Every finding on record at Eventide Fargo

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 12 sampled residents (Resident #3, #13, #17, and #45) observed during cares. Failure to practice infection control standards related to bodily fluid spills, hand hygiene, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility.Findings include: Review of the facility policy titled Blood and Body Fluid Clean-up occurred on 09/18/25. This policy, revised July 2025, stated, . requires that all body fluids. be cleaned and disinfected with an appropriate disinfectant. Resident Care Staff is responsible for this. To maintain a safe environment to prevent cross-contamination. Review of the policy/procedure titled Transmission-Based Precautions occurred on 09/18/25. This policy, revised December 2024, stated, provide staff with guidance to reduce or prevent the indirect transmission of infectious diseases through personal contact, surfaces, and equipment used for the residents . to prevent transmission of infection using the least restrictive approach possible that adequately protects the resident's and others . Enhanced barrier precautions. used to limit or prevent the spread of resistant organisms during high-contact resident care activities . put on gown and gloves before all high-risk activities . in addition to standard precautions, gown and gloves must be worn during high-contact resident care activities such as . transferring in room, providing hygiene, changing briefs, and assisting with toileting .” Review of Resident #45's medical record occurred on all days of survey and identified EBP related to sutures. - Observations of Resident #45 showed the following: *9/15/24 at 4:15 p.m., a certified nurse aide (CNA) (#7) entered the room to provide incontinent cares. After providing incontinent cares, the CNA (#7) applied a clean brief and pulled up the resident's pants. The CNA (#7) then removed the soiled gloves, her gloves, applied new gloves, cleaned bowel movement (BM) and urine on the toilet, and removed the soiled gloves. Without performing hand hygiene, the CNA (#7) removed the gait belt from the resident's waist and transported him/her to the dining room. *9/16/25 at 7:27 a.m., CNA (#8) provided perineal cares in the resident's bathroom. The CNA (#8) failed to wear a gown or gloves during perineal cares. During an interview on 9/16/25 at 8:01 a.m., a nurse (#9) confirmed staff are expected to perform hand hygiene before and after glove changes and wear a gown and gloves during personal cares with residents on enhanced barrier precautions. - Observation on 09/15/25 at 3:06 p.m. showed two CNAs (#2 and #3) transferred Resident #3 from her wheelchair to bed with a full-body mechanical lift and removed her wet pants and brief. The wheelchair cushion was visibly soiled with urine. One CNA (#2) provided perineal care and handed the soiled wipes to the other CNA (#3) to discard in the trash. Both CNAs removed the soiled gloves and without performing hand hygiene, pulled up the resident's clean pants and placed the lift sling under the resident before completing hand hygiene. During an interview on 09/16/25 at 3:00 p.m., an administrative nurse (#5) stated she expected staff to ensure all cushions have covers and are clean. - Review of Resident #17's medical record occurred on all days of survey. The current care plan stated, . has a . catheter in place . A progress note, dated 10/09/24 at 5:07 p.m., stated, . Family voiced concerns of catheter bag often leaking. Observation on 09/16/25 at 7:54 a.m. showed an EBP sign outside of Resident #17's door. A CNA (#2) applied a gown and gloves and entered the resident's room. Resident #17 rested in bed with the catheter drainage bag hung on the side of bed and a dark, dried substance on the floor under the catheter bag. The CNA (#2) emptied the catheter bag into a container and a small amount of urine spilled on the floor. The CNA (#2) emptied the container into the toilet. The CNA removed the soiled gloves, performed hand hygiene, applied new gloves and transferred Resident #17 from bed to the toilet with the sit to stand lift. The CNA removed the resident's soiled brief, removed the soiled gloves, and without performing hand hygiene, removed the sit to stand lift and sling. The CNA (#2) then performed hand hygiene, applied new gloves, and performed morning cares. The CNA removed the soiled gloves, and without performing hand hygiene, brought the sit to stand lift back to the bathroom, applied new gloves, stood the resident up, performed perineal care, removed the soiled gloves. Without performing hand hygiene and applying new gloves, adjusted the resident's pants, transferred the resident to the wheelchair, placed the catheter bag under the wheelchair, made the bed, gathered the linen and garbage, applied new gloves and sanitized the lift. The CNA (#2) then removed the gown and gloves, performed hand hygiene and exited the room. The CNA (#2) failed to clean the spilled urine from the floor, and failed to perform hand hygiene after removing soiled gloves, before touching other surfaces, and before applying clean gloves. - Review of Resident #13's medical record occurred on all days of survey. The current care plan stated, . catheter in place . Observation on 09/16/25 at 4:07 p.m. showed an EBP sign on the wall outside of Resident #13's door. A CNA (#12) applied a gown and gloves, entered the resident's room, emptied the catheter bag, removed her gloves, and without performing hand hygiene, applied a new pair of gloves to dress Resident #13. The CNA (#12) failed to perform hand hygiene after removing gloves and before applying clean gloves. During an interview on 09/17/25 at 2:50 p.m., an administrative nurse (#6) confirmed she expected staff to perform hand hygiene after removing gloves, before applying clean gloves, and to clean the floor after a urine spill.

Based on observation, record review, review of facility policy, review of facility pharmacy guidelines, and staff interview, the facility failed to ensure accurate labeling of medications for 2 supplemental residents (Resident #22 and #55) observed during medication administration. Failure to obtain new medication labels from the pharmacy for oral medications and insulin or affix a label noting change in the directions, may result in residents receiving an incorrect dose of medications.Findings include:Review of the facility policy titled Medications: Administration and Storage occurred on 9/18/25. This policy revised March 2025, stated, . Medications will be administered according to the following directives . to provide safe and effective drug therapy for the residents . Medications will be labeled according to accepted pharmacy standards . Multi dose vials must be labeled when opened .Review of the facility's contracted pharmacy guidelines regarding label changes for existing medication orders occurred on 9/18/25. This guideline states, . To meet all federal and state labeling requirements . upon receiving a medication direction change [the facility], will place a 'refer to MAR' sticker on the existing medication and follow the MAR [medication administration record] directions when administering the medication to the resident. Pharmacy will supply a new and correct label .-Observation on 9/17/25 at 8:12 a.m. showed a nurse (#10) removed a medication container from the medication cart for Resident #22. The container label identified Norvasc 5mg [milligram], [heart medication] take 2 tablets daily . Review of Resident #22's current physician orders and MAR identified a dosage change on 06/11/25 from 2 tablets a day to 1 tablet a day. The container lacked a refer to MAR sticker. The nurse (#10) confirmed the label affixed to the container as incorrect, and staff failed to order a new label. -Observation on 9/17/25 at 4:38 p.m. showed a nurse (#11) removed a Novolog insulin pen from the medication cart for Resident #55. The insulin pen label included the resident's name and directions for administration which stated, Give Novolog flex pen 10 units SQ [subcutaneous] TID [three times a day] before meals. Review of Resident #55's physician orders and MAR stated, Give Novolog, 8 units SQ TID before meals. The insulin pen lacked a refer to MAR sticker over the label. The nurse (#11) confirmed the label affixed to the insulin pen as incorrect and staff failed to order a new label. During an interview on 9/17/25 at 4:10 p.m., an administrative nurse (#1) confirmed she expected staff to follow facility policy and ensure medications have a refer to MAR sticker or a correct dose label on them.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 22 sampled residents (Resident #7 and #8). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include:SECTION J: HEATLH CONDITIONSThe Long-Term Care Facility RAI User's Manual, revised October 2024, pages J 27-28, stated, . J1400 Prognosis: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? . Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services.SECTION M: SKIN CONDITIONSThe Long-Term Care Facility RAI User's Manual, revised October 2024, page M 23-24, stated, . M0300F1: Enter the number of pressure ulcers that are unstageable related to slough [non-viable tissue] and/or eschar [dead or devitalized tissue].Review of Resident #7's medical record occurred on all days of survey and identified a terminal illness, hospice services beginning on 05/22/25, and unstageable wounds to the right heel and great toe. A Wound Care Flow Sheet, dated 07/23/25, stated, Right heel - 3 [centimeters (cm)] x 2.7 [cm] x 0 [cm] unstageable, and R. [right] great toe is 0.6 [cm] x 0.6 [cm] x 0 [cm], unstageable. Eschar [thick, dry, crusty layer of dead tissue that forms over a wound]. The quarterly MDS, dated [DATE], failed to identify a prognosis of life expectancy less than 6 months and the presence of an unstageable pressure ulcer.During an interview on 09/17/25 at 10:44 a.m., an MDS nurse (#4) agreed staff failed to code life expectancy of less than six months and an unstageable pressure ulcer.SECTION N: MEDICATIONSThe Long-Term Care Facility RAI User's Manual, revised October 2024, page N-4, stated, . N0415: High-Risk Drug Classes . Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days . C. Antidepressant .Review of Resident #8's medical record occurred on all days of survey. A physician's order, dated 07/31/25, stated, Venlafaxine [antidepressant medication] . one time a day for depression/anxiety. The significant change MDS, dated [DATE], failed to identify the resident received an antidepressant.During an interview on 09/17/25 at 4:06 p.m., an MDS nurse (#4) stated, I must have just missed it [coding venlafaxine].

This REQUIREMENT is NOT MET as evidenced by: Based on record review, policy and procedure review, professional reference review, and staff interview, the facility failed to provide the care and services for 1 of 1 sampled resident (Resident #5) on hemodialysis with a Permacath (a type of vascular access for dialysis). Failure to assess the hemodialysis vascular access site may result in complications and adverse effects, such as clotting and possible loss of the access site. Findings include: Review of the facility policy titled “Hemodialysis Access Sites” occurred on 09/18/25. This policy, revised April 2022, stated, “. The facility is responsible to . Provide ongoing monitoring and care of the resident's vascular access . Central Venous Access . Assess site BID [two times per day]. Observe for redness, warmth, drainage. Report problems immediately to physician/practitioner/dialysis center . Review of the Core Curriculum for the Dialysis Technician - A Compressive Review of Dialysis, Fifth Edition, page 121 and 127 stated, . Vascular access makes chronic hemodialysis (HD) possible . An access is an HD patient's lifeline. Each access must be cared for as if it is the last one a patient can have. access failure means loss of the HD life-line. The access must be repaired or replaced - if the patient has a site left. Access problems can cause hospital stays, surgery illness, limb loss, and death. Review of Resident #5's medical record occurred on all days of survey and included a diagnosis of End Stage Renal Disease (ESRD). The current care plan stated, . Monitor CMS [circulation, motion, sensation] of extremity with access site per facility policy. Update provider/dialysis center if concerns are noted . Resident receives dialysis (M/W/F) [Monday/Wednesday/Friday] . Review of Resident #5's nurses' notes identified the following: *06/23/25 at 3:29 p.m., . No longer using fistula [a surgical connection between an artery and a vein to make it possible for hemodialysis]. Utilizing port to R [right] upper chest. Dressing in place. No obvious bruising, bleeding, redness, or drainage. *07/28/25 at 12:55 p.m., . returned from Dialysis early. Per report from [Resident #5], she has a clot to her dialysis cath and will need to have it replaced.*08/20/25 at 6:44 p.m., . Resident had dialysis today, her Perma Cath. blew during dialysis. *08/21/25 at 9:31 p.m., . Perma cath replacement. During an interview on 09/17/25 at 2:36 p.m., a nurse manager (#5) confirmed the medical record lacked documentation of assessment of Resident #5's vascular access site twice a day.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #6) received proper treatment and care to maintain good foot health. Failure to confirm podiatry were aware of and assessed the wounds to Resident #6's right toes, may have contributed to the foot amputation.Findings include: Review of the facility's policy titled Skin Assessment occurred on 08/06/25. This policy, revised December 2023, stated, . The nurse is responsible for: Accurately assessing skin . Identifying and evaluating . changes in resident's condition, Providing treatment per facility protocol or provider order . If a problem is identified the nurse will . Notify the provider . Review of Resident #6's medical record occurred on all days of survey. Diagnoses included abnormalities of mobility, amputation of the 5th toe on the right foot, chronic osteomyelitis (infection of the bone), diabetes with diabetic neuropathy, edema, foot ulcer, obesity, and venous insufficiency. The admission Minimum Data Set (MDS), dated [DATE], identified diabetic foot ulcer and at risk for developing pressure ulcer. The record showed staff treated the right foot arterial wounds with betadine (an antiseptic). The care plan stated, . [Resident #6] has potential for skin breakdown . Current chronic diabetic ulcer to L [left] foot . 4/3/25 Arterial wounds to tops of R [right] 2nd, 3rd, 4th toes. Air mattress . Foot board extended, Foot cradle to foot of bed, Monitor for changes in skin integrity when providing cares and provide appropriate follow up if areas of concern are noted, Podiatry consult as needed, Prevalon [pressure relieving] boots as ordered, Treatment as ordered . Review of the weekly Wound Care Flow Sheets from 04/03/25 to 6/4/25 showed an increase in wound size and deterioration of Resident #6's right toe wounds as follows: 2nd toe: 1.1 centimeters (cm) by (X) 0.5 cm to 6 cm X 2.5 cm 3rd toe: 1.8 cm X 1.2 cm to 4 cm X 1.5 cm 4th toe: 1.3 cm X 1.3 cm to 3 X 2 cm The nurses' progress notes identified the following: *04/04/25 at 10:21 a.m., . [Podiatry] . Reason for appointment: L) heel callus worsening R) toes arterial wounds . 4/11/25 11:30 [a.m.] . Must see [Podiatry Nurse Practitioner (NP) (#1)] as she is the wound care podiatrist, so appt [appointment] was rescheduled from 4/7/25. * 05/19/25 at 3:44 p.m., identified, . Healing scab continues to R 5th digit [right 5th toe had previously been amputated]. Dark brown and intact. 2+ pitting edema noted to bilateral lower extremities with rubor [redness] noted. [Resident #6] continues to have healing arterial wounds to the tops of the left 2nd, 3rd, 4th toes. There is black intact eschar [dead tissue] with peeling yellow callus surrounding each scab. While assessing . his toenails [were] coming off . Updated provider on loss of 2nd toenail. [Resident #6] is already followed by podiatry . The nurse described Resident #6's wounds as continuing to heal at the same time she identified black eschar and lost nails.* 06/02/25 at 6:36 p.m., . Continues with necrotic tissue to his R) 2nd, 3rd, and 4th toes .* 06/04/25 at 6:22 p.m., . Continues with eschar tissue covering 2-4th toes on R foot .* 06/06/25 at 9:23 a.m., . Foul odor noted from right toes this AM [morning] when applying treatment . Will be seen at podiatry this AM .A Foot and Ankle Surgery [Podiatry] - Follow Up report, dated 04/11/25, stated, . [Resident #6] . presents . for follow up [left] heel ulcer . Ulcer is progressing . Follow up as needed if worsening . The Podiatry NP (#1) failed to address the arterial wounds on Resident #6's toes/right foot and the facility failed to follow up with podiatry regarding the wounds. A physician's progress note, dated 04/23/25, stated, . Diabetic ulcer present on the left sole some arterial ulcer [sic] present on the 2nd, 3rd, and 4th toe on the right foot . His [Resident #6's] arterial ulcers of the toe [sic] as well as the diabetic ulcers are healing well, also being followed by specialist . Follow up with the patient in few months or sooner if the need arises . The physician (#5) indicated Resident #6 was under the care of a specialist. However, the medical record lacked evidence of an assessment by podiatry of the arterial ulcers to Resident #6's right toes. A Foot and Ankle Surgery [Podiatry] - Follow Up report, dated 05/09/25, stated, [Resident #6] . presents to clinic today for follow up heel ulcer . LOWER EXREMITY Exam: Left heel ulcer: healed over at this time. The Podiatry NP (#1) failed to address the arterial wounds on Resident #6's toes/right foot and the facility failed to follow up with podiatry regarding the wounds. A Foot and Ankle Surgery [Podiatry] - Follow Up report, dated 06/06/25, stated, . [Resident #6] . presents to clinic today with right foot toes turning black . States that they started getting discolored about 3 weeks ago. Have continued to progress. Son states that he noticed starting at the tip of the little toe and has slowly been spreading . LOWER EXTREMITY Exam: Right toes: wet eschar, odor present, Redness to midfoot, Non-palpable pulses, No pain due to severe neuropathy . Recommend being sent to the ED [Emergency Department [for progressing cellulitis, IR [Interventional Radiology] intervention . Podiatry will follow peripherally once revascularized and stabilized, will more than likely need TMA [Transmetatarsal (all or part of the forefoot) Amputation] . During interviews on 08/06/25 at 1:40 p.m. and 5:40 p.m., an administrative nurse (#6) indicated staff would notify a provider of a change in the resident's condition if it was an emergency. The facility failed to follow up with podiatry after Resident #6's appointment on 04/11/25 and 05/09/25 and failed to notify the resident's provider or podiatry when the resident's toes became necrotic and odorous.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 20 sampled residents (Resident #58 and #85). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages N-6 to N-8 stated, . N0415: High-Risk Drug Classes: Use and Indication . Coding Instructions . N0415G1. Diuretic: Check if a diuretic medication was taken by the resident at any time during the 7-day look-back period . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin .) was taken by the resident at any time during the 7-day observation period . - Review of Resident #58's medical record occurred on all days of survey. A physician's order, dated 05/30/24, stated Aspirin Oral Capsule 81 MG [milligram] . give 81 mg by mouth one time a day . The quarterly MDS, dated [DATE], showed staff failed to identify Resident #58 received an antiplatelet medication. - Review of Resident #85's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], showed N0415G1 coded as the resident received a diuretic medication within the 7-day look back period. The resident's medical record lacked documentation Resident #85 received a diuretic during the look back period. During an interview on 08/28/24 at 2:07 p.m., an administrative staff member (#1) agreed staff failed to code the MDS correctly for Resident #58 and #85.

Based on record review, review of the hospice contract, and staff interview, the facility failed to ensure residents' records contained the hospice election form, most recent hospice plan of care, and/or certification of terminal illness for 2 of 5 sampled residents (Resident #4 and #83) receiving hospice services. Failure to obtain these documents limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: The hospice contract for (hospice agency name), signed 01/30/20, stated, . The designated interdisciplinary team member is responsible for . obtaining the following information from Hospice: (A) the most recent Hospice plan of care specific to each resident; (B) Hospice election form; (C) physician certification and recertification of the terminal illness specific to each resident . - Review of Resident #4's medical record occurred on all days of survey. A nurse's note, dated 05/31/24, stated, . Resident plans to remain in LTC [long-term care] with [name of organization] hospice services. [Resident's daughter] signed all necessary documents and writer answered all questions. Resident #4's medical record failed to contain the hospice election form and certification of terminal illness. Resident #4 elected hospice services on 03/13/24 (prior to admission). - Review of Resident #83's medical record occurred on all days of survey. A nurse's note, dated 07/25/24, stated, . [Resident #83] is [name of hospice] for CHF [congestive heart failure] and HTN [hypertension] . Resident #83's medical record failed to contain the hospice election form, plan of care, and certification of terminal illness. Resident #83 elected hospice services on 04/12/24 (prior to admission). During an interview on the afternoon of 08/28/24, an administrative nurse (#1) confirmed Resident #4 and #83's medical records lacked all required hospice information. 46259

Based on observation, review of facility policy, review of profession reference, and staff interview, the facility failed to follow professional standards of practice for 2 of 2 sampled residents (#28 and #51) and 1 supplemental resident (#47) observed for insulin preparations and administrations. Failure to clean the end of the insulin pens prior to placing on a new needle, and failure to prime the insulin pens correctly may result in infections and/or the residents receiving an inaccurate dose of insulin. Findings include: Review of professional reference, How to Use an Insulin Pen found at https://www.learningabout diabetes, stated, . take the cover off the pen. use alcohol to clean the end of the pen where the needle twist on . peel back the cover on the needle. Screw the needle onto the pen. Review of the facility policy Insulin-Subcutaneous occurred on 08/29/24. This policy, revised May 2022, stated, . Prime the insulin pen by turning the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. Observation on 08/26/24 at 5:00 p.m. showed a nurse (#2) prepared Resident #28's Humalog insulin pen for administration. The nurse (#2) removed the cap from the insulin pen and without cleaning the end of the pen with alcohol, applied a new needle. Observation on 08/26/24 at 5:15 p.m. showed a nurse (#2) prepared Resident #51's Aspart insulin pen for administration. The nurse (#2) removed the cap from the insulin pen and without cleaning the end of the pen with alcohol, applied a new needle. Observation on 08/27/24 at 8:00 a.m. showed a nurse (#3) prepared Resident #47's Novolog and Levemir insulin pens for administration. The nurse (#3) removed the caps from the insulin pens and without cleaning the end of the pens with alcohol, applied new needles. The nurse (#3) dialed each insulin pen to 2 units and primed both with the pens in a horizontal position. During an interview on 08/28/24 at 10:08 a.m., an administrative nurse (#4) stated she expected staff to clean the end of the insulin pen with alcohol prior to placement of a new needle and to prime insulin pens vertical as per policy.

Based on record review, review of facility investigation, and review of facility policy, the facility failed to ensure adequate supervision and assistance for 1 of 2 sampled residents (Resident #3) who required staff supervision while toileting. Failure to provide supervision in the bathroom resulted in an avoidable fall and fracture. Findings include: Review of the facility policy titled Standards of Care occurred on 11/08/23. This policy, last revised October 2016, stated, . Each staff member providing direct nursing care will have in their possession throughout their shift the written plan of care for each resident and will perform specific cares as directed according to this form. Review of Resident #3's medical record occurred on 11/08/23. Resident #3's care plan at the time of the fall stated, Do not leave alone on toilet. Nursing progress notes identified the following: *10/02/23 at 5:52 p.m., . According to [Resident #3] she was trying to reposition herself on the toilet and fell forward on her face. Staff ran in to help her and found her lying in a pool of blood with her face stuck to the wall. Staff were able to remove her from the wall, called the ambulance, and cleaned her up. A large laceration was noted to the left side of her head. [Resident #3] was transferred to [hospital name] ER [emergency room ] for further evaluation d/t [due to] the head injury. *10/02/23 at 6:47 p.m., . Time of fall: 1600 [4:00 p.m.] Description of event: Staff called that [Resident #3] was on the floor face down in her bathroom in a pool of blood. Writer ran in there and found resident bleeding profusely. Was the fall witnessed?: no Did the resident hit their head?: yes . *10/02/23 at 6:52 p.m., Fall Update . Staff called for assistance in [Resident #3]'s bathroom at 1600 stating that she had fallen. Writer entered the bathroom to find [Resident #3] face down on the bathroom floor to the right of the toilet with her head pushed into the wall, her L [left] arm under her body, and her R [right] arm tucked back to her R side. There was a large amount of blood noted on the floor under [Resident #3]'s face. Staff were directed to call the ambulance. Writer asked [Resident #3] what she was doing prior to falling off the toilet, and she said she was leaning forward to reposition her buttocks on the toilet. She said as she leaned forward she 'toppled over' onto the floor. *10/02/23 at 10:21 p.m., .Update from [hospital name] ER: Resident will be admitted to hospital with dx [diagnosis] of C2 [cervical axis] vertebra fx [fracture] and laceration to forehead. Review of the facility's investigation of the incident identified the following: . [Resident #3] is . assist of 2 to transfer on and off of toilet with hoyer lift [full body lift] for toileting. [Resident #3] had an unwitnessed fall on 10/2/23 at 1600. C.N.As [certified nurse aides] [(CNA (#4) and CNA (#5)] assisted [Resident #3] onto the toilet per [Resident #3]'s request using hoyer lift. [Resident #3] asked to sit on the toilet for a bit. CNA (#4) stepped out of the bathroom to provide [Resident #3] privacy, per [Resident #3]'s preference, keeping the door ajar and remained in [Resident #3]'s room ready to assist her when she was done using the toilet. [Resident #3] reports she had leaned forward to reposition her buttocks on the toilet and toppled over onto the floor. Staff heard the sound of [Resident #3] falling from just outside her bathroom door and rushed to her. C.N.A [CNA (#4)] found [Resident #3] on the floor face down on her stomach. The right side of her head was against the wall, her left arm under her body, and her right arm tucked back to her right side. On 11/08/23 at 4:13 p.m., an administrative staff member (#1) confirmed facility staff unhooked Resident #3's sling from the full body lift after positioning her on the toilet. The facility failed to ensure Resident #3 received adequate supervision to attain the highest degree of safety possible while toileting which resulted in a fall with a fracture.

Based on observation, record review, review of facility policy, and staff interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 sampled residents (Residents #48) receiving oxygen by nasal cannula. Failure to administer oxygen according to the physician's order may result in complications and compromise the residents' respiratory status. Findings include: Review of the facility policy titled Oxygen Use and Storage occurred on 08/31/23. This policy, dated July 2023, stated, Oxygen will be administered per practitioner orders . Review of Resident #48's medical record occurred on all days of survey and identified a physician's order, dated 05/02/23, Oxygen at 2 liters/minute per nasal cannula as needed for dyspnea [shortness of breath]. The treatment administration record failed to show Resident #48 receiving oxygen. Observation on 08/29/23 at 10:10 a.m. and 08/30/23 at 1:40 p.m. showed Resident #48 receiving oxygen at three liters/minute per nasal cannula. During an interview on 08/30/23 at 1:40 p.m. an administrative nurse (#3) verified Resident #48's oxygen at three liters per nasal cannula. During an interview on 08/31/23 at 9:45 a.m. two administrative nurses (#1 and #2) confirmed Resident #48's did not have an order for oxygen at three liters/minute and the treatment administration record failed to identify Resident #48 receiving oxygen.

Based on observation, record review, and resident and staff interview, the facility failed to provide treatment and care in accordance with professional standards for 1 of 1 sampled resident (Resident #38) observed to have an unprescribed over-the-counter medication on the bedside table. Failure to identify all medication may result in adverse health effects for the resident. Findings include: Review of Resident #38's medical record occurred on all days of survey. Diagnosis included hypomagnesemia (an electrolyte disturbance caused by a low magnesium level in the blood). The residents current care plan stated, . [Resident] has diagnosis of osteoporosis. She also has noted other vitamin deficiencies (Vitamin B, Magnesium, Vitamin D). Review of physician's orders stated Magnesium Oxide Oral Tablet 400 milligrams (mg) by mouth two times a day for hypomagnesemia. Observation and interview on 08/29/23 at 11:07 a.m., showed a bottle of Magnesium Phosphate 30X for pain and muscle cramps on resident's bedside table. Resident (#38) stated, It's all natural and I take it once in a while when I get a cramp. Resident #38 stated he/she does not notify staff when taking the Magnesium from personal supply. The medical record failed to identify the additional magnesium supplement observed in the resident's room and lacked a physician's order. During an interview on 08/30/23 at 3:05 p.m. an administrative staff (#1) stated Resident #38 does not have an order for this medication and was unaware the resident had it.

Based on record review, review of facility policy, and staff interview, the facility failed to provide care and services for the provision of hemodialysis consistent with professional standards of practice for 1 of 1 sampled resident (Resident #56) receiving hemodialysis. Failure to assess and monitor the resident's Arterio-venous (AV) fistula daily may result in bleeding, loss of access site, or other complications. Findings include: Review of the facility policy titled Hemodialysis Access Sites occurred on 03/24/21. This policy, revised September 2019, stated, . AV fistula should be monitored for thrill [feel the vibration] and bruit [hear the swishing] daily . Arm (with the fistula present) assessment should include CMS [circulation, motion, and sensation] of the limb distal to the fistula specifically checking for mottling, coolness, and decreased sensation or tingling. Fistula site should be monitored for pain, redness, drainage, excessive warmth, or swelling . Review of Resident #56's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review identified Resident #56 received [CONDITION(S)] three days per week via a left AV fistula. Resident #56's medical record failed to show staff monitored the resident's AV fistula daily. During an interview on the morning of 03/24/21 an administrative nurse (#2) confirmed staff failed to monitor and assess Resident #56's AV fistula daily.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) reflected residents' status for 2 of 20 sampled residents (Resident #40 and #74). Failure to accurately complete Section [NAME] (Behaviors) and Section K (Nutrition) does not allow each resident's assessment to reflect their current status/needs, and may result in the development of an inaccurate care plan. Findings include: SECTION E: BEHAVIORS The Long-Term Care Facility RAI Manual, revised (MONTH) (YEAR), page E-18, stated, . E0900: Wandering-Presence & Frequency . Wandering is the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to his or her physical or safety needs. The resident may have a purpose such as searching to find something, but he or she persists without knowing the exact direction or location of the object, person or place. The behavior may or may not be driven by confused thoughts or delusional ideas (e.g., when a resident believes she must find her mother, who staff know is deceased ). Traveling via a planned course to another specific place (such as going to the dining room to eat a meal or to an activity) is not considered wandering. Review of Resident #40's medical record occurred on (MONTH) ,[DATE], 2019. [DIAGNOSES REDACTED]. The medical record lacked adequate documentation of wandering behavior occurring on ,[DATE] days during the seven-day look back period. SECTION K: NUTRITION The Long-Term Care Facility RAI Manual, revised (MONTH) (YEAR), page K-5 and K-6, stated, . K 0300 . Code 2, yes, not on a physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. Review of Resident #74's medical record occurred on (MONTH) ,[DATE], 2019. [DIAGNOSES REDACTED].#74 weighed 148.4 pounds (lbs) on [DATE] and 135.4 lbs on [DATE], which is an 8.76% weight loss in 30 days. A progress note dated [DATE] at 11:19 a.m., stated . has had significant wt (weight) loss >5% (more than five percent) in one month, current wt: 135.4# (pounds), 30d (days): 148.4#, 90d: 173#. The resident's significant change MDS, dated [DATE], Section K, identified no significant weight loss in section K. During an interview on [DATE] at 3:25 p.m., a facility nurse (#1) agreed staff should have coded section K for weight loss.

Based on observations, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.15), and staff interview, the facility failed to ensure accurate coding of Minimum Data Sets (MDSs) for 6 of 20 sampled residents (Resident #16, #63, #72, #73, #142, and #293). Failure to accurately complete Section H (Bladder and Bowel), Section J (Health Conditions), Section N (Medications), and Section P (Restraints and Alarms) of the MDS does not allow each resident's assessment to reflect their current status/needs, and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION H: BLADDER AND BOWEL The Long-Term Care Facility RAI Manual, page H2 - H9, stated, . Coding Instructions: Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances A-D were used in the past 7 days. H0100A, indwelling catheter (including suprapubic catheter and nephrostomy tube). H0100B, external catheter . H0300: Urinary Continence Code 0, always continent: if throughout the 7-day look-back period the resident has been continent of urine, without any episodes of incontinence. Code 1, occasionally incontinent: if during the 7-day look-back period the resident was incontinent less than 7 episodes. This includes incontinence of any amount of urine sufficient to dampen undergarments, briefs, or pads during daytime or nighttime. Observation on 06/26/18 at 8:58 a.m. showed Resident #73 with an indwelling catheter connected to a leg drainage bag. Review of Resident #73's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Medicare 30 day MDS, dated [DATE], showed a check next to H0100A, indwelling catheter and H0100B, external catheter. Section H0300 showed a 1, indicating occasionally incontinent of urine. During an interview on 06/27/18 at 3:50 p.m., an administrative nurse (#8) confirmed she coded section H0100B and H0300 incorrectly SECTION J: HEALTH CONDITIONS The Long-Term Care Facility RAI Manual, page J24, stated, . J1400 Coding Instructions: Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. - Review of Resident #293's medical record occurred on all days of survey. The medical record showed Resident #293 started on hospice services on 05/22/18. A Physicians Certification of Terminal Illness form, signed and dated 05/23/18, indicated Resident #293's terminal diagnosis. The significant change in status MDS, dated [DATE], showed a no in section J1400. During an interview on 06/27/18 at 12:45 p.m., an administrative nurse (#8) confirmed she should have coded yes for section J1400. - Review of Resident #142's medical record occurred on all days of survey. The medical record showed Resident #142 started receiving hospice services on 05/31/18. A Hospice Initial Certification form, dated 05/31/18 and signed by the physician, identified a 6 month terminal diagnosis. An admission MDS, dated [DATE], showed a no in section J1400. SECTION N: MEDICATIONS The Long-Term Care Facility RAI Manual, pages N-4 to N-7, stated, . Indicate the number of days the resident received the following medications by pharmacological classification, not how it is used, during the last seven days . Enter 0 if medication was not received by the resident during the last 7 days . N0410C, Antidepressant: Record the number of days an antidepressant medication was received by the resident at any time during the 7-day look-back period . N0410E, Anticoagulant (e.g., [MEDICATION NAME], or low- molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here. - Review of Resident #16's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], showed a 0 in section N0410C: Antidepressant. - Review of Resident #72's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The quarterly MDS, dated [DATE], showed a 0 in section N0410C. During an interview the morning of 06/28/18, an administrative nurse (#8) confirmed she should have coded a 7 for medication received in last 7 days in section N0410C. - Review of Resident #73's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The Medicare 30 day MDS, dated [DATE], showed a 7 in section N0410E. During an interview on the morning of 06/28/18, an administrative nurse (#8) confirmed she should not have coded Resident #73's MDS a 7 for anticoagulant use in section N0410E. SECTION P: RESTRAINTS AND ALARMS The Long-Term Care Facility RAI Manual, pages P-9 to P-10, stated, . After determining whether or not an item listed in P0200 was used during the 7-day look-back period . Code 0, not used: if the device was not used during the 7-day look-back period . Code 1, used less than daily: if the device was used less than daily . Code 2, used daily: if the device was used on a daily basis during the look-back period . Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to resident's assistive device (e.g., walker, wheelchair, cane) or other belongings. Review of Resident #63's medical record occurred on all days of survey. The current physician's orders [REDACTED]. Check placement of wander guard to left ankle . The quarterly MDS, dated [DATE], showed a no in section P0200E (wander/elopement alarm). During the afternoon of 06/26/18, observation showed Resident #63 sitting in the common area with a wander guard to the left ankle. During an interview on 06/28/18 at 11:24 a.m., an administrative nurse (#8) confirmed she coded Resident #63's MDS incorrectly.

Based on observation, review of facility policy, and staff interview, the facility failed to label mulit-dose insulin pens and discard outdated medications on 2 of 4 units (1 East and 2 East). Failure to label multi-dose insulin pens with the date opened and discard expired medications increased the risk of residents receiving outdated medications with reduced medication efficacy. Findings include: Review of the facility policy titled Medication Administration Information occurred on 06/27/18. This policy dated (MONTH) (YEAR), stated, . Mulit-dose vials must be labeled with the date opened. - Observation on 2 East on 06/27/18 at 9:10 a.m., showed a staff nurse (#4) administer a scheduled dose of [MEDICATION NAME]with a mulit-dose insulin pen. The insulin pen/pharmacy label did not contain a date when opened. During the observation the nurse (#4) stated the insulin pen should have been dated when it was opened and verified the date was not written on the pen or the pharmacy label. - Observation on 1 East on 06/28/18 at 8:40 a.m., showed a staff nurse (#5) administer a scheduled dose of [MEDICATION NAME]with a mulit-dose insulin pen. The insulin pen/pharmacy label did not contain a date when opened. During the observation the nurse (#5) stated the insulin pen should have been dated when it was opened, and she would write the date on the label since she opened the pen that morning. - Observation of the medication storage areas located in the nurse stations and in resident rooms occurred on 06/27/18 with a Medication Assistant II (MA) (#6). Observation identified the following medications and the expiration date: Nurse station (2 East) medication storage area: * Seven single dose syringes of Prevnar 13 pneumococcal vaccine - (MONTH) (YEAR) Resident rooms on 2 East : * Antidiarrheal 2 mg capsules - (MONTH) (YEAR) * Tylenol 500 mg tablets - (MONTH) (YEAR) * Milk of Magnesia (bottle) - (MONTH) (YEAR) * [MEDICATION NAME] suspension (bottle) - (MONTH) (YEAR) * [MEDICATION NAME] ointment (tube) - (MONTH) (YEAR) * Tylenol 325 mg tablets - (MONTH) (YEAR) * Antidiarrheal 2 mg capsules - (MONTH) (YEAR) * Saline Nasal spray (bottle) - (MONTH) (YEAR) * Antacid tablets (bottle) - (MONTH) (YEAR) * Antidiarrheal 2 mg capsules - (MONTH) (YEAR) During the observation, the MA (#6) agreed the above items needed to be discarded. Failure to correctly label and dispose of medications may increase the risk of residents receiving an inaccurate dose of medication and/or reduced medication efficacy.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to provide the necessary care and services for 1 of 2 sampled residents (Resident #244) receiving oxygen. Failure to provide oxygen as ordered has the potential for residents to experience complications related to inadequate oxygen saturation levels. Findings include: Berman and Synder, S., Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice, 9th ed., Pearson Education, Inc., New Jersey, page 1397, stated, OXYGEN THERAPY . Like any medication, oxygen is not completely harmless to the client. Clients receive an inadequate amount or an excessive amount of oxygen and both can lead to a decline in the client's condition. An inadequate amount of oxygen ([MEDICAL CONDITION]) will lead to cell death, and if left untreated can ultimately lead to death. Review of Resident #244's medical record occurred on all days of survey. The physician's orders [REDACTED]. Oxygen at 2 liters (L)/minute per nasal cannula as needed for dyspnea . The resident's (MONTH) (YEAR) eMAR (electronic medication administration record) identified oxygen had not been used since admission. The vital records showed staff checked Resident #244's O2 (oxygen) saturations once since her admission on 06/20/18. During observation on the afternoon of 06/25/18 and the morning of 06/26/18, the resident was lying in bed receiving oxygen at 2L/minute per nasal cannula. During an interview on 06/27/18 at 1:54 p.m., an administrative nurse (#1) stated she was unable to find documentation to support the use of O2 continuously.

Based on record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a significant change in status assessment (SCSA) for 1 of 5 sampled residents (Resident #67) admitted to hospice. Failure to determine the need for and complete a SCSA limited the facility's ability to accurately assess the resident's status, and identify and implement appropriate care approaches. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.15), dated (MONTH) (YEAR), page 2-23 stated, . A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD (assessment reference date) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). Review of Resident #67's medical record occurred on all days of survey. A physician's orders [REDACTED]. The care plan stated, . (Resident's name) was admitted to (name of hospice agency) service on 05/16/18. Hospice will assist to provide support to (Resident's name) and her family . During an interview on 06/27/18 at 12:45 p.m., an administrative nurse (#8) confirmed Resident #67 should have had a SCSA completed for the start of hospice.

1. MEDICATION ADMINISTRATION Based on observation, review of professional reference, and staff interview, the facility failed to ensure staff followed professional standards of practice for 1 of 5 observations of medication administration. Failure to prepare medications for the resident immediately before administration by pre-dishing ahead of time andfailure to document the time controlled medications are dispensed has the potential to increase the risk of medication errors. Findings include: The Geriatric Medication Handbook, 7th ed., American Society of Consultant Pharmacists, page 148 stated, . Medications should be prepared for the resident immediately before administration; medications should never be prepared in advance for multiple residents . Observation on 06/27/18 at 7:51 a.m., showed a Medication Assistant II (MA) (#6) enterd Resident #80's room, the MA (#6) set down three medication cups, one stacked inside the other, each medication cup contained one to two pills. When asked about the pre-dished medications, the MA (#6) stated, I prepared them earlier and after I give them I write the time on the medication cup. When I am done with my medication pass I enter the time on the narcotic sign out sheet. Observation showed, written on the cups, the first initial of Resident #80, Resident #53 and Resident #72. The MA (#6) identified all three cups contained controlled medications. * At 8:08 a.m., observation showed the MA (#6) had not yet administered the medications to Resident #53 and Resident #72. The MA (#6) placed the two medication cups into a storage container in the locked medication room at the nurse's station. *At 10:28 a.m., review of the document to sign out controlled medications, showed the medications for Resident #80, Resident #53 and Resident #72 were not documented as dispensed. During an interview on 06/27/18 at 4:25 p.m., an administrative nurse (#1) reported nursing staff should not pre-dish medications and should sign out narcotics/controlled medications immediately when removed from the package. 2. PRIMING INSULIN PEN Based on observation, review of manufacturer's instructions, and staff interview, the facility failed to ensure staff followed professional standards of practice for 1 of 2 observations of insulin administration. Failure to correctly prime an insulin pen may result in the resident not receiving the prescribed dose of insulin. Findings include: The manufacturer's instructions for the [MEDICATION NAME] flex pen, revised (MONTH) (YEAR), stated, . Step 4: push the capped needle straight onto the pen and twist the needle on until it is tight. Step 5: Pull off the outer needle cap . Priming your [MEDICATION NAME] FlexTouch pen, Step 7: turn the dose selector to select 2 units. Step 8: Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Step 9: Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0 . A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9, . Observation on 06/27/18 at 9:10 a.m., showed a staff nurse (#4) prepared a [MEDICATION NAME]pen. The staff nurse (#4) held the tip of the insulin pen horizontally and primed the insulin pen with the needle cap in place. During an interview on the morning of 06/28/18, an administrative nurse (#1) confirmed an insulin pen should be primed in the upward position with the needle cap off.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow infection control practices for 3 of 14 sampled residents (Resident #35, #192, and #293) observed during personal cares. Failure to follow infection control practices of hand hygiene during toileting/personal cares has the potential to spread infection to other residents, personnel, and visitors. Review of the facility policy titled Gloves-Guidelines For The Wearing occurred on 06/27/18. This policy, dated (MONTH) 2013, stated, . Always wash hands before and after gloving. Review of the facility policy titled Hand Hygiene occurred on 06/27/18. This policy, dated (MONTH) 2013, stated, . Hand hygiene will be done: . b. before every clean procedure, c. after every dirty procedure. Review of the facility policy titled Management of Residents with [MEDICAL CONDITIONS] occurred on 06/27/18. This policy, dated (MONTH) (YEAR), stated, . Exceptional hand washing is a must as hand sanitizers do not work, no other form of hand hygiene is acceptable. - Review of Resident #192's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Observation on 06/27/18 at 2:30 p.m. showed a certified nursing assistant (CNA) (#12) applied a gown and gloves and entered Resident #192's room. The resident stated he had a bowel movement (BM) in his brief. Using a gait belt, the CNA (#12) assisted the resident into the bathroom, removed the brief containing BM, and assisted the resident onto the toilet. Without changing gloves or performing hand hygiene, the CNA removed the resident's gait belt and pants, obtained wipes from a cabinet, and opened the door looking for staff assistance. When Resident #192 finished on the toilet, the CNA (#12) applied the gait belt, assisted the resident to stand, and performed perineal care after an other BM. Without changing gloves or performing hand hygiene, the CNA (#12) assisted the resident into bed, adjusted the blankets, moved the bedside table closer to the bed, gave the resident his call light, and obtained the resident's dirty clothes. The CNA (#12) then removed his/her gown and gloves and performed hand hygiene with soap and water. The CNA (#12) failed to remove his/her gloves and perform hand hygiene after removing a brief containing BM, after providing perineal cares and prior to completing other tasks. - Observation on 06/26/18 at 11:40 a.m. showed a CNA (#11) assisted Resident #35 off the toilet and provided perineal care after a BM. The CNA (#11) changed gloves, assisted the resident into her wheelchair, and removed the resident's gait belt. Without performing hand hygiene, the CNA (#11) wheeled the resident to the sink, removed his/her gloves and obtained a clean paper towel for the resident. The CNA (#11) collected the garbage in the bathroom and performed hand hygiene. The CNA (#11) failed to perform hand hygiene after providing perineal care and prior to completing other tasks. - Observation on 06/26/18 at 10:09 a.m. showed two CNA's (#9 and #10) donned gloves and performed perineal care for Resident #293 while he was in bed. One CNA (#9) assisted Resident #293 with perineal care, disposed of the soiled brief, removed her gloves, and failed to complete hand hygiene. The CNA's (#9 and #10) applied a clean brief, pulled his pants up, repositioned him on his side, placed pillows behind his back and between his legs. The CNA (#9) held the bed control in her hand and lowered the bed, offered Resident #293 a drink and held the straw with her fingers to place it into the residents' mouth, touched her walkie-talkie to respond to a coworker, and placed the call light and bedside table next to Resident #293. The CNA (#9) then performed hand hygiene. During an interview on 06/27/18 at 3:10 p.m., an administrative nurse (#13) stated she expected staff to remove gloves and perform hand hygiene after removing a brief with BM. After perineal care, once the resident is safe, she expected staff to remove gloves and perform hand hygiene before doing other tasks.

Based on observation and staff interview, the facility failed to ensure emergency suction machine, remained in safe operating condition for 1 of 3 units (1 West). Failure to ensure the suction machine remained functional in the event of an emergency situation placed residents at risk for choking and aspiration. Findings include: Observation of the suction machine at the 1 West nurse station occurred on 06/27/18 at 2:12 p.m. with two nursing staff members (#2 and #3). Observation showed a nursing staff member (#2) attempted to connect tubing from the suction machine to the two collection canisters for the suction machine. After two minutes of unsuccessful attempts to connect and operate the suction machine, the nurse (#2) asked for assistance from another nursing staff member (#3). Both nurses (#2 and #3) attempted for a total of eight minutes to operate the suction machine. The nurses (#2 and #3) failed to connect the tubing correctly and the machine did not produce full suction when turned on. The nursing staff member (#3) started to page through the instruction manual and stated she would call maintenance to check the machine. During an interview on 06/27/18 at 3:50 p.m. an administrative nurse (#1) acknowledged the nursing staff members (#2 and #3) had not properly connected the tubing to the suction machine and stated, all nursing staff complete suction machine training upon hire and at the annual skills review.