Every finding on record at Good Samaritan Society Augusta Place a Prospera Co

Based on observation, review of manufacturer's instructions and staff interview, the facility failed to sanitize surfaces in 1 of 1 facility kitchen. Failure to ensure the concentration of quaternary (quat) sanitizing solution is within manufacturer's guidelines may result in an incorrect solution concentration. Inadequate sanitization of the kitchen surfaces places residents at risk for foodborne illness. Findings include: Review of the manufacturer's instructions for Ecolab's Oasis 146 Multi-Quat Sanitizer occurred on [DATE]. This information identified a concentration of 150- 400 ppm (parts per million) for effective sanitizing. Observation during the initial kitchen tour on [DATE] at 10 a.m., showed a dietary staff member (#11) wiped a food-prep counter in the kitchen with a cloth from a bucket of solution. The dietary staff (#10) identified the solution in the bucket as the quat disinfecting solution she obtained from the main kitchen earlier that morning. Upon request, the dietary staff member (#10) tested the solution twice using expired Hydrion QT 40 test strips. The results measured ,d+[DATE] ppm, below the ,d+[DATE] ppm manufacturer's recommendation. Observation in the kitchen on [DATE] at 10:20 a.m., showed an administrative staff (#2) tested a bucket of pre-mixed quat solution prepared for disinfection of the kitchen counters. The quat solution tested below 100 ppm, and staff discarded it. Testing of a second bucket of pre-mixed quat solution showed 100 ppm and staff discarded it. During an interview on [DATE] at 10:30 a.m., an administrative staff (#2) stated staff are expected to test quat solution with up to date test strips and assure the solution is mixed to the correct concentration.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 13 sampled residents (Resident #20, #30, #36, #38 and #200) and one supplemental resident (Resident #2) observed during cares and medication pass. Failure to practice infection control standards related to enhanced barrier precautions (EBP), droplet precautions, and hand hygiene, has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 01/28/25. This policy, revised on 03/29/22, stated, . Policy: . All employees in patient cares areas . will adhere to . Hand Hygiene . 3 After bodily Fluid/Glove Removal . according to standard precautions . 2. Hand hygiene should be performed after glove removal . Procedure: HCW [Health Care Workers] will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: . After removing gloves regardless of task completed . After contact with a patient's excretions . When moving from contaminated body site to clean body site during patient care . Review of the facility policy titled Standard and Transmission-Based Precautions occurred on 01/28/25. This policy, reviewed/revised on 04/02/2024, stated, . Standard precautions apply to . all body fluids . excretions . Standard precautions include handwashing, personal protective equipment, cleaning of resident care equipment . Enhanced Barrier Precautions . refer to the use of gown and gloves during high-contact resident care activities . Enhanced Barrier Precautions are needed for . Residents with Indwelling Medical Devices (. indwelling urinary catheters, feeding tubes .) . High-Contact Resident care Activities include: Transfers, dressing, assisting during bathing, providing hygiene, changing briefs . contact while assisting with transfers . Droplet Precautions will be used in addition to standard precautions for a resident/patient known or suspected to be infected with microorganism transmitted by droplet . clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE [personal protective equipment] . - Review of Resident #30's medical record occurred on all days of survey. The current care plan stated, . The resident needs Enhanced Barrier Precautions related to indwelling catheter and feeding tube. Observation on 01/27/25 at 9:43 a.m. showed an enhanced barrier precaution sign outside of Resident #30's room. A certified nurse aid (CNA) (#6) entered Resident #30's room without applying a gown to complete morning cares. With gloved hands, the CNA (#6) completed personal and catheter cares. Without removing the gloves and performing hand hygiene, the CNA performed perineal cares after a bowel movement. Without removing the soiled gloves or performing hand hygiene, the CNA (#6) continued with the rest of the morning cares, including placing clothing on the resident. - Review of Resident #200's medical record occurred on all days of survey. The current care plan stated, . The resident has an ADL [activities of daily living] self care performance deficit . check resident . for incontinence/toileting needs . Observation on 01/27/25 at 1:32 p.m. showed a CNA (#6) performed perineal cares for Resident #200 after a bowel movement. After completing cares, the CNA (#6) failed to remove his/her gloves, applied a new brief, pulled up the resident's pants, and adjusted the resident's shirt. The CNA then removed the soiled gloves and without performing hand hygiene, placed a blanket over the resident, placed the call light within reach of the resident, and opened the window blind. During an interview on 01/30/25 at 12:19 p.m., an administrative nurse (#1) confirmed she expected staff to remove gloves and perform hand hygiene after perineal cares, and for staff to follow the policy when providing high-contact cares for residents in enhanced barrier precautions. - Review of Resident #36's medical record occurred on all days of survey. The current care plan stated, . requires enhanced barrier precautions . monitor lung sounds . Observation on 01/27/25 at 2:43 p.m. showed a staff nurse (#4) entered Resident #36's room and assessed lung sounds with a stethoscope. After the assessment, the nurse placed the stethoscope around her neck, left the room, and walked down the hall. The nurse (#4) failed to disinfect the stethoscope. During an interview on 01/30/24 at 12:20 p.m., an administrative nurse (#1) stated she expected staff to sanitize medical equipment used for a resident on EBP. - Review of Resident #20's medical record occurred on all days of survey. The care plan stated, The resident needs Enhanced Barrier Precautions related to indwelling catheter. Observation on 01/28/25 at 8:43 a.m. showed a CNA (#7) transferred Resident #20 from the wheelchair to the recliner. The CNA (#7) stated, the resident is in EBP for his foley catheter and staff only need a gown when working with the catheter. The CNA (#7) failed to wear a gown when transferring Resident #20. During an interview on 01/30/25 at 12:14 p.m., an administrative nurse (#1) stated she expected staff to wear a gown for all transfers in EBP rooms. - Observation on 01/29/25 at 11:45 a.m., showed a Medication Aide (MA) (#8) administered eye drops to Resident #2. The MA (#8) applied gloves, administered the eye drops, removed the gloves, and left the room without performing hand hygiene. The MA returned to the medication cart and failed to perform hand hygiene. During an interview on 01/30/25 at 12:24 p.m., an administrative nurse (#1) stated she expected staff to perform hand hygiene after administering eye drops. - Review of Resident #38's medical record occurred on all days of survey. Diagnosis included influenza. Observation on 01/27/25 at 4:09 p.m., showed a droplet precautions sign outside of Resident #38's room. A CNA (#5) entered Resident #38's room and performed toileting and transferring cares. After cares, the CNA (#38) exited the room and failed to remove his mask. During an interview on 01/30/24 at 12:20 p.m., an administrative nurse (#1) stated she expected staff to remove PPE after cares in a droplet precautions room. 39685 46477

Based on record review and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 13 sampled residents (Resident #33 and #39). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: - Review of Resident #33's medical record occurred on all days of survey. A physician's order, dated 07/16/24, stated, Hiprex [antibiotic/antibacterial medication] Oral Tablet 1 GM [gram] . Give 1 tablet by mouth two times a day for prevent uti [urinary tract infection]. The current care plan stated, . Monitor/document for s/s [sign/symptoms of] UTI . The facility failed to update Resident #33 care plan to include a medication to prevent UTIs. - Review of Resident #39's medical record occurred on all days of survey. A physician's order, dated 09/23/24, stated, Hiprex Oral Tablet 1 GM . Give 1 tablet by mouth two times a day for Recurrent [sic] UTIs. The current care plan stated, . Monitor/document for s/s UTI . The facility failed to update Resident #39's care plan to include a medication for recurring UTIs. During an interview on 01/30/25 at 12:19 p.m., an administrative nurse (#1) confirmed staff failed to revise Resident #33 and Resident #39's care plans.

Based on observation, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 2 residents (Resident #33) observed for insulin preparation and administration. Failure to properly prime an insulin pen and administer insulin correctly may result in residents receiving an inaccurate dose of insulin. Findings include: Review of the facility policy titled Insulin Administration, Insulin Pens, Insulin Pumps occurred on 01/30/25. This policy, revised 09/05/24, stated, . Insulin Pen. Turn the dosage knob to '2' units to prime the pen. 10.) Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. 11.) Dial in the ordered dose of units. Inject the dose into the chosen site. Be sure to wait 6 seconds to ensure that the full dose has been delivered. Review of manufacturer's Instructions For Use of Lantus occurred on 01/30/25 and stated, . Injecting your Lantus Dose: Place your thumb on the injection button. Then press all the way in and hold. Keep the injection button held in and when you see '0' in the dose window, slowly count to 10. This will make sure you get your full dose. After holding and slowly counting to 10, release the injection button. Observation on 01/29/25 at 11:30 a.m. showed a staff nurse (#9) prepared Resident #33's Lantus insulin pen for administration. The nurse (#9) primed the insulin pen holding the pen down towards the garbage can. The nurse (#9) administered the insulin and immediately removed the needle from the resident's skin. The nurse failed to hold the pen upward when priming, hold the injection button in and count to 10. During an interview on 01/30/25 at 12:24 p.m., an administrative nurse (#1) stated she expected staff to prime an insulin pen with the needle upright and to hold the needle into the skin per policy/instructions.

Based on record review, review of the facility reported incident investigation, review of facility policy, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 4 sampled residents (Resident #1) receiving insulin. Failure to administer insulin according to a physician's order may have contributed to Resident #1's hyperglycemia (elevated blood sugar level) and hospitalization . This citation is considered past noncompliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 07/30/24. The facility implemented corrective action on 07/30/24 and completed staff education and began audits on 07/31/24. Review of the facility policy titled Medication: Administration Including Scheduling and Medication Aides occurred on 08/01/24. This policy, dated 05/21/24, stated, . Medications are administered to the resident according to the 'Six Rights.' . PROCEDURE . 4. Follow the 'Six Rights': Right medication, right dose . 5. Perform three checks: Read the label on the medication container and compare with the MAR [Medication Administration Record] when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication. The initial facility reported incident form, dated 07/30/24, stated, . Resident [#1] was sent to ER [emergency room ] to monitor high blood sugar. The resident received multiple doses of Lantus [long-acting insulin] but should have received HumaLOG [fast-acting insulin]. Resident #1's 07/30/24 orders included: * Lantus SoloStar Pen insulin 22 units subcutaneously (sq) at bedtime daily * HumaLOG (Lispro) KwikPen insulin sq per sliding scale before meals, with 8 units if blood sugar 351-400 milligrams/deciliter (mg/dl) Resident #1's vital sign record showed the following blood sugar levels on 07/30/24: * 7:00 a.m., 379 mg/dl * 11:00 a.m., 456 mg/dl * 4:00 p.m., 566 mg/dl A progress note, dated 08/01/24 at 10:05 a.m., stated, Upon investigation of incident dated 7/30/24 . LPN [licensed practical nurse] stated she gave [NAME] [sic] throughout the day [07/30/24]. At 7:30 [a.m.] resident received 8 units of [NAME] [sic] instead of Humalog. LPN received an additional telephone order at 11:00 [a.m.] from the provider for an additional 2 units of (short acting) Humalog. LPN administered total of 10 units of [NAME] instead of Humalog. LPN followed up again with provider at 1600 [4:00 p.m.] and received another order for 10 units of (short acting) Humalog. 10 units of [NAME] [sic] was administered instead of Humalog at 1600. During an interview on 08/01/24 at 12:20 p.m., an administrative nurse (#1) stated the nurse (#3) coming on duty on 07/30/24 at 6 p.m. asked the nurse (#2) what insulin she gave Resident #1, and the nurse (#2) showed her the Lantus pen which she confirmed she used instead of the Humalog insulin pen each time that day (July 30th). Based on the following information, noncompliance at F760 is considered past noncompliance. The facility implemented the corrective actions to ensure the deficient practice does not recur by: * The facility conducted an investigation on 07/30/24 with interviews of staff that determined the cause of the incident. Nursing staff failed to follow all the Rights of medication administration. Resident #1 received the wrong type of insulin. * Provided 1 on 1 education immediately after the incident on 07/30/24 with the involved staff regarding the proper medication administration process. * Suspended the nurse until the investigation was completed. * Provided education to nursing staff prior to the start of their shifts beginning on the evening of 07/30/24. Will continue with education on the Six Rights of medication administration by the Director of Nursing or designee from August 1-16, 2024. * On 07/31/24 began audits of insulin administration during med pass to ensure residents receive the correct insulin and nurses follow the Rights of medication administration.

Based on observation, record review, review of the facility reported incident investigation, and resident and staff interview, the facility failed to ensure an environment free of hazards for 1 of 1 sampled resident (Resident #1) injured while consuming a hot beverage. Failure to place the hot beverage lid securely to the cup resulted in an injury to Resident #1. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Interviews with Resident #1 occurred on the morning of 05/09/24. The resident stated she likes the lid of her hot beverages loosened to allow them to cool and staff assist her with the hot beverages. She stated, on the day of the burn, staff placed the hot beverage in front of her with the lid loosened and she forgot to wait for assistance and the hot liquid spilled onto her chest. Random observations on 05/09/24 showed secured likds on hot beverages. Review of Resident #1's medical record occurred on 05/09/24. The nurse's progress notes identified the following: * 05/08/24 at 7:30 a.m., Late Entry: Note Text: RN [registered nurse] was informed in report by night shift nurse of area of blistering on resident's chest. At approximately 0730 [7:30 a.m.], RN assessment resident's chest. RN noted blister and small area of redness surrounding blister and above the blister. Resident denied pain at the site. RN confirmed that resident was on provider's list to be seen on rounds 5/8/24. * 05/08/24 at 9:35 a.m., Late Entry: Note Text: Provider saw resident on rounds and assessed blister and area of redness on chest at approximately 0930 [9:30 a.m.]. Resident reported that provider assessed area and had discussed that new orders would be written for area discussed above. * 05/08/24 at 4:15 p.m., Late Entry: Note Text: Received faxed order from [physicians name] at 1312 [1:12 p.m.] for the following: Silvadene [an antibiotic cream used to treat moderate burns] to Burn Chest Wall BID [twice a day] PRN [as needed] for Burn Chest Wall. * 05/08/24 at 10:19 p.m., incident, On 5/7/24 at 1900 [7:00 p.m.] staff reported to author that resident has a hot tea spill on her chest. Staff took resident to her room and removed her shirt and assessed area which was red and measured 2 inches x [by] 3 inches at this time. Cool washcloth applied to chest area for 20 minutes. Area was still red at this time and left open to air. Resident put on rounds list for Md [physician] to see Wed. [Wednesday] morning 5/8/24. Nurse assessed the area again at end of shift. At this time redness was gone and a blister had formed measuring 3 inches x .5 inch. The care plan, in place on 05/07/24 (at the time of the burn), stated, Focus: HOT BEVERAGES/SOUP; [Resident #1] has impaired ability to manage hot beverages and soups R/T [related to] arthritis in hands and shoulder. Interventions: *HOT BEVeRAGE AND SOUP SAFETY: Provide a cup with lid. *Supervise at all times while drinking hot beverages and eating soup. Focus: Nutrition . Interventions . Staff assist resident to eat meals. Provided 1:1 supervision. Straws are ok. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for the deficient practice by: * Completing an investigation that determined the primary cause of the accident (not securing the lid to the hot beverage cup). * Provided education immediately to all staff through a text communication on 05/08/24 stating facility staff are to ensure all hot liquid covers are securely fastened before giving them to residents to prevent injury and burns. * Interview on 05/09/24 at 11:30 a.m. with two administrative staff members (#1 and #2) and a corporate staff member (#3) identified the facility will reiterate hot beverage safety at the next CNA meeting this month. The surveyor determined a deficient practice existed on 05/07/24. The facility implemented corrective action and completed training to all staff on 05/08/24.

42397 Based on observation, review of facility policy, review of food temperature logs, review of resident council meeting minutes, and resident, family, and staff interviews, the facility failed to serve hot foods at palatable temperatures on 3 of 3 units (Pine Ride, [NAME] Hills, and Eagle Bend). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Food Temperature Monitoring - Food and Nutrition Services occurred on 01/18/24. This policy, revised 12/21/23, stated, . Proper holding temperature - Temperature required for food safety ( . hot food > [greater than] 135 degrees Fahrenheit) . Proper serving temperature - A temperature that is . appetizing to the resident . Food is cooked, reheated or cooled to ensure proper holding temperatures . Food temperatures are taken and recorded before each meal service. Periodically, temperatures are taken at other times during or at the end of meal service to ensure temperatures are held within acceptable ranges . hot foods should be served at 135 degrees Fahrenheit or higher. Interviews on the morning of 01/16/24 identified the following: * Resident A - The food is sometimes cold. I eat it anyway. * Resident B - Eats in her room. The food is sometimes cold, and she will not eat it if it's cold. * Family member AA - Feeds her family member and the food does not come very warm, the only thing hot is the soup. Review of resident council meeting minutes for September - December 2023 occurred on 01/16/24 and identified the following: * November 22, 2023 minutes stated, Food is sometimes cold by the time it is served to them. * December 27, 2023 minutes stated, Residents said the food is always cold when they receive it. During an interview on 01/16/23 at 10:20 a.m., a dietary manager (#3) reported staff take food temperatures in the main kitchen before taking food to kitchenettes for service, in the kitchenettes at beginning of service, in the middle of service, and at the end of the service. Review of temperature logs from November 1, 2023 to January 17, 2024 identified the following: * [NAME] Hills - 20 days with temperatures recorded below 135 degrees. * Pine Ridge - 2 days with temperatures recorded below 135 degrees. * Eagle Bend - 5 days with temperatures recorded below 135 degrees. Observation on 01/18/24 at 8:54 a.m. showed Resident #6 asked a staff nurse (#6) for a breakfast room tray. The nurse asked a dietary staff member (#7) to prepare a breakfast tray for the resident and to include French toast. Observation showed the breakfast foods on a rolling cart and not in the steam table. The dietary staff member (#7) placed two pieces of French toast on a plate, placed a cover over the plate, and handed the plate to the nurse (#6). The surveyor asked the dietary staff (#7) to obtain a temperature reading of the French toast. The thermometer read 126 degrees. Without reheating the French toast, the dietary staff member replaced the cover on the plate and handed it to the nurse (#6). The nurse then asked the dietary staff member what the temperature should be. The dietary staff (#7) member responded, Oh about 140 to 145 degrees. The nurse asked the dietary staff member to reheat the French toast. The dietary staff reheated the toast, the nurse asked for a temperature reading, and the temperature reading read under 140 degrees. The nurse again asked the dietary staff member to reheat the French toast with the last temperature reading 165 degrees. During an interview on 01/18/24 at 7:51 a.m., a dietary manager (#3) stated he expected staff to serve food at 135 degrees or above and monitor and maintain the food temperature for the entire service. During an interview on 01/18/24 at 10:47 a.m., a dietary manager (#3) confirmed dietary staff member (#7) failed to follow food safety requirements and stated if the French toast was not at the holding temp of 135 degrees, he would expect staff to reheat the French toast to 165 degrees before serving it to Resident #6.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 01/19/23 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 12 sampled residents (Resident #29 and #44) and one supplemental resident (Resident #12). 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 E: BEHAVIORS The Long-Term Care Facility RAI User's Manual, revised October 2023, page E-1, stated, Intent: The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Page E-4 stated, . E0200C: Behavioral Symptom-Presence & Frequency. Note presence of symptoms and their frequency. C. Other behavioral symptoms not directed towards others (e.g., verbal/vocal symptoms like screaming, disruptive sounds) . Review of Resident #44's medical record occurred on all days of survey. Review of nursing progress notes from 10/19/23 through 10/25/23 (the 7-day look back period) showed the following: * 10/20/23 at 2:43 p.m., . shouting out most of the morning. * 10/22/23 at 5:51 a.m., . screamed intermittently between 0100 [1:00 a.m.] and 0200 [2:00 a.m.] and then between 040430 [sic] to 0510 [5:10 a.m.]. * 10/24/23 at 11:14 a.m., . shouting out loud repeatedly since he has been in his w/c [wheelchair]. * 10/25/23 at 7:32 p.m., . Yelling on and off during the shift, upset several residents at supper . The quarterly Minimum Data Set (MDS), dated [DATE], showed staff failed to code section E200 for behaviors for Resident #44. During an interview on 01/18/24 11:46 a.m., an administrative staff member (#2) confirmed staff failed to code Resident #44's MDS correctly. SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised October 2023, page I-8, stated, . Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period . Check off each active disease. Check all that apply. If a disease or condition is not specifically listed, enter the diagnosis and International Classification of Diseases [ICD] code in item I8000, Additional active diagnosis. Review of Resident #29's medical record occurred on all days of survey. The record showed ZyPREXA [an antipsychotic medication] . for paranoia . ordered on 11/22/23. The quarterly MDS, dated [DATE], showed staff failed to code Resident #29's diagnosis of paranoia. During an interview on 01/18/24 11:46 a.m., an administrative staff member (#2) confirmed the facility failed to code paranoia as an active diagnosis on Resident #29's MDS. 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 . Coding Instructions: Code all high-risk medications according to their pharmacological classification, not how they are being used. N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g. clopidogrel) was taken by the resident at any time during the 7-day observation period . Review of Resident #12's medical record occurred on all days of survey. Physician's orders included clopidogrel, initiated on 01/31/23. The annual MDS, dated [DATE], showed staff failed to code Resident #12's use of an antiplatelet medication. During an interview on 01/18/24 at 10:58 a.m., an administrative staff member (#2) confirmed the facility failed to code clopidogrel on the MDS. 40488

Based on record review, review of the North Dakota Provider Manual Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 2 sampled residents (Resident #29) reviewed for PASARR. Failure to complete a change in status assessment with a newly diagnosed mental illness may result in the delivery of care and services inconsistent with the resident's needs. Findings include: The North Dakota PASARR Provider Manual, revised 12/29/20, page 13 states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Maximus to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability [referred to in regulatory language as related conditions or RC]) was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #29's medical record occurred on all days of survey and identified a Level I PASARR completed on 03/03/23. The record showed Resident #29 received a new diagnosis of paranoia on 11/22/23. The record lacked evidence the facility completed a change in status assessment with the new diagnosis. During an interview on 01/18/24 at 9:39 a.m., an administrative staff member (#2) confirmed the facility failed to submit another PASARR for Resident #29 following the new diagnosis.

Based on observation, record review, review of manufacturer's instructions, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 1 of 4 sampled residents (Resident #9) observed during a transfer utilizing a sit-to-stand mechanical lift transfer. Failure to ensure proper use of a stand lift during transfers placed the resident at risk for accidents and injury. Findings include: Review of the facility policy titled Safe Resident Handling, dated January 2023, stated, . enables caregivers to safely support residents who require partial or total assistance to ambulate, transfer and reposition . mobility equipment . refers to sit to stand lifts . slings a resident uses with mobility tasks . caregivers with perform am TIME OUT safety stop while the resident is in a sling or harness and still over the surface . to ensure all straps are secure before moving away from the surface . this is to be completed once the straps are taut, but before the resident leaves the surface . Review of Resident #9's medical record occurred on all days of survey. The current care plan stated to transfer . EZ stand lift with two assist and seat sling . Observation on 01/16/24 at 1:27 p.m. showed two certified nurse aides (CNAs) (#8 and #11) attached the harness, the shin strap of the sit-to-stand mechanical lift, the resident yelled, ouch, and, it hurts, and grimaced as the CNAs raised the lift. The harness straps pulled upward into Resident #9's armpits, her shoulders raised to her ear level and her elbows extended horizontally. The CNAs failed to apply the seat sling before they transferring Resident #9 from the wheelchair to the toilet. The CNA (#9) noticed the harness loosely positioned on the resident, and tightened the strap while the resident sat on the toilet. As the resident hung with the harness under her armpits, she stated, ouch and grimaced while the CNAs transferred her across the room to her recliner chair. One of the CNAs (#11) asked Resident #9 if she felt better after being lowered into her recliner, and Resident #9 responded Yes. During an interview on 01/16/24 at 4:40 p.m., an administrative nurse (#1) stated the CNAs are expected to provide safe transfers.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's medication regimen remained free of unnecessary medications for 1 of 3 sampled residents (Resident #44) reviewed for antipsychotic medications. Failure to consistently monitor residents while on the medication may result in the residents experiencing adverse consequences related to the antipsychotic medication. Findings include: Review of the facility policy titled Tardive Dyskinesia occurred on 01/18/24. This policy, reviewed 02/07/23, stated, . Tardive Dyskinesia (TD) is an involuntary movement disorder that may appear after use of neuroleptic medications [antipsychotics]. Upon initiation of antipsychotic medication therapy, a baseline assessment shall be completed . Positive screenings will be . considered in the continuation of drug therapy . The User-Defined Assessment (UDA) utilized by the facility for Abnormal Involuntary Movement Scale (AIMS) assessments, stated, . Abnormal Involuntary Movement Scale . Required at least every six months when resident is receiving an antipsychotic medication. Review of Resident #44's medical record occurred on all days of survey. Physician's orders included Risperdal (an antipsychotic) initiated on 07/29/22. The record identified the facility completed an AIMS on 04/24/23. During an interview on 01/18/24 at 11:46 a.m., an administrative staff member (#1) stated the facility completes AIMS assessments when an antipsychotic medication is started and every six months thereafter and confirmed the facility failed to complete an AIMS assessment for Resident #44 six months after April 2023.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure appropriate labeling of medications for 1 of 6 residents (Resident #45) observed during medication administration. Failure to ensure medication cards contain the correct administration information may result in medication errors and adverse drug effects. Findings include: Review of the facility policy titled Medications: Acquisition Receiving Dispensing and Storage occurred on 01/18/24. This policy, revised 02/02/23, stated, . Licensed nursing employees are responsible for ordering from pharmacy . and checking all new orders of medications from the physician's orders . The medication orders/changes are communicated to the pharmacy. All medications . are packaged in accordance with . state pharmacy rules. Observation on 01/17/24 at 9:46 a.m. showed a nurse (#5) administered Resident #45's medications. The pharmacy labels on the cards identified Lorazepam 0.5 mg [milligrams] 1 tablet BID [two times a day] and every 6 hours PRN [as needed] and Oxycodone 5 mg 1 tablet BID and every 6 hours PRN. Review of Resident #45's medical record identified the physician discontinued the PRN orders for Lorazepam and Oxycodone on 11/06/23. During an interview on 01/17/24 at 2:30 p.m., an administrative nurse (#1) confirmed she expected staff to communicate order changes to pharmacy and a new label to be affixed by pharmacy.

Based on observation, review of facility policy, and staff interview, the facility failed to maintain sanitary food service in 1 of 3 kitchenettes (Eagle Bend). Failure to ensure safe transportation of foods to resident rooms and ensure utilization of sanitary food service equipment has the potential to result in contamination of food and spread illness to resident, staff, and visitors. Findings Include: Review of the facility policy titled Safe Meal Service occurred on 01/18/24. This policy, reviewed 01/11/23, stated, . Meals served in resident's rooms . need to be covered during transportation. Upon completion of the meal by the resident in their room, nursing will document the necessary detail of food consumption before placing the used tray into the enclosed 'dirty' cart in the kitchenette. The Nutrition and Food Services employees will retrieve the tray to bring back to the dish room for processing. Observation on 01/18/24 at 8:47 a.m. showed a certified nurse aide (CNA) (#9) transported a meal tray to Resident #8's room. The tray contained three uncovered cups of liquids. The CNA arrived outside the resident's room, placed the tray on the hallway floor, donned the necessary personal protective equipment (PPE), and carried items from the food tray into the resident's room. The CNA (#9) then doffed the PPE, removed the serving tray from the hallway floor, and placed the tray in the middle of a stack of clean serving trays to be used to serve additional residents' meals. During interviews on 01/18/24 at 10:11 a.m. and 10:47 a.m., administrative staff members (#3 and #9) agreed staff should not place room trays containing food items on the floor, cover items delivered to residents, and place the dirty meal tray onto the dirty cart.

Based on observation, review of facility policy, record review, and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment for 1 of 1 sampled resident (Resident #46) with a personal fan. Failure to clean personal fans does not provide a comfortable/homelike environment and has the potential to place the resident at risk for injury or illness. Findings include: Review of the facility policy titled Cleaning of the Resident Personal Fans occurred on 01/19/23. This policy, dated 01/01/17, stated, PURPOSE: Process for ensuring residents personal fans are kept clean . PROCEDURE: 1. Family is to make facility aware . 2. Maintenance is to ensure the fan is in good working condition . Observation on 01/17/23 at 11:50 a.m., showed Resident #46 seated in the recliner chair with oxygen administered by nasal cannula. A small fan located on the overbed table blew air directly toward the resident. The outside fan cover/grate and fan blade contained visible dust. After an unidentified staff member transferred Resident #46 to the bed, the staff member placed the small fan on the overbed table next to the bed, the fan blew air directly toward the resident. Review of Resident #46's medical record occurred on all days of the survey. Diagnoses included acute and chronic respiratory failure with hypoxia, pneumonia, and chronic obstructive pulmonary disease. Resident #46's current care plan stated, . Resident currently utilizing oxygen continuously due to acute/chronic respiratory failure. During an interview on 01/19/23 at 11:00 a.m., an administrative staff member #1 stated his/her expectation is all staff should clean dirty equipment in resident's rooms.

Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 14 sampled residents (Resident #26 and #28) and one supplemental resident (Resident #7). 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 2019, page N-6 and N7 stated, . Coding Instructions N0410A-H: Code medications according to the pharmacological classification, not how they are being used. N0410E, Anticoagulant [blood thinner] . 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, dipyridamole, or clopidogrel here. - Review of Resident #26's medical record occurred on all days of survey. A medication order, dated 04/21/21, stated, Clopidogrel Bisulfate [Plavix, a platelet aggregation inhibitor] Tablet 75 mg [milligrams] by mouth one time a day for acute CVA [cerebral vascular accident] The quarterly MDS, dated [DATE], identified an anticoagulant medication coded for seven days. The record failed to show an order for an anticoagulant. 28398 - Review of Resident #7's medical record occurred on January 17-18, 2023. A medication order, dated 01/14/21, stated, Clopidogrel Bisulfate Tablet 75 MG, Give 75 mg by mouth in the morning related to atherosclerosis [narrowing of arteries caused by buildup of plaque] . The quarterly MDS, dated [DATE], identified an anticoagulant coded for seven days. The record failed to show an order for an anticoagulant. 46477 - Review of Resident #28's medical record occurred on January 17-18, 2023. A medication order, dated 01/08/20, stated, Clopidogrel Bisulfate Tablet 75 MG, Give 75 mg by mouth one time a day for CVA. Resident #28's quarterly MDS, dated [DATE], identified an anticoagulant coded for seven days. The record failed to show an order for an anticoagulant. During an interview on 01/19/23 at 9:52 a.m., an administrative nurse (#2) confirmed she coded the MDSs incorrectly for the medication. SECTION P: RESTRAINTS AND ALARMS The Long-Term Care Facility RAI User's Manual, revised October 2019, page P-9 stated, P0200: Alarms . Coding instructions: Identify all alarms that were used at any time (day or night) 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. Coding Tips, Bed alarm includes devices such as a sensor pad placed on the bed or a device that clips to the resident's clothing. Chair alarm includes devices such as a sensor pad placed on the chair or wheelchair or a device that clips to the resident's clothing. Observation on 01/17/23 at 1:00 p.m. showed Resident #26 used both a bed and a chair alarm. Review of Resident #26's medical record occurred on all days of survey. A progress note dated 10/05/22 at 11:20 a.m. stated, . bed alarm on and working properly. Facility staff completed a Physical Device and Restraint Assessment on 10/10/22 which identified the devices of silent alarm to bed and chair. The care plan identified the intervention Monitor [resident's name] every 30 minutes for fall, prevention, silent alarm to bed and chair dated 10/10/22. Review of the quarterly MDS, dated [DATE], identified the facility coded sections P0200 A. Bed Alarm and B. Chair alarm, as 0 not used. During interviews on the morning of 01/19/23, the administrative staff (#1 and #2) confirmed the staff failed to code Resident #26's MDS for a bed and chair alarm.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 1 resident (Resident #23) observed during administration of short acting insulin. Failure to administer rapid-acting insulin within five to ten minutes of a meal may result in a hypoglycemic (low blood sugar) reaction. Findings include: Review of the facility policy titled MEDICATION ADMINISTRATION occurred on 01/18/23. This policy, dated April 2022, stated, PURPOSE: . To provide safe administration of medication to residents by a nurse or CMA [certified medication aide] . PROCEDURES: 1. Follow the '6 rights' in medication administration at all times. a. Right resident b. Right medication . e. Right time . Review of the facility guideline regarding Humalog insulin by the Therapeutic Research Center, dated September 2021, stated, . Humalog is rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus . usual frequency . Inject subcutaneously within five to ten minutes before a meal . Review of Resident #23's medical record occurred on all days of survey. Diagnoses included diabetes mellitus. Observation on 01/17/23 at 11:10 a.m., showed a nurse (#6) administered five units of Humalog insulin to Resident #23 per physician's orders. The nurse left the room and failed to offer any drink or food. At 11:28 a.m., an unidentified staff member brought the resident to the dining room. Resident #23 received the meal tray at 11:43 a.m., 33 minutes after receiving Humalog Insulin. During an interview on 01/19/23 at 10:00 a.m., an administrative staff member (#5) confirmed rapid-acting insulin should be injected within five to ten minutes before a meal.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate assistance for 1 of 4 sampled residents (Resident #42) who required assistance for repositioning. Failure to ensure the correct technique in repositioning puts the resident at risk for pain and/or injury. Findings include: Observation on 01/17/23 at 12:54 p.m., showed two certified nurse aides (CNAs) (#3 and #4) assisted Resident #42 with repositioning in a recliner. The CNAs reached under the resident arms, grabbed the back of his pants, and lifted the resident further back into the recliner. Review of the facility policy/procedure titled Gait-Transfer Belt - LTC [Long Term Care] occurred on 01/19/22. This policy, dated 05/03/22, stated,. Do not use the pants/slacks belt as a gait (transfer) belt. Upward movement of the belt can cause male residents severe pain. During an interview on 01/19/23 at 9:22 a.m., administrative staff (#1 and #5) stated they expect staff not to lift under the arms and use the back of the pants to lift/reposition a resident.

Based on observation, review of facility policy, and staff interview, the facility failed to accurately label multi-dose insulin pens for 1 of 1 resident (Resident #23). Failure to label multi-dose insulin pens with the date opened increases the risk of residents receiving outdated medications with reduced medication efficacy. Findings include: Review of the facility policy titled Medication Administration, Insulin Administration occurred on 01/18/23. This policy dated August 2022, stated, . For medication designed for multiple administrations (e.g., insulin), the employee opening the mediation writes the open date on the label to promote correct administration . check label on vial carefully to ensure correct date vial was opened . Observations on 01/17/23 of insulin pens showed the following: * 11:10 a.m., a staff nurse (#6) administered Humalog insulin to Resident #23. The insulin pen failed to contain an open date. During the observation, the nurse (#6) confirmed the pen lacked an open date and stated the insulin pen should be dated. * 11:12 a.m., showed Resident #23's Lantus Insulin pen, located in the mediation cart, lacked a date when opened. During an interview on 01/19/23 at 10:00 a.m., an administrative nurse (#5) confirmed staff failed to date the insulin pens when opened.

Based on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 1 of 4 ice machines (main kitchen) observed. Failure to provide the required air gap for the ice machine has the potential to allow contamination of these machines in the event of a sewer back up. Findings include: Review of the 2018 North Dakota Plumbing Code, Section 801.2 Air Gap or Air Break Required, stated, Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. Where a drainage air gap is required by this code, the minimum vertical distance as measured from the lowest point of the indirect waste pipe or the fixture outlet to the flood-level rim of the receptor shall be not less than 1 inch (25.4 mm). Section 801.3.3 Food-Handling Fixtures, stated, Food-preparation sinks, steam kettles, potato peelers, ice cream dipper wells, and similar equipment shall be indirectly connected to the drainage system by means of an air gap. Bins, sinks, and other equipment having drainage connections and used for the storage of unpackaged ice used for human ingestion, or used in direct contact with ready-to-eat food, shall be indirectly connected to the drainage system by means of an air gap. Each indirect waste pipe from food-handling fixtures or equipment shall be separately piped to the indirect waste receptor and shall not combine with other indirect waste pipes. The piping from the equipment to the receptor shall be not less than the drain on the unit and in no case less than 1/2 of an inch (15 mm). Observations on 01/17/23 at 10:45 a.m. and on 01/19/23 at 9:40 a.m. showed the following in the main kitchen: * The end of the ice machine drainpipes laying directly on the grate of the floor drain. During an interview on 01/19/22 at 10:45 a.m., an administrative staff member (#1) confirmed the ice machine failed to have an air gap.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY CONDUCTED ON [DATE] Based on observation, review of facility policy, and staff interview, the facility failed to ensure food was stored and labeled correctly in 2 of 2 food storage cooler units (main kitchen walk in refrigerator and freezer). Failure to label food to identify the expiration date and discard expired food has the potential to result in foodborne illness to residents, staff, and visitors and decrease food quality. Findings include: Review of the facility's policy titled Date Marking occurred on [DATE]. This policy, revised [DATE], stated, To provide guidelines for proper date-marking to ensure that food is handled and stored safely . When TCS [time/temperature control for safety food] is received, employees . Observe for vendor's date of delivery and if not available, date-mark the item with the delivery date . Observe for USE by date or USE or Freeze by date. This is an expiration date . food items should remain in their original container/packaging . If the items are removed from the original container/package, individual items are labeled and dated with date of receiving . as much as possible, store food items in the original container to retain manufacturer date guidance . Ensure that if the product is frozen and thawed before service, the total time in the thawed state does not exceed seven days . A food item is discarded when . the container or package does not bear a date or day . The TCS item is beyond the USE by date . A dietary tour occurred on [DATE] at 3:03 p.m. with the dietitian (#4) and the dietary manager (#3). Observation of the food storage walk in freezer in the main kitchen showed the following items out of the original container/package, and not labeled with the contents, date received, or a discard date: * One bag of chicken strips * Three large bags of cookies * One large bag of broccoli * One bag of donut holes Observation of the food storage walk in refrigerator in the main kitchen showed the following items were stored beyond their use by/expiration dates: * Two large containers of sour cream, use by date of [DATE] * One defrosted ham dated ,d+[DATE], eleven days since pulled from freezer. During an interview at the time of the tour, the dietary manager (#3) verified staff failed to label food items with a received and/or discard date and discard expired food. The facility failed to follow their policies related to date-marking for food safety/quality and discard TCS items by the use by date.

Based on information provided by the complainant, record review, review of professional reference, review of facility policy, and staff interview, the facility failed to follow professional standards for medication administration for 1 of 1 sampled resident (Resident #6) who required hospitalization as a result of a significant medication error. Failure of staff to administer medications using safe administration practices resulted in a significant medication error which required Resident #6 to be hospitalized . Findings include: Berman, Snyder, Kozier, and Erb, Fundamentals of Nursing Concepts, Process, and Practice, 10th Edition, Copyright 2016 by Pearson Education, Inc., New Jersey, page 769-771, stated, . Before administering a medication, identify the client correctly using the appropriate means of identification . Errors can and do occur, usually because one client gets a drug intended for another. The Joint Commission's National Patient Safety . goal requires a nurse to use at least two client identifiers whenever administering medications. Neither identifier can be the client's room number or physical location. Acceptable identifiers may be the person's name, assigned identification number, telephone number, photograph, or other person-specific identifier. Review of the facility policy titled Medication Administration, Including Scheduling and Medication Aides occurred on 07/06/17. This policy, revised May 2016, stated, . Pre-setting medications is not an acceptable practice. Medications will be administered to the resident according to the Six Rights.Perform three checks: . when placing the medication in an administration cup/syringe and just before administering the medication. Information provided to the State agency indicated facility staff failed to ensure Resident #6 received only her medications per physician order. Review of Resident #6's medical record occurred on the day of survey. The medical [DIAGNOSES REDACTED]. The Progress Notes for May 2017 identified the following: * 05/24/17 at 6:01 a.m., Resident very sleepy during the shift. No urine output noted in bag. * 05/24/17 at 9:15 a.m., Resident is very lethargic today and not herself. No urine output on the night shift, and scant amount in the bag this morning. She states she is dizzy and had a small emesis . Answers questions . although delayed. Notified Nurse Manager . notified (nurse practitioner) of situation. She gave orders to send resident in via ambulance to ER (emergency room ). The nurse practitioner's progress notes, dated 05/2417 at 8:00 a.m., identified the following: * Encounter Reason/Date: Unresponsive, nausea/vomiting, no urine output . * Resident seen and evaluated today per nursing home request as nursing staff report that the resident has had an acute change in mental status. increased weakness. sent to . emergency room for further evaluation due to the resident's acute change in status. * Mental status: lethargic and confused, Speech: trouble comprehending. The medication error investigation report, dated 05/24/17, identified, . Resident #6 on 5:23 (05/23/17) @ (at) 9:00 p.m. received the following medications that were intended for a male resident: [MEDICATION NAME] (antianxiety) . [MEDICATION NAME] (anitpsychotic) . [MEDICATION NAME] (antidepressant) . [MEDICATION NAME] (opidoid) . Senna-S (stool softener) . [MEDICATION NAME] (muscle relaxer) . and [MEDICATION NAME] (anticonvulsant) . The Resident #6 was subsequently admitted to ICU (Intensive Care Unit) as a result of the medication error related to receiving multiple opioids and an antipsychotic medication. Failure of staff to administer medications using safe administration practices resulted in Resident #6 requiring hospitalization . During an interview on 07/06/17 at 4:40 p.m., an administrative staff (#2) verified the facility staff nurse (#3) preset the evening medications on 05/23/17 for two residents, grabbed the medications intended for the male resident and administered them to Resident #6. The staff nurse (#3) failed to follow the facility policy/procedure for medication administration. Based on the following information non-compliance at F333 is considered past non-compliance. The facility addressed the corrective action accomplished for those residents affected by the deficient practice by: * Risk Management completed a thorough investigation. * Administrative staff (#2) interviewed the staff nurse (#3), notified the hospital staff of the medication error and provided a list of the medications administered to Resident #6. * The facility suspended and relieved the staff nurse (#3) from her duties until the investigation was completed. The facility addressed identification of all residents having the potential to be affected by the deficient practice by: * Administrative staff (#2) placed a medication administration policy and procedure at all three neighborhoods with instructions for nurses to read and sign the instruction sheet after finishing their review. * Administrative staff (#2) required the staff nurse (#3) to complete additional training as a condition of her future employment: Six floor shifts observed/shadowed by a staff registered nurse during medication administration, learning center course Medication Administrator: Avoiding Common Errors, and review of the medication administration policy. * Direct observation/audits of medication administration using the medication administration clinical skill checklist with the nursing staff. * A nursing staff meeting held on Thursday June 1, 2017 to review the Medication Administration policy and procedure, possible changes to be made, and the importance of right medications to the right resident. * Administrative staff (#2) reported the incident to the North Dakota Board of Nursing and the Department of Health. The facility plans to address how the facility will monitor its performance to ensure solutions are permanent by: * Continuous and ongoing direct random observation/audits of medication administration using the medication administration clinical skill checklist with the nursing staff.

ELOPEMENT 1. Based on record review, and review of facility policy, the facility failed to ensure the safety of 1 of 1 sampled resident (Resident #11) and 1 of 1 discharged resident (Resident #13) who wandered and exited the facility while wearing a wander alert bracelet. Failure to provide adequate supervision, evaluate the effectiveness of the resident's wanderguards, and provide a functioning Roam Alert system over a period of 55 days, resulted in Resident #11's elopement from the facility on three separate occasions and Resident #13's elopement from the facility on seven separate occasions over a four month period, fell during one of the elopements, and sustained abrasions. Findings include: Review of the facility policy titled "ELOPEMENT" occurred on 11/06/14. This policy, revised September 2013, stated, "PURPOSE: . . . *To provide a system of documentation for the prevention of, and in the event of, elopement. *To minimize risk for elopement through individualized interventions . . . PROCEDURE: . . . 5. Exit door alarms are to be checked weekly to determine if they are in working order. 6. Wander alert bracelets are to be checked daily by rehab (rehabilitation) or nursing to determine if they are in working order. . . ." Review of the "Roam Alert service history," (the facility's wanderguard system) provided by an administrative nurse (#1), occurred on 11/05/14. The history notes showed the facility's director of environmental services (#3) identified a problem with the Roam Alert system on 08/19/14. The final history note, dated 10/13/14 (55 days after the first notification), stated, "Added the additional antennas then adjusted and tested to confirm operation and we believe that all is working correct at this time." - Review of Resident #13's medical record occurred on November 05-06, 2014. [DIAGNOSES REDACTED]. . . Check wanderguard placement q shift (wanderguard initiated on 10/02/13) . . ." Resident #13's care plan stated, "Focus: The resident has a behavior symptom R/T (related to) dementia E/B (evidenced by) wandering and at times exit seeking . . . Interventions: *Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. . . . *BEHAVIOR #1 wandering: offer cup of coffee with sugar. *BEHAVIOR #2 wandering: offer snack." The care plan failed to identify the placement of a wander alert bracelet on Resident #13. Review of Resident #13's progress notes identified the following: *04/04/14 at 6:00 p.m. - "Out side door alarms sounding. Noted by staff res. (resident) going outside. No problem with redirecting res and bringing back into building and back to unit." *04/04/14 at 8:55 p.m. - "Resident was found outside of the building between 3 and 4AM on the morning of April 4, 2014. Resident went out the door facing the east parking lot. Resident was out for a short time as the alarm sounded and a staff member from another household brought the resident indoors and back to his household. Resident was safe upon returning indoors. *05/11/14 at 8:30 a.m. - "resident found outside facility walking to parking lot. resident wanderguard inplace (sic) and when tested machine states test 'ok'. resident encouraged and assisted to come back into facility. . . ." *05/13/14 at 1:19 p.m. - "Staff was alerted by door alarm and found (Resident #13) had left facility at South door. He was walking on sidewalk and had a fleece blanket on his FWW (front-wheeled walker) . . . no further attempts to leave household so far today." *07/10/14 at 7:30 a.m. - "aid sees resident outside walking with walker. aid assists resident back into facility. resident does have wanderguard on and test states wanderguard is working. no alarm sounds when resident walked out of facility . . . " *07/15/14 at 7:30 a.m. - "resident found outside facility with fww walking down sidewalk . . . wanderguard in place on resident . . ." *08/11/14 at 9:30 a.m. - "resident wanders outside of facility, resident assisted back into facility and back to unit. resident wander guard test indicates it is working properly. wander guard alarm did not set off . . ." *08/17/14 at 1:45 p.m. - "passerby (name of two people) reported they found resident approximately 3 blocks from facility on ground. resident was alert and was assisted into passerbys personal vehicle. 911 was called by passerby. facility staff notified and went to scene. resident identified as (Resident #13) by GSS (Good Samaritan Society) staff and brought back to facility by passerbys. resident assisted back into facility by GSS staff . . . physical assessment completed . . . minimal bruising to bilateral knees noted. small 1/4 to 1/2 cm (centimeter) skin tear noted to area between right index finger and thumb . . . " *08/17/14 at 3:53 p.m. - "wanderguard applied to residents walker." *08/21/14 - "Discharge resident from Good Samaritan Society . . ." The facility discharged the resident to a locked memory care facility. The facility failed to provide adequate supervision and evaluate the effectiveness of the wanderguard and the functioning of the the Roam Alert system in place until Resident #13 eloped from the facility on 08/17/14. - Review of Resident #11's medical record occurred on 11/06/14. [DIAGNOSES REDACTED]. The resident's care plan stated, "Focus: The resident has potential for elopement R/T Dementia and Cognitive impairment, E/B Exhibits wandering behavior, Exit seeking behavior, History of elopement, History of elopement attempts . . . Interventions: *Provide diversionary activity holding and 'taking care of' the baby doll . . . *PERSONAL ALARM: Wander Guard, bed alarm . . . to alert staff to resident's movement and to assist staff in monitoring movement." Review of Resident #11's progress notes identified the following: *08/31/14 at 3:40 p.m. - "Staff noted Res. wheeling self outside on sidewalk. stated 'I am going home' Brouhgt (sic) back to unit without any problem." *08/31/14 at 11:20 p.m. - Res. noted to be wheeling self in wheelchair outside of building. Stated 'I am going home' Brought back into facility without any problem." *09/06/14 at 9:43 p.m. - (Resident #11) was found in the facility parking lot after another resident tol (sic) a universal worker that she was outside. Her wandergard (sic) had not sounded. She was brought back inside . . . She was also instructed not to go outside by herself." Resident #11's elopements from the facility occurred after Resident #13's elopement on 08/17/14 and after the facility realized a problem existed with the Roam Alert system. The facility failed to provide adequate supervision and effective interventions to prevent Resident #11 from eloping from the facility during the time the Roam Alert system was not functioning correctly. FALLS 2. Based on record review and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #5) who required a chair alarm. Failure to use the chair alarm may have resulted in an avoidable fall. Findings include: Review of Resident #5's medical record occurred on 11/06/14. [DIAGNOSES REDACTED]. . . The resident has limited physical mobility R/T (related to) dementia . . . AMBULATION: Resident requires weight bearing support to ambulate: gait belt, 4WW (four wheeled walker) and assist of 1 . . . The resident is at risk for falls R/T dementia, osteoporosis E/B (evidenced by) weakness, limited mobility . . . Bed alarm used to alert staff to resident's movement and to assist staff in monitoring movement. . . . " During an interview on 11/06/14 at 11:15 a.m., an administrative nurse (#1) stated a chair alarm was initiated on 04/24/14. The care plan failed to identify a chair alarm as a current intervention to prevent falls. Review of Resident #5's fall incident report, dated 10/29/14, stated, " . . . Resident ambulating independently with FWW (front wheeled walker) from dining room in attempt to go to room, resident not ambulating properly (legs were not moving right) et (and) resident fell to ground, hitting back of head when she landed. . . . Chair alarm needs to be present on chair that she sits at in dining room so nursing staff is aware when she is up without asst (assistance). . . . " During an interview on 11/06/14 at 11:35 a.m., an administrative nurse (#1) confirmed the chair alarm should have been in place.

Based on observation, record review, review of professional literature, resident interview, and staff interview, the facility failed to provide the necessary care and services for 1 of 1 sampled resident (Resident #5) with nonsurgical treatment of [REDACTED]. Failure to assist Resident #5 to move, position, turn, and transfer in a safe, controlled manner resulted in the resident experiencing unnecessary pain, placed the resident at risk of displacement of his [MEDICAL CONDITION], and placed the resident at risk of skin breakdown. Findings include: Dugan, "Successful Nursing Assistant Care," 2nd edition, Hartman Publishing, Albuquerque, pages 176-178, "Turning a resident away from you" and "Turning a resident toward you," and stated ". . . 6. Lower the head of the bed. . . . 9. Avoid trauma or pain to the resident throughout the procedure. 10. Move the resident to side of bed nearest you. . . . 15. Position resident properly in good alignment: . . . supportive device between legs . . .; and pages 179-180, "Assisting a resident to sit up on side of bed," stated ". . . 6. Avoid trauma or pain to the resident throughout the procedure. . . . 8. . . . Help resident slowly move toward the side of the bed on which you are standing. 9. Place one arm under resident's shoulder blades. Place the other arm under resident's thighs. 10. On the count of three, gently and slowly turn resident into sitting position with legs dangling over the side of bed. . . ." Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice," 9th edition, Pearson Education, Inc. New Jersey, pages 1160-1162, stated, ". . . Transferring between bed and chair . . . 4. . . . Place the wheelchair parallel to the bed and as close to the bed as possible. Put the wheelchair on the side of the bed that allows the client to move toward his or her stronger side. . . . For clients who have difficulty walking, place the wheelchair at a 45 degree angle to the bed. . . . When the client has an injured lower extremity, movement should always occur toward the client's unaffected (strong) side. . . ." During the initial tour of the facility, on 03/04/13 at 3:20 p.m., a supervisory nursing staff member (#7) reported Resident #5 experienced a fall in the facility approximately ten days earlier when he attempted to self transfer from the bed to the wheelchair. This staff member reported initial x-rays failed to reveal a fracture, however repeat x-rays the previous week did reveal a right [MEDICAL CONDITION]. The staff member (#7) further reported the family had decided against surgical repair. Review of Resident #5's medical record occurred on March 05-07, 2013. The facility admitted the resident in November 2012. Current [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified no short or long term memory problems, modified independence in daily decision making, the resident required limited assistance of one person to walk in his room with a walker, and received no scheduled or prn (as needed) pain medications during the assessment period. Resident #5's radiology report, dated 02/16/13, stated ". . . no evidence for an acute fracture or dislocation involving the hips or pelvis. . . ." A clinic radiology report, dated 02/22/13, stated ". . . Conclusion: Mildly impacted subcapital (below the head of the femur) [MEDICAL CONDITION] hip. . . ." The physician orders [REDACTED]." The medical record lacked physician orders [REDACTED]. Resident #5's medications included [MEDICATION NAME]/[MEDICATION NAME] 5/325 milligrams every four hours prn for pain. Resident #5's Pressure Ulcer Care Area Assessment (CAA), dated 11/15/12, stated ". . . requires assistance of staff for all ADL's (activities of daily living) . . . monitor skin for breakdown during cares . . ." Resident #5's current care plan, dated 02/12/2013, stated "Problems, Alteration in self cares r/t (related to) dementia . . . weakness m/b (manifested by) inability to independently groom, dress, bathe . . . (modified) 02/23/13 R (right) hip fx (fracture) . . . Approaches . . . Assist of 1 . . . Problems, Potential for alteration in skin integrity r/t recent hospitalization . . . m/b bruises, fragile skin. (modified) 02/23/13 R (right) hip fx (fracture) . . . Approaches . . . Observe skin daily with care/bath for residents at risk. . . . (modified) 02/23/13 Reposition every 2-3 hours & (and) prn. . . . Problems, Alteration in mobility r/t dementia, weakness, m/b inability to independently move in bed, transfer, ambulate, fall risk. (modified) 02/23/2013 (R) hip fx . . . Approaches . . . Transfers: Assist of 2 (modified) 02/23/13 with FWW (front wheeled walker) and gait belt . . . Bed mobility: Assist of 1 to turn side to side, assist of 2 to move up in bed, assist of 2 to move legs in/out of bed . . . Problems, Alteration in comfort r/t . . . verbal complaints of pain . . . Approaches . . . Non-medication approaches: Repositioning . . . (undated modification) Tol. (Tolerable) pain identified by resident 'Level 3' . . ." Resident #5's physical therapy plan of care, dated 02/20/13 (prior to identification of the [MEDICAL CONDITION]), stated ". . . Assessment: Since there is no fx (fracture), Pt. (patient) sufferred (sic) a deep bruise to the R (right) hip area. Treatment to the area should help decrease his pain . . . Short Term Goal(s) . . . strength of 3+/5 (0-no strength, 5-normal strength) due to pain impacting his ability to transfer, stand and walk . . . R hip pain rated at 6 out of 10 (0-no pain, 10-worst pain) impacting need for mod A (moderate assistance) to transfer . . ." The facility failed to reassess Resident #5 after the identification of the [MEDICAL CONDITION]. Observations of facility staff providing care and transfers for Resident #5 identified the following: *03/05/13, 9:05 a.m. - The resident supine in bed with a pillow under his right leg and head of bed elevated approximately 30 degrees. Two certified nursing assistants (CNAs) (#13) and (#14) assisted the resident with morning cares. The CNAs removed the pillow from under the resident's right leg during which time Resident #5 complained of pain (with the movement). After the completion of frontal pericares, the CNAs lowered the head of the bed and turned the resident approximately 30 degrees onto the fractured right hip, remove a brief and provided peril care. During the turning, the resident complained of pain. The CNAs placed a clean brief under the resident, returned him to his back, and partially turned him to his left side to position the brief. While turning Resident #5 to each side the CNAs failed to support the fractured right leg, either manually or with pillows. While performing perineal cares and turning the resident from side to side, the CNAs were unable to observe or provide thorough skin cares to the buttocks or back. After completion of the perineal cares, the CNAs dressed the resident. The CNA (#13) grasped Resident #5's right leg at the ankle and lifted the right leg to apply a slipper at which time Resident #5 complained of pain. The CNAs elevated the head of the bed to approximately 75 degrees and grasped the resident's lower legs to move them to the edge of the bed. The resident again complained of pain. After assisting the resident to sit on the edge of the bed, the CNAs positioned a wheelchair parallel (180 degrees) to the bed, grasped the gait belt, and assisted the resident to a standing position, allowing the resident to bear weight on the right leg. Resident #5 complained of pain, and the CNAs responded by returning the resident to a sitting position on the bed. The CNAs acknowledged Resident #5's pain, told the resident he needed to be out of bed, and asked him if he would try to stand again. Resident #5 agreed to try again. When questioned by the surveyor if the resident should be weight bearing, the CNA (#13) reported she was not sure. The CNAs repeated the process, the resident bore weight on the right leg, turned 180 degrees to the fractured right side, and transferred from the bed to the wheelchair. Resident #5 continued to express pain during the transfer. After being seated in the wheelchair, one of the CNAs grasped Resident #5's right ankle, failed to support the fractured right leg, and placed the right leg on the wheelchair leg rest. Resident #5 expressed pain again in his right leg. Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. *03/05/13, 12:05 p.m. - Resident #5 supine in bed with his right leg supported on a pillow and his wife in the room. CNAs (#13) and (#14) removed the pillow from under his right leg, raised the head of the bed 75 degrees, and applied a gait belt around the resident's waist. The CNAs grasped the resident's lower legs, moved his legs to the edge of the bed, and the resident sat at the edge of the bed with his feet dangling. The CNAs lowered the bed so the resident's feet touched the floor and positioned a wheelchair 180 degrees opposite the bed. The CNAs grasped the gait belt and assisted the resident to a standing position. Bearing weight on his fractured right leg, Resident #5 turned 180 degrees to the fractured right side, and transferred from the bed to the wheelchair. After the resident was seated in the wheelchair, the CNAs positioned the resident's lower extremities on the wheelchair leg rests. During this observation, Resident #5 grimaced and tensed as if in pain. *03/06/13, 9:15 a.m. - Resident #5 supine in bed with a pillow under his right leg. CNAs (#13) and (#15) removed the pillow from under his leg and the resident moaned in pain. The CNAs provided perineal care, requiring them to turn the resident approximately 30 degrees onto his right side on the right [MEDICAL CONDITION], and roll him from side to side to remove a brief, and perform the pericare. While turning, the resident cried out in pain. While turning Resident #5 to each side, the CNAs failed to support the fractured right leg, either manually or with pillows. The CNAs asked the resident if he wished to get up into the wheelchair and the resident declined. The CNAs asked the resident to position on his side and the resident declined. The CNAs placed a pillow under the resident's right leg and used a lift pad to move him up in the bed. Resident #5 attempted to assist the CNAs with the positioning bars on both sides of the head of the bed, without success. Throughout these observations of cares the CNAs (#13), (#14), and (#15)expressed their concern for Resident #5's pain. The CNAs failed to support the [MEDICAL CONDITION] and leg during turning and moving in bed; failed to support the [MEDICAL CONDITION] and leg with pillows during turning; turned Resident #5 onto the fractured right hip during cares; failed to support the fractured right leg and hip adequately to turn to Resident #5's uninjured left side to provide perineal and skin care to the buttocks; and failed to properly position the wheelchair and transfer Resident #5 to the uninjured left side. During interview, on 03/05/2013 at 2:50 p.m. and on 03/06/2013 at 3:20 p.m., a physical therapy staff member (#12) stated the facility received initial reports that Resident #5 did not have a [MEDICAL CONDITION], then a fracture was revealed. This staff member (#12) reported Resident #5 continued to be weight bearing as tolerated, pivot transferring with assistance of 2 persons, and not ambulating. This staff member reported the facility did not receive physician instructions or restrictions regarding Resident #5's [MEDICAL CONDITION]. This staff member (#12) also stated he did not provide specific training/education to facility staff regarding positioning, moving, and transferring Resident #5 or other residents with similar injuries. During interview, on 03/06/13 at 3:30 p.m., the observations of Resident #5's transfers on 03/05/13 were discussed with an administrative nursing staff member (#3). This staff member reported the facility did not have specific protocols, policies, or procedures regarding staff positioning, moving, and transferring Resident #5 or other residents with similar injuries. This staff member stated she expected the CNAs to support Resident #5's fractured right leg during moving and turning in bed, place a pillow between his knees, and place the wheelchair at an angle to the bed for transfers. *Observation, on 03/06/13 at 5:30 p.m., identified Resident #5 laying in bed partially turned to his left side with a pillow supporting his back and between his knees and his wife in the room. Two CNAs (#16) and (#17) removed the pillows, supported the resident's trunk and lower extremities, including the fractured right leg, and brought the resident to a sitting position at the edge of the bed. The CNAs applied a gait belt to the resident's waist and positioned a wheelchair at a 45 degree angle to bed on the resident's left side. The CNAs grasped the gait belt, assisted Resident #5 to a standing position, bearing weight on the fractured right leg, and pivoted the resident to his left to the wheelchair. The CNAs positioned the lower extremities on the wheelchair leg rests. During this observation, the resident grimaced with pain. The resident's MAR indicated [REDACTED] The facility failed to modify Resident #5's treatment plan regarding positioning and transfers after identification of his right [MEDICAL CONDITION]; failed to communicate changes in moving, positioning, turning, and transfer techniques to facility staff; failed to instruct staff in these techniques; and, failed to implement appropriate moving, positioning, turning, and transfer techniques. These failures resulted in Resident #5 experiencing unnecessary pain and placed him at increased risk for fracture displacement and skin breakdown.

Based on record review, policy/procedure review, professional reference review, and staff interview, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being for 3 of 6 sampled residents (Resident #3, #6, and #7) currently experiencing pain and requiring frequent use of narcotic pain medications. Failure to comprehensively assess, implement interventions, and evaluate the effectiveness of interventions for residents with pain does not allow them to reach their highest level of well-being and has the potential to result in uncontrolled pain. Findings include: Review of the facility policy titled "Pain Data Collection and Management" occurred on 06/03/11. This policy, reviewed November 2009, stated, "Purpose: To consistently collect information for data collection of pain in a systematic process. To determine what pain relief interventions can be utilized and established to aid resident in maintaining comfortable level of function in ADLs (activities of daily living), eating, mobility and all other physical activities. Note: A pain management plan can include, but not be limited to, a medical regime. The analysis should help determine what other methods or alternatives of pain control/relief may be implemented prior to contacting a physician. The Care Team and nurses must continually monitor and evaluate the pain management plan. . . . Procedure 1. Complete the baseline data collection of pain on admission using the pain section of the Initial Interdisciplinary Data Collection Tool. Also complete the baseline data collection on re-admission using the Physical Nursing Data Collection Tool. 2. Use the Pain Data Collection Supplement Tool to identify pain and document on the Pain Data Collection Tool. 3. Develop a pain management program attempting specific non-medication type interventions if appropriate. 4. Notify physician of pain data collection information including residents current rating of pain and at what level of pain resident can tolerate. 5. Develop care plan including pain, goal and interventions: a. define on care plan what pain scale is being used. b. include level of pain that resident can tolerate. 6. Follow prescribed orders for pain, documenting results on back of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 7. Resident identified at high risk for pain will be reviewed weekly. 8. Document the effectiveness of the pain management plan at least monthly. All pain medication, routinely scheduled and PRN are reviewed in the Nursing Documentation. If the current pain management is not effective or pain is of new onset, reassess using Pain Data Collection Tool. 9. Update the care plan to include type of pain, required monitoring including pain management plan and a measurable goal relating to the pain management plan. 10. Document summarization of pain analysis on Pain Data Collection Tool. This is to be completed quarterly for ongoing pain and for residents on a pain management program. Include medication changes, status of pain control, resident's general condition noting any significant changes (either improvement or decline), changes in elimination pattern, cognitive status, behavior manifestations or occurrence of new pain and resident's acceptance of pain level. 11. After a single episode of pain is resolved with the pain management plan, any new occurrence of pain will initiate the process again. . . ." Review of monthly "Nursing Documentation" form occurred on 05/31/11. The section related to pain stated, "Review the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. . . . Include review of non-pharmacological type interventions, resident response and resident's acceptance of pain level." "Nursing 2011 Drug Handbook," 31st edition, Lippincott, Williams and Wilkins, pages 755-756, states "[MEDICATION NAME] . . . INTERACTIONS, Drug-drug. . . . other opioid [MEDICATION NAME] . . . May cause additive effects. Use together with caution . . . a commonly abused opioid . . .;" and, pages 765-766, states "[MEDICATION NAME] . . . INTERACTIONS, Drug-drug. . . . other opioid [MEDICATION NAME] . . . May cause additive effects. Use together with caution. . . . Drug is potentially addictive . . ." - Review of Resident #3's medical record occurred on May 31-June 03, 2011. The facility admitted the resident in 07/10. Current [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), dated [DATE], identified headache, joint, and other sites of pain at horrible/excruciating intensities on a daily basis. The quarterly MDS, dated [DATE], identified the resident was cognitively intact, felt tired and little energy during half or more of the two week assessment period, had almost constant pain that did not affect her sleep or day to day activities, and rated her pain "8" on a scale of "0 to 10," with "10" being the worst pain imaginable. Resident #3's Resident Assessment Protocol Summaries (RAPS), including ADL Functional/Rehabilitation and Potential, and Psychosocial Well-being, dated 07/19/10, lacked information regarding the resident's pain. Resident #3's Pain Data Collection Tool, dated 10/14/10, stated ". . . A pain level of 4/10 is desired . . . Resident c/o (complained of) persistant (sic) generalized body aches. 8/10 usually stated when requesting [MEDICATION NAME] (opioid pain reliever) for pain, stated receives temporary relief. Resident has hx (history) of chronic type generalized pain - medicated as able. See scheduled & PRN MAR - reposition and use pillows also PRN for comfort and continue to monitor." The resident's medical record lacked additional pain assessments. Resident #3's current care plan, dated 10/16/10, stated "Problems . . . Alteration in comfort r/t (related to) chronic pain with [MEDICAL CONDITION] . . . Plans . . . Non-medication approaches: repositioning, diversional activities; Administer meds (medications) as ordered; Observe for signs and symptoms of pain and report to charge nurse; Pain scale: 0-10, numeric, verbal . . ." Resident #3's current physician orders for medications included: [MEDICATION NAME] 300 milligrams (mg), three times each day (TID) (anticonvulsant used for neuropathic pain); [MEDICATION NAME] 5 mg, every 6 hours (q6h) PRN (opioid pain reliever); [MEDICATION NAME] 4 mg, q6h PRN (opioid pain reliever); and Tylenol 1000 mg, two times each day (BID) (non-opioid pain reliever). Resident #3's PRN MARS, for the period March through May 2011, identified the resident received the following: [MEDICATION NAME] 5 mg - March - 30 times; April - 20 times; and, May - 29 times. [MEDICATION NAME] 4 mg - March - 49 times; April - 46 times; and, May - 36 times. Resident #3's medical record showed she was seen periodically by a pain clinic physician, received injections, and instructions to continue current medications. The medical record lacked physician progress notes [REDACTED]. The medical record lacked physician progress notes [REDACTED].#3 received. During interview, on 06/02/11 at 5:30 p.m., two administrative management staff members (#1) and (#2) reported the facility lacked a record of a pain assessment for Resident #3 since 10/14/10, lacked physician progress notes [REDACTED].#3's PRN opioid [MEDICATION NAME] use to the physicians. The facility identified Resident #3's pain level at "8" of "10" since admission with limited relief. The facility failed to assess Resident #3's pain medication program; failed to ensure the resident's physicians were aware of the amount and frequency of the opioid [MEDICATION NAME] provided to Resident #3; and, failed to consider other alternatives to these medications, including diversional activities. These failures limited the physicians' ability to consider other treatment options, ensure the quality of care, and placed Resident #3 and all facility residents with pain at risk of receiving inappropriate treatment for [REDACTED]. - Review of Resident #6's medical record occurred on all days of survey. Resident #6's medical [DIAGNOSES REDACTED]. Review of Resident #6's admission MDS, dated [DATE], identified the resident as cognitively intact, received PRN pain medications and non-pharmacological interventions to treat pain, experienced pain occasionally, and rated the pain as a "5" on a numeric scale of 0-10, with zero being no pain, and ten as the worst pain imaginable. Review of Resident #6's most recent quarterly MDS, dated [DATE], identified the resident experienced pain almost constantly which interfered with day-to-day activities, and rated the pain as an "8" on a numeric scale of 0-10. Review of Resident #6's current care plan identified "Problem/Needs/Concerns: Alteration in comfort r/t (related to) recent left carpal tunnel release m/b (manifested by) pain . . . Plans and Approaches: Non-medication approaches: Repositioning, ice, diversional activities. Administer meds as ordered. Observe for signs and symptoms of pain and report to charge nurse." Review of Resident #6's current pain medications included: - Tylenol 325 mg two tablets every four hours PRN - [MEDICATION NAME] 5/500 mg one to two tablets q4-6h PRN (opioid pain reliever) - [MEDICATION NAME] 1/2 tablet to one tablet q4-6h PRN (narcotic pain reliever) - [MEDICATION NAME] ([MEDICATION NAME]) 100 mg two tablets q6h PRN Review of Resident #6's PRN MAR from February 01, 2011 - May 31, 2011 identified the resident received the following: PRN [MEDICATION NAME] - February - 32 times; March - 26 times; April 31 - times; May - 31 times. PRN Tylenol - February - 9 times; March - 12 times; April - 20 times; May - 31 times. Physician's Progress Notes for Resident #6 identified the following regarding pain: *05/25/11 - ". . . severe bilateral carpal tunnel syndrome pain and disability despite carpal tunnel releases . . . She recently saw . . . a neurosurgeon for further followup and was told that unfortunately her bilateral hand pain and weakness may take up to a year to recover. . . ." *04/27/11 - ". . . She is still quite troubled about her severe left hand pain. . . ." *03/22/11 - ". . . she complains bitterly of severe bilateral hand pain. She says that her left hand hurts just like her right hand . . . Unfortunately she continues to have a fair amount of pain despite the use of a wrist splint and occupational therapy. . . ." *03/30/11 - ". . . Severe ongoing bilateral hand pain - exact etiology unclear but worrisome for bilateral carpal tunnel syndrome despite previous right carpal tunnel release. . . ." Medical record review identified staff completed a Pain Data Collection Tool assessment for Resident #6 related to right wrist pain on 12/16/10. The resident's medical record lacked additional pain assessments, despite hospitalization s for a laminectomy in 03/11, and a left wrist carpal tunnel release in 04/11. Review of Resident #6's interdisciplinary progress (IDP) notes from February 04, 2011 - June 3, 2011 identified the resident complained of pain and staff administered pain medications. The notes do not indicate the use of any non-pharmacological interventions, as mentioned in the plan of care. In addition, the IDP notes and the PRN MARs do not consistently identify pain scale intensity and/or response to pain medication. - Review of Resident #7's medical record occurred on all days of survey. Resident #7's medical [DIAGNOSES REDACTED]. Review of Resident #7's quarterly MDS assessment, dated 04/19/11, identified the resident as cognitively intact, received scheduled pain medications, PRN pain medications, and non-pharmacological interventions to treat pain, experienced pain almost constantly, and verbally described the pain as "severe." Resident #7's current physician's orders for pain medication included: - [MEDICATION NAME] 10/500 one tablet q4-6h PRN - [MEDICATION NAME] 10/500 one tablet every evening - Tylenol 500 mg 1-2 tablets q4h PRN - [MEDICATION NAME] 600 mg q6h PRN (anti-[MEDICAL CONDITION] pain reliever) - [MEDICATION NAME] 50 mg four times a day PRN (opioid pain reliever) - [MEDICATION NAME] cream (Biofreeze) to the affected area q4-6h PRN Review of Resident #7's PRN MARs, from January 01, 2011 - May 31, 2011 identified the resident received the following: PRN [MEDICATION NAME] - January - 10 times; February - 5 times; March - 9 times; April - 6 times; May - 4 times. PRN [MEDICATION NAME] - January - 19 times; February - 23 times; March - 14 times; April - 19 times; May - 27 times. PRN Tylenol - January - 2 times; March - 2 times; April - 1 time. Resident #7's current care plan does not address the resident's chronic pain, use of topical and oral pain medications, and does not identify non-pharmacological interventions to treat the pain. Review of Resident #7's IDP notes from March - May 2011 identified the resident complained of pain and staff administered oral pain medications and topical [MEDICATION NAME]. The notes do not indicate the use of any non-pharmacological interventions other than repositioning. In addition, the IDP notes and the PRN medication administration records do not consistently identify pain scale intensity and/or response to pain medication. Review of a Pain Data Collection Tool assessment for Resident #7, not dated, identified the resident did not verbalize any pain. The resident's medical record lacked additional pain assessments, despite continued complaints of pain and use of PRN pain medication. During interview the morning of 06/03/11, an administrative staff member (#2) confirmed staff had not completed comprehensive pain assessments to assess pain intensity, amount and frequency of PRN [MEDICATION NAME], or implemented non-pharmacologic interventions to alleviate pain.