.m. with registered dietitian F revealed she: *Had worked for the facility for several years. *Had been responsible for completing the dietary assessments for all the residents at the facility. *Tried to assess quarterly. *Worked from home during the COVID-19 outbreak. -Had also not been able to come into the building during the pandemic. -Stated the electronic medical record had only been used for a few things and had not contained the residents' daily documentation. *Had been on maternity leave from March 2021 until May 2021. *Did not have anyone covering her during that time. *Would typically complete more frequent assessments on someone who was experiencing significant weight losses. *Was aware resident 1 had required a monthly dietitian assessment. *Was questioned about medication administration and water flushes, she stated she did not deal with the water flushes; that was up to the nurses and physician. *Stated if anything had been updated in-between the quarterlies it would be in the chart. *Agreed she had not been updating or reassessing in-between the quarterlies as she should have to address weight loss concerns. *Agreed that some quarterly assessments had been late. *Had not attended care conferences. Surveyor : Review of the provider's January 2021 Weight Monitoring policy revealed: *Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. *1. The facility will utilize a systemic approach to optimize a resident's nutritional status. The process includes: a. Identifying and assessing each resident's nutritional status and risk factors. b. Evaluating/analyzing the assessment information. c. Monitoring the effectiveness of interventions during care conferences or sooner if necessary. *5. Documentation: a. The physician will be informed of a significant change in weight and may order nutritional interventions. b. The physician should be encouraged to document the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Meal consumption information is recorded at each meal and will be referenced by the interdisciplinary care team at care conferences. Review of the providers September 2013 Nutritional Assessment policy revealed: *Documentation of a resident's nutritional care is the responsibility of the Dietary Professionals. This will include the Registered/ Licensed Dietitian, Dietetic Technician, and the Dietary Manager. *A nutritional assessment would be completed for any of the following: *2. Following a significant change. *3. Monthly for any resident receiving tube feedings. A monthly tube feeding assessment must include nutritional adequacy of calories, protein and fluids. *4. On any resident will progressing disease conditions putting the resident at significant nutritional risk. *5. On each resident prior to his/her annual Care Conference or every 92 days. Review of the provider's Dietary Manager job description revealed: *The dietary manager was supposed to ensure the dietary needs of the residents were met in compliance with state and federal regulations. *Perform all duties effectively and timely. *Maintain contact with the Registered Dietitian ensuring that all needed assessments are completed, ensure that menus are approved at least yearly or when a change is needed, new admissions and any diet concern regarding residents. Review of the provider's Registered Dietitian's job description revealed: *Developing nutritional care of residents in accordance with current federal, state, and local guidelines and to assist with policy and procedures regarding the nutritional needs of the residents at [facility name]. *4. Assist in nutrition screening, assessment, and care planning for all newly admitted residents and upon a significant change, readmit, quarterly, and annually. *She reported to and was supervised by the administrator. *She was to attend resident care conferences as needed. *She was to communicate with the dietary manager through a communication log or sheet, or in person of any concerns and updates that were recommended after each visit.

Based on observation, interview, record review, and job description review, the provider failed to identify and promote individualized approaches and social services that met the mental and psychosocial needs for thirteen of sixteen sampled residents (3, 6, 8, 9, 10, 11, 13, 14, 16, 17, 20, 24, 28 ). Findings include: 1. Review of resident 17's record for social service documentation revealed: *A social history interview dated 1/29/21. *The resident had admitted to the facility on [DATE]. *The last date the social history was changed was 7/14/21. *The dietary manager/licensed social worker (DM/LSW) D signed the social history on 9/16/21. Review of resident 17's care conference meeting and review social service notes revealed: *On 4/19/21, OK. *On 7/19/21, OK, good family support - lots of phone calls. There was no documentation in the record to indicate the DM/LSW D had input regarding: *The use of seat and chair alarms as potential restraints. Refer to F604, finding 1. *Her psychosocial well-being related to her diagnoses of anxiety and recent changes in mood. 2. Review of resident 28's record for social service documentation revealed: *A Social History interview dated 1/6/21. *The resident was admitted to the facility on [DATE]. *The last date the Social History was changed was blank. *The DM/LSW D signed the Social History on 1/6/21. Review of resident 28's Care Conference Meeting and Review social service notes revealed OK on both 3/15/21 and 6/15/21. There was no documentation in the record to indicate the DM/LSW D had input regarding: *The use of seat and chair alarms as potential restraints. Refer to F604, finding 2. *Psychosocial support related to the impact of her cognitive impairment on: -Interactions with others. -Behavioral symptoms. -Wandering and elopement. -Visual limitations. -Diagnosis of depression. 3. Review of resident 11's medical record revealed: *Her 3/15/21 care plan indicated she required antianxiety and antidepressant medication. *She was to have been observed for changes in her moods, behaviors, and psychotic symptoms. *Review of her 3/15/21 care conference meeting revealed DM/LSW D's addition to the review indicated OK. -There was no indication of the resident's current mood or behaviors. -DM/LSW D had not documented her status in the interdisciplinary notes. 4. Review of resident 13's medical record revealed: *Her 7/12/21 care plan indicated she had potential for wandering and delusions, and potential for mood and behavior problems. *Review of her 7/12/21 care conference meeting revealed DM/LSW D's addition to the review indicated OK. Good family support. -There was no indication of the resident's current mood or behaviors. -DM/LSW D had not documented her status in the interdisciplinary notes. 5. Review of resident 6's medical record revealed: *Her 4/26/21 care plan indicated she had potential for wandering and hallucinations, and potential for mood and behavior problems. *Review of her 4/26/21 care conference meeting revealed DM/LSW D's addition to the review indicated OK. -There was no indication of the resident's current mood or behaviors. -DM/LSW D had not documented her status in the interdisciplinary notes. 6. Review of resident 10's medical record revealed: *Admission to the facility on [DATE]. *His diagnosis of [CONDITION(S)]. *Medication had been prescribed for his psychotic symptoms. *His social history was completed on 1/6/21, more than a month after his admission. Review of resident 10's care conference meeting and review notes. *He had a care conference on 2/22/21 and 5/17/21. *The 2/22/21 social services note stated:Ok. Good family support. *The 5/17/21 social services note stated: Ok. *No information had been included to describe the resident's current mood, symptoms, or behavior issues. 7. Review of resident 20's medical record revealed: *Admission to the facility on [DATE]. *Her diagnosis of depression. *Medication had been prescribed for her depression symptoms. *Her social history had not been completed. -The family history questionnaire form had a note attached stating the family had not returned the information. -No documentation had been provided to support further contacts with the family had been made to complete the form. Review of resident 20's care conference meeting review notes revealed: *He had a care conference on 7/5/21. *Ok. Good family support. *There was no information to describe the resident's current mood, symptoms, or behavior concerns. *The only signature on the care conference meeting and review sheet was infection control/MDS coordinator C. 8. Review of resident 9's medical record revealed: *She had admitted on [DATE]. *Her social history had been completed on 4/6/21. -It had not indicated a revision had been made. Review of resident 9's care conference meeting and review notes revealed: *She had a care conference on 5/17/21. *The social services note stated: Ok. Great family involvement. *There was no information to describe the resident's current mood, symptoms, or behavior concerns. *No other care conference meeting reviews had been provided. 9. Review of resident 8's medical record revealed: *He had admitted on [DATE]. *His diagnoses of [CONDITION(S)] and depression. Review of resident 8's care conference meeting and review noted revealed: *He had a care conference on 5/24/21 and 8/23/21. *On 5/24/21 the social services note stated: Ok. Wife visits frequently. -No information had been included to describe the resident's current mood, symptoms, or behavior concerns. *On 8/23/21 the social services not stated: Ok. Wife visits QD [daily]. -No information had been included to described the resident's current mood, symptoms, or behavior concerns. 10. Review of resident 14's social services notes revealed: *He had been admitted to the facility on [DATE]. *His social services note was dated 1/6/21. -There were no other social services notes other than the one on 1/6/21. Review of resident 14's care conference meeting and review notes revealed: *He had a care conference on 3/29/21 and 6/28/21. *The social services note stated the same thing: -Great family support. 11. Review of resident 16's social services notes revealed: *She was admitted to the facility on [DATE]. *The document only contained one social service note which had been dated 9/14/21. Review of resident 16's care conference meeting and review notes revealed: *She had a care conference on 3/29/21 and 6/28/21. *On 3/29/21 the social services note stated: -Ok *On 6/28/21 the social services note stated: -Ok. Good family support. 12. Review of resident 24's social services notes revealed: *She had been admitted on [DATE]. *She had one social service note dated 4/6/21. Review of resident 24's care conference meeting and review notes revealed: *She had a care conference on 3/22/21 and 6/21/21. *On 3/22/21 the social services note stated: -Ok *On 6/21/21 the social services note stated: -Ok. Good support. 13. Review of resident 3's social services notes revealed: *She had an admission family questionnaire completed on 2/9/21 *She did not have any social services notes. Review of resident 3's care conference meeting and review notes revealed: *She had a care conference on 5/3/21 and 8/2/21. *On 5/3/21 the social services note stated: -Ok- great family support. *On 8/2/21 the social services note stated: -Ok- great family support. Daughter visits freq.[frequently] son calls. Interview on 9/15/21 at 11:45 a.m. with DM/LSW D revealed she: *Had not had any additional social service notes on the residents. *Agreed she needed to improve her documentation. *Agreed most of the resident's social service notes were the same. Review of the licensed social worker's job description revealed: *Her position summary: -Plans, organizes, supervises, and directs all administrative and operational activie4s [activities] of the Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, and the facility's established policies and procedures. *10. Contributes to the facility efforts to maintain and/or improve quality of care through participation in the following: -a. Attends Care Conference meetings[.] -b. Services as a member of the QAPI [quality assurance process improvement] Committee[.] -c. Attends Department Head meetings[.] -d. Attend and provide educational information at mandatory in-services [.] *12. Advocate for residents and assist them in assertion of their rights.

Based on observation, interview, and policy review, the provider failed to maintain infection control practices for: *One of one laundry staff (E) in wearing of laundry apron and gloves within the laudry area. *One of one registered nurse (RN) J in appropriate hand hygiene and glove use while assisting residents (16 and 23) with dining. *Four of five certified nursing assistants (CNA) (I, K, L, and M) after assisting residents (12 and 22) with cares. *Appropriate disinfection and sanitization of mechanical lifts between residents (3 and 16). Findings include: 1. Observation on 9/14/21 at 10:00 a.m. revealed: *CNAs I and K were helping residents back to their rooms after breakfast. *Had not performed hand hygiene after helping resident 12. 2. Observation on 9/14/21 at 10:30 a.m. revealed: *Laundry staff E in the main lobby of the facility *She had been wearing plastic gloves and a plastic apron. *She had been assisting a staff member with a resident. 3. Observation on 9/14/21 at 11:39 a.m. of CNA L revealed she: *Came out of resident 3's room with the lift. *Took the lift into resident 16's room. *Had not disinfected the lift in between residents. 4. Observation on 9/14/21 at 12:11 p.m. with RN J revealed: *She was assisting two residents (16 and 23). *Both residents required a lot of assistance and only ate when RN J fed them. *RN J did not sanitize her hands before to feeding either resident. *Some pureed food had dropped on resident 23's clothing protector. -RN J scooped that food up with a spoon and fed it to resident 23. *She wiped their mouths with their spoons. *In between feeding residents 16 and 23 she: -Put on a glove to feed resident 23. -Took off that same glove. -Did not sanitize her hands. -Start feeding resident 16. -Then put on that same soiled glove and feed resident 23. *This was the process she used for the entire meal service. 5. Observation and interview on 9/15/21 at 9:45 a.m. with laundry staff E revealed she: *Had worked in the facility for about [AGE] years. *Used a plastic apron and plastic gloves to sort soiled laundry. *Would walk through a door, to the laundry room to take off the plastic apron and gloves. *Agreed she was wearing a soiled plastic apron and gloves in the lobby yesterday. *Agreed she should not be wearing the soiled apron and gloves outside of the soiled laundry sorting room. 6. Observation on 9/15/21 at 10:00 a.m. of activities aide/CNA M revealed she: *Brought resident 22 in her bathroom so she could use the restroom. *Helped resident 22 get situated. *Walked out of resident 22's room and had not performed hand hygiene. Interview on 9/15/21 at 5:24 p.m. with minimum data set/infection control coordinator C revealed: *Staff were expected to perform hand hygiene after caring for residents. *She agreed laundry staff E should not leave the soiled laundry area with her soiled gown. *Staff were expected to disinfect lifts after use. *Staff should be practicing hand hygiene while feeding residents. *She agreed that RN J had not practiced appropriate infection control while feeding residents 16 and 23. Review of the provider's August 2015 Transfer with Hydraulic or Electric Hoyer lift policy revealed: *Lifts will be wiped with a Super Sani-Cloth follow each use unless the lift is being used by only one resident. *All lifts will be cleaned with a Super Sani-Cloth nightly and documented on the monthly cleaning schedule. Review of the provider's November 2015 Transfer with Standup Lift policy revealed the lifts were to be wiped with a Super Sani-Cloth after each use unless lift is used by only one resident. Review of the provider's February 2015 Hand-Washing policy revealed: *Proper hand washing is the single most effective means of preventing disease and infection transmission in our facility. The purpose of this procedure is to outline the steps to follow to ensure proper hand washing. *Hands should be cleaned during some of the following situations: -Before and after resident contact. -Before and after handling food. -After handling anything that could be contaminated or dirty.

Based on observation, interview, record review, and policy review, the provider failed to follow professional standards of practice for: *Administering medication through an enteral tube for one of one resident (1) who required her medication through an enteral tube. *Three of sixteen sampled residents (3, 14, and 16) received treatment in order to help prevent constipation. *One of two sampled residents (14) received a nebulizer treatment with supervision. Findings include: 1. Observation on 9/15/21 at 2:00 p.m. of registered nurse (RN) G administering medication to resident 1 through an enteral tube revealed the RN: *Poured 300 milliliters of water into a measuring cup. *Checked for the placement of the tube and checked for any residual formula that might have remained in the stomach. *Set up one tablespoon of [MEDICATION(S)] powder one scoop of Upcal powder. *Crushed one [MEDICATION(S)] pill and three Vitamin D pills and added those medications to the powdered medication. *Added 30 ml of water to the medication mixture. *Without administering a water flush to ensure the enteral tube was in place, RN G gave all medication at the same time through the tube using a large syringe. *Followed the medication with a 100 ml water flush. *Gave twelve ounces of Coke through the enteral tube that was ordered to clear the tube weekly. *Followed the Coke with 200 ml of water. Interview at that time with RN G regarding the medication provided through the tube revealed: *Resident 1 did have an order to crush all oral medications. *She did not have an order to give all medications together at the same time. *RN G confirmed: -The above medication administration was her normal process for medicating resident 1. -She had administered the medication without first testing the tube with a water flush. -She had not been instructed to give the medications separately. Interview on 9/15/21 at 5:15 p.m. with director of nursing B confirmed the provider's policy had not been followed. Review of the provider's undated Medication administration via enteral tube revealed:*The pharmacist was to have been utilized as a resource concerning potential reactions between medications. *When a liquid suspension was not available medications were to have been crushed and mixed with water. *Medication will be administered separately, not combined or added to an enteral feeding formula. 2. Observation and interview on 9/14/21 at 10:00 a.m. with RN H revealed: *Surveyor heard a resident yelling from nearby. *RN H walked out of resident 14's room. *She stated: -He had been constipated. -He will sometimes yell out while trying to use the restroom. Review of resident 14's bowel movement (BM) records revealed: *He had many gaps in his bowel elimination records. *From: -9/1/21 through 9/14/21 he had 8 recorded days without a BM. -8/1/21 through 8/31/21 he had 12 recorded days without a BM. -7/1/21 through 7/31/21 he had 10 days recorded without a BM. --This included a three-day period. -6/1/21 through 6/30/21 he had 13 days recorded without a BM. --This included three and four-day periods. -5/1/21 through 5/29/21 he had 13 days recorded without a BM --This included a three-day period. Review of resident 14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *He was scheduled to receive [MEDICATION(S)] 100 milligram (mg) two times per day. *He had an as needed (prn) order for milk of magnesia for constipation. *In May 2021 he had been given MOM two times. -Neither of which had been given during the three-day gaps of constipation. *In June 2021 he had a new prn order for [MEDICATION(S)] 10 mg, which started on 6/16/21. *He had received MOM four times in June. *He had received [MEDICATION(S)] one time in June. -Neither prn medication had been given throughout his three without a BM. --He had received MOM once on day three of his four-day gaps without a BM. *In July he had a 3 day gap without a BM. -Neither prn constipation medication had been given during that time. 3. Review of resident 16's bowel movement records revealed: *From May 2021 through September 2021 she had: -A three-day gap without a bowel movement two times in May 2021. -One three-day gap in July 2021. Review of resident 16's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *She was scheduled to receive MOM and [MEDICATION(S)]. *She had a prn order for [MEDICATION(S)] and [MEDICATION(S)]. *In May 2021: -None of the prn medications had been administered during her two, three-day gaps without a BM. *In July 2021: -She had not been given any prn medications during her three-day periods without a BM. 4. Review of resident 3's BM records revealed: *She had many documented gaps in her record. *In May 2021, she had: -Two, three-day periods without a recorded BM. *In June 2021 she had one, three-day periods without a BM. *In July 2021, she had: -A three-day period without a BM. -A four-day period without a BM. *In August 2021, she had: -Two, three day periods without a BM. -A four day period without a BM. Review of resident 3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *In May 2021 she had: -A prn order to receive [MEDICATION(S)]. -Not received her prn constipation medication during her two, three day periods without a BM. *In June 2021 she had: -A prn order to receive [MEDICATION(S)] and MOM. -Not been given her prn medication during her three day period without a BM. *In July 2021 she had: -A prn order to receive [MEDICATION(S)]. -Not received her prn medication during her three day period without a BM. -Received one dose of prn [MEDICATION(S)] on day four without a BM. *In August 2021 she had: -A new order for [MEDICATION(S)] on 8/18/21. -A new order for [MEDICATION(S)] on 8/6/21. -Prn order for [MEDICATION(S)]. --Not been given [MEDICATION(S)] during her four day period without a BM. --Not been given [MEDICATION(S)] during her two three day periods without a BM. Review of a 8/4/21 fax to resident 3's doctor revealed: *Resident has been going multiple days without a bm. Her only med is Senna [at symbol] 0800 [8:00 a.m.] and prn [MEDICATION(S)] suppositories. We are going to start prune juice every morning with breakfast. May we have orders for something more med wise? . *Resident 3's physician responded on the same day to give MOM prn. *The nurse responded again and asked for something scheduled in the morning. *The physician responded with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . *MOM was not on resident 3's MAR for August 2021. Review of the provider's current standing orders revealed: *If a resident had not had a bowel movement for 3 days they were to receive: -MOM. -[MEDICATION(S)]. *If the resident had not responded to the above interventions then they were to notify the doctor and complete a nursing assessment. Review of the provider's 2/17/16 Bowel and Bladder policy revealed: * .Documentation will be maintained on the bowel and bladder flow sheet noting that resident had been toileted or changed. Daily documentation will continue on the daily BM log to monitor and prevent constipation issues. If constipation issues arise refer to the standing order for implementation of medications. Review of the provider's October 2012 Bowel Elimination policy revealed: *The nurse aides on duty will complete the resident bowel record at least daily, prior to the completion of their shift. The resident bowel elimination record is to be kept in the chart room to maintain confidentiality. The nurse aides will report any abnormalities to the charge nurse on duty and the charge nurse will assess and treat as needed . *The night nurse will check the bowel record nightly and assess and treat as needed. The night nurse will monitor for trends and notify the doctor as needed. 5. Observation on 9/14/21 at 9:30 a.m. of resident 14 revealed: *RN H had been in his room setting up his nebulizer treatment. *After she placed his nebulizer mask on him and turned on his treatment she walked back out to the nurse's desk. Review of resident 14's 7/5/21 quarterly self-assessment screening revealed: *Resident had a brief interview for mental status (BIMS) of 3. *He had been marked as not able to safely self administer nebulizer treatment once set up by nursing staff. Interview on 9/16/21 at 11:39 a.m. with director of nursing (DON) B revealed: *Resident BMs were documented on their BM record. *They had standing orders to treat constipation. *She agreed staff should be following orders and giving prn medications as prescribed. *She agreed resident 14 was to receive supervision during his nebulizer treatments.

Based on observation, interview, record review, and policy review, the provider failed to ensure four of four sampled residents (14, 17, 24, and 28) had been assessed for the use of a scooped mattress and chair and/or bed alarms as restraints or enablers. Findings include: 1. Observation on 9/14/21 at 10:30 a.m. revealed resident 17 in her wheelchair at the beauty shop with an chair alarm cord clipped to her collar. Further observation on 9/15/21 of resident 17 at the following times revealed: *8:00 a.m.: -Not in her room, a bed alarm pad was draped across the reclining chair in her room. *8:13 a.m.: -Seated in her wheelchair in the dining room with chair alarm cord clipped to her collar. *10:36 a.m.: -Seated in her wheelchair with a chair alarm cord clipped to her collar in the front lobby lounge facing a large screen television but with her eyes closed. Review of resident 17's current care plan as provided by the facility, with handwritten date notations of 1/22/21 and 4/19/21 in the left margin, revealed the following resident problems and needs: *Modified independence with cognitive skills. *Supervision, cuing, was required for walking with a walker. *Restraints was checked as Not Used. *Risk for falls/injury dated 2/7/21 with an added handwritten approaches to Use seat & bed alarm daily dated 7/8/21 and using w/c [wheelchair] with staff assist dated 8/30/21. *Total dependence with mode of hoyer lift handwritten and dated 9/13/21. Assistance required with one or two persons was yellowed out. Review of the following documents from resident 17's record revealed: *An alarm assessment dated [DATE] noted: -The resident was reported as falling during hospital stays with minor injuries. -Her functional mobility had declined. -The potential benefit of using an alarm was noted as decrease falls and the staff/family believed the alarm would not refrain the resident from getting up and would not startle the resident. *A Fall Risk Evaluation dated 7/19/21 scored the resident's risk at 22 points. A score of 10 or above represents HIGH RISK. *A significant change Minimum Data Set (MDS) dated [DATE] noted the resident's: -Cognitive score as 3, meaning severely impaired. -Ability for walking in the hallway and around the facility was coded as needing weight-bearing support with one person. *A Care Conference Meeting and Review form dated 7/19/21 noted the resident needed more physical assistance and the use of seat & bed alarm daily, and the resident was forgetting to ask for assist. *The Quarterly/Annual Review by physical therapy dated 7/20/21 noted the recommendations for restorative therapy services included assist with walking using a four-wheeled walker (FWW) 4-5 times a week. *The August 2021 Restorative Flow Sheet noted the resident walked with her FWW during 10 of the 17 times the service was offered to the resident. *A Fall Risk Evaluation dated 9/15/21 noted the resident's score was 12, just slightly above the score of high-risk score of 10. The resident was noted as being chair bound. Interview on 9/15/21 at 10:37 a.m. with restorative nursing assistant (RNA) O revealed resident is now a non-ambulator [not able to walk] and they use a lift. Interview on 9/15/21 at 1:50 p.m. with certified nursing assistant (CNA) P revealed: *Using the chair and bed alarm with this resident prevented falls. *They started today using a lift for transferring the resident. Interview on 9/15/21 at 2:10 p.m. with CNA K revealed: *The alarms helped with fall prevention with this resident. *The resident moved less but was agitated by alarm sound. *There was enough staff to monitor this resident and other residents with alarms. Interview on 9/15/21 at 4:09 p.m. with infection control/minimum data set (MDS) coordinator C revealed she: *Approved the CNAs to use the lift with the resident today *Tried to make little changes to the care plans right away. *Highlighted in yellow means no longer in place. *Must have missed handwriting dates on the resident's care plan when changes were made. 2. Observation and interview on 9/14/21 at 9:20 a.m. revealed resident 28 was: *Seated in her recliner in her room with her feet up. *A wheelchair was parked facing her and up against the foot end of the mattress. *A chair alarm cord was clipped to her shirt. *She could not explain what was clipped to her shirt. *She said she broke her ankle and was told she had to use the wheelchair to keep off my feet. Observations of the resident 28 on 9/14/21 during the group exercise before the noon meal and on 9/15/21 during the breakfast meal revealed she was seated in her wheelchair in the dining room with a chair alarm cord clipped to her collar. The Minimum Data Set (MDS) quarterly assessments dated 3/15/21 and 6/14/21 coded: *Cognitive score as 3, meaning severely impaired. *Walking in her room needed one person support with limited assistance on the 3/15/21 MDS. *Walking in her room did not occur during the observation window for the 6/14/21 MDS. *Moving about in her hallway was one person support and extensive assistance on both MDSs. *Moving about away from her hallway was total dependence of one person on both MDSs. Review of resident 28's current care plan as provided by the facility, with 4 handwritten date notations between 12/22/20 and 6/14/21 in the left margin, revealed the following resident problems and needs: *Modified independence with cognitive skills was yellowed out and moderately impaired was checked with a handwritten date of 3/15/21. *The behavior of wandering/elopement as not exhibited was yellowed out and behavior occurs was checked with a handwritten date of 3/15/21. *Locomotion/ambulation required the assistance of one person. *Total dependence and wheelchair were checked with a handwritten date of 3/15/21, and a walker was checked but yellowed out. *Restraints were marked as Not used. *Risk for falls r/t [related to] vision impairment, dated 1/8/21, had multiple modifications to the approaches (actions): -Approaches yellowed out but not dated included uses a walker to walk plus staff assist, seat and bed alarm to be used daily, and provide frequent reminders to use call light for help. -Added handwritten approaches dated 3/4/21 included uses a wheelchair, pull tab alarm, and bed alarm used. -An added handwritten approaches dated 6/14/21 to attempt to keep in common areas, as able. An alarm assessment completed on 12/28/20 and reviewed on 3/15/21 and 6/14/21, noted: *The resident had impaired mobility and was unsafe with transfers but is forgetful or unwilling to ask for help. *had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] *The benefits of alarm use were to decrease falls, staff assist provided as resident forgets to use call lights. *The action taken before using the alarms was frequent reminders to use call light. The care conference meeting and review forms noted: *Uses seat and bed alarms daily. *Uses a wheelchair to move around. *The resident has had many falls related to poor vision and weakness (3/15/21). *Determined to help self - many reminders to ask for help (3/15/21). *Resistive to assistance, tries to help herself (6/15/21). The quarterly/annual review by physical therapy dated 3/9/21 and 6/14/21 revealed: *The resident was using her wheelchair for mobility in hallways and walking with one person. *Recommendation for restorative therapy exercises of NuStep 4 - 6 times a week. *As resident has spent more time in w/c [wheelchair], her knees have gotten tighter & lack extension. (6/14/21). Restorative Flow Sheets for March 2021 through June 2021 revealed resident 28 participated in the NuStep exercise 35 times of the 90 times the exercise was offered. Review of Incident/Accident Reports revealed resident 28 fell on four occasions: *6/19/21 at 2:45 p.m. by the west wing door, the resident attempted to stand from her wheelchair and fell while staff were turning off the door alarm that the resident set-off by trying to go out the door. *7/22/21 at 12:20 p.m. in the resident's room, the bed alarm sounded, and staff found the resident on the floor beside her bed. *8/3/21 at 4:30 p.m. in the resident's room, the chair alarm sounded, and staff found the resident on the floor in front of her bathroom door. The resident experienced a fractured left femur. *8/27/21 at 9:25 p.m. in the resident's room, the chair alarm sounded, and staff found the resident lying on the floor next to her bed. A fall risk evaluation for resident 28 was completed on 8/6/21, 8/20/21, and 9/3/21 with a score of 20 points each time. A score of 10 or above represents HIGH RISK. Resident 28's quarterly/annual review by physical therapy dated 9/14/21 revealed: *The NuStep was d/c'd [discontinued] due to hipfx [[CONDITION(S)]]. *Resident's walking has declined but has been able to return to prior level with transferring. Employee interviews conducted on 9/15/21 regarding resident 28 revealed the following: *RNA O at 10:37 a.m. reported the resident had been non-weight bearing since she broke her femur but was now allowed to stand on leg as tolerated. *CNA P at 1:50 p.m. reported they used to walk with the resident to the dining room but not since her fracture. 3. Observation on 9/14/21 at 9:15 a.m. of resident 14 revealed he: *Was sitting in his room in his chair. *Had a scooped mattress on his bed. *Had an alarm on his chair and his bed. Review of resident 14's alarm assessment revealed: *He had assessments completed on: -12/28/20. -3/29/21. -6/28/21. *The assessments were for bed and chair alarms. *He had not been assessed for the use of a scooped mattress and if it was a restraint or enabler. 4. Observation on 9/14/21 at 9:25 a.m. of resident 24 revealed she had: *A scooped mattress as a bed. *Chair alarms. 5. Review of resident 24's alarm, assessments revealed *She had assessments completed on 3/22/21 and 6/21/21. -The assessments were for bed and chair alarms. *She had not been assessed for the use of a scooped mattress as if it was a restraint or enabler. Review of the provider's August 2020 Resident Alarms policy revealed: *It is the policy of the [facility name] to utilize resident alarms in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being. *1. The use of alarms does not eliminate the need for adequate supervision of the resident . *2. The facility shall establish and utilize an approach for the safe and appropriate use of resident alarms, including efforts to identify risks: evaluate and analyze risk; implement interventions to reduce risk; and monitor for effectiveness of the interventions and modifying interventions when necessary. *Implementation of interventions included: -a. Resident-directed approaches shall be implemented in accordance with the resident's needs, goals, and preferences. -b. Alarms shall be initiated only to address a specific medical symptom or unique risk, when the benefit of the alarm outweighs the risk associated with its use. -c. Supervision and other resident-specific interventions shall be implemented and documented. -d. Interventions shall be communicated to all relevant staff, including time frames and responsibility. *7. When alarms are used, the interdisciplinary team shall determine whether the alarm meets the definition of a restraint.

Based on observation, interview, policy review, and manufacturer's instructions review, the provider failed to ensure five of five opportunities for glucose meter disinfection had been completed according to the guidelines for three of three randomly observed residents (14, 19, and 20) by two of two licensed practical nurses (LPN) (A and B). Findings include: 1a. Observation on 6/18/19 at 5:00 p.m. of LPN A during resident 19's blood glucose testing revealed: *She brought the shared glucose meter into the resident's room and performed the blood glucose test. *When she brought the meter back to the medication cart she: -Opened a single package of Sani-Cloth Bleach germicidal disposable wipes. -Wiped the machine using the wet wipe for about five seconds. -Threw the wipe away in the garbage. -Set the meter on top of a tissue on the cart. -Left the meter there to air dry until she used it for the next resident. *The disinfectant on that meter appeared to be dry within about thirty seconds after she had wiped it. b. Observation, interview, and disinfectant instructions review on 6/18/19 at 5:06 p.m. with LPN A during and following resident 20's blood glucose testing revealed: *She completed the resident's blood glucose test and disinfection of the meter using the same process as above. *When asked how long the disinfectant should have remained wet to properly disinfect the meter she was unsure. *Review of the instructions on the back of the single packet of wipes for cleaning and disinfecting included: - .Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous 4 minute wet contact time . *She confirmed she had not followed the manufacturer's guidelines for proper disinfection. 2a. Observation on 6/19/19 at 10:52 a.m. of LPN B during resident 14's blood glucose testing revealed: *She brought the shared glucose meter into the resident's room and performed the blood glucose test. *When she brought the meter back to the medication cart she: -Opened a single package of Sani-Cloth Bleach germicidal disposable wipes. -Wiped the machine using the wet wipe for about fifteen seconds. -Threw the wipe away in the garbage. -Set the meter directly on the top of the cart. -Left the meter there to air dry until she used it for the next resident. *The disinfectant on that meter appeared to be dry within about thirty seconds after she had wiped it. b. Observation on 6/19/19 at 11:03 a.m. of LPN B during resident 19's blood glucose testing revealed:*She brought the shared glucose meter into the resident's room and performed the blood glucose test. *When she brought the meter back to the medication cart she set it directly on the top of the medication cart. *She had not disinfected it at all prior to using it for the next resident below. c. Observation and interview on 6/19/19 at 11:08 a.m. with LPN B during and following resident 20's blood glucose testing revealed:*She brought the potentially contaminated shared glucose meter into the resident's room and performed the blood glucose test. *When she brought the meter back to the medication cart she wiped it with a Sani-cloth Bleach wipe for about ten seconds and set in directly on the top of the cart to air dry. *She confirmed she should have disinfected the glucose meter after every use and especially between residents' uses. *She was unsure of the contact time needed for the wipes to properly disinfect the meter. *She agreed the wipes should have been used according to the manufacturer's instructions to ensure proper disinfection had occurred. 3. Interview on 6/19/19 at 11:52 a.m. with the director of nursing (DON) regarding the above findings revealed: *She confirmed the manufacturer's instructions for use should have been followed when staff used the disinfectant wipes to ensure proper disinfection had occurred. *The glucose meter was shared for multiple residents and proper disinfection should have been completed in order to maintain infection control. Interview on 6/19/19 at 2:00 p.m. with the administrator confirmed the above findings and interview with the DON. Review of the provider's revised 2/11/15 Blood Glucose Testing policy revealed: *All surfaces of the glucose meter should have been wiped using the disinfectant wipes. *It listed Sani-Cloth wipes to be used for residents who had [MEDICAL CONDITION] and to let the machine dry for one minute prior to using it again. *It listed Gluco-Chlor wipes to be used for generalized cleaning between residents and to allow the machine to dry five minutes prior to using it again. *The policy had not matched the manufacturer's instructions for use to keep the surface visibly wet for four full minutes.

Based on observation, interview, and policy review, the provider failed to ensure the control and accountability of three random residents' (13, 14, and 22) narcotic medications stored in one of one medication room. Findings include: 1. Observation and interview on 6/19/19 at 11:29 a.m. with licensed practical nurse B in the medication room revealed: *Medication packages for resident 13 containing: -Sixty tablets (tab) of [MEDICATION NAME] 0.5 milligrams (mg). -Thirty tabs of [MEDICATION NAME] 1 mg. --Those were sent from the pharmacy on 6/13/19. *Medication packages for resident 14 containing: -Ninety tabs of [MEDICATION NAME] 50 mg. --Those were sent from the pharmacy on 6/17/19. *Medication packages for resident 22 containing: -Ninety tabs of [MEDICATION NAME] 50 mg. --Those were sent from the pharmacy on 6/13/19. *The above medications were all narcotics that were considered a high risk for potential theft or diversion. *She indicated those packages were the refills and would be used when the current packages in the medication cart were empty. -Once they were being used and put in the cart the staff dated them and were able to reconcile the doses. *They always stored the refill narcotic medications in with all the other non-narcotic medication packages in the medication room until they needed them. *Those narcotic medications in the medication room were not being monitored for their control and accountability. *She agreed there was a risk for potential diversion with how they were currently handling them. -There was no monitoring or accounting for them from the time they arrived from the pharmacy until they were put into the medication cart. Interview on 6/19/19 at 11:52 a.m. with the director of nursing regarding the above concern revealed: *She agreed narcotic medications were high risk and should have been monitored and accounted for to prevent potential theft or diversion. *With their current process if one of those medications went missing it would have been difficult to identify when it had occurred, where it had gone, or who had taken it. Interview on 6/19/19 at 2:00 p.m. with the administrator confirmed the above findings. Review of the provider's revised 2/16/16 Medication Administration policies and procedures related to narcotic or controlled medications revealed:* .If the the Schedule III or IV medication is a scheduled medication, it does not have to be double locked. These medications will not be counted daily, but accountability will be maintained by monthly spot checks done by the director of nursing in the nursing home . *There was no mention of a process to maintain control and accountability of the narcotic medications that had been stored in the medication room until they were needed.

Based on observation, interview, record review, policy review, manual review, and manufacturer's instructions review, the provider failed to ensure insulin was administered according to the manufacturer's guidelines related to: *The needle was not held into two of two randomly observed residents' (19 and 20) skin the proper amount of time by one of one licensed practical nurse (LPN) (A). *The medication was not given in an appropriate time frame prior to eating for three of three randomly observed residents (14, 19, and 20) by two of two LPNs (A and B). *Those observations resulted in a medication error rate of 13.33%. Findings include: 1a. Observation and Medication Administration Record [REDACTED] *The resident had sliding scale insulin ordered for 6:00 a.m., 11:00 a.m., and 5:00 p.m. daily. *She used a [MEDICATION NAME]flex pen to administer the six units of insulin needed for the resident's blood glucose level of 258. *When the LPN injected the insulin into the resident's right side of the abdomen she held the needle in place for approximately one second. *That insulin was given sixty minutes before the evening meal was scheduled to be served. b. Observation and MAR indicated [REDACTED] *The resident had sliding scale insulin ordered for 8:00 a.m., 12:00 noon, and 5:30 p.m. daily. *She used a [MEDICATION NAME]flex pen to administer the eight units of insulin needed for the resident's blood glucose level of 349. *When the LPN injected the insulin into the resident's right side of the abdomen she held the needle in place for approximately one to two seconds. *That insulin was given fifty-four minutes before the evening meal was scheduled to be served. c. Interview with LPN A following the above observations revealed: *That was her usual practice for insulin administration using the flex pens. *She confirmed she had not held the needle in the residents' skin for more than one or two seconds. *She was aware the manufacturer's instructions recommended the needle be held in place for at least six to ten seconds to ensure the resident received their full dose of insulin. -She should have followed the manufacturer's instructions. *She usually gave the resident's insulin at those times, because it was scheduled to be given before supper. Interview on 6/18/19 at 5:15 p.m. with the certified dietary manager revealed resident meal times were at 8:00 a.m., 12:00 noon, and 6:00 p.m. every day. Observation of the 6/19/19 6:00 p.m. evening meal service revealed: *Resident 19 was not served her supper meal until 6:12 p.m. which was seventy-two minutes after her rapid-acting insulin had been given. *Resident 20 was not served her supper meal until 6:10 p.m. which was sixty-four minutes after her rapid-acting insulin had been given. 2a. Observation and MAR indicated [REDACTED] *The resident had sliding scale insulin ordered for 6:00 a.m., 12:00 noon, and 5:00 p.m. daily. *She gave the resident seven units of [MEDICATION NAME] R insulin for her blood glucose level of 204. -That insulin was given sixty-two minutes before the lunch meal was scheduled to be served. b. Observation on 6/19/19 at 11:13 a.m. of LPN B during resident 20's insulin administration revealed: *The resident was given two units of [MEDICATION NAME]for a blood glucose level of 171. -That insulin was given forty-seven minutes before the lunch meal was scheduled to be served. c. Interview with LPN B following the above two insulin administrations revealed: *That was the usual time she administered the residents' insulin. *She agreed it was a long time before they would be served and able to eat lunch. *She was aware [MEDICATION NAME] and [MEDICATION NAME] R insulin were rapid and short acting insulins and should have been given close to the time the resident would have been eating. -She felt there was not enough time to get the insulins done if they waited until closer to meal service, so they did them early. *She agreed there was a potential risk of [DIAGNOSES REDACTED] for the resident when the insulin was given too early. *She agreed the manufacturer's instructions for the insulin administration had not been followed and should have been. 3. Interview on 6/19/19 at 11:52 a.m. with the director of nursing regarding the above findings revealed: *She confirmed the needle should have been held into the residents' skin for the proper amount of time to ensure the full dose had been given. *[MEDICATION NAME] and [MEDICATION NAME] R were rapid and fast acting insulins and should not have been given too early to prevent a potential hypoglycemic episode. *The manufacturer's instructions for use should have been followed for insulin administration. -When those had not been followed it would have been considered a medication error. Interview on 6/19/19 at 2:00 p.m. with the administrator confirmed the above findings. Review of the provider's revised 2/16/16 Medication Administration policies and procedures revealed:*The nurse administering medications should have followed the five rights of medication administration that included: -Right resident. -Right medication. -Right dosage. -Right time. -Right route. *There was no mention of following the manufacturer's instructions for use for medication administration. Review of the (MONTH) 2019 [MEDICATION NAME] Patient Information and instructions for use revealed: *[MEDICATION NAME] starts acting fast. You should eat a meal within 5 to 10 minutes after you take your dose of [MEDICATION NAME]. *[MEDICATION NAME] could have caused serious side effects that could lead to death including low blood sugar ([DIAGNOSES REDACTED]). *Instructions for the Flex Pen included to: .Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given. Review of the provider's Wolters Kluwer, Nursing (YEAR) Drug Handbook, 37th ED., Philadelphia, pp. 789 to 798, revealed: *Pages 789 through 795 for [MEDICATION NAME]included: -It was a rapid-acting insulin. -It should have been given within fifteen minutes before a meal or twenty minutes after starting a meal. -The onset was fifteen minutes, and it peaked in one to three hours. -Use cautiously in elderly patients (resident), who may be at increased risk for adverse effects. Signs and symptoms of [DIAGNOSES REDACTED] may be more difficult to recognize in these patients. -Teach patient to give insulin at appropriate time around a meal, depending on product. *Pages 795 to 798 for [MEDICATION NAME] R insulin included: -It was a short-acting insulin. -It should have been given within thirty minutes before a meal. -The onset was thirty minutes, and it peaked in one and one-half to three and one-half hours. -Use cautiously in elderly patients, who may be at increased risk for adverse effects. Signs and symptoms of [DIAGNOSES REDACTED] may be more difficult to recognize in these patients. -Teach patient to eat within 30 minutes of injecting short-acting insulin.

Based on observation, interview, and policy review, the provider failed to ensure resident food preference was accommodated for one of one randomly observed resident (5) during one of two observed meal services. Findings include: 1. Observation on 6/18/19 at 12:06 p.m. of the noon meal service revealed: *Residents were served mixed vegetables, mashed potatoes, and pork. -Brown gravy was placed on top of the potatoes and meat. *Dietary aide (DA) C asked residents at each dining table how the meal was after it was served. *Resident 5 answered, I don't like gravy. *DA C replied she would let someone in the kitchen know and then walked away. -She did not return to resident 5's table for the remainder of the meal service. *Resident 5 was later observed scraping gravy off the meat with her spoon. -She ate about 75% of the meat and none of the potatoes or mixed vegetables. Interview on that same day at 12:25 p.m. with resident 5 revealed: *She preferred not to have brown gravy with her food, because it upset her stomach. -That was the reason she did not eat her potatoes and only some of her meat. *She had previously informed staff of her dislike for brown gravy. Interview at 12:37 p.m. with DA C regarding the above with resident 5 revealed: *The resident had told her she did not like the gravy, but she had not offered her an alternative food choice. *She had not notified kitchen staff of her preference for no brown gravy. *She said it was the dietary manager's (DM) responsibility to interview and note residents' food preferences. *She agreed she could have offered the resident an alternative food choice, but she did not think to do so. Interview on 6/19/19 at 1:50 p.m. with the DM revealed: *She had completed a food Likes and Dislikes inventory for all residents upon admission, quarterly, and sooner if needed. -Gravy was not a listed food item on the inventory. *There was a notebook in the kitchen with every residents' current food preference information based on the food Like and Dislikes inventory. -Any staff person was able to update information in that book. -Resident 5's preference for no brown gravy was not noted in that book. *It was the DM's expectation that DA C would have offered resident 5 potatoes and meat without gravy or the alternative lunch option. *It was the DM's expectation that DA C would have notified a kitchen staff person of resident 5's preference for no brown gravy. Review of the 9/25/13 Menu and Menu Substitution policy revealed: *3. All residents have the right to make their own personal dietary choice. *4. Whenever a resident indicates that he/she doesn't want or is unable to eat a regular menu item, the on-duty cook will ensure that a menu substitution is offered to the resident, and that the item is an acceptable substitute to their current diet order.

Based on observation, interview, and policy review, the provider failed to ensure food items in one of one refrigerator designated for use by all residents were stored in accordance with professional standards for food safety. Findings include: 1. Observation on 6/18/19 at 10:36 a.m. revealed: *Inside the refrigerator designated for use by all residents was a corsage in a plastic bag labeled (Resident name)-Birthday Flower. -The white flowers of the corsage were turning brown, and the blue flowers had white colored mold on them. *There were nutritional supplements, applesauce used for medication pass, and other individual resident snacks in the refrigerator. *A typewritten sign was on the freezer door dated 5/30/13 and signed by the director of nursing that read: Reminder: Resident food items cannot be placed in this freezer, only ice packs. -Inside the freezer were two Dairy Queen Blizzards each in a plastic bag that were labeled with a resident's name and not dated. Interview on 6/19/19 at 9:30 a.m. with the dietary manager revealed the above refrigerator was used for residents' food and drink items. Interview on that same day at 2:45 p.m. with the administrator revealed: *The corsage was not to be kept in the refrigerator, and she disposed of it at that time. *The undated Blizzards were not to have been stored in that freezer. *The night shift nursing staff were to inspect the refrigerator and freezer contents nightly, label, date, and dispose of items as needed. -On 6/20/19 at 8:39 a.m. the Blizzards were still in the freezer. Review of the 11/30/17 Use and Storage of Food Brought in by Family or Visitors policy revealed: *Purpose: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. *The policy did not include refrigeration of non-food items. *The policy did not include storage of frozen food items.

Based on observation, interview, record review, and policy review, the provider failed to ensure nurses provided the following treatments correctly for one of one sampled resident (1) who had a gastric tube ([DEVICE]): *Verified [DEVICE] placement.*Obtained a physician's orders [REDACTED]. *Ensured the [DEVICE] feeding order was followed. Findings include: 1a. Review of resident 1's 6/4/19 Minimum Data Set (MDS) assessment revealed: *She had a Brief Interview for Mental Status assessment score of nine indicating she was moderately impaired. *[DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Dysphagia. -Incontinence without sensory awareness. -[DEVICE]. -Lower [MEDICAL CONDITION]. *She had a total dependence on staff for: -Bed mobility. -Dressing. -Eating. -Personal hygiene. Record review, observation, and interview on 6/18/19 at 5:57 p.m. with licensed practical nurse (LPN) A during a medication (med) pass for resident 1 revealed: *A physician's orders [REDACTED]. *She checked the placement of the [DEVICE] by injecting 30 cubic centimeters (cc) of air while listening to her stomach with a stethoscope. -She did not aspirate for gastric contents per the physicians's placement order. *There was an order for [REDACTED]. *She crushed [MEDICATION NAME] 20 milligrams (mg) and mixed that with an unmeasured amount of warm water. -It was approximately 50 ml of water. *She stated that was the usual amount of water she added when she crushed resident 1's meds. -She did not subtract that amount from the 900 ml daily total to be given. -She did not document that amount anywhere. *She agreed there was no order or accounting for the amount of water they used to mix with the meds. -She was not sure what other nurses were doing. -She agreed there should have been an order or accounting of that water.Interview on 6/19/19 at 3:05 p.m. with the director of nursing (DON) regarding resident 1 revealed: *She would have expected that both auscultation and aspiration of the [DEVICE] were completed: -Per the physician's orders [REDACTED].>-To ensure placement. *There was no way of knowing what amount of water the resident was getting per day. Interview on 6/19/19 at 3:17 p.m. with LPN B concerning resident 1 revealed: *The resident received meds four times a day. *She mixed 60 to 100 ml of water when she passed crushed meds to her. -She probably mixed meds with 30 cc of water then flushed the [DEVICE] with another 30 to 60 ml. -She did not subtract that amount from the 900 ml daily total. -She did not document that amount anywhere. *She agreed there should have been an order or accounting of that water. Interview on 6/20/19 at 9:42 a.m. with the administrator regarding the above for resident 1 revealed there needed to be consistency and accountability of the amount of water she was receiving. b. Record review, observation, and interview on 6/18/19 at 6:00 p.m. of LPN A revealed: *Formula order: -Calories/day: 1422 calories a day. -Promote with fiber at 125 ml an hour. -Start at 5:00 p.m. until completed. -Hang new bag (6 cans). *She hooked the feeding tube to the [DEVICE]. *She stated there were four cans of Promote with fiber in the feeding tube bag. -That was a total of 948 calories. *She could not add all six cans into the bag at one time, because it would be filled to the top. *She signed the 6/18/19 enteral feeding record as completed. *She stated she left the other two cans next to the sink in the medication room. *She stated Maybe that was wrong, but that was how they did it. *The night nurse should see them and pour those two cans into the feeding bag. *She acknowledged she had no way of knowing if it got done. -She just figured it did. Interview on 6/19/19 at 3:09 p.m. with the DON concerning resident 1 and the above observation revealed: *She had been aware all six cans would not fit into the feeding bag at one time. *Resident 1 had been there for a long time. *They all just knew, it was common knowledge. *That had been the routine for everyone. -Four cans of formula were added to the bag. -Two cans of formula were left in the medication room. -The order was signed off as completed by the first nurse. -The other two cans of formula would have been added later.*There was no documentation by night nurses of giving the two cans each evening.*She agreed she could not be certain the other two cans of formula were given at night. *There was no way of knowing whether she was getting the ordered calories per day. Interview on 6/20/19 at 9:39 a.m. with the administrator concerning resident 1 revealed: *The night nurse knew to add the other two cans of formula. -We all know. *They needed to have the order split up. -It should have been two orders of three cans each. *For documentation purposes it needed to be split into two orders. *There was no way to know if she was getting the ordered 1422 calories a day.Review of the provider's revised 1/22/19 Tube Feeding policy and procedure revealed:*Delivering of feeding:-2) Check placement of feeding tube to be sure it remains in proper placement.-3) Check tube patency and position by removing cap or open tube entry. Use a 60 ml syringe to inject 5-10 cc of air through the tube while auscultating resident's stomach with a stethoscope. Listen for a whooshing sound to confirm tube placement in the stomach. Also, aspirate stomach contents to confirm tube patency and placement. Reinstill any aspirate contained.

Based on observation, interview, record review, and policy review, the provider failed to ensure nurses providing care and treatment for one of one sampled resident (1) who had skin concerns. *Completed documentation and notification of resident 1's worsening wound. *Notified the administrator, director of nursing (DON), and physician of new bruising to right great toe and worsening skin concerns. *Receive physician treatment orders. Findings include: 1a. Observation on 6/18/19 at 9:26 a.m. of resident 1 in the dining room revealed: *She was in a reclining style wheelchair (w/c). *It had a: -Matrix style back. -Right lateral support. -Lower extremity positioning pillow. -Lower extremity positioning device. -ROHO cushion. -Activity table with a grab handle. Observation and interview on 6/18/19 at 10:32 a.m. of certified nursing assistant (CNA) D and [NAME] while performing a brief change for resident 1 revealed: *Her brief was removed, and she was rolled onto her left side. *There was an area on the left upper thigh directly under the buttocks that was opened. -It was approximately four inches long by three inches wide. --Not all of that area was opened. -It was pink with redness and slough. -There was no odor, and it was moist. -There was no dressing. -There was an area the size of a dime with some depth. *CNA D stated she got that all the time. *At noon when they laid her down they would leave that area open to air. *They would position her, so she would be off of that area. Record review on 6/18/19 at 12:16 p.m. of the Wound book at the nurses station revealed there was no documentation of any wounds for resident 1. Record review revealed a Braden scale assessment score of twelve indicating high risk for predicting a pressure ulcer. Observation and interview on 6/19/19 at 9:50 a.m. of CNAs D and F while performing a brief change for resident 1 revealed: *The brief was removed, and she was rolled onto her left side. *She began urinating. -Urine ran into the opened area. -The opened area was not cleaned out or washed after the above happened. -Ointment was applied to the opened area. *CNA F stated the opened area looked worse than when she had worked that weekend. Interview on 6/19/19 at 1:38 p.m. with the DON revealed: *Doctor (physicians name) saw resident 1 on 5/7/19. -She stated that opened area was not a pressure ulcer due to her having: --A ROHO cushion. --A pressure relieving mattress. *She stated it was a scuff injury. *She recommended managing the gel cushion and watching [MEDICAL CONDITION]. Review of the physician's progress note dated 5/7/19 at 9:30 a.m. revealed: *S: Recertification. She needs replacement of her feeding tube and she has got an abrasion/ulcer to her thigh fold on the left. *She has got contractures on the right and this is actually on the left. *Assessment/Plan, Assessment, A/P: -2. Left lower buttock, upper thigh, and scuff injury. *Recommend managing gel cushioning in chair and watching [MEDICAL CONDITION]. *She may be rubbing against it. *Not consistent with true pressure ulcer or moisture related skin breakdown. Record review and interview on 6/19/19 at 2:09 p.m. with the DON concerning resident 1's opened area revealed: *There was a wound status form dated 3/17/19 through 3/14/19 for the resident. *It showed a wound problem to the left ischial with dates and measurements of: -3/7/19: 1.4 x 1.8 centimeter (cm), depth 0.2 cm. -3/11/19: 1.4 x 1.7 cm, depth 0.2 cm. -3/14/19: 1.0 x 1.3 cm, depth 0.2 cm. -Healed 3/18/19. *Duoderm had been applied during each wound care measurement. *There was a current order for Duoderm to the left buttock every three days or as needed (PRN). *There was an order for [REDACTED].>*If wounds got worse licensed practical nurse (LPN) B would let her know and interventions were put into place. Interview on 6/19/19 at 2:25 p.m. with the DON and LPN B revealed: *She had been the wound care nurse for one year. *She was notified of all wounds. *She worked three days a week. *LPN B agreed that opened area was common for pressure ulcers (PU). *She stated the wound had come and gone so many times. -It healed over and occasionally opened up. *She sometimes placed a Duoderm on the site. *She believed the brief irritated it. *The site was really looking good. -About a week ago it started looking like it was not healing. *On 6/3/19 it was decided to release the brief when she was in bed. *She did not notify: -The DON. -Administrator. -Physician. -Of the recent worsening of the wound. *She did not document: -The worsening of the wound. -The size, shape, or color. -The measurements of the wound. *She believed if she had better documentation maybe she would be able to tell when it had started worsening. *The DON stated she had not been informed of the worsening of the wound. *She stated when reading LPN B's documentation she was unable to tell the wound was worsening. *By the documentation she would guess the wound was stable. *LPN B added that looking at the wound if it was considered a PU she would stage it currently at a stage two or three. Interview and record review on 6/19/19 at 4:41 p.m. with the Minimum Data Set (MDS) assessment coordinator regarding resident 1 revealed: *Quarterly MDS dated [DATE], section M had been check marked for moisture associated skin damage (MASD). *She had a discussion with the DON and discussed what to code the opened area. -The DON had stated MASD. Interview on 6/19/19 at 4:51 p.m. with the DON revealed: *She went by what the physician said.* She was unable to give me the definition of a scuff injury as referred to in the physician 5/7/19 progress note.*She had not asked the physician for a definition. *The physician had not charted is as a pressure ulcer. *She did not remember saying to code it as a MASD.Interview on 6/19/19 at 5:34 p.m. with the administrator concerning resident 1 revealed:*She agreed on 5/7/19 the physician referred to her sore as a scuff injury.*She was unable to give me a policy or procedure for a scuff injury. *She could not give me the definition of a scuff injury.*She had not asked the physician for a definition.b. Observation and interview on 6/18/19 at 10:32 a.m. during the above brief change for resident 1 with CNAs D and [NAME] revealed: *A right big toe bruise. *It was purple and red in color. *It was covering the top portion of her toe. *Both CNAs stated they had not been aware of it previously. *CNA D stated they would report it to the charge nurse. Record review on 6/18/19 at 11:19 a.m. of the CNA and nurses note binder revealed: *An 11/19/18 typed nursing clarification signed by the DON. *Nurses, just a couple of things that need to be clarified. Please read and initial: -2) The CNAs were instructed at their CNA meeting to start filling out stop and alert form (Stop and watch form) for any concerns they have on residents. Review of the undated Stop and Watch form revealed: *Instructions: *If you have identified a change while caring for or observing a resident. -Circle the change. -Write a brief description. -Notify the charge nurse. -The charge nurse will then place this form in the DON's box. *There was a list of twelve items that could be circled. *One of those items was a change in skin color or condition. *The resident's name was to be filled in. *The person's name identifying the concern was to be filled in. *Charge nurses name was to be filled in. Interview on 6/19/19 with the DON concerning resident 1 revealed: *She was unaware of her bruised right toe. *A Start and Watch form should have been filled out. -It went to her once completed. -She had not received anything, so they had not reported it. -There was no nursing note or any documentation in her chart regarding that bruise. Interview on 6/19/19 at 5:36 p.m. with the administrator revealed: *She agreed the Stop and Watch form should have been filled out. *She was unaware of the bruise to resident 1's right big toe. *She agreed there was no: -Nursing note on the bruising of the right toe. -Investigation. -Stop and Watch form. *She stated the DON had not been notified, so she was not notified. Interview on 6/20/19 at 9:00 a.m. with CNA [NAME] about reporting of resident 1's bruise revealed: *She had not reported it. *She was unaware if CNA D had reported it. c. Observation on 6/18/19 at 10:32 a.m. during the above brief change with CNAs D and [NAME] concerning resident 1 revealed: *A sore on her left wrist. *It appeared deep and about a half inch round. *It was opened to air. *It looked scabbed over. Interview on 6/19/19 at 2:09 p.m. with the DON concerning resident 1's sore to her left wrist revealed: *She knew about the sore. *She was notified and had gone to the restorative manager. *The two of them made a decision to move the brace on that wrist. *The DON had not completed any documentation. *She did not remember when the brace was removed. *She had not notified the physical therapist. *She had not notified the physician. Observation and interview on 6/19/19 at 5:05 p.m. with the restorative manager concerning resident 1 revealed: *On 5/22/19 she had noticed a skin sore when doing range of motion (ROM) exercises with her. *She had been wearing a brace on her left arm/wrist where the sore was. -The sore was from the brace rubbing on her wrist. *She had notified the DON. -They had decided to leave the brace off until the wound was healed. *She had notified: -The administrator. -CNAs -Charge nurse. *After deciding to hold the splint that was where she stopped. *She had not notified: -The physician. -Wound care nurse. Interview on 6/19/19 at 5:29 p.m. with the administrator revealed: *When I was notified I thought I could put the brace on hold. *The physical therapist (PT) had a family emergency approximately two weeks ago. -She had been back to work for a week. *It is my fault, I still haven't notified her that we stopped using the brace. -I felt like she would have just told me to take it off. *I did not notify the wound nurse. -I would just keep an eye on it myself. *There should have been notifications and better documentation.*There was no notification to the physician for treatment orders. Record review of the 9/20/18 PT order revealed: *Restorative therapy was to place the left hand/wrist and forearm splint on resident 1 four to six times a week. -For eight to twelve hours a day.Review of the providers revised 5/1/18 Wound/Skin Impairment policy and procedure revealed:*2. The Braden Scale for Predicting Pressure Sore Risk is completed on each new resident or return admit.-5. Skin concerns are identified by the date observed, location and staging, size, presence of tunneling or sinus tracts, exudate, wound bed description, and presence of pain.-6. A request for treatment order(s) is faxed to the primary care physician when skin concerns are identified.-8. Each wound is specifically noted. Skin concerns are assessed and treated as ordered and the concern is documented daily and weekly.-11. Skin concerns that are not diagnosed as pressure related will be charted weekly in the nurses notes by the wound nurse.

Based on observation, interview, and policy review, the provider failed to ensure: *Pasteurized eggs were used for soft cooked eggs in one of one dining room for one of nine sampled residents (5) and three randomly observed residents (11, 12, and 13). *Sanitary conditions were maintained for residents' food and liquid for two of two sampled residents (5 and 9) with room trays and for food on one of two observed afternoon residents' snack passes (east wing). Findings include: 1a. Observation on 2/15/17 at 7:30 a.m. with cook E in the kitchen revealed: *Eggs were being prepared in a fry pan on the kitchen's stove top. *Poached eggs had been prepared and were in individual small white bowls on that same stove top. b. Observation on 2/15/17 at 8:00 a.m. in the resident dining room revealed resident 5 had received a fried egg and the yolk was not firm. c. Observation and interview on the above date at 8:05 a.m. with resident 11 in the same dining room revealed she: *Had received a fried egg and the yolk was not firm. *Liked her eggs dippy. *Preferred a fried egg with a runny yolk. d. Observation and interview on the above date at 8:06 a.m. with resident 12 in the same dining room revealed she: *Had received a fried egg and the yolk was not firm. *Liked her eggs the runnier the better. e. Observation and interview on the above date at 8:07 a.m. with resident 13 in the same dining room revealed he: *Had received a poached egg in a small white bowl. *Was eating that egg, and the yolk was runny. *Preferred a poached egg with a runny yolk. f. Interview on the above date at 8:10 a.m. with cooks E and F in the kitchen revealed: *Residents 5, 11, 12, and 13 preferred their eggs prepared soft and not firm. *Pasteurized eggs were not used for those eggs. *There was no pasteurized eggs available in the kitchen. *They were unaware that pasteurized eggs needed to have been used for soft cooked eggs. Interview on the above date at 10:10 a.m. with the dietary manager in the kitchen revealed: *The eggs located in the kitchen were not pasteurized. *The eggs were cooked as the residents preferred them and included runny yolks, over easy, and soft cooked eggs. *She had been unaware that pasteurized eggs needed to have been used for soft cooked eggs. *She agreed the eggs needed to have been thoroughly cooked and firm, as they were not using pasteurized eggs. *Staff preparing residents' requests for soft cooked and undercooked eggs needed to have used pasteurized shell eggs or liquid pasteurized eggs. *She had placed an order for [REDACTED]. *She confirmed no soft cooked eggs were to be served until the pasteurized eggs were available for serving to residents that preferred soft cooked eggs. Review of the provider's 2/15/17 Food Preparation and Handling policy revealed: *All eggs must be cooked; no raw eggs are ever to be served. *Eggs that were not fully cooked were to have been pasteurized eggs. 2a. Observation on 2/13/17 at 6:20 p.m. with dietary assistant (DA) G during the evening meal service regarding resident 5's room tray revealed: *His meal was taken to his room by DA G with two chocolate-colored drinks in glasses and a full water glass uncovered. -That above tray went through a resident hallway prior to being delivered to the resident. *Those liquids had not been covered. b. Observation on 2/14/17 at 3:30 p.m. with DA H during the afternoon resident snack pass on the east wing using a three-tiered cart revealed: *Cookies on a tray were uncovered. *Two pureed cookies in Styrofoam cups located next to that tray were also uncovered. -The above cookies went through a resident hallway prior to being delivered to the residents. *Those foods had not been covered. c. Observation on 2/14/17 at 5:35 p.m. with DA I during the evening meal service regarding resident 9's room tray revealed: *Her meal was taken to her room by DA I with two soup bowls containing a red-colored soup, tea, and a water pitcher that were all uncovered. -That above tray went through a resident hallway prior to being delivered to the resident. *Those foods and liquids had not been covered. Interview on 2/15/17 at 10:10 a.m. with the dietary manager revealed she agreed: *The food and liquid needed to have been covered for residents 5 and 9 who had received a room tray. *The residents' afternoon snacks had needed to have been covered during delivery to the residents. *Did not have a policy regarding covering residents' food and liquid during transportation and distribution to residents.

Based on observation, record review, interview, and policy review, the provider failed to assess, monitor, and manage one of one sampled resident's (4) chronic pain. Findings include: 1. Observation on 1/26/16 at 2:15 p.m. of resident 4 revealed she: *Was sitting out in the hall outside her room in her wheelchair and voicing discomfort of pain especially in her left shoulder. *Was given her scheduled 2:00 p.m. [MEDICATION NAME] (narcotic pain medication) by licensed practical nurse F. *Was assisted onto the commode (portable toilet) by certified nursing assistants (CNA) A and B with the use of a mechanical stand-up lift (requires resident to be able to bear some weight on legs). *Was showing facial grimacing while being transferred onto the commode, sitting on the commode, and when assisted off the commode back into her wheelchair. *Was complaining of pain especially in her shoulders and was grabbing onto her left shoulder. Interview at that time with CNAs A and B regarding resident 4 revealed she: *Almost always complained of pain especially in her shoulders during any kind of transfer or movement. *Was assisted onto the commode at a minimum of four times a day and PRN. Review of resident 4's medical record revealed: *A 2/12/15 admitted . *Diagnoses: [REDACTED]. Review of resident 4's 2/12/15 physician's orders [REDACTED].>*[MEDICATION NAME] 10/325 milligrams (mg) three times a day (TID) at 8:00 a.m., 2:00 p.m., and bedtime (HS). *[MEDICATION NAME] 10/325 mg one tablet every four hours as needed (PRN). Review of resident 4's 8/13/15 physician's orders [REDACTED]. Review of resident 4's 10/20/15 and 1/11/16 Minimum Data Set (MDS) assessments section J regarding pain revealed: *10/20/15: -Pain almost constantly in shoulders. -Have you had pain or hurting at any time in the last five days was answered yes. -Has pain made it hard for you to sleep was answered yes. -Has pain limited your day-to-day activities was answered yes. -Intensity of worst pain over the last five days was documented moderate pain. *1/11/16:- -Pain almost frequently. -Have you had pain or hurting at any time in the last five days was answered yes. -Has pain limited your day-to-day activities was answered yes. -Intensity of worst pain over the last five days was documented moderate pain. Review of resident 4's 2/12/15 through 1/19/16 nurses' notes revealed: *2/12/15, States she has pain all the time, but that it is tolerable at this time. *3/17/15, Resident lying in bed, states she went to reach for her water and rolled out of bed onto the floor. States her legs and hips hurt. No complaints of pain when moving. *6/10/15, Currently up in her wheelchair in her room. Resident offers complaints that she has been having a little more pain in her right middle finger. Doctor expressed to resident that it is arthritis and there really is not much we can do. Resident is currently on scheduled [MEDICATION NAME] TID and may have a dose PRN. Reinforced to resident that if she is having increased pain needs to ask for something. *7/28/15, Group exercise is offered and encouraged. She is not consistent with participation, however, when she does participate she tolerates this activity well. New contractures (body limitations) noted to her bilateral elbows. *8/12/15, Resident examined by doctor. Expresses to doctor that she has been having a lot more pain in her shoulders. Order to have physical therapy (PT). Scheduled for a PT evaluation (eval) on 8/13/15. *8/13/15, Resident returned with PT instructions recommending hot wet packs to bilateral shoulders PRN and passive range of motion (PROM) and active exercises to bilateral shoulders PRN. 9/15/15, Resident continues to deny any pain other than her normal arthritic pain. She does have severe arthritis in her left wrist. *9/28/15, Resident poured water on floor and went to grab bed frame to stand up and wheelchair rolled back and resident slipped to the floor. When assessment was done able to do range of motion (ROM) to all extremities but when asked about pain stated it hurt everywhere including her great toe. Assist of two with gait belt to stand. Continues to complain of pain to left shoulder. She is inconsistent with answers. *10/8/15, When asked about pain resident states she has pain all over which is her normal (norm). *10/11/15, Resident was sitting on the floor in her bathroom. CNA was helping resident to the restroom as her pants were wet. CNA stated she was changing resident's brief and provide perineal (peri) care with resident standing up when resident began to slide to the floor. Resident pleasantly confused. *10/13/15, Resident currently up in wheelchair and confused per her norm. Resident states that she has pain all over which is also her norm. Resident is unable to explain if her pain is worse since her fall. Has had increased complication with transfers. Will start to use the stand-up aide for all transfers to help prevent injury to resident and staff. *1/12/16, Group exercise is offered and encouraged, however she is not consistent with this activity. Individual exercises of pulleys and shoulder shrugs are completed four to six times per week. She tolerates these activities well. New contracture noted to her right knee. Review of resident 4's 6/10/15 through 12/8/15 physician's progress notes revealed: *6/10/15: -Is having increased pain in the right hands, digits 2, 3, and 4 on the right hand. I did not attempt to try to straighten as even just basic touch increases her pain. Hands have slight contractures. -We will go ahead and discuss with the nurses of being more liberal with the PRN [MEDICATION NAME] along with the scheduled. *8/12/15: -Chronic pain requiring narcotics. -Complains of bilateral shoulder pain, ongoing and long term. Hands consistent with advanced [MEDICAL CONDITION] joint disease. -We will see her back in approximately a month to see how well the PT went. *10/6/15: -Chronic pain requiring narcotics. -Pain is reasonable well controlled with the daily [MEDICATION NAME]. *12/8/15: -The staff have no concerns for her. Review of resident 4's September 2015 through January 2016 MAR indicated [REDACTED] *September 2015: None. *October 2015: Two times. *November 2015: One time. *December 2015: One time. *January 2016: None. Review of resident 4's September 2015 through January 2016 treatment administration records revealed no documentation the PRN hot packs to her shoulders was offered to the resident or refused by her. Review of resident 4's 1/26/16 care plan revealed: *Problem of complaints of pain to hips, knees, ankles, and shoulders. *Outcome would be for pain measures to be effective. *Administer pain medication as indicated per order and reposition frequently. *Pain assessment quarterly and PRN. *Assess characteristics of pain and report any changes to the charge nurse. *Monitor verbals and non-verbals (moaning, groaning, facial expressions, and guarding) and report promptly. *Non-medication interventions available and used PRN. *Memory deficit related to disorganized thinking. Is inattentive, forgetful, and confused. Interview on 1/27/16 at 11:00 a.m. with the director of nursing regarding resident 4 revealed she: *Was unaware the nursing staff were rarely administering the PRN [MEDICATION NAME] for her daily pain. *Was unaware the PRN hot packs ordered by the PT had never been used. *Confirmed the physician had not been asked to change her pain medication regimen since her admission and likely should have been asked to. *Revealed the resident always complained about many things and was never satisfied when a problem was resolved. Review of the provider's undated Pain Assessment and Management policy revealed: *Purpose is to keep residents comfortable and pain free. *It is the goal of all staff at this facility to keep residents pain free and comfortable. *Pain assessments are done quarterly by the MDS coordinator and monthly on a resident's monthly summary by the charge nurse. *All staff has been educated in pain, signs and symptoms of pain and alternatives for pain management. *If pain is exhibited by the resident or expressed it is reported to the charge nurse for PRN pain assessment or pain medication.