Every finding on record at Good Samaritan Society - Bottineau

Based on record review, review of facility reported incident (FRI), review of the facility policy, and resident and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #20) who displayed sexual behaviors towards another resident. Failure to protect Resident #21 and all residents from sexual abuse may result in physical harm, pain, mental anguish, and emotional distress. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.Findings include:Review of the facility policy titled Abuse and Neglect . Skilled occurred on 06/29/26. This policy, dated 04/07/25, stated, . The resident/client has the right to be from abuse . Resident/clients must not be subjected to abuse by anyone, including . other residents/clients . Procedure . If it is an allegation of resident/client to resident/client abuse, the residents/clients will be separated immediately, and both ensured a safe environment.The surveyor determined a deficient practice existed on 05/30/26 when Resident #20 placed a hand down Resident #21's shirt. The facility immediately implemented correction action and completed it on 05/31/26.- Review of Resident #20's medical record occurred on 06/29/26. The current care plan stated, . Resident has a behavior symptom R/T [related to] dementia E/B [evidenced by] has made inappropriate touching . Resident was moved to different wing of building . If reasonable, discuss resident's behavior. Explain/reinforce to resident why behavior is inappropriate and/or unacceptable . attempts to inappropriately touch female residents.- Review of Resident #21's medical record occurred on 06/29/26. Diagnosis included Alzheimer's disease and dementia. A Brief Interview for Mental Status (BIMS), completed on 04/03/26, identified severely impaired cognition. The current care plan stated, . The resident has a behavior symptom R/T dementia . wanders . Intervene as necessary to protect the rights and safety of others . Remove from situation and take to alternate location as needed.The FRI initial report, received 06/01/26 at 2:54 p.m., stated at approximately 6:45 p.m. on 05/30/26, Resident to resident, inappropriate touching . resident went to bed after incident, but they were separated and monitored .A nurse's note, dated 05/30/26 at 7:58 p.m., stated, . CMA [certified medication aide] reported incident to writer of resident having hand placed in resident [Resident #21's] shirt. CMA quickly removed resident's hand out shirt [sic] and assisted him to TV where CNA [certified nurse aide] quickly brought him to his room to assist with bedtime cares. Resident [Resident #21] away [sic] from resident [Resident #20] assisted by CMA to hall where medication cart was to be by CMA. Will continue to monitor throughout night.During an interview on 06/29/26 at 12:40 p.m., a nurse (#3) stated Resident #20 reaches out to touch both staff and residents frequently and staff are expected to redirect the resident.During an interview on 06/29/26 at 12:45 p.m., Resident #20 stated he does not remember placing his hand down another resident's shirt.During an attempted interview on 06/29/26 at 1:00 p.m., Resident #21 responded with disorganized and incoherent speech. During an interview on 06/29/26 at 3:07 p.m., an administrative staff member (#1) stated staff followed the policy as they intervened immediately. The administrative staff member confirmed completed training immediately on 05/31/26.During an interview on 06/29/26 at 3:27 p.m., when asked if he/she had been inappropriately touched by any residents, Resident #23 Stated, No. That has not happened. I am safe here.During an interview on 06/29/26 at 3:30 p.m., When asked if he/she had been inappropriately touched by any residents, Resident #24 stated, No.During an interview on 06/29/26 at 3:36 p.m., an administrative staff member (#2) stated facility staff moved Resident #20 to an area of the facility with more supervision.Based on the following information, non-compliance at F0600 is considered past non-compliance. The facility implemented corrective actions for the resident affected by the deficient practice as follows:*Staff immediately intervened, separated the residents, and assessed for psychosocial effects.*Notified the Administrator and the Director of Nursing and reported the incident to the State Agency.*Informed staff on upcoming shifts to ensure staff continue to monitor the residents.*Reviewed the camera footage and interviewed the residents.*Notified families and providers.*Reviewed and updated the residents' care plans.

Based on observation, record review, review of facility policy, and staff interviews, the facility failed to follow infection control standards for 4 of 8 sampled residents (Resident #8, #15, #34, and #36) and 1 supplemental resident (Resident #37) observed during cares. Failure to follow infection control standards related to hand hygiene, glove use, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled, Standard, Enhanced Barrier, and Transmission-Based Precautions, All Service Lines occurred on 03/11/26. This policy, revised 07/07/25, stated, Standard precautions include hand hygiene, the use of personal protective equipment . textile and laundry handling practices . Enhanced barrier precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms to staff hands and clothing. Enhanced barrier precautions are also used for residents with . pressure ulcers . High-contact resident care activities include transfers, dressing . providing hygiene, changing briefs . changing linens . Review of the facility policy titled, Hand Hygiene occurred on 03/11/26. This policy, revised 11/13/25, stated, . HCW [health care workers] will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: When entering the patient room . before donning gloves . after removing gloves . when moving from contaminated body site to a clean body site during patient care . when exiting a patient room . - Review of Resident #8's medical record occurred on all days of survey. The current care plan stated, The resident requires Enhanced Barrier Precautions (EBP) R/T [related to] pressure ulcer . Observations showed the following: * 03/09/26 at 8:48 a.m., an EBP sign on Resident #8's door frame and Resident #8 rested in bed. A certified nurse aide (CNA) (#4) delivered Resident #8's meal tray. Without applying a gown or gloves, the CNA (#4) adjusted Resident #8's legs, torso, bedding, raised the head of the bed to an upright seated position, and assisted the resident the meal. After Resident #8 finished the meal, the CNA (#4) applied gloves, removed the resident's brief, and provided perineal cares. The CNA removed the soiled gloves, and without performing hand hygiene, applied new gloves, applied a new brief, and removed the resident's shirt and bilateral heel protectors. The CNA (#4) removed the soiled gloves, and without performing hand hygiene or applying new gloves, dressed Resident #8, placed a pillow under the resident's hip, adjusted the blankets and combed the resident's hair. The CNA (#4) gathered the garbage, and without performing hand hygiene, exited the room with the meal tray and garbage. The CNA (#4) failed to apply a gown prior to completing high-contact resident cares, failed to wear gloves during all high-contact cares, and failed to perform hand hygiene prior to glove application, after removing gloves, and prior to exiting the room. * 03/09/26 at 12:15 p.m., Resident #8 rested in bed. Two CNAs (#3 and #4) entered the resident's room and the CNA (#4) applied gloves, removed Resident #8's wet brief, and provided perineal care. The CNA (#4) removed the soiled gloves, and without performing hand hygiene, applied new gloves, and placed a clean brief and pants on Resident #8. The CNA (#3) applied gloves and assisted the CNA (#4) to place a transfer sling under Resident #8. Using a full body mechanical lift, the CNAs (#3 and #4) transferred the resident to a wheelchair. The CNA (#4) adjusted Resident #8 in the wheelchair and removed the soiled gloves. The other CNA (#3) wiped down the lift with a disinfecting wipe, removed the soiled gloves, performed hand hygiene, pushed the lift into the hallway, re-entered the room, combed the resident's hair, and without performing hand hygiene escorted Resident (#8) out of the room. The CNA (#4) made Resident #8's bed, gathered the garbage, performed hand hygiene and exited the room. The CNAs (#3 and #4) failed to apply a gown prior to completing high-contact resident cares, failed to wear gloves during all high-contact cares, and failed to perform hand hygiene prior to applying gloves, and after removing gloves. * 03/09/26 at 3:06 p.m. showed Resident #8 seated in a wheelchair. A CNA (#4) performed hand hygiene, applied a gown and gloves, gathered supplies to provide colostomy (an opening in the abdominal wall, connecting the colon to an external pouch to divert stool) cares, and placed a washable cloth protector on Resident #8's lap. The CNA (#4) emptied the colostomy bag into a graduate, emptied, rinsed, and stored the graduate. The CNA (#4) removed the soiled gloves, and without performing hand hygiene, applied new gloves, wiped the colostomy bag with a wet washcloth, and sealed the colostomy bag. The CNA placed the soiled washcloth and cloth protector directly onto the floor. The CNA (#4) removed the soiled gown and gloves, and without performing hand hygiene, applied new gloves, removed Resident #8's soiled shirt, added it to the laundry pile on the floor, and placed a new shirt on the resident. The CNA gathered the garbage, placed the soiled laundry into a separate garbage bag, removed the soiled gloves, performed hand hygiene and escorted the resident out of the room. The CNA (#4) failed to complete hand hygiene between glove changes, removed the gown prior to completing cares and placed soiled laundry directly on the floor. - Observation on 03/09/26 at 7:55 a.m. showed Resident #37 seated on the toilet. A CNA (#1) entered the room, performed hand hygiene, applied gloves, completed hygiene cares, removed the soiled gloves, and dressed the resident. The CNA (#1) assisted the resident into a chair and exited the resident room. The CNA (#1) failed to perform hand hygiene after removing the soiled gloves and assisting with other tasks and before exiting Resident #37's room. - Observation on 03/09/26 at 11:17 a.m. showed a CNA (#1) transferred Resident #34 onto the toilet with a mechanical sit to stand lift. The CNA (#1) left the bathhouse without performing hand hygiene. The CNA (#1) returned to the bathhouse, and without performing hand hygiene, applied gloves, provided toileting hygiene, adjusted the resident's clothes, and transferred the resident back to the wheelchair. The CNA (#1) removed the soiled gloves, and without performing hand hygiene, put on one new glove, cleaned the lift, removed the glove, and without performing hand hygiene, pushed Resident #34 to hallway. - Observation on 03/09/26 at 11:31 a.m. showed the CNA (#1) transported Resident #36 from the solarium to the bathhouse. Without performing hand hygiene, the CNA applied gloves, utilized the sit to stand lift, and placed the resident on the toilet. The CNA (#1) provided perineal cares, applied a new brief and clothing, and removed the soiled gloves. Without performing hand hygiene, the CNA applied one glove, cleansed the lift with a disinfecting wipe, removed the glove, and without performing hand hygiene, pushed the resident into the hall. The CNA (#1) then went back to Resident #36's room, returned with a sweater, and helped the resident put the sweater on. - Observation on 03/09/26 at 11:42 a.m. showed Resident #15 seated in a wheelchair in the bathhouse. Two CNAs (#1 and #5) applied gloves, used a sit to stand lift to assist the resident to stand, removed the resident's soiled brief, and sat the resident on the toilet. The CNA (#5) cleansed the front perineal area, removed the soiled gloves, and without performing hand hygiene, used the lift control to operate the lift, and assisted the resident to stand. The CNA (#1) cleansed the buttocks area, adjusted the brief/pants, removed the soiled gloves, and without performing hand hygiene, continued cares. The CNA (#5) applied gloves, cleansed the lift with a disinfecting wipe, gathered the garbage, and without performing hand hygiene, both CNAs exited the bathhouse. During an interview on 03/10/26 at 3:30 p.m., an administrative nurse (#2) stated she expected staff to perform hand hygiene when entering and exiting rooms, in-between glove changes, and follow EBP precautions.

Based on review of Medicare Part A letters/notices and staff interview, the facility failed to ensure the resident and/or their representative received the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC) at least two days prior to the end of services for 1 of 3 residents (Resident #45) reviewed for termination of Medicare Part A services. Failure to ensure the resident and/or their representative received the SNFABN and NOMNC at least two days prior to the end of skilled services limited the resident/representative's ability to exercise their rights regarding Medicare Part A services.Findings Include:Review of Medicare Part A beneficiary notices identified Resident #45 discharged from Medicare Part A on 11/28/25. The SNFABN and the NOMNC showed the resident signed the forms on 11/28/25. The facility failed to provide the forms at least two days before the Medicare A services ended.During an interview on 03/10/26 at 11:48 a.m., an administrative staff member (#3) confirmed staff failed to provide the SNFABN and the NOMNC forms at least two days in advance.

Based on observation, record review, and facility policy review, facility staff failed to properly utilize assistive devices necessary to prevent accidents for 1 of 2 sampled residents (Resident #34) observed during a pivot transfer. Failure to use a gait belt during a transfer placed the resident at risk for injury and/or pain.Finding Include: Review of the policy titled Safe Resident Handling Program (SRHP) Resource Packet - . LTC [Long Term Care] . occurred on 03/11/26. This policy, dated 07/07/25, stated, . Follows resident plan of care (Kardex)/service plan for mobility device, . The Care Plan is part of the communication process to the caregiver. Ambulation: (SPECIFY: X staff assist, mobility device and harness size, and any restrictions) and (SPECIFY assist device: Gait belt, walker etc.). Review of the policy titled Ambulation of Resident . LTC . Ambulation of Resident Clinical Skill Checklist occurred 03/11/26. This undated policy, stated, 1. Review resident information on the PCC [point click care] Kardex/Care Plan. 5. Use gait belt, if not contraindicated, around resident's waist. Review of Resident #34's medical records occurred on all days of survey. The care plan stated, Focus: The resident has an ADL self care performance deficit R/T [related to] weakness, failure to thrive E/B [evidenced by] difficulty performing ADLs . Interventions: . SRHP - Transfer - Transfer Between Surfaces: assist of 1 staff with use of walker. Has episodes of weakness and is unable to transfer safely without sit to stand as needed. The care plan did not identify a gait belt as contraindicated for Resident #34.Observation on 03/09/26 at 11:12 a.m. showed resident #34 seated in a recliner in the solarium. A certified nurse aide (CNA) (#1) placed the wheelchair with an arm rest at a 90-degree angle to the left arm rest of the recliner and locked the brakes. The CNA (#1) assisted the resident to reach across the wheelchair and take hold of the arm rest on the far side of the wheelchair with his left hand. The CNA (#1) then told the resident to stand and grabbed on and under his right arm. Resident #34 continued to hold onto the wheelchair while leaning to the left, which caused the recliner and wheelchair to slide left. The CNA (#1) stated, Come on [Resident #34's name], gave another pull on the resident's right arm and pulled him over the right arm rest to the wheelchair seat. The CNA (#1) put her face into the resident's line of site and said, You hurt my back. the resident smiled at the CNA (#1). The CNA (#1) failed to use a walker and a gait belt as care planned and per policy.

Based on observation, record review, review of the facility policy, and staff interview, the facility failed to ensure safe transfers for 2 of 7 sampled residents (Residents #1 and #34) and 1 of 1 supplemental resident (Resident #22) observed during transfers. Failure to assess the need for mechanical lifts and to use a gait belt placed residents at risk of serious injury.Findings include: Review of the facility policy titled Mobility Support and Positioning occurred on 09/11/25. This policy, dated 04/06/25, stated, . Always check the Kardex, or care plan/service plan prior to the transfer or repositioning task for type and amount of assistance needed. Follow any specific lift/transfer instructions for the resident. -Review of Resident #1's medical record occurred on all days of survey. The current care plan stated, TRANSFER . Total lift (Hoyer lift) with assist of 2 staff and large sling for transferring in/out of bed. Observation on 09/11/25 at 7:00 a.m. showed a certified nurse aide (CNA) (#3) placed a mechanical sit to stand lift outside the door of Resident #1's room. During an interview on 09/11/25 at 7:00 a.m., when asked if any residents on the 300 hallway required a Hoyer lift, the CNA (#3) stated, No, they [residents] are located in the other wing. During an interview on 09/11/25 at 7:20 a.m., the CNA (#3) stated she used the sit to stand lift to transfer Resident #1 from the bed. During an interview on 09/11/2025 10:44 a.m., an administrative nurse (#1) stated she would expect the CNAs to follow the current care plan and use a total lift with assist of two staff to transfer Resident #1 from the bed. -Review of Resident # 22's medical record occurred on all days of survey. The current care plan stated, . TRANSFER - Transfer Between Surfaces: With total lift x2 [with two] staff . Resident is unable to weight bear with total lift assist x 2 . During an observation on 09/09/25 at 4:15 p.m., two CNAs (#11 and #12) transferred Resident #22 from the recliner to a wheelchair. One CNA (#11) applied a gait belt and both CNAs (#11 and #12) attempted to stand the resident. The resident could not bear weight and the CNAs lifted him with the gait belt to the wheelchair. One CNA (#11) stated, he was a [mechanical] lift but today they [administrative staff] said he can pivot. During an observation on 09/11/25 at 5:30 a.m., a CNA (#13) assisted Resident #22 with toileting. The CNA (#13) positioned the resident's wheelchair next to the toilet, directed the resident to hold onto the grab bar, and assisted the resident to stand by placing her hands under the resident's armpits and lifting. The CNA (#13) then called for assistance to transfer the resident off of the toilet. The CNA (#13) and the nurse (#14) directed the resident to hold onto the grab bar and assisted the resident to stand by lifting under the resident's arms. The CNA (#13) and nurse (#14) failed to utilize a mechanical lift or a gait belt. -Review of Resident #34's medical record occurred on all days of survey. Diagnoses included osteoporosis and history of a healed traumatic fracture. The current care plan stated, . The resident has an ADL self-care performance deficit . E/B needs assist . TRANSFER - assist of 1 staff with transfers . During an observation on 09/08/2025 at 4:15 p.m., a CNA (# 3) assisted the resident to toilet using a stand lift. The CNA failed to transfer the resident as care planned. During an interview on 09/11/25 at 10:45 a.m. an administrative staff member (#1) confirmed the facility allowed CNAs to decide whether to use a lift, they can always go up [use a lift] but they can't go down [not use a lift] if care planned but confirmed she expected staff to use a gait belt with all pivot transfers. The facility failed to have a nurse assess and update the care plan for a change in resident's condition requiring the use or discontinuation of a mechanical lift. 2. Based on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to ensure an environment free of accidents and hazards for 2 of 2 sampled residents (Resident #2 and #26) observed with a door alarm and cleaning chemicals in the room. Failure to ensure a functioning door alarm for Resident #2 placed the resident at risk for falls/injury. Failure to ensure Resident #6's room remained free from chemicals placed the residents at risk for injury. Findings include: Review of facility policy titled Alarms- Bed, Chair, and Door occurred on 09/11/25. This policy, dated August 2025, stated, . Nursing staff will be responsible for visually checking placement of alarms . Review of facility policy titled Housekeeping, Standard or Light Cleaning occurred on 09/11/25. This policy, dated August 2025, stated, . No Cleaning supplies . should be . in the resident rooms. Review of the Safety Data Sheet for Ecolab carpet spray remover, dated 08/26/19, stated, . Causes serious eye irritation. Avoid contact with skin and eyes . - Observation on all days of survey showed a spray bottle of Ecolab carpet spot remover located on Resident #26's bed side table. During an interview on 09/11/25 at 1:40 p.m., an administrative staff member (#10) stated, Chemicals should not be left in resident rooms. - Review of Resident #2's medical record occurred on all days of survey. The care plan stated, . resident has an ADL [Activities of Daily Living] self-care performance deficit . mobility deficits, shuffled gait . Alarm to door to alert staff when resident comes out of his room . Observation on 9/11/25 at 5:31 a.m. showed Resident #2 ambulated out his room into the hallway without the door alarm sounding. The resident walked across the hall, approached a CNA (#18) and stated, Bathroom. The CNA assisted the resident back to his room and activated the resident's call light for assistance. At 5:36 a.m., a nurse (#19) answered the resident's call light and the CNA (#18) reported to the nurse the door alarm was not hooked up. The facility staff failed to ensure Resident #2's door alarm remained connected. During an interview on 9/11/25 at 1:30 p.m., an administrative staff member (#1), stated she expected staff to ensure Resident #2's door alarm was connected. Review of Resident #1's medical record occurred on all day of survey and identified diagnoses including other poly-osteoarthritis, adult failure to thrive, and secondary malignant neoplasm of the breast. The current care plan stated, TRANSFER . Total lift with assist of 2 staff and large sling for transferring in/out of bed. Observation on 09/11/25 at 7:00 a.m. showed a certified nurse aide (CNA) (#3) parked a mechanical sit to stand lift outside the door of Resident #1's room. During an interview on 09/11/25 at 7:00 a.m. a CNA (#3), when asked if any residents on the 300 hallway required a Hoyer lift (full body lift), the CNA stated, No, they are located in the other wing. During an interview on 09/11/25 at 7:20 a.m. the CNA (#3), stated, she used the sit to stand lift to transfer Resident #1 from the bed to the wheelchair. During an interview on 09/11/2025 10:44 a.m., an administrative nurse (#1) stated she would expect the CNAs to follow the current care plan and use a total lift with assist of two staff for transferring Resident #1 from the bed.

Based on observation, record review, review of facility policy, and staff interview the facility failed to follow standards of infection control for 5 of 11 sampled residents (Resident #4, #5, #26, #34, and #48) and 3 supplemental residents (Resident #19, #22 and #40) observed during cares. Failure to follow infection control practices during resident cares related to handling soiled linen, hand hygiene, glove use, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility.Findings include: Review of the facility policy titled Hand Hygiene occurred on 09/11/25. This policy, dated March 2022, stated, . To establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settings . Procedure . use waterless alcohol-based hand sanitizer or soap and water to clean their hands . When entering patient room . If gloves are used to perform a . procedure, hand hygiene must be completed before donning [applying] gloves . After removing gloves regardless of task completed . When moving from contaminated body site to a clean body site during patient care . When exiting patient room. Review of the facility policy titled Standard, Enhanced Barrier, and Transmission Based Precautions occurred on 09/11/25. This policy, dated July 2025, stated, . Enhanced barrier precautions expand the use of personal protective equipment [PPE] . and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug-resistant organisms (MDROs) to staff hands and clothing. Enhanced barrier precautions are also used for residents with chronic wounds . and residents with indwelling urinary catheters . High -contact resident care activities include transfers, dressing, providing hygiene, changing briefs or assisting with toileting . changing linens, indwelling medical device care or use . and wound care. -Observation on 09/09/25 at 3:45 p.m. showed Resident #4 ambulating down the hallway with their pants and brief sliding down. A certified nurse aide (CNA) (#3) placed an ungloved hand between the resident's skin and brief and pulled the brief/pants up. Without performing hand hygiene, the CNA sat in a chair and began typing on a computer. - Observation on 09/09/25 at 9:52 a.m. showed CNA (#3) entered Resident #5's room to assist with toileting. Without performing hand hygiene, the CNA applied gloves and transferred the resident to the toilet. The CNA removed the gloves, applied new gloves, completed perineal cares, applied a clean brief, and pulled up the resident's pants. The CNA removed the soiled gloves and without performing hand hygiene, applied clean gloves and transferred the resident back into the wheelchair. The CNA (#3) removed the gloves and performed hand hygiene. The CNA (#3) failed to perform hand hygiene after removing the soiled gloves and applying clean gloves. - Observation on 09/09/25 at 1:41 p.m., showed two CNAs (#2 and #3) entered Resident #19's room to provide incontinence cares. The CNA (#3) failed to perform hand hygiene before entering the room. After completing incontinence cares, the CNA (#3) removed the soiled gloves, bagged the soiled linen and exited the room. The CNA (#3) failed to perform hand hygiene and exited the room. The CNA (#2) removed the soiled gloves, removed the wheelchair from the room, reentered the room and performed hand hygiene. -Review of Resident #22's medical record occurred on all days of survey. The current care plan stated, . The resident requires Enhanced Barrier Precautions (EBP) R/T [related to] indwelling medical device- catheter . [NAME] [apply] gown and gloves when performing high contact care activities including dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care and/or use, and wound care. Observation on 09/11/2025 at 5:35 a.m. showed a CNA (#13) entered Resident #22's room without performing hand hygiene and without applying a gown. The CNA applied gloves and assisted the resident to the toilet. At 5:55 a.m., a nurse (#14) entered Resident #22's bathroom without applying a gown to assist the CNA (#13) with perineal cares and transfer back into the wheelchair. Without performing hand hygiene, the nurse removed gloves from their pocket, completed the resident's perineal cares, pulled the resident's pants up, and assisted the CNA (#13) to transfer the resident back into the wheelchair. The CNA and the nurse then removed their gloves and performed hand hygiene. The CNA (#13) and the nurse (#14) failed to apply gowns before completing high contact cares and failed to perform hand hygiene after perineal cares. -Review of Resident #26's medical record occurred on all days of survey. The current care plan stated, . The resident requires Enhanced Barrier Precautions R/T open wound . [NAME] [apply] gown and gloves when performing high contact care activities including . checking and changing . Observations of Resident #26 showed the following:*09/08/25 at 3:51 p.m., two CNAs (#16 and #17) applied gowns, and without performing hand hygiene, applied gloves, entered the resident's room, and provided incontinent cares. During cares, the CNA (#16) discarded a soiled brief and soiled gloves into the trash can and without performing hand hygiene, obtained gloves from their own pocket, applied the gloves, and transferred the resident with a hoyer lift. *09/09/25 at 1:23 p.m., Two CNAs (#2 and #3) performed hand hygiene, applied gloves, failed to apply gowns, and provided incontinent cares for the resident. During cares, the CNA (#2) removed one glove and asked the CNA (#3) for a clean glove. The CNA (#3) removed a handful of gloves from their pocket, which fell onto the resident's bed. The CNA (#2) picked up one glove from the bed and applied without performing hand hygiene. The CNA (#3) picked up the remaining gloves from the resident's bed and placed them back into her pocket. The CNAs (#2, #3, #16, and #17) failed to perform hand hygiene between glove changes, apply clean gloves, and apply gowns before completing Resident #26's cares. -Observation on 09/08/25 at 4:15 p.m. showed a CNA (#3) applied gloves without performing hand hygiene and transferred Resident #34 from a wheelchair to the toilet utilizing a sit to stand lift. The CNA removed the resident's soiled brief, placed the brief into a trash can, and lowered the resident onto the toilet. The CNA (#3) removed her gloves, and without performing hand hygiene, applied clean gloves, removed the trash bag from the can, and removed her gloves. Without performing hand hygiene, the CNA applied clean gloves, performed perineal cares, applied a clean brief, pulled up the resident's pants, removed her gloves and transferred the resident back into the wheelchair. The CNA removed the lift sling, straightened the resident's clothing, and exited the room with the lift. The CNA (#3) returned to the resident's room, carried the trash bag to a soiled utility room down the hallway, and then performed hand hygiene. The CNA (#3) failed to perform hand hygiene between glove changes, after completing perineal cares, before moving on to other tasks, and before exiting the resident's room. - Observation on 09/11/25 at 7:33 a.m. showed a medication aide (MA) (#7) entered Resident #40's room with medications. The resident was in the bathroom at the time, so the MA applied gloves, removed the soiled linen and garbage room the room, and placed them in the soiled utility room. The MA (#7) returned to the room and failed to perform hand hygiene. -Observation on 09/09/25 at 8:17 a.m. showed a CNA (#12) transferred Resident #48 into the bathroom. Without performing hand hygiene, the CNA (#12), applied gloves, removed resident's soiled shirt and soiled brief, and performed perineal cares. Without removing her soiled gloves, the CNA applied a clean brief, removed the resident's soiled shoes, socks, and pants, cleansed the resident's legs, and then removed the soiled gloves. Without performing hand hygiene, the CNA applied new gloves and dressed the resident. During an interview on 9/11/25 at 10:45 am, an administrative staff member (#1) stated she expected staff to perform hand hygiene before entering and exiting resident rooms, between glove changes, after resident cares, and apply gowns/gloves when providing high contact cares for residents on EBP.

Based on observation, review of facility policy, and staff interview, the facility failed to provide reasonable accommodation of needs regarding call lights for 1 of 18 sampled residents (Resident #19) observed during cares. Failure to ensure residents can reach/access the call light may result in unmet needs and the inability to call for help. Findings include:Review of the facility policy titled Call Light occurred on 09/11/25. This policy, dated July 2025, stated, . PURPOSE to ensure residents always have a method of calling for assistance . when leaving the room, place call light within easy reach of resident.During an observation on 09/08/25 at 4:18 p.m., Resident #19 asked this surveyor, Can you give me that call light back there? I want to lay down. Observation showed the resident's call light not within reach. Observation on 09/08/25 at 5:05 p.m. showed Resident #19's call light remained out of reach and at 5:15 p.m., staff assisted the resident to the dining room. Observation on 09/09/25 at 1:41 p.m. showed two certified nurse aides (CNAs) (#2 and #3) assisted Resident #19 with a transfer. The CNAs failed to place the resident's call light within reach before exiting the room. During an interview on 09/11/25 at 1:30 p.m., an administrative staff member (#1) confirmed she expected staff to place the residents' call light within reach prior to exiting the room.

Based on record review, review of facility policy, and staff interview, the facility failed to report an alleged violation of abuse and neglect to the State Survey Agency (SSA) for 1 of 2 residents (Resident #36) with an unwitnessed fall resulting in an injury and hospital admission. Failure to report alleged incidents to the SSA placed Resident #36 and other residents at risk for possible abuse and/or injury.Findings include:Review of the facility policy titled Abuse and Neglect-Rehab/Skilled, Adult Day Services, Therapy & Rehab occurred on 09/10/25. This policy, dated, 04/04/25, stated, . PURPOSE To ensure that all identified events of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported .Review of Resident #36's medical record occurred on all days of survey. Diagnoses included non-Alzheimer's dementia. An admission Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairment.Review of progress notes identified the following:* 09/03/25 at 05:46 p.m., Date and Time of event: 9-3-25 @0405 (at 4:05 a.m.) . resident found slumped against the door to their bathroom with their head and shoulders leaning against the door. Obvious laceration with active bleeding to right frontal/parietal skull.additional laceration to R [right] rear parietal/occipital skull noted. Bleeding to scalp . Resident's v/s [vital signs] obtained and found to be hypoxic [inadequate oxygen level] initial SpO2 [peripheral oxygen saturation] was 68 RA [room air]. Resident unsure of how they fell or why they were up. * 09/03/25 at 10:08 a.m., stated, . Spoke with ER [emergency room] and notified that resident was admitted to the hospital for pneumonia.* 09/04/25 at 9:42 a.m., stated, . hospital notified facility of resident's death.During an interview on 09/11/25 at 12:56 p.m., an administrative staff member (#4) identified the facility completed an internal investigation, did not find the injury to be significant or of unknown origin, and did not complete a Facility Reported Incident (FRI) notification.The facility failed to identify Resident #36's injury as potential abuse or neglect and submit an incident report to the SSA.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to complete a Significant Change in Status Assessment (SCSA) for 2 of 2 of sampled residents (Resident #2 and #5) who experienced a significant change in status. Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facility's ability to accurately assess the resident's status and identity and implement appropriate care approaches.Findings include:The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.19.1), dated October 2024, page 2-24 stated, . A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without staff intervention . 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. Page 2-27 stated, A SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement. Any decline in an ADL [activities of daily living] physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning. - Review of Resident #2's medical record occurred on all days of survey. A SCSA Minimum Data Set (MDS), dated [DATE], identified no wandering, partial/moderate assist with toileting, bathing, and lower body dressing, and supervision with upper body dressing and putting on/taking off footwear.A quarterly MDS, dated [DATE], identified wandering 1-3 days, substantial/maximum assistance with toileting, bathing, lower and upper body dressing, and putting on/taking off footwear.- Review of Resident #5's medical record occurred on all days of survey. An annual MDS, dated [DATE], identified no mood indicators, no behaviors, wandering 1-3 days, substantial/maximum assistance with lower body dressing, and partial/moderate assistance with roll left to right (bed mobility).- A quarterly MDS, dated [DATE], identified 0-3 mood indicators, verbal behaviors 4-6 days, other behaviors 1-3 days, wandering 4-6 days, dependent with lower body dressing, and substantial/moderate assistance with roll left to right.The record lacked evidence facility staff identified and/or completed a SCSA related to Resident #2's and #5's change in behaviors and decline in ADLs.During an interview on 09/10/25 at 4:22 p.m., an administrative staff nurse (#5) confirmed Resident #2 and Resident #5 declined and staff should have completed a SCSA.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 12 sampled residents (Resident #2, #5, and #21) reviewed. 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 C: COGNITIVE PATTERNSThe Long-Term Care Facility RAI User's Manual, revised October 2024, page C-24, of the RAI Manual stated, . If the test cannot be conducted (resident will not cooperate, is non-responsive, etc.,) and staff were unable to make a determination based on observation of the resident, use the standard 'no information' code (a dash, '-'), to indicate that the information is not available because it could not be assessed. SECTION D: MOODThe Long-Term Care Facility RAI User's Manual, revised October 2024, page D-3, of the RAI Manual stated, . If the resident interview was not conducted within the look-back period . item D0100 must be coded 1, Yes, and the standard 'no information' code (a dash '-') entered in the resident interview items. SECTION GG: FUNCTIONAL ABILITIESThe Long-Term Care Facility RAI User's Manual, revised October 2024, page GG-14, of the RAI Manual stated . Individualized care plans should be based on an accurate assessment of the resident's self-performance and the amount and type of support being provided to the resident. Page GG-21 stated . A dash ( -) indicates No information. CMS [Centers for Medicare & Medicaid Services] expects dash use to be a rare occurrence.- Review of Resident #2's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], showed Section C and D dashed. The factors listed on page C-24 of the RAI manual did not apply to Resident #2. The facility failed to assess the resident's cognitive abilities and mood. - Review of Resident #5's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], showed Section C, D and GG dashed. The facility failed to assess the resident's cognitive abilities, mood, and functional abilities.During an interview on 09/09/25 at 11:11 a.m., an administrative staff member (#5), stated, If nursing staff doesn't complete those assessments I use dashes.SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMSThe Long-Term Care Facility RAI User's Manual, revised October 2024, page O-7, stated, . O0110K1, Hospice care code residents identified as a being in a hospice program for terminally ill persons . - Review of Resident #21's medical record occurred on all days of survey. A physician's order dated 06/27/25. stated, Admit to skilled nursing facility under HOSPICE care. The current care plan stated, . The resident has a terminal prognosis . Is on hospice care . The facility failed to code hospice services on the admission MDS, dated [DATE].During an interview on 09/11/25 at 8:15 a.m., an administrative staff member (#5) confirmed staff failed to code hospice on Resident #21's MDS.

Based on record review, review of professional reference, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 18 sampled residents (Resident #3 and Resident #6). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.Findings include:Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education Inc., New Jersey, pages 203 and 212, stated, . The nurse uses . care plans. creates an individual plan for unusual . problems needing special attention. Observations include assessments made to determine whether a complication is developing. The nurse should write observations for both real problems and those for which the client is at risk.-Review of Resident #3's medical record occurred on all days of survey. Diagnoses included diabetes, and a physician's order for insulin. The resident's care plan lacked monitoring for signs/symptoms and interventions for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar).-Review of Resident #6's medical record occurred on all days of survey. Diagnoses included diabetes and a physician's order for glipizide (an oral antidiabetic). The resident's care plan lacked monitoring for signs/symptoms and interventions for hypoglycemia and hyperglycemia.During an interview on 09/11/2025 at 10:44 a.m., an administrative nurse (#1) stated staff failed to update the care plans for Resident #3 and Resident #6.

Based on observation, record review, review of facility policy, review of manufacturer's instructions, review of professional reference and staff interview, the facility failed to ensure staff followed professional standards of practice for 1 of 2 supplemental residents (Resident #3) observed during medication administration. Failure to properly prepare insulin pens (Resident #3) may result in residents receiving the wrong medication dose and/or result in adverse health consequences.Findings include:Review of the facility policy titled Medication: Insulin Administration, Insulin Pens, Insulin Pumps 09/05/24, stated, Intermediate or mixed insulins ( . 70/30 . ) . This type of insulin should be gently mixed before use. To mix, roll the pen between your hands. You must also turn the pen up and down ten times .Review of manufacturer's instructions for the NovoLog 70/30 Mix FlexPen, dated February 2023, stated, . roll NOVOLOG MIX 70/30 FlexPen gently between hands in a horizontal position 10 times. Then, turn NOVOLOG MIX 70/30 FlexPen upside down so that the glass ball moves from one end of the reservoir to the other 10 times until the suspension appears uniformly white and cloudy. Inject immediately.- Observations during medication administration showed the following:- 09/11/25 at 7:18 a.m. a medication aide (MA) (#7) primed the insulin pen and immediately administered Novolog mix 70/30 to Resident #3 (a combination insulin containing 70 percent immediate acting insulin and 30 percent rapid acting insulin) insulin without following the mixing protocol. During an interview on 09/11/25 at 1:30 p.m., a staff nurse (#1) stated she was unaware of the mixing process for a Novolog 70/30 insulin pen.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide treatment and services to aid in the healing of a pressure ulcer for 1 of 2 sampled residents (Resident #26) with a current pressure ulcer. Failure to implement interventions as ordered may result in a new pressure area and delayed healing/deterioration of an unstageable pressure ulcer.Findings include:Review of the facility policy titled Pressure Ulcers occurred on 09/11/25. This policy, dated 02/17/25, stated, . A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Review of Resident #26's medical record occurred on all days of survey. Diagnoses included diabetes mellitus and protein calorie malnutrition. A quarterly Minimum Data Set (MDS), dated [DATE], identified dependent on staff with rolling from side to side (bed mobility) and transfers, and an unhealed unstageable pressure ulcer. The current care plan stated, . The resident has pressure ulcer to sacral area. offer/assist to turn/reposition at least every 2 hours. Provide open heel boots to bilateral feet or float heels on pillow . A physician's order, dated 11/03/23, stated bilateral pressure relieving boots on while in bed and in chair.Observations on 09/09/25 showed Resident #26 seated in a wheelchair in the hallway by the nurses station from 8:08 a.m. until 1:23 p.m. (over 5 hours) without being repositioned. At 1:23 p.m. two certified nurse aides (CNAs) (#2 and #3) assisted Resident #26 with a check and change. Observation showed the pressure ulcer dressing to the coccyx soiled with bowel movement (BM). The CNA (#2) used a wipe to clean the BM from the resident's dressing. After cares the resident remained in bed, and the CNAs exited the room. The CNAs failed to notify the nurse of the soiled dressing and apply the pressure ulcer relieving boots.Observation on 09/09/25 at 3:51 p.m. showed Resident #26 remained in bed without pressure relieving boots or heels floated.During an interview on 09/09/25 at 5:23 p.m., a nurse (#22) stated the CNAs (#2 and #3) failed to report Resident #26's soiled dressing. Observation on 09/10/25 at 8:45 a.m. showed Resident #26 in bed without pressure relieving boots or heels floated. Observation on 09/10/25 at 10:20 a.m. showed two nurses (#6 and #23) changed Resident #26's pressure ulcer dressing. When completed, the resident remained in bed and the nurses exited the room without placing the pressure relieving boots or floating his heels on a pillow. Review of Resident #26's repositioning documentation from 08/12/25 to 09/09/25 showed the following: 1 day - occurred two times.9 days - occurred three times.14 days - occurred 4 times.5 days - occurred five times.The number of hours between repositioning ranged from 2-24 hours. During an interview on 9/11/25 at 1:30 p.m., an administrative staff member (#1) stated she expected staff to turn and reposition residents every two hours, place pressure relieving boots when ordered, and care planned.

Based on observation, record review, facility policy review, and staff interview, the facility failed to provide appropriate toileting for 1 of 5 sampled residents (Resident #2) observed during toileting. Failure to provide timely toileting may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and fall and/or injuries.Findings include:Review of the facility policy titled Activities of Daily Living occurred on 09/11/25. This policy, dated 12/23/24, stated, . Any resident who is unable to carry out activities of daily living will receive necessary services to maintain . grooming and personal and oral hygiene.Review of Resident #2's medical record occurred on all days of survey. The care plan identified the following, . TOILET USE: Resident requires assist of 1 staff. TOILETING PROGRAM: Offer resident the toilet every 2 hours when awake . BRIEF USE: . Check Q2 [every] 2 hours and prn [as needed]. During an observation on 09/09/25 at 3:05 p.m., a certified nurse aide (CNA) (#9) assisted Resident #2 to the bathroom. The resident's incontinent product and shorts were saturated with urine. Review of the resident's toileting log for 09/09/25 showed staff last assisted the resident with toileting at 11:31 a.m. (3.5 hours prior).Review of Resident #2's toileting log, dated 08/13/25 through 09/10/25, showed additional five occasions, (08/13/25, 08/16/25, 08/17/25, 09/05/25, 09/07/25) when staff failed to toilet the resident every two hours. The occasions ranged from 4 to 11 hours between toileting times and resulted in urinary and bowel incontinence. During an interview on 09/11/25 at 1:30 p.m., a nurse (#1) stated, If a resident is in a brief, the expectation is to check and change them every two hours.

Based on record review and staff interview, the facility failed to ensure resident records contained the hospice election form for 1 of 1 sampled resident (Resident #21) receiving hospice services. Failure to obtain the form limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include:Review of Resident #21's medical record occurred on all days of survey and identified Resident #21 elected hospice services on 06/27/25. The care plan stated, . The resident . Is on hospice care .The medical record lacked the hospice election form.During an interview on 09/11/25 at 12:30 p.m., an administrative staff member (#20) confirmed the medical record lacked the hospice election form.

Based on observation, review of facility policy, and resident and staff interviews, the facility failed to provide a safe, sanitary, and comfortable environment for 2 of 18 sampled residents (Resident #5 and #26), and 2 of 5 supplemental residents (Resident #14 and #19). Failure to ensure residents' fans, walls, and wheelchairs are clean, and failure to remove non-working refrigerators in resident rooms may affect the well-being, comfort, health, and safety of the residents.Findings include: Review of the facility policy titled Housekeeping, Standard or Light Cleaning occurred on 09/11/25. This policy, dated 08/21/25, stated, . PURPOSE To provide procedures for the proper, daily cleaning of resident rooms . thorough, routine, and high-quality cleaning procedures are necessary to minimize the prevalence of infection. Review of the facility policy titled Standard, Enhanced Barrier, and Transmission-Based Precautions occurred on 09/11/25. This policy, dated 07/07/25, stated, . Standard precautions are based on the principle that all . body fluids, secretions, . may contain transmissible infectious agents. Observations on all days of survey showed a thick layer of dust on the personal fan in Resident #26's room and an unidentified brown substance on the wall beside the resident's bed. During an interview on 09/08/25 at 1:08 p.m., Resident #26 stated he could not use the bed pan for bowel movements, I blew it all over, look at the wall it's still on there. - Observation on all days of survey showed a refrigerator located in Resident #14 and #19's room. The refrigerator emitted a strong foul odor. The thermometer in the refrigerator read 78 degrees Fahrenheit. Both residents stated it was not their refrigerator, and Resident #19 stated, It was my prior roommates. - Observation on 09/09/25 at 9:52 a.m. showed food crumbs on Resident #5's wheelchair. A certified nurse aide (CNA) (#3) assisted the resident from the toilet, and without cleaning the cushion placed the resident back in the soiled wheelchair. -Observation of Resident #6's room on 09/09/25 at 10:00 a.m., showed crumbs covering the wheelchair seat pad and a shirt laying on the floor. During an interview on 09/11/25 at 1:40 p.m., two administrative staff members (#1 and #10) stated they expected staff to clean resident fans weekly, clean dirty walls, and remove nonfunctioning appliances immediately from resident rooms.

Based on review of the facility reported incident (FRI) investigation, record review, review of facility policy, and staff interview, the facility failed to provide an environment free of mental/physical abuse for 1 of 1 sampled resident (Resident #1) Failure to prevent Resident #1 form the abusive actions of other residents (Resident #2 and #3) resulted in Resident #1 experiencing fear, anxiety, and injury.During the on-site FRI investigation survey, the team consulted with the State Survey Agency (SSA) on 07/10/25 at 12:19 p.m. and determined an immediate jeopardy (IJ) situation existed on 04/30/25. The facility failed to protect residents from abuse which resulted in resident-to-resident altercations. * 07/10/25 at 12:55 p.m., the survey team notified the Administrator and Director of Nursing (DON) of the IJ situation, provided the IJ template, and requested a removal plan for the IJ. * 07/10/25 at 3:30 p.m., the survey team reviewed and accepted the facility's removal plan. *07/16/25, the survey team verified the implementation of the removal plan and the IJ removal. The deficient practice remained at a G scope and severity following the IJ removal.The removal plan contained the following: * Resident #1 will have 1:1 supervision when mobile in his wheelchair.* The physician referred Resident #1 to Rural Psych Associates.* All staff received education on abuse, resident-to-resident altercations, and reporting. Findings include:Review of the facility policy titled Abuse and Neglect occurred on 07/10/25. This policy, dated April 2025, stated, . The resident . has the right to be free from abuse . residents . must not be subject to abuse by anyone, including, . other residents . Review of Resident #1's medical record occurred on 07/10/25. Diagnoses included Alzheimer's disease, dementia, and anxiety disorder. An annual Minimum Data Set (MDS), dated [DATE], identified the resident severe cognitive impairment. The current care plan identified, . has impaired cognitive function . or impaired thought processes . E/B [evidenced by] confusion, short- and long-term memory loss . Review of Resident #2's medical record occurred on 07/10/25. Diagnoses included dementia, impulsiveness, and expressive language disorder. A quarterly MDS, dated [DATE], identified severe cognitive impairment. The current care plan identified, . becomes uncomfortable at times with groups of people/loud areas E/B raises his voice, yells and at times curses . does not like to be touched by other resident's . h/o [history of] resident to resident interactions . Review of Resident #3's medical record occurred on 07/10/25. Diagnoses included behavioral and emotional disorders. A quarterly MDS, dated [DATE], identified severe cognitive impairment. The current care plan identified, . has hallucinations/delusions . verbal behaviors .-The FRI, dated 04/30/25, stated, . [Resident #1] was sitting in wheelchair in E/W [east/west] commons area next to [Resident #2] who was also sitting in his wheelchair. [Resident #2] grabbed this resident's shirt sleeve and hit him multiple times with a closed fist.Review of facility video footage, dated 04/30/25, showed Resident #2 backed up and parked his wheelchair in front of the nurse's station. Resident #1 propelled his wheelchair toward Resident #2, grabbed his wheelchair, and moved him forward. Resident #2 grabbed Resident #1's sleeve and punched him in the arm three times with a closed fist before staff intervened.-The FRI, dated 05/03/25, stated, . [Resident #1] told [Resident #2] to move old man and then . [Resident #1] was observed slapping at [Resident #2's] hands and forearms. [Resident #2] . slapped back before staff intervened.Review of facility video footage, dated 05/03/25, showed Resident #2 in his wheelchair near the dining room entrance. Resident #1 attempted to propel his wheelchair past Resident #2 and flinched when Resident #2 gestured, like he was going to strike him. Resident #1 attempted to propel his chair past Resident #2, when Resident #2 grabbed his wheelchair and started slapping him. Resident #1 retaliated by slapping Resident #2 before staff intervened. -The FRI, dated 07/06/25, stated, . Floor nurse heard commotion, and two residents [Resident #1 and Resident #3] swearing at each other in the hallway by the conference room. The floor nurse turned the corner and found [Resident #1] tipped backwards in his wheelchair holding his head.Review of facility video footage, dated 07/06/25, showed Resident #1 in his wheelchair and Resident #3 approached him from behind. Resident #1 was attempted to propel his wheelchair forward when Resident #3 grabbed/tipped his chair and put her arm around his neck as he leaned backwards in her lap. During an interview on 07/10/25 at 1:00 p.m., two administrative staff members (#1 and #2) confirmed the altercations occurred and the altercation on 07/06/25 resulted in a large hematoma to the back of Resident #1's head requiring an emergency room visit. Facility staff failed to supervise residents and implement interventions in an effort to prevent Resident #1 from mental and physical abuse from other residents in the facility.

Based on review of the facility reported incident (FRI) and review of facility policy, the facility failed to conduct a thorough investigation of physical abuse for 3 of 3 sampled residents (Resident #1, #2, and #3). Failure to investigate all allegations of abuse and ensure all residents were protected during the investigation placed Residents #1, #2, and #3 and all facility residents at risk for possible abuse, mental an emotional distress, and/or physical injury. thoroughly investigate allegations of abuse for 1 of 1 sampled resident (Resident #1). Failure to thoroughly investigate all abuse allegations, ensure Resident #1 was protected during each investigation, and implement corrective actions/evaluate their effectiveness following each investigation, placed Resident #1 and other residents at risk for possible abuse. Findings include: Review of the facility policy titled Abuse and Neglect occurred on 07/10/25. This policy, dated April 2025, stated, . 6. The investigation team . will review all events no later than the next working day following the event. 7. Ensure that someone is assigned to complete the investigation and that the care plan has been updated with any new interventions . 8. The investigation may include interviewing employees, residents/clients or other witnesses to the event.The FRI, dated 04/30/25, stated, . [Resident #1] was sitting in wheelchair in E/W [east/west] commons area next to [Resident #2] who was also sitting in his wheelchair. [Resident #2] grabbed this resident's shirt sleeve and hit him multiple times with a closed fist. The FRI investigation report, dated 05/03/25, stated, . [Resident #1] told [Resident #2] to move old man and then . [Resident #1] was observed slapping at [Resident #2's] hands and forearms. [Resident #2] . slapped back before staff intervened.The FRI investigation report, dated 07/06/25, stated, . Floor nurse heard commotion, and two residents [Resident #1 and Resident #3] swearing at each other in the hallway by the conference room. The floor nurse turned the corner and found [Resident #1] tipped backwards in his wheelchair holding his head.The facility lacked evidence of thorough investigations related to abuse and failed to protect all residents during the investigation.

Based on record review, the facility failed to provide necessary care and services for 1 of 1 closed record (Resident #1) who experienced multiple medical incidents and a decline in health status. Failure to notify the provider and resident representative of the initial choking event and further medical incidents, delayed physician and representative input for testing/monitoring/treatment, contributed to the resident's decline followed by hospitalization, and may have contributed to the resident's subsequent death. Findings include: Review of Resident #1's medical record occurred on 05/13/25. A Minimum Data Set (MDS)Assessment, dated 03/10/25, identified severely impaired cognition, and dependent on staff for all activities of daily living (ADLs). Review of Resident #1's progress notes identified the following: * 03/22/25 at 8:45 a.m. Resident had choking episode. This nurse performed Heimlich [a first aid procedure used to dislodge an obstruction from a person's windpipe] on resident. Resident expelled a small chunk of food and large amount of phlegm. No adverse effects noted. * 03/24/25 at 9:26 a.m. Trial run of pureed food until diet order can be changed. * A fax to Resident #1's medical provider, dated 03/31/25, stated, . Resident continually yells out. Does not answer if asked questions such as if she needs something for pain. This behavior is not normal for her. It started on 3-30-25. The fax addressed the resident's new onset behaviors but failed to include the resident's choking episode on 03/22/25. * 03/31/25 at 1:45 p.m. Dietary is doing a trial of pureed diet to see how she does . Plan to continue to monitor & follow up in 1 month. * 04/4/25 at 3:37 p.m. [Resident #1's name] urine is very strong. Please push water and cranberry juice over the weekend. * 04/10/25 at 12:23 a.m. During routine rounds resident was discovered making usual loud, incomprehensible noises but with a somewhat wet sound. Pt [patient] discovered to have vomited their dinner up . CNA [certified nurse aide] had already begun attending to resident's needs. Resident placed in high-fowler's [semi-sitting position where the head of the bed is elevated between 60 and 90 degrees] and oral suctioning provided with minimal vomitus suctioned into Yaunkur [medical tool used for suctioning secretions from the mouth and throat] [sic] tubing. Resident w/ [with] no verbally expressed needs. resident's lungs w/congestion noted to all four fields. Resident's v/s [vital signs] obtained and found to be hypotensive (abnormally low blood pressure] and tachycardic [fast heart rate]. Resident w/ no other complaints throughout shift. Resident slept remainder of shift. The facility failed to contact the resident's provider and representative related to vomiting, low blood pressure, and tachycardia. * 04/10/25 . 0626 [6:26 a.m.] - Aide [CNA] came to this nurse to report . 79% [oxygen saturation] RA [room air] 0630 [6:30 a.m.] This nurse completed assessment; crackles to all lung fields with externally audible bubbling, O2 [oxygen] sats [saturation] rechecked via finger and ear with reading of 78% and 79%. O2 via NC [nasal cannula] at 3L[liters]/min [per minute] administered. 0635 [6:35 a.m.] - O2 rechecked via ear with reading of 82% 0640 [6:40 a.m.] - Family notified 0648 [6:48 a.m.]- Resident transported to ER [emergency room] 0650 [6:50 a.m.] . The medical record failed to document a provider's notification and order for transport to the ER. * 04/10/25 at 2:45 p.m. Late entry 1130 [11:30 p.m.] Received report from . [name of hospital]. Resident will be admitted to comfort cares r/t [related to] aspiration . and sepsis. The medical record failed to show facility staff consistently notified the provider and obtained orders to ensure proper care and services were provided to the resident after the choking episode, change of diet, odorous urine, and the change in condition on 04/10/25 at 12:23 a.m.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician and/or resident representative of a change in condition for 1 of 1 closed record (Resident #1) who experienced a choking episode and 1 of 3 sampled residents (Resident #2) with a skin tear. Failure to notify the physician and/or resident representative of changes in condition may have prevented the physician from altering treatment/care and prevented the resident representative from making informed decisions regarding medical care. Findings include: Review of the facility policy titled Notification of Change occurred on 05/13/25. This policy, dated December 2024, stated, . The facility must immediately . consult with the resident's physician and notify . the resident representative(s) when there is . A significant change in the resident's physical . status . A need to alter treatment significantly - a need to discontinue or change an existing form of treatment or to commerce a new form of treatment. - Review of Resident #1's medical record occurred on 05/13/25. The nurses' notes identified the following: * 03/22/25 at 8:45 a.m. Resident had choking episode. This nurse performed Heimlich [a first aid procedure used to dislodge an obstruction from a person's windpipe] on resident. Resident expelled a small chunk of food and large amount of phlegm. No adverse effects noted. * 03/24/25 at 9:26 a.m. Trial run of pureed food until diet order can be changed. * 04/04/25 at 3:37 p.m. [Resident #1's name] urine is very strong. Please push water and cranberry juice over the weekend. * 4/10/25 at 12:23 a.m. During routine rounds resident was discovered making usual loud, incomprehensible noises but with a somewhat wet sound. Pt [patient] discovered to have vomited their dinner up . Resident's light was already on as CNA [certified nurse aide] had already begun attending to resident's needs. Resident placed in high-fowler's [semi-sitting position where the head of the bed is elevated between 60 and 90 degrees] and oral suctioning provided with minimal vomitus suctioned into Yaunkur [medical tool used for suctioning secretions from the mouth and throat] (sic) tubing. Resident w/ [with] no verbally expressed needs. resident's lungs w/congestion noted to all four fields. Resident's v/s [vital signs] obtained and found to be hypotensive [abnormally low blood pressure] and tachycardic [fast heart rate]. Resident w/ [with] no other complaints throughout shift. Resident slept remainder of shift. * 04/10/25 at 6:58 a.m. 0626 [6:26 a.m.] - Aide [CNA] came to this nurse . 79% [oxygen saturation] RA [room air] 0630 [6:30 a.m.] This nurse completed assessment; crackles to all lung fields with externally audible bubbling, O2 [oxygen] sats [saturation] rechecked via finger and ear with reading of 78% and 79%. O2 via NC [nasal cannula] at 3L[liters]/min [per minute] administered. 0635 [6:35 a.m.] - O2 rechecked via ear with reading of 82% 0640 [6:40 a.m.] - Family notified 0648 [6:48 a.m.]- Resident transported to ER [emergency room] 0650 [6:50 a.m.] . Resident #1's medical record failed to show the facility informed the resident's physician and representative of the choking episode, change in urine, and acute changes in the resident's status. - Review of Resident #2's medical record occurred on 05/13/25. A nurse's note, dated 04/23/25 at 11:39 a.m., stated, . Resident observed to have ST [skin tear] to posterior [back] upper Lt [left] leg near gluteal [buttock] crease measures approximately 0.3 cm [centimeters] in length by 0.5 cm in width measurements are approximate as Resident was moving . during measurement. Skin approximated [pulled together] and tegaderm [type of dressing] applied. Resident #2's medical record failed to identify the facility informed the resident's representative of the skin tear. During an interview on 05/13/25 at 4:28 p.m., an administrative nurse (#2) stated she/he would expect facility staff to notify Resident #1's medical provider and resident representative of the choking episode, change in urine, and acute changes in the resident's condition, and notify Resident #2's representative about the skin tear.

Based on record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and interventions to prevent accidents for 1 of 1 closed record (Resident #4) reviewed for falls. Failure to implement and monitor the effectiveness of fall prevention interventions, modify the care plan as necessary, and implement new interventions resulted in Resident #4's continued falls, pain, and subsequent fracture. Findings include: Review of the facility policy, Fall Prevention and Management - Rehab[rehabilitation]/Skilled, Therapy and Rehab, occurred on 07/16/24. This policy, dated 04/02/24, stated, PURPOSE: *To promote resident well-being by developing and implementing a fall prevention and management program. Proactive Approach before a Fall Occurs . Procedure. 2. Complete the Falls Tool . for fall screening and identifying fall risk factors. 3. Care Plan the appropriate interventions . 4. Communicate fall risks and interventions to prevent a fall before it occurs per . care plan and Kardex . For Fallen Resident . Procedure . 11. Complete the Falls Tool . 17. Review and update the Care Plan with any changes/new interventions. 19. Continue to monitor condition and the effectiveness of the interventions. Review of Resident #4's medical record occurred on 07/16/24. A fall assessment completed on 02/12/24 identified Resident #4 as high risk for falls. Review of Resident #4's care plan stated, Focus: The resident is at risk for falls R/T [related to] cognitive loss, balance deficits, visual deficit. Goal: The resident will be free of falls through the review date. The care plan identified two interventions since admission, Interventions: Educate resident/family about safety reminders and what to do if a fall occurs [initiated 02/27/24]. Provide fall mat to bedside [initiated 04/01/24]. Review of nurses' notes related to Resident #4's falls identified the following: * 03/22/24 at 10:50 a.m., CNA [certified nurse aide] called writer . for resident found on floor in room. Resident laying on blanket on left side of body when writer entered. Vitals stable. Hoyer pad put under resident and mechanical lift used to assist resident back to bed . * 03/29/24 at 6:51 p.m., Resident's Grandson came to visit resident and saw her on the floor and called for assistance. Resident was lying on the floor on her back. Resident was able to move all extremities with no restriction or sign of pain. Resident was not able to follow commands. Resident had slur [sic] speech. Resident was transferred from floor to her wheelchair using a Hoyer assisted by 3. [Name of physician] was notified by fax. * 03/30/24 at 9:17 a.m., This morning, this nurse went to assess resident and noticed bruises on right hip, right ribs, back and coccyx. Resident's son . notified . * 03/31/24 at 2:48 p.m., Resident observed lying on floor in resident's room. Unable to determine cause of fall due to resident's cognitive status and disorientation. No obvious signs of new injuries. Staff advised to keep resident at nurses station or in the common area with other residents for safety. Record showed staff failed to update the care plan regarding this intervention. * 03/31/24 at 9:13 p.m., Who did you talk to/notify?: [names of Resident #4's son and daughter] . [name of daughter] asked this nurse if resident could be seen in the clinic for an x-ray of her right arm. Resident c/o [complains of] pain with ROM. [Name of son] notified . agreed to have her seen. This nurse will place in the appointment book to call for an appointment. * 03/31/24 at 9:46 a.m., Resident disoriented during this night shift. C/o pain to rt [right] arm elbow area. Bruising . noted. Painful to ROM. Family would like a clinic appointment. * 04/01/24 at 12:42 p.m., Returned from appointment at clinic. New orders received. Ice to elbow 3 times day x [times] 1 week. Tylenol 500mg [milligram] po [by mouth] 3x day x 1 week. * 04/01/24 at 11:19 p.m., Staff reported to this nurse that when doing PM [evening] cares it took two aides. Resident is very disoriented, fidgety, and impulsive all PM shift. Could not move whole right side of her body while doing cares. Cried out in pain from her arm. PRN [as needed] Tylenol administered by CMA [medication aide] per this nurse. * 04/04/24 at 5:57 p.m., Resident was sitting on her w/c in the activity area. CNA saw resident trying to get up from w/c and fell forward on her head. Resident had a bump on her forehead right side of 5 cms [centimeters] in diameter and 1 cm high. Resident was complaining of right arm and back pain. Resident is on Plavix [blood thinning medication] and ER was call [sic] for advice which recommended to send resident in to ER. [Name of son] was notified about fall and agreed to send resident to ER. * 04/04/24 at 5:49 p.m., Nurse from ER called to notify that resident was ready to go back to the nursing home. A head scan was done and was negative. Son was notified. * 04/10/24 at 7:50 a.m., This nurse summoned to resident's room. [Names of two certified nursing aides] . in room with resident. Resident was lying in the middle of the floor on her back. ROM was that as before. No injuries noted. She had non-grip socks on, and a blanket was lying on the floor between resident and the bed. * 04/10/24 at 11:29 a.m., Resident was seen for focus visit by [name of physician] . * 04/10/24 at 5:40 p.m., Nurse was called into resident's room around 1700 [5:00 p.m.]. Family was concerned of resident's right arm being warm to touch and of her swollen right ankle. Doctor was called and told nurse it was up to family if they wanted her to be seen tonight by the emergency room or tomorrow in the clinic. Family chose to have her seen tonight via ER. 911 called at 1720 [5:20 p.m.] to pick up and transfer resident. 04/10/24 at 9:29 p.m., Resident returned from [Name of hospital] ER . Resident has right elbow fracture. Denies pain at this time. Resident has a sling to right arm at this time. Review of Fall Tool documents, completed for each of Resident #4's falls identified the following: * 03/22/24 - . Action Plan: Check all that apply: Update care plan .(No additional interventions noted on care plan)* 03/29/24 - . Action Plan: Check all that apply: Refer to provider/practitioner.(No additional interventions noted on care plan) * 03/31/24 - . Action Plan: Check all that apply: [nothing checked] .('Provide fall mat to beside' added on 04/01/24)* 04/04/24 - . Action Plan: Check all that apply: [nothing checked] .(No additional interventions noted on care plan)* 04/10/24 - . Action Plan: Check all that apply: Update care plan .(No additional interventions noted on care plan) Along with the fall prevention policy, an administrative nurse (#1) provided a document titled, Suggested Resident Interventions to Manage Falls. This undated document identified several different interventions to implement based on the following categories: Fall from bed (resident able to transfer and resident unable to transfer), fall out of wheelchair, falls with cognitively impaired residents, falls for ambulatory residents, and residents with multiple falls. Resident #4 experienced five falls from March 22 to April 10, 2024, and the facility failed to implement any of the several interventions, other than a fall mat. During an interview on the afternoon of 07/26/24, an administrative nurse (#2) confirmed the staff had not updated the care plan with new interventions.

Based on observation; information received from the complainant; review of the North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights; and resident, family, and staff interview, the facility failed to treat residents with respect and dignity and care for residents in a manner and an environment that promotes, maintains, or enhances of their quality of life for 4 of 10 sampled residents (Resident #1, #2, #3, and #9) and 6 supplemental residents (Resident #13, #14, #15, #18, #19, and #20). Failure to protect residents from wandering and aggressive residents and the unwanted physical touch of a visitor violated their right to live in a safe environment free from abuse/neglect and resulted in negative psychosocial outcomes. During the on-site complaint survey, the team determined an Immediate Jeopardy (IJ) situation existed on 05/17/23 at 3:34 p.m. The IJ resulted from multiple resident interviews and observations regarding wandering and physically aggressive residents, and a visitor who comes to the facility. These findings placed residents in situations of feeling afraid and anxious in the environment causing the potential for negative psychosocial outcomes. * 05/17/23 at 4:45 p.m. - The survey team notified the administrator and director of nursing of the IJ situation and requested they develop a plan for removal of the immediate jeopardy. * 05/18/23 at 3:41 p.m. - The survey team reviewed and accepted the facility's removal plan for the IJ. * 05/23/23 at 5:55 p.m. The team notified the administrator of the IJ removal. * On 05/23/23, the survey team verified the implementation of the removal plan and the IJ removal on 05/18/23. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: The North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, updated 03/21/23, stated, . You cannot be subjected to verbal, sexual, physical, or mental abuse . You have the right to safe, clean, and comfortable surroundings . Information received from the complainant identified concerns with aggressive/combative resident behaviors and wandering residents. The complainant stated a resident has hit other residents and staff and some residents are afraid to come out of their rooms. The complainant stated the wandering resident enters other residents' rooms at night, which scares them, and often takes their belongings. The complainant voiced concerns about a visitor who comes to the facility and touches residents' faces, hands, and shoulders without permission, some of whom are non-verbal. - During an interview on 5/16/23 at 3:11 p.m., Resident #9 stated she has fears, anxiety, anger, and sometimes does not sleep due to other residents that reside within the facility. When they [Residents #5, #6, and #8] are in my room or around me my anxiety shoots up to a ten plus-plus. I have brought my concerns to Resident Council, but nothing is done about it. - During an interview on 05/16/23 at 4:00 p.m., a staff member (#15) stated a visitor comes daily and is often seen touching the residents' faces and shoulders. She stated she observed the visitor caressing Resident #15's face, and the resident looked scared, I saw her face. She stated the visitor came yesterday and was trying to touch two residents. One of the residents became very upset, she [the resident] was going to get up and hit him. The resident stated, Get the hell out of here and Don't touch me! The other resident stated the visitor does this (touches them) often, and it makes her uncomfortable. The staff member (#15) further stated she has seen the visitor alone in residents' rooms, and one of the residents is not coherent, she wouldn't be able to say if something happened. The staff member (#15) identified an incident when a resident (Resident #4) slapped another resident (Resident #5). The staff member (#15) stated staff do report incidents and voiced concerns regarding a lack of administrative follow-up after reporting of the incidents. - Observation on 5/16/23 at 4:07 p.m. showed the visitor identified in the complaint in the north lounge. He touched Resident #13's face while she played cards. He then stood near the residents playing cards and stared at them for some period of time. The visitor then sat beside Resident #14 and touched her face and hands multiple times and the resident pulled her hands away. Observation showed no facility staff present. - During an interview on 05/16/23 at 4:40 p.m., Resident #2 stated, I don't feel safe here. It's very scary. Resident #2 stated there are several mental patients. Regarding the visitor's interactions with residents, Resident #2 stated, It is inappropriate. He is a problem. He doesn't want to leave. Resident #2 stated the residents have reported these concerns in Resident Council, and have stated, We [the residents] don't feel safe here. - Observation in the dining room on 05/16/23 at 4:51 p.m. showed the visitor stood by Resident #15 holding onto the side of her wheelchair. Resident #15, visibly upset, stated, [Visitor name], no, stop! The visitor then moved to another table of residents, touched their shoulders, and came back to stand beside Resident #15 again. - During an interview on 05/16/23 at 5:05 p.m., Resident #1 stated she has seen Resident #5 hit other residents and staff, and is often unsupervised while wandering in the hallways, entering residents' rooms. Resident #1 stated on one occasion, Resident #5 was on a rampage, and the facility had to call the cops and emergency medical services. Resident #1 expressed frustration that Resident #5 returned to the facility a few hours later and was allowed to wander the hallways unsupervised again. Resident #1 further stated, [The staff] don't do anything, they just redirect. What good does that do? - During an interview on 05/17/23 at 8:05 a.m., Resident #3 stated Resident #8 often enters her room at night. She woke up at 3:00 a.m. and Resident #8 was standing over her bed. When asked if she was afraid, Resident #3 stated, Oh, yeah. My heart skipped quite a few beats. She stated Resident #5 hasn't hit her yet but has given [me] mean looks. You don't know from one minute to the next if they'll smile or hit you. Resident #3 further stated, This is getting way out of hand. I don't feel a bit safe here. I walk on pins because I'm afraid. Regarding the visitor, Resident #3 stated, He gives me the creeps. He grabbed the back of my neck once. I let out a [NAME], and he just laughed. They asked him to leave once and he wouldn't. Resident #3 stated the visitor has touched her many times, it was unwelcome, and it feels creepy. Resident #3 added, I didn't like that, it's inappropriate. - During an interview on 5/17/23 at 8:16 a.m., Resident #14 stated she knows the visitor and does not care to talk with him or have him around her. - During an interview on the morning of 05/17/23, Resident #20 reported she did not feel safe at the facility due to wandering and aggressive residents (Resident #5, #6, and #8). - During an interview on 05/17/23 at 2:00 p.m., Resident #19 stated, I am afraid of [Resident #5]. - During an interview with the family of Resident #18 on 5/17/23 at 2:25 p.m., the family members voiced concerns of Resident #8 coming in and out of their mother's room, touching things, and sleeping in their mother's bed. The family also voiced concerns related to the visitor being around their mother and stated, We do not want our mother touched by this man, we don't want him around her. During the onsite complaint investigation, resident and staff interviews identified concerns with wandering and aggressive residents, and a visitor who comes to the facility nearly every day. The behaviors of wandering and aggressive residents and the actions of the visitor violated the residents' right to a dignified existence in a safe environment that is free from abuse and neglect and placed residents at risk for psychosocial harm. Refer to F565, F600, and F744.

Based on observation; information received from the complainant; record review; review of facility policy; and resident, family, and staff interview, the facility failed to ensure residents remained free from physical abuse and neglect for 4 of 10 sampled residents (Resident #1, #2, #3, and #9) and 6 supplemental residents (Resident #13, #14, #15, #18, #19, and #20) and failed to protect 2 of 2 sampled residents from resident to resident abuse (Resident #5 and #7). Failure to provide services necessary to avoid mental anguish and emotional distress resulted in fear, anxiety, an unsafe environment for residents, and actual psychosocial harm. During the on-site complaint survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on 05/17/23 at 3:34 p.m. The IJ situation resulted from multiple resident concerns regarding wandering and physically aggressive residents, as well as a visitor who comes to the facility. This finding placed residents in immediate danger due to unresolved fear, anxiety, and an unsafe environment. * 05/17/23 at 4:45 p.m. - The survey team notified the administrator and director of nursing of the IJ situation and requested they develop a plan for removal of the immediate jeopardy. * 05/18/23 at 3:41 p.m. - The survey team reviewed and accepted the facility's written plan of correction for the IJ situation. * 05/23/23 at 5:55 p.m. - The survey team removed and reduced the IJ situation from a scope/severity of K to a scope and severity of E. Findings include: Information received from the complainant identified concerns with aggressive/combative resident behaviors and wandering residents. The complainant stated a resident has hit other residents and staff and some residents are afraid to come out of their rooms. The complainant stated the wandering resident enters other residents' rooms at night, which scares them, and often takes their belongings. The complainant voiced concerns about a visitor who comes to the facility and touches residents' faces, hands, and shoulders without permission, some of whom are non-verbal. Review of the facility policy titled Abuse and Neglect occurred on 05/24/23. This policy, dated 10/13/22, stated, . Purpose . To ensure the location has an effective system in place that, regardless of the source, prevents mistreatment, neglect, exploitation, and abuse of residents and misappropriation of their property . To ensure that residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals . Alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse including injuries of unknown origin will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services. These designated individuals are delegated the authority by the administrator to: 1. Intervene in any situation in order to protect the residents. 2. Remove any individual from the location if necessary for the protection of residents or employees, including but not limited to employees, visitors, contractors, or family members. 3. Call local law enforcement for assistance with interventions necessary for the protection of residents or employees. 4. Call 911 for any type of emergency assistance. The location will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in process. - Observation on 05/16/23 at 11:43 a.m., showed Resident #6 yelling profanities by the dining room entrance, hitting the wall, and banging the phone on the wall. The resident then walked into dining room, continuing to yell profanities and throwing her walker. Staff observing made no attempts to intervene. - During an interview on 5/16/23 at 3:11 p.m., Resident #9 stated she has fears, anxiety, anger, and sometimes does not sleep due to other residents that reside within the facility. Resident #9 stated, At night when I can't sleep it's because I'm afraid to wake up and see who is standing above me. She goes onto state During the day when I'm in my chair I am helpless because I can't move. I've had residents [#5, #6, and #8] in my room all at one time fighting with each other, picking up my things, and yelling profanities, one time [Resident #5 name] came rushing at me, I thought she was going to hit me but all she did was throw my oximeter at me. Resident #9 states that shes does put on her call light, but it doesn't get answered for some time and by then one of these residents could have hit her or taken/broken her things. When they [Residents #5, #6, and #8] are in my room or around me my anxiety shoots up to a ten plus-plus. I have brought my concerns to Resident Council, but nothing is done about it. - During an interview on 05/16/23 at 3:30 p.m. with Resident #9, observtion showed Resident #5 and #8 entered the room without knocking. The residents picked up Resident #9's belongings and moved them around. Resident #5 approached Resident #9 and touched her things on her overbed table. Resident #9 asked the residents to leave her room, but they continued to linger, argue, and eventually left the resident's room. Resident #9 expressed anxiety and angry and wished something could be done about this. - During an interview on 05/16/23 at 4:00 p.m., a staff member (#15) stated a visitor comes daily and is often seen touching residents' faces and shoulders. She stated she observed the visitor caressing Resident #15's face, and the resident looked scared, I saw her face. She stated the visitor came yesterday and was trying to touch two residents. One of the residents became very upset, she [the resident] was going to get up and hit him. The resident stated, Get the hell out of here and Don't touch me! The other resident stated the visitor does this (touches them) often, and it makes her uncomfortable. The staff member (#15) further stated she has seen the visitor alone in residents' rooms, and one of the residents is not coherent, she wouldn't be able to say if something happened. The staff member further identified an incident of a resident (Resident #4) slapping another resident (Resident #5). The staff member stated staff do report incidents and voiced concerns regarding a lack of administrative follow-up after reporting of the incidents. - Review of Resident #5's medical record occurred on all days of survey. A nurse's note, dated 05/06/23, stated, . Res. continues to walk into other residents [sic] rooms. She was slapped in the face by another resident today in the evening for wanting to take her walker. No injuries. They were both redirected. Refer to F607. - Observation on 5/16/23 at 4:07 p.m. showed the visitor identified in the complaint in the north lounge. He touched Resident (#13) face while she played cards. He then stood near the residents playing cards and stared at them for some period of time. The visitor then sat beside Resident #14 and touched her face and hands multiple times and the resident pulled her hands away. Observation showed no facility staff present. - During an interview on the afternoon of 05/16/23, a staff member (#17) identified the visitor has touched her butt during one of his visits. She reported the incident to administration but no action was taken. - During an interview with Resident #2 on 05/16/23 at 4:40 p.m., the resident stated, I don't feel safe here. It's very scary. Resident #2 stated there are several mental patients. She stated Resident #6 is rowdy, cussing and swearing. [She is] fine one minute, and then she freaks out. They had to call the cops. She stated regarding Resident #8, Half the time, they can't find her. She goes in everyone's rooms, finds an empty bed and she's sleeping in it. She steals things, and [the items] end up in someone else's room. Resident #2 stated she was sleeping, and I woke up and she's [Resident #8] standing over me. Resident #2 stated regarding Resident #5, All of a sudden she'll lash out. She's real feisty. She's punched staff. Resident #2 stated Resident #5 tried to hit me a month ago. I protected myself with my walker, and [Resident #5] came up to me and started hitting at me, she's been in my room several times. Regarding the visitor, Resident #2 stated, It [his touching of residents and staff] is inappropriate. He is a problem. He doesn't want to leave [when he visits]. Resident #2 stated the residents have reported these concerns in Resident Council, and have stated, We [the residents] don't feel safe here. - Observation in the dining room on 05/16/23 at 4:51 p.m., showed the visitor stood by Resident #15 holding onto the side of her wheelchair. Resident #15 was visibly upset, stated, [Visitor name], no, stop! The visitor then moved to another table of residents, touched their shoulders, and came back to stand beside Resident #15 again. - During an interview with Resident #1 on 05/16/23 at 5:05 p.m., the resident stated Resident #8 has come into her room many times, she threw a shoe at her once, and she takes things that don't belong to her from other resident's rooms. Resident #1 reported that Resident #5 hits other residents and staff. Resident #1 stated, If she (Resident #5) ever tried anything, I wouldn't be able to fend for myself. The resident further stated, Afraid? Not exactly, but I would say cautious. They (Resident #5, #6, and #8) make me uneasy. Regarding the visitor, Resident #1 stated he weirds them (the residents) out. - During an interview with Resident #3 on 05/17/23 at 8:05 a.m., the resident stated Resident #8 often enters her room at night. She woke up at 3:00 a.m. and Resident #8 was standing over her bed. When asked if she was afraid, Resident #3 stated, Oh, yeah. My heart skipped quite a few beats. She stated Resident #5 hasn't hit her yet but has given [me] mean looks. You don't know from one minute to the next if they'll smile or hit you. Resident #3 further stated, This is getting way out of hand. I don't feel a bit safe here. I walk on pins because I'm afraid. Regarding the visitor, Resident #3 stated, He gives me the creeps. He grabbed the back of my neck once. I let out a [NAME], and he just laughed. They asked him to leave once and he wouldn't. Resident #3 stated the visitor has touched her many times, it was unwelcome, and it feels creepy. Resident #3 added, I didn't like that, it's inappropriate [for him to touch her]. - During an interview on 5/17/23 at 8:16 a.m., Resident #14 stated she knows the visitor and does not care to talk with him or have him around her. - Observation on 05/17/23 at 8:45 a.m., showed Resident #6 in the main hallway by the dining room. The resident picked up her front wheeled walker (FWW) and threw it down the hallway where other residents were present. - During an interview on the morning of 05/17/23, Resident #20 reported she did not feel safe at the facility due to wandering and aggressive residents (Resident #5, #6, and #8). - During an interview on 05/17/23 at 2:00 p.m., Resident #19 stated, I am afraid of [Resident #5]. - During an interview with the family of Resident #18 on 05/17/23 at 2:25 p.m., the family members voiced concerns of Resident #8 coming in and out of their mother's room, touching things, and sleeping in their mother's bed. The family also voiced concerns related to the visitor being around their mother and stated, We do not want our mother touched by this man, we don't want him around her. - Review of facility incident reports occurred on 05/24/23. A report, dated 04/25/23, stated, . This resident [Resident #7] was hit with a closed fist to the chest by [Resident #5] while he was doing exercises. Another report, dated 04/25/23, stated, . Resident [#5] walked into therapy room and grabbed resident [#7] by the shirt and punched resident with a closed fist. - During an interview on 05/17/23 at 2:55 p.m., when asked if other residents come into his room Resident #7 stated, [Expletive] yeah but I'm not afraid of them, I'm just gonna [expletive] hit them and that will keep them from coming back. During an interview on 05/17/23, a social services staff member (#14) stated the visitor makes some residents and staff uncomfortable, and He scares other residents. He just sits there and stares at them. The staff member stated the residents brought up the visitor at Resident Council last week. The staff member also stated there have been issues of Resident #5 hitting staff or hitting other residents. The staff member identified she has reported the incidents to management but has not gotten a response. During an interview on 05/17/23 at 12:15 p.m., the facility's medical director stated she was unaware of the visitor coming to the facility, and agreed his behavior was inappropriate. The facility failed to protect residents from wandering and combative residents and the unwanted physical touch of a visitor. These failures resulted in fear, anxiety, an unsafe environment for residents, and actual psychosocial harm. Refer to F550, F565, F607, and F744. 40489 46477

Based on observation, information received from the complainant, record review, and resident and staff interview, the facility failed to ensure an environment free of accident hazards for 1 of 1 coffee/hot water machine in the dining room. Failure to ensure appropriate coffee/water temperatures resulted in serving temperatures above the acceptable range and may result in serious burns/injuries to residents. During the on-site complaint survey, the team determined an Immediate Jeopardy (IJ) situation existed on 05/17/23 at 3:34 p.m. The IJ resulted from temperature readings obtained from the coffee/hot water machine, a lack of temperature monitoring by staff, and an injury to a resident. This finding placed residents in immediate danger due to hot temperatures and the potential for serious burns. * 05/17/23 at 4:45 p.m. The survey team notified the administrator and director of nursing of the IJ and requested they develop a plan for removal of the immediate jeopardy. * 05/18/23 at 3:41 p.m. The survey team reviewed and accepted the facility's removal plan for the IJ. * 05/23/23 at 5:55 p.m. The team notified the administrator of the IJ removal. (can you say this) *On 05/23/23, the survey team verified the implementation of the removal plan and the IJ removal on 05/18/23. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Information received from the complainant identified concerns with the temperatures of food/drink served in the dining room, and a resident sustaining a burn due to hot coffee. Observation in the main dining room occurred on 05/16/23 at 11:52 a.m. A staff member brought a cup of hot water and a lid to Resident #17 and made tea. The staff member placed the lid on the table instead of putting it on the resident's cup. Another resident stated to her tablemate, Be careful, it's hot [referring to her cup of tea]. Mine is really hot. -Review of Resident #17's care plan occurred on 05/16/23 and identified, . HOT BEVERAGE AND SOUP SAFETY: Assist/supervise resident with all hot beverages by providing safety cup for coffee at meals . On the afternoon of 05/16/23, the survey team measured the temperature of the coffee, which read 169 degrees Fahrenheit (F). The hot water temperature measured 167.8 degrees F. - Review of Resident #16's medical record occurred on 05/17/23. A nurse's note, dated 04/30/23 at 9:15 a.m. stated, . LATE ENTRY . observe wet coffee stain on resident shirt. skin directly under stain mid chest area red blanchable skin intact no blisters or abnormalities noted at this time. resident states she spilled some coffee but it does not hurt. NP [nurse practitioner] updated via fax . The resident's record lacked further follow-up/assessment related to this incident. On 05/17/23 at 2:58 p.m., a dietary services staff member (#1) stated she measured the temperature of the coffee and it read 178 degrees F. The staff member stated, That's way too hot. It should never be that hot. She stated the temperature should not be above 160 degrees F and confirmed dietary staff do not measure the temperature of the coffee/hot water. During an interview on the afternoon of 05/16/23, an administrative staff member (#2) stated she would expect staff to report and investigate a coffee burn incident.

Based on observation, record review, review of professional reference, review of facility policy, and staff interviews, the facility failed to provide the necessary treatment and services to prevent the development and promote the healing of pressure ulcers for 2 of 3 sampled resident (Resident #4 and #9) identified with pressure ulcers. Failure to provide timely and appropriate skin assessment and/or dietary interventions resulted in the development of Resident #4 and #9's facility-acquired heel pressure ulcers and in Resident #9 experiencing pain/discomfort. Findings include: Review of the facility policy titled Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements occurred on 07/16/15. This policy, revised September 2012, stated, . A systematic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin breakdown. The nursing assistant responsible for this will report any abnormal findings or signs of skin impairment to the licensed nurse. If a pressure ulcer is identified . The registered nurse should record the type of wound and the degree of tissue damage . the location of the area, the measurements and the ulcer/wound characteristics. Dietary automatically will be notified when the Wound Data Collection (form) is signed and locked. - Review of Resident #9's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), dated [DATE], identified intact cognition, limited-to-extensive assistance for most activities of daily living (ADLs), one or more unhealed pressure ulcers, one unstageable pressure ulcer due to slough (light colored tissue) and/or eschar (brown/black necrotic tissue), longest length from head to toe: 7.0 centimeters (cm), widest width side-to-side perpendicular to length: 5.9 cm, and receiving skin treatments including: pressure reducing device for chair/bed and ulcer care. Resident #9's Braden Scale for Predicting Pressure Sore Risk, dated 07/11/15, revealed a score of 16; indicating he was at risk. The current physician orders identified the following: * 05/28/15, Blister to left outer heel: 1. [MEDICATION NAME]/ABD (absorbant dressing)/kerlix dressing applied. 2. Multipodus boot on, two time a day. * 06/30/15, 1 cup of protein jello daily. Resident #9's current care plan stated, . Focus The resident has unstageable pressure ulcer to left heel. Interventions . Assist to turn/reposition at least every 2 hours. Reposition with 1 person. Avoid positioning resident on left heel, float heel with pillows placed under left calf. Assess/record/monitor wound healing weekly. Report improvements and declines to the health care provider. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care (all initiated 05/26/15). Provide supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing (initiated 07/08/15). Provide pressure relieving/reducing device on bed: multipodus boot to left foot, pressure relief mattress and float left heel (initiated 05/26/15/revised 07/09/15). The progress notes and wound data collection forms identified the following: * 05/16/15 at 3:41 p.m., WEEKLY SKIN EVALUATION sat (Saturday) Legs are in excellent condition. No new skin issues at this time. * 05/26/15 at 4:00 p.m., . C/O (complained of) having Lt (left) heel pain. Res. nurse to check and noted clear fluid leaking from large blister to heel. Reported same to Unit Supervisor. * At 4:15 p.m., . Nurse reports to me that resident has a blister to the left outer heel and when I measured, noted that measurements are 6.2 x 9 cm. in size; area is draining clear liquid and skin is wrinkled and wet looking; surrounding tissue is red and underneath the blister area is noted that skin is red. Dr. (name) notified . * At 4:31 p.m., . initial data collection . Left heel . Appears to have been a blister that opened up as moist and wrinkled up against base of wound. Red/purple in color with white center . length 6.2 cm . width 9 cm . Skin adheres over the base of the wound, red/purple, wrinkled and moist. Pain when measuring wound, pressure relieving boot placed to left lower leg. [MEDICATION NAME], ABD and gauze were placed to protect the heel and multipodus boot for pressure relief. Will see medical provider tomorrow morning for further evaluation. The record lacked evidence the Dietary department was automatically notified of Resident #9's wound as per facility policy. * At 6:02 p.m., Resident has blister area to side of left heel that measures appr. (approximately) 6.2 x 9 cm. in size and is draining clear liquid. Dr. (name) notified and gauze dressing applied. * 05/27/15 at 11:30 a.m., Patient returned to facility . 1. Friction blister to left heel. New orders. 1. apply nonstick dsg (dressing) to left heel until healted (sic) BID (twice daily). If opens, apply [MEDICATION NAME] also. 2. Avoid and (sic) friction to heel protect in bed. On 05/27/15, the facility contact the State survey and certification agency and reported Resident #9's left heel blister as an injury of unknown origin. The progress notes and wound data collection forms identified the following: * 05/28/15 at 4:16 p.m., . pain scale of 3/10. Multi-podus boot helps to decrease pain. * 05/29/15 at 2:16 p.m., . the resident voice(d) complaints of pain related to the wound. * (Exact date and time not identified), . resident has ambulation boot to assist with pressure relief during ambulation which is currently broken. Therapy working to get this working again for resident. * 06/22/15 at 3:29 p.m., . Resident requires increased assistance at times with mobilization due to pain in heel. * 06/24/15 at 9:52 a.m., . Due to pressure ulcer (Resident #9) was started on Fortified foods on 06/02/15 for added protein in meals. * At 3:38 p.m., Dean is triggering for nutrition risk due to pressure ulcer. Dietary started fortified foods on 06/12/15. he would benefit from high protein nutritious snacks . Also recommended trying protein jello . This was the first indication Dietary staff had been notified of Resident #9's wound (17 days after facility staff first discovered his wound). During an interview on 07/15/15 at 2:15 p.m., a managerial dietary staff member (#15) stated, I found out (about Resident #9's ulcer) on 06/12/15. I always care plan fortified foods the same day I'm told of the ulcer. The progress notes and wound data collection forms identified the following: * 06/29/15 at 1:53 p.m., . Residents Multipoodus (sic) boot is at PT (Physical Therapy) as is broken. Note redness/bruising to arch of bottom of foot, resident states is sore, appears to be from walking on boot. [MEDICATION NAME] applied to heel . Wrapped with Kelix (sic) . Resident wearing loose fitting slipper at this time, until boot returns from PT. * 06/30/15 at 2:35 p.m., . left heel . Length 7 cm . Width 5.9 cm . PAtient has c/o pain when he walks . * At 2:42 p.m., . wound assessment . Patient has c/o pain with ambulation. * At 4:26 p.m., Due to condition of resident's walking boot, a new walking boot was ordered and has been given to resident to use during ambulation due to heel ulcer. The order for protein jello was written 06/30/15 (34 days after facility staff first discovered his wound). * 07/01/15 at 2:35 p.m., . Left heel . 3/10 on pain scale. * (Exact date and time not identified), . Resident continues to ambulate when he feels able due to pain in heel. Resident does have new walking boot to use. provides support to heel and relieves pressure during ambulation. * 07/02/15 at 3:53 p.m., . Left heel . Resident says that it hurts when he applies pressure to it. * 07/13/15 at 3:15 p.m., . left heel . Length 6.8 cm . Width 5.5 cm . Wound has mostly resolved, outline of old scab present. Skin firm, no c/o pain, blanchable to touch. Will continue to monitor for 1 week to ensure proper wound healing. Observation on 07/13/15 at 3:47 p.m. showed a managerial nurse (#14) providing Resident #9's cares. As she attended to Resident #9, she described his left heel ulcer as blanchable with firm new skin. The outline of the blister is still there, 6.8 x 9.5 cm. (Resident #9) does not have any pain. The facility failed to identify Resident #9's ulcer prior to it being a 6.2 x 9 cm draining blister, failed to notify the Dietary department at the time they first discovered his wound (17 days delayed), and failed to initiate fortified foods per physician's order (34 days delayed). - Resident #4's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. A Significant Change in Status Minimum Data Set (MDS), dated [DATE], identified the resident with severe cognitive impairment, required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, and had no current pressure ulcers. A Braden Scale for Predicting Pressure Sore Risk, dated 04/30/15, identified a score of 15 indicating a mild risk for pressure ulcers. Recommended interventions included Protect Heels. The resident's current care plan identified a problem: The resident has potential for pressure ulcer development R/T (related to) incontinence, mobility deficits, dementia. Braden=15. 06/01/15: Superficial [MEDICAL CONDITION] to right outer 5th toe . Interventions included: Assist to turn/reposition at least every 2 hours . Provide pressure relieving mattress on bed . Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration, etc (etcetera), noted during bath or daily care. The care plan lacked interventions to protect the resident's heels, such as floating the heels when in bed. During an interview on 07/15/15 at 10:15 a.m., a managerial nurse (#14) reported nursing staff used to check the resident's skin during their bath. Currently, the night nurse checks the resident's skin prior to bed, with medication pass, or with night cares. A Skin Observation sheet, dated 07/14/15 at 2:07 a.m., stated, Skin check was completed - no skin conditions observed. Currently applying corn pad to 5th toe and between 3-4th toe on right foot. Applying antibiotics ointment to those areas. Observation on 07/14/15 at 1:55 p.m. showed Resident #4 lying on her bed with her heels resting directly on the mattress. The surveyor asked the Certified Nursing Assistant (CNA) (#8) to remove the sock from Resident #4's foot in order to observe her toes. Observation showed foot drop of the right foot and revealed the corn pads in place on the 5th toe and between the 3rd and 4th toes. Observation also showed a reddened area approximately five centimeters (cm.) in diameter on the resident's right heel with a dark red center approximately 0.5 cm. in diameter. Following the observation, the surveyor informed the charge nurse (#9) of the reddened heel. A nursing progress note, dated 07/14/15 at 3:17 p.m., stated, In to see patient heels for concerns of reddness (sic). Right heel is soft to center, blanchable (color lightens when touched). No open areas noted. Heels to be floated while in bed, care plan updated. A second observation of Resident #4's right heel occurred with a licensed nurse (#9) and an administrative nurse (#1) on 07/14/15 at 4:15 p.m. at the surveyor's request. Observation showed the heel remained reddened. The nurse (#9) palpated the resident's heel and stated it felt soft. Observation showed the red area blanched at the outer edge when touched by the nurse. The nurse stated Resident #4 does not usually wear shoes, but wears slipper socks provided by the family. The nurse failed to measure the area at that time. Observation on 07/15/15 at 7:45 a.m. showed Resident #4 seated in her wheelchair wearing shoes on both feet. Observation on 07/15/15 at 11:12 a.m. showed Resident #4 in bed with her right foot resting directly on a pillow. A licensed nurse (#9) measured the reddened area on the resident's right heel at the surveyor's request. Observation of the heel revealed a red outer edge lightening to pink towards the center with a dark red center. The nurse measured the reddened/pink area as 4.5 by 6 cm. and the dark red center as 0.5 by 0.5 cm. Observation on 07/15/15 at 4:45 p.m. with an administrative nurse (#1) showed the resident seated in her wheelchair and wearing shoes. The nurse (#1) immediately removed the shoe from the right foot and asked a licensed nurse (#9) to put slippers on the resident. A Wound Data Collection sheet, dated 07/16/15 at 12:22 a.m., stated, Heels floated on pillows. Slipper socks. No shoes. Will continue to monitor skin integrity. Denies pain. Encouraged resident to keep feet floating on pillow. Explained this would relieve pressure. Red area blanches well. During an interview on 07/15/14 at 2:20 p.m. a dietary manager (#15) stated staff had not informed her of Resident #4's reddened heel and stated she would implement fortified foods immediately. The facility's failure to identify the reddened area on Resident #4's right heel during the daily skin assessments, measure the area at the time of identification, and promptly implement interventions such as not wearing shoes and ensuring the heels remained floated, placed Resident #4 at risk of the reddened area progressing to a stage 2 pressure ulcer.

Based on record review and facility policy, the facility failed to provide services to treat urinary tract infections (UTIs) for 2 of 9 sampled residents (Resident #5 and #8) with a history of UTIs. Failure to provide prompt treatment of [REDACTED].#5 & #8 delayed treatment, and #8's hospitalization for [MEDICAL CONDITION] (a type of infection of the urinary tract that usually begins in the bladder/urethra and moves up into the kidneys) with dehydration and shock. Findings include: Review of the facility policy titled Urogenital Tract Infections occurred on 07/16/15. This policy, revised June 2012, stated, . Signs/Symptoms: Suprapubic pain, Urethral burning, Urgency, Frequency, Dysuria (pain/discomfort associated with urination), Fever . Confusion, Change in behavior . Review of the facility policy titled Reporting and Initial Management of Suspected Infections occurred on 07/16/15. This policy, revised June 2012, stated, . The charge nurse will take the following actions as soon as possible if an infection is suspected. Notify the attending physician. Document the time of onset, any cultures obtained, any treatment initiated and the outcome in the nurse's notes. - Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition, extensive assistance of one person for toileting, frequent urinary incontinence and occasional bowel incontinence. The current care plan stated, . Focus: . frequent bladder incontinence . Interventions: . Monitor/document for s/s (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp (temperature) urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The progress notes identified the following: * 06/15/15 at 7:05 p.m., Resident very restless; will not eat, has been toileted and reassured/redirected several times; is exit seeking . resident got out of her wheelchair and walked unassisted in hallway with very unsteady gait . * 06/18/15 at 4:40 p.m., Resident has been restless . kicked at CNA (certified nursing assistant) . reassured several times . * 06/19/15 at 4:56 p.m., Resident has been displaying out of ordinary aggressive and anxious behavoirs (sic) in the previous shifts leading the unit supervisor to request a dipstick on urine for s/s (signs/symptoms) of infection. Dipstick reading on urine at 5:00 p.m. on 06/19/15 displayed positive leul (leukocytes), pos (positive) [MEDICATION NAME] and +1 of blood. Urine was moderately dark yellow (straw to brownish) in color, oderous (sic), and cloudy. Will continue to monitor. Fax for request for a UA (urine analysis). * At 6:31 p.m., Fax sent to Dr. (Doctor) (name) regarding positive dipstick of urine. * 06/26/15 at 6:16 p.m., Fax re-sent (7 days after the original fax was sent) to Dr. (name) regarding urinary sx (symptoms) as no reply noted from fax sent on 06/19/15 regarding this. * 06/29/15 at 2:34 p.m., Fax received (10 days after the original fax was sent) from Dr. (name) and UA/UC (urine culture) to be sent to lab regarding altered mental status and in reply to my fax sent on 06/26/15. * At 4:26 p.m., UA obtained. Urine dip positive for Leu (leukocytes), Nit ([MEDICATION NAME]), blood, UA sent to hospital lab . * At 5:18 p.m., Lab report received regarding urine sent to lab and will await physician recommendations. * 06/30/15 at 12:08 p.m., U/A results returned from Dr. (name). Orders for [MEDICATION NAME] (antibiotic) 100 mg (milligrams) BID (twice daily) x (times) 7 days. They will culture and get back to us. * 07/03/15 at 3:00 p.m., Resident is currently on a/b (antibiotic) therapy for UTI, urine is amber colored with no foul smell. Resident c/o of shaking and chills, T (temperature) 98.9, she is currently resting in bed. Fluids have been encouraged. * 07/04/15 at 5:49 a.m., Resident has temp (temperature) of 99.6, received scheduled Tylenol as ordered. When asked how she is feeling stated, 'I am not feeling very well.' . Resident stated how thirsty she was et (and) received . water . et . orange juice. *07/05/15 at 12:01 p.m., For the past couple of days, resident has been complaining of feeling cold; noted to have a low-grade temp but skin warm/dry; had a small emesis after breakfast today and is resting in bed at this time and CNAs reported that she was slightly clammy; resident is currently on [MEDICATION NAME] for UTI. * At 1:41 p.m., Call placed to (hospital) regarding resident symptoms and no results back yet from urine culture (6 days after the physician's order was received for a UC and 16 days after the physician was initially contacted regarding the resident's symptoms) and she will check on this and get back to me. * At 3:00 p.m., Resident vomited after breakfast today and has been resting in bed most of the day and having poor intake due to sleepy - Low grade temp and respirations more labored; skin warm/clammy . doctor would like to assess resident in the ER (emergency room ) for possible admission and will be sent per ambulance. * At 5:39 p.m., (Hospital) notifies us that resident will be kept there at the present time possibly overnight for further evaluation and treatment of [REDACTED]. The hospital report, dated 07/05/15, stated, . ASSESSMENT: [MEDICAL CONDITION] with dehydration and shock. Failure of the facility to 1) notify the physician in a timely manner of Resident #8's signs/symptoms of infection and 2) obtain the culture results in an effort to determine if Resident #8 had been placed on the correct antibiotic, resulted in her experiencing unnecessary discomfort, fatigue, restlessness, poor appetite, increased confusion, fever, and resulted in her hospitalization for [MEDICAL CONDITION], dehydration, and shock. - Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], identified intact cognition, extensive assistance of two or more people for toileting, frequent urinary/bowel incontinence. The current care plan stated, . Focus: . h/o (history of) UTIs . recurrent UTIs . Interventions: . Monitor/document for s/s UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. A progress note, dated 05/01/15 at 10:02 p.m., identified, Reported by . CNA to nurse, that resident upon changing and (sic) mustard-colored discharge, that was explained as gooey and foul-smelling. A fax to Resident #5's physician, dated 05/22/15, stated, . Patient has c/o (complains of) burning in peri area. Positive dipstick of leukocytes, protein, [MEDICATION NAME]. Also inner labia is red, looks to be inflammed (sic) and sensitive to touch. Some vaginal discharge noted from CNAs. Nursing staff failed to document the above information in the resident's progress notes. Also, the first signs/symptoms of infection were noted on 05/01/15, 22 days prior to staff notifying Resident #5's physician. The progress notes identified the following: * 05/22/15 at 1:43 p.m., u/a (urine analysis) sent to lab at this time per orders. * At 1:44 p.m., Fax received from Dr. (name). 1. [MEDICATION NAME] 1% topical vaginal cream. Apply Externally to peri-area BID x 7 days. 2. Send U/A Re: Dysuria (pain or discomfort during urination). * At 4:25 p.m., (Resident #5) . states she has been . tired . poor appetite . trouble concentrating . (Review of past physician's orders identified an order for [REDACTED]. * 05/30/15 at 2:27 p.m., Resident completed Bactrim for UTI 05/29/15, resident has no further symptoms of UTI. Failure of the facility to 1) document Resident #5's complaints of burning and staff observations of her red, inflamed, and sensitive labia, 2) document the completion and/or results of Resident #5's positive urine dipstick, and 3) notify the physician in a timely manner of Resident #5's signs/symptoms of infection resulted in her experiencing unnecessary discomfort, fatigue, poor appetite, and trouble concentrating.

Based on observation, record review, and staff interview, the facility failed to ensure 3 of 7 sampled residents (Resident #1, #2, and #5) remained free of chemical restraints imposed for the purposes of discipline or staff convenience. Failure to assess and implement behavioral interventions to manage Resident #1, #2, and #5's behaviors resulted in the frequent utilization of [MEDICAL CONDITION] medication for the purpose of discipline and/or convenience. Findings include: - Resident #5's medical record, reviewed September 23-26, 2013, identified [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified problems with memory, moderately impaired daily decision making skills and extensive assistance required for activities of daily living (ADLs). The antipsychotic Care Area Assessment (CAA), completed 05/10/13, further identified, ". . . The prn (as needed) [MEDICATION NAME] dose was recently decreased due to too sedating. (sic) . . . On 05/07/13 the [MEDICATION NAME] dose was again increased. . . ." The current care plan identified, "Problem: Alteration in mood/behaviors r/t (related to) dementia, delusiona (sic) disorder . . . Approaches: Observe/report changes in mood/behavior, Mental health referral as needed, Remove scissors from room . . ." The physician's orders [REDACTED]. * 07/11/12, [MEDICATION NAME] (an antidepressant) 10 mg daily at hour of sleep for anxiety * 02/20/13, [MEDICATION NAME] (an antipsychotic) 0.25 mg twice daily for [MEDICAL CONDITION] * 05/08/13, [MEDICATION NAME] 0.5 mg every four hours as needed for agitation/restlessness The progress notes identified the following: * 04/27/13 at 2:00 a.m., ". . . Res attempting to self stand . . . (medicated with) [MEDICATION NAME] . . ." * 05/03/13 at 6:35 a.m., ". . . did not want to stay in bed - didn't seem to comprehend that it was her usual time that she goes to bed - [MEDICATION NAME] . . . given with good results - was much more relaxed (and) then settled into sleep - slept well (after) wards without complaints or trying to get (up) out of bed." * 05/06/13 at 3:30 p.m., "[MEDICATION NAME] . . . will not stay in bed . . ." * 05/07/13 at 1:30 p.m., ". . . Resident was laid down to rest but did not stay there very long. Was given [MEDICATION NAME] . . ." * 05/08/13 at 7:45 a.m., "Resident . . . started climbing out of bed again," and at 10:30 a.m., "Resident remains restless [MEDICATION NAME] . . . given." * 05/15/13 at 1:00 p.m., ". . . CNA attempted to lay resident down but she kept getting out of bed so they put her back in her w/c," and at 1:30 p.m. "[MEDICATION NAME] . . . given for anxiety/restlessness (and) laid back down . . . resident did stay in bed at this time." * 05/16/13 at 12:00 p.m., "restless not wanting to stay in her w/c (wheel chair) - [MEDICATION NAME] . . . given" * 05/18/13, "Resident . . . attempting to get out of her w/c [MEDICATION NAME] (given) . . ." * 05/22/13 at 1:30 p.m., ". . . restless staff attempted several times to lay back down but resident attempted to get out of bed - staff got her up in w/c," and at 2:30 p.m., "medicated . . . (with) [MEDICATION NAME] . . ." * 05/26/13 at 7:00 p.m., ". . . resisting staff's attempts at helping her get ready for bed was given . . . [MEDICATION NAME] . . . which was effective." * 05/31/13 at 9:30 p.m., "Resident . . . attempting to get (up) out of bed . . . was given [MEDICATION NAME] . . . (with) good results." * 06/04/13 at 12:30 p.m., "Resident . . . refusing to sit in her w/c staff unable to get her to sit down - [MEDICATION NAME] . . . given," and at 2:00 p.m., "Resident resting quietly in bed." * 07/06/13 at 1:30 p.m., "Resident . . . keeps standing up out of w/c . . . [MEDICATION NAME] given . . ." * 08/05/13 at 1:00 a.m., "Resident . . . Was given [MEDICATION NAME] . . . with little effect. Patient continues to attempt to get out of bed. . . ." * 08/16/13 at 3:30 p.m., "Resident . . . medicated (with) . . . [MEDICATION NAME] which did not help . . . she cont (continued) to attempt to get out of w/c." Failure of the facility to appropriately assess and implement behavioral interventions to manage Resident #5's behaviors (attempts to rise from her bed/chair) resulted in the frequent utilization of [MEDICATION NAME] to control her behaviors for staff's convenience. - On the morning of 09/23/13, a supervisory nursing staff member (#1) stated Resident #2 doesn't sleep in her bed, but rather sleeps in a Broda chair (a tilt and recline positioning wheelchair/chair). Review of Resident #2's medical record occurred on all days of survey. Resident #2's medical [DIAGNOSES REDACTED]. Resident #2's medication regimen identified orders for [MEDICATION NAME], an antianxiety medication, as follows: * 04/04/12: [MEDICATION NAME] 0.5 mg (milligrams) to one mg by mouth every 4 hours as needed for anxiety; discontinued on 11/02/12 * 04/04/12: [MEDICATION NAME] 0.5 mg one to two tablets by mouth every 6-8 hours; discontinued on 09/07/12 * 09/07/12: [MEDICATION NAME] 0.5 mg to one mg intramuscularly (IM) every 4 to 6 hours as needed for agitation; discontinued 11/02/12 On 11/02/12, a psychiatrist ordered Trazadone, an antidepressant, three times a day Resident #2's current medication regimen included the following with corresponding start dates: * 09/06/12: [MEDICATION NAME] (an anti-depressant) 10 mg every day * 09/07/12: Fentyl patch (a narcotic pain medication for moderate to severe pain) 25 mcg (micrograms)/hour every 72 hours * 01/18/13: [MEDICATION NAME] 6/50 mg (a combination drug of [MEDICATION NAME] 6 mg - an anti-psychotic medication, and [MEDICATION NAME] 50 mg) every day at bedtime * 03/05/13: Trazadone (an antidepressant) 150 mg every evening * 09/20/13: [MEDICATION NAME] 3/25 mg everyday at bedtime in addition to the 6/50 mg * [MEDICATION NAME] (a narcotic pain medication for moderate to severe pain) 5 mg every 6 hours as needed. The record showed nursing staff administered two doses in June; three in July, and two in August A comprehensive assessment for the annual Minimum Data Set (MDS), dated [DATE], identified the following care areas triggered: * Communication: ". . . is confused d/t (due to) Dx (diagnosis) Dmentia (sic) . . . She is also restless. Her confusion has been long standing. She continues to require meds (medication) for restlessness, and has varying mood tones from pleasant to aggitiated (sic). She is not showing s/s (signs or symptoms) of adverse side effects. She is on multiple [MEDICAL CONDITION] with adjustment (sic) so is at risk for adverse side effects." * [MEDICAL CONDITION] Drug Use: ". . . Resident is on psychoactive medications for her mood and behavior issues. She has mood disorder requiring treatment. . . . Adverse consequences . . . Sedation . . . drowsiness, little/no activity involvement . . . Resident is at risk for falls due to cognition and physical function deficits . . . can be very restless at times. . . ." Resident #2's current care plan identified the problem of "Impaired mobility and potential for falls r/t (related to) dementia, arthritis . . ." with approaches of "Will not sleep in bed. Place in Broda chair or recliner at bedtime. . . ." The record identified the use/availability of a Broda tilt-n-space chair since on 05/22/12. The purpose of the chair being "helps her get restful sleep." Observations of Resident #2 on all days of survey identified Resident #2 frequently resting during the day hours with eyes closed. These observations occurred while Resident #2 sat in a recliner near the nurses' station, at a table near the nurses' station, during a group activity (a Bible study), and during meals. During the survey, random interviews with nursing staff reported Resident #2 slept poorly during the night. Resident #2's record identified falls six falls which occurred from the wheelchair. Staff administered [MEDICATION NAME]/[MEDICATION NAME] by mouth or IM at various times of the day beginning on 09/27/12 and at least once or twice daily throughout the month of October for behaviors. Several of the behaviors were related to the resident's attempts to get out of her chair or bed, restlessness, or failure to sleep during the night. The record included the following entries: * On 09/27/12 at 7:30 a.m. a nurse gave Resident #2 [MEDICATION NAME] "for anxiety, agitation" with short-term relief. * 09/28/12 at 6:00 a.m., "Resident was restless and anxious, PRN (as needed) [MEDICATION NAME] IM was given at 9:00 p.m. Resident was awake in bed, trying to climb out of bed. There was no relief for the 9 PM PRN [MEDICATION NAME]. At 1:00 a.m. PRN IM 0.5 (mg) was given with relief. Resident is sleeping comfortably. . . ." * 09/29/12 at 3:00 a.m., "Resident has been restless tonight. Medicated (with) [MEDICATION NAME] et (and) it has not been effective. Res. (resident) is up in w/c (wheelchair) now and is crying and restless. . . ." * 09/30/12 at 1:00 a.m., "Resident has been crying et anxious throughout shift, also restless, does not sit still. [MEDICATION NAME] po et (and) IM given per orders, it is not effective . . . Resident was crying stating 'I'm scared' et pounding on the wall; redirection is difficult as res. has very short attention span." * 10/01/12 at 5:05 a.m., ". . . restless during shift. Does not sit still. Was in w/c (wheel chair) at nurse's station for much of the night. [MEDICATION NAME] po & IM given. . . . Was not very effective. Redirection not effective due to short attention span. Also seemed to agitate her at times." * 10/02/12 at 3:30 a.m., ". . . placed in recliner. . . restless during first part of shift. Would self propel self in w/c around nurse's station becomes very anxious. Medicated x 2 (two times) (with) PRN [MEDICATION NAME] as directed. Resident has been sleeping since." * On 10/04/12 between 3:00 p.m. and 10:00 p.m., nursing staff "Medicated x 2 for anxiety." * On 10/06/12 at 7:15 a.m., nursing staff administered Resident PRN [MEDICATION NAME] IM for being "anxious and restless early in the shift. . . ." * On 10/19/12 at 3:15 p.m. nursing staff administered the [MEDICATION NAME] as "Resident very anxious and restless this a.m. Trying to get out of w/c (wheelchair). Nurse administered 1 mg [MEDICATION NAME] 7:20 (a.m.). Ate some of breakfast and took all (8 a.m.) meds. Resident fell asleep shortly after. Sleeping most of morning into afternoon (3 p.m.) . . . Remains sleeping in recliner. . . . (No) (noon) medications or dinner." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. * On the afternoon of 10/20/12 a nurse documented, "Resident was very restless during the afternoon. She was preoccupied (sic) by staff. Res (resident) had crying episodes and would try to get out of chair. She would slip her body off her chair. Medication was given for restlessness". The MAR indicated Resident was found on the floor face down." The incident report identified the nurse administered the [MEDICATION NAME] prior to the fall. * On 10/25/12, a nursing staff member faxed a psychiatrist, "(primary care physician-PCP) has prescription for [MEDICATION NAME] for (Resident #2) - as Resident is given the PRN (po) dose 1-3 x daily & we use IM [MEDICATION NAME] also - (the PCP) wants you to prescribe the [MEDICATION NAME] . . ." * On 11/01/12, Resident #2's PCP discontinued the oral and IM orders for [MEDICATION NAME] and the psychiatrist, per a telephone order, ordered Trazadone (an anti-depressant). Interdisciplinary Progress Notes (IDPN), between 11/16/12 and 11/26/12 included six entries regarding Resident #2 not sleeping at night. The notes included, ". . . Noc (night) nurses report that she does not go to sleep until around 0100 (1:00 a.m.). . . Noc nurse reported res. slept a 'few' hours last noc . . . Night nurse reported (Resident #2) 'up all noc' . . . Hollering from 7 p.m. till midnight. Slept from 12 (midnight) - 3 A (a.m.) . . ." IDPN, dated 11/26/12 at 5:50 p.m. stated, "Return call from (psychiatrist) re (regarding) [MEDICAL CONDITION]/anxiety give [MEDICATION NAME] (an anti-psychotic medication) 5 mg po at hs (bedtime) tomorrow (11/27) . . . Call (psychiatrist) in AM of 11/28 to report effect on sleep - Then (check) after 11/27 give [MEDICATION NAME] 5 mg po daily at hs PRN [MEDICAL CONDITION]/anxiety." The IDPN notes identified that on the night of 11/28 (after 11/27 dose of [MEDICATION NAME]) "resident was awake almost all night. - (psychiatrist) office contacted & updated. On the morning of 11/29/12 (after Resident #2 received two consecutive doses of [MEDICATION NAME]), nursing wrote, ". . . she only slept 1-1 1/2 (one to one and a half hours) all night." A nursing staff member contacted the psychiatrist's office and [MEDICATION NAME] (an anti-psychotic) 100 mg once per day PRN was ordered, and the psychiatrist discontinued the [MEDICATION NAME]. Following one dose of [MEDICATION NAME], the psychiatrist discontinued the medication as "Nursing staff reported since she had taken the new order for [MEDICATION NAME] - noted she was having tremors. . . ." During interview on 09/26/13 at 9:00 a.m., a social services staff member (#7) stated nursing staff cannot "contain" Resident #2. The staff member stated she did not know if there is a known cause for Resident #2's behaviors. Failure to assess and implement behavioral interventions to manage Resident #2's behavior resulted in utilization of [MEDICATION NAME] to control her behaviors and the presence of adverse effects including falls. - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] 0.5 mg every morning and every 8 hours PRN and [MEDICATION NAME] (antidepressant) 15 mg daily. Resident #1's current care plan stated, "Problem . . . Alteration in mood/behaviors R/T anxiety, senile dementia with delusional features . . . medicate as ordered . . . observe/report S/S (signs or symptoms) anxiety: easily annoyed, irritable, tired, worried, restless, startles easily." Review of Resident #1's progress notes and MAR indicated [REDACTED] *05/12/13 ". . . one crying spell. . . ." *05/18/13 "restless/agitation" *05/19/13 ". . .. . Resident medicated (with) [MEDICATION NAME] (pain medication) . . . @ (at) 1230 (12:30 p.m.) for upset stomach pain . . . [MEDICATION NAME] effective . . . also medicated @ 1230 (with) [MEDICATION NAME] . . . as Resident restless. [MEDICATION NAME] . . . also was effective . . ." Facility staff failed to allow time for the pain medication to take effect before they administered the [MEDICATION NAME]. *05/20/13 ". . . resisting help with feeding. Refused meds (medications). . ." The MAR indicated agitation." *05/28/13 ". . . (no) crying or (increased) anxiety today . . ." The MAR indicated restlessness." *05/29/13 - The MAR indicated restless, irritable, anxious." The progress notes failed to identify any behavioral concerns on this day. *05/31/13 - The MAR indicated restlessness/anxiety." The record did not identify any behavioral concerns on this day. *06/04/13 - The MAR indicated agitation." The record did not identify any behavioral concerns on this day. Failure to assess and implement behavioral interventions to manage Resident #1's behavior resulted in utilization of [MEDICATION NAME] to control her behaviors.

1. Based on record review, review of professional literature, and staff interviews, the facility failed to provide interventions to promote regular bowel elimination for 5 of 13 sampled residents (Resident #1, #7, #8 and #11) who required frequent as needed (PRN) interventions for constipation and 1 of 1 sampled resident (Resident #5) who required manual extraction of stool on four occasions. The facility failed to schedule and administer stool softeners/laxatives in a manner that stimulated bowel activity and prevented constipation (Resident #1, #7, #8, and #11) and four manual extractions (Resident #5) from occurring. Findings include: Berman, Snyder, Kozier, Erb, "Fundamentals of Nursing, Concepts Process, and Practice," 9th edition, Pearson Education, Inc., New Jersey, pages 1349-1350, stated, "Constipation may be defined as fewer than three bowel movements per week. This infers the passage of dry, hard stool or the passage of no stool. . . . Many causes and factors contribute to constipation. Among them are the following: Insufficient fiber intake, Insufficient fluid intake . . . Emotional disturbances such . . . mental confusion . . . Medications such as opioids (for pain) . . . Fecal impaction is a mass or collection of hardened feces in the folds of the rectum. Impaction results from prolonged retention and accumulation of fecal material. . . . Impaction can also be assessed by digital examination of the rectum, during which the hardened mass can often be palpated. . . . Along with fecal seepage and constipation . . . a general feeling of illness results . . . the abdomen becomes distended . . . The causes of fecal impaction are usually . . . constipation. . . ." Review of the facility policy titled "Bowel Assessment" occurred on 09/26/13. This policy, revised September 2010, stated, "Procedure: Assessment . . . establish elimination patterns, including times, volume, circumstances and frequencies of incontinent episodes . . . Establish the resident's own familiar terms and cues used for indication of a toileting need. . . . The Bowel Assessment . . . should be completed for residents who . . . have problems with elimination such as constipation or a history of impactions . . . The care plan interventions should be individualized based on the CAA (care area assessment) and modify the plan as appropriate based on an assessment of the resident's unique bowel elimination patterns. . . ." During an interview on the morning of 09/25/13, a managerial nursing staff member (#12) explained the facility's policy/procedure as follows, "After two days (without a BM), we would give the residents' the oral medications listed on their physician's orders. After three days, we would use a suppository. After four days, if they still can't push (have a bowel movement), we would do a rectal check, listen for bowel sounds, and give them an enema." "Nursing 2013 Drug Handbook," 33rd edition, Lippincott, Williams & Wilkins, Philadelphia, pages 576-580, identified, "[MEDICATION NAME] . . . CONTRAINDICATIONS & CAUTIONS . . . Drug may cause constipation. Assess bowel function and need for stool softeners and stimulant laxatives. . . ." - Resident #5's medical record, reviewed September 23-26, 2013, identified [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified problems with memory, moderately impaired daily decision making skills, extensive assistance of two persons for toileting, and use of scheduled and as needed pain medications. The record further identified the most recent bowel assessment had been completed on 06/26/08. The progress notes identified the following: * 05/05/13 at 6:00 a.m., ". . . [MEDICATION NAME] Sup (suppository) given this a.m. for bowel regulation - BS (bowel sounds) hypoactive in (lower) quads (quadrants). Only sm (small) BM (bowel movement) x (times) (one) documented since return from hosp (hospital) (on 05/02/13)" . . . at 12:00 p.m., "resident has trouble pushing to have BM - moderate amount to soft stool removed manually - bowel sounds noted today in all four quadrants of abdomen on auscultation with stethoscope . . ." * 05/12/13 at 10:30 a.m., "Resident on Day 4 (with) no BM - bowel sounds present in all four quadrants of abdomen on auscultation with stethoscope - rectal done and (sic) large amount of hard and soft formed stool felt - fleet enema given and poor results of no BM - (transferred Resident #5) to bed and digital stimulation with only small amount of stool removed (Nurse Practitioner) notified and orders received - [MEDICATION NAME] suppository given for bowel regulation. Resident has two large BMs of both formed and soft stool." * 05/17/13 at 7:00 p.m., ". . . fleet enema given and has large formed BM after . . ." * 05/23/13 at 1:00 p.m., "Abdomen appears distended moderately but soft - bowel sounds present in all four quadrants of abdomen on auscultation (with) stethoscope - [MEDICATION NAME] suppository given for bowel regulation," and at 7:30 p.m., "Resident has moderate BM . . . has eaten poor the last two meals of today . . ." * 06/23/13 at 7:00 a.m., ". . . [MEDICATION NAME] suppository this a.m. (with) only small constipated stool - laxatives given as ordered and fleet enema given (with) no results - small amount of blood tinged mucous noted from rectum - bowel sounds noted in all four quadrants of abdomen on auscultation (with) stethoscope." * 07/22/13 at 1:30 p.m., "Resident had dulc ([MEDICATION NAME]) supp this a.m. (with) only small results. Bowel sounds very active in all four quadrant (sic). Rectal (check) done (with) very little soft stool felt (up) high. Abdomen soft to touch. Will put her as one day BM list." * 08/05/13 at 8:00 a.m., "Resident on toilet - Had [MEDICATION NAME] suppository earlier and unable to push stool out - rectal alone and moderate amount of hard, formed stool removed (with) digital stimulation." * 08/10/13 at 11:30 a.m., "Resident on toilet (and) unable to expel form (sic) stool . . . Digital stimulation done (with) mod (moderate) results. Fleet enema given (with) lg (large) results." The documentation of Resident #5's eliminations (BM Report) between April 4, 2013-September 5, 2013 identified the resident failed to have a bowel movement for three days on five occasions, four days on five occasions, five days on one occasion, and nine days on one occasion. The physician's orders identified the following: * 06/28/08: [MEDICATION NAME] Suppository 10 milligrams (mg) daily as needed for constipation * 06/08/08: Fleet Enema 7 grams (gm)/19 g daily as needed for constipation * 07/28/08: Milk of Magnesia 30 milliliter (ml) daily as needed for constipation * 09/22/09, [MEDICATION NAME] 15 mg every two hours as needed for pain * 01/16/10, [MEDICATION NAME] 40 mg twice daily for pain * 01/19/10, [MEDICATION NAME] Patch 150 micrograms (mcg)/hour for pain * 03/05/13: [MEDICATION NAME] 17 gm daily for constipation * 05/02/13: [MEDICATION NAME] 5 mg 2 tabs daily as needed for constipation * 05/12/13: Senna S 50 mg/8.6 mg twice daily for constipation The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The current care plan identified, "Problem: Altered bowel elimination r/t (related to) constipation . . . Approaches: Medicate as ordered. . . . Offer high fiber foods, fruits, and juices in diet. . . ." The interdisciplinary assessments and summary review notes, dated 04/09/13, 05/13/13, and 07/31/13, all stated, ". . . We are to offer high fiber foods fruits (and) juices in diet along with encourage fluids r/t constipation. . . ." Review of the assessments indicated dietary staff were unaware of Resident #5's four manual extractions. During an interview on 09/26/13 at 11:55 a.m., a managerial dietary staff member (#9) reported Resident #5 received "prune juice at breakfast." She further stated, "She will drink prune juice." The facility failed to identify the specific dietary interventions (including prune juice) to be implemented in order to stimulate Resident #5's bowel activity and prevent constipation from occurring. The facility failed to assess and implement an individualized/specific plan of care for management of Resident #5's problem with constipation, including any revisions (i.e.: nutritional, fluids, physician directed changes to the resident's medication regimen, etc) following the above referenced episodes of fecal impaction, and lacked evidence of monitoring the effectiveness of an established plan in promoting normal bowel patterns/habits for Resident #5. - Resident #7's medical record, reviewed September 23-26, 2013, identified [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified moderately impaired cognitive skills and extensive assistance of two persons for toileting. The record further identified the most recent bowel assessment had been completed on 05/15/13. The only item checked on the assessment indicated Resident #7 was "continent." The documentation of Resident #7's eliminations (BM Report) between May 22, 2013-September 15, 2013 identified the resident failed to have a bowel movement for three days on five occasions and four days on one occasion. The physician's orders identified the following: * 05/26/11: [MEDICATION NAME] Suppository 10 mg daily as needed for constipation * 05/26/11: Fleet Enema one bottle daily as needed for constipation * 05/26/11: Milk of Magnesia 30 ml as needed for constipation * 05/26/11: Senna one-to-two teaspoons as needed at hour of sleep for constipation * 09/10/11: Senna 50 mg/8.6 mg tab twice daily for constipation * 02/20/13: [MEDICATION NAME] 100 mg daily for constipation The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The current care plan identified, "Problem: Potential altered bowel elimination: constipation . . . Approaches: Medicate as ordered. . . . Offer high fiber foods, fruits, and juices in diet. . . ." The facility failed to identify the specific dietary interventions to be implemented in order to stimulate Resident #7's bowel activity and prevent constipation from occurring. The facility failed to assess and implement effective interventions to Resident #7's plan of care following the above described episodes of constipation. - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE] identified severely impaired cognition, required extensive assistance for toilet use, and continent of bowel and bladder. Resident #1's bowel assessment, dated 04/20/13 and completed by the nursing staff, identified suppositories ([MEDICATION NAME]), laxatives (MOM), and enemas (Fleets) used PRN. Recommendations stated, "high fiber foods, fruits et (and) juices will be offered in diet." Review of Resident #1's nutrition progress notes failed to identify any concerns with constipation. Resident #1's current care plan stated, "Problem . . . Potential altered bowel elimination R/T (related to) constipation . . . Approaches: Medication as ordered. Monitor for adverse consequences. Encourage fluids. Offer high fiber foods, fruits and juices in diet." Review of Resident #1's BM reports and MARs from May through September 2013 showed the facility randomly administered a suppository and/or an enema before attempting a less invasive medication (MOM) on the following days: *05/09/13 - MOM and a Fleets enema administered on the same day with results. *05/31/13 - MOM and a suppository administered on the same day with results on the following day. * 06/14/13 - A Fleets enema administered with results. *The BM records identified the resident had a large BM on 07/08/13. The facility administered MOM on 07/09/13 even though the resident had a BM the day before. *07/27/13 - MOM administered with results on 07/28/13, 6 days after the last BM (07/21/13). *08/01/13 and 08/04/13 - MOM administered with results on 08/07/13, 7 days after the last BM (07/30/13). *08/22/13 and 08/23/13 - a suppository administered on both days with results on 08/24/13. *09/01/13 - a suppository administered with medium results. *09/02/13 - small BM *09/04/13 - MOM and a suppository administered on the same day without results. *09/06/13 - MOM administered with results on 09/07/13. *09/16/13 - MOM administered with no results. *09/17/13 - a Fleets enema administered with results. - Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The resident's annual MDS, dated [DATE], identified severely impaired cognition, required extensive to total assistance of one or more staff for toilet use and personal hygiene, and frequently incontinent of bowel and bladder. Review of Resident #8's bowel assessment, dated 09/20/13 and completed by the nursing staff, identified suppositories ([MEDICATION NAME]), laxatives (MOM), and enemas (Fleets) used PRN. The assessment identified no further interventions. Resident #8's current care plan stated, "Problem . . . Potential altered bowel elimination R/T constipation, H/O (history of) colon CA (cancer) . . . Approaches: Medicate as ordered. Monitor for adverse consequences. Encourage fluids. Offer high fiber foods, fruits & juices in diet." Review of Resident #8's BM records and MARs from May through September 2013 showed the facility randomly administered a suppository before attempting a less invasive medication (MOM) on the following days: *06/08/13 - a suppository administered with results. The record showed the last BM on 06/03/13, 5 days before the administration of the suppository, and no MOM given before the suppository. *06/11/13 - a suppository administered followed by 3 BMs. The record showed the last BM on 06/08/13 and no MOM given before the suppository. *06/16/13 - a suppository administered with large results. The record showed the last BM 06/13/13 and no MOM given before the suppository. *06/17/13 - MOM administered even though the resident had a suppository the day before with results. *06/18/13 - small BM *06/19/13 - a suppository administered (large results) even though the resident had a BM on the 16th and the 18th. *07/11/13- a suppository administered with large results. The record showed the last BM on 07/07/13, 4 days before the administration of the suppository, and no MOM given before the suppository. *07/19/13 - a suppository administered followed by 2 BMs. The record showed the last BM on 07/15/13 and no MOM given before the suppository. *07/20/13 - a suppository administered with results even though the resident had a suppository with results on the 19th. *08/05/13 - MOM and a suppository administered on the same day followed by 3 BMs. The BM record showed the last BM on 08/02/13 and no MOM administered before the suppository. *08/29/13 - a suppository administered followed by 2 BMs. The record showed the last BMs on 08/26/13 and no MOM administered before the suppository. *09/09/13 - a suppository administered with results. The record showed the last BMs (3) on 09/06/13 and no MOM administered before the suppository. *09/14/13 - MOM and a suppository administered on the same day with results. The record showed the last BM on 09/10/13, 4 days before the MOM and suppository were administered. The facility failed to administer the MOM and wait for results before administering the suppository. *09/21/13 - a suppository administered with results on 09/22/13, the next day. The record showed the last BM on 09/18/13 and no MOM administered before the suppository. - Review of Resident #11's medical record occurred on September 25-26, 2013. [DIAGNOSES REDACTED]. Medications included MOM, [MEDICATION NAME] suppository, and a Fleets enema PRN for constipation. The resident's quarterly MDS, dated [DATE], identified severely impaired cognition, required extensive assistance of one or more staff for toilet use and personal hygiene, and always incontinent of bowel and bladder. Resident #11's current care plan stated, "Problem . . . altered bowel elimination, diarrhea vs (verses) constipation R/T Alzheimer's dementia . . . Approaches: Medicate as ordered. Offer high fiber foods, fruits & juices in diet." Review of Resident #11's BM reports and MARs from May through September 2013 showed the facility randomly administered a suppository before attempting a less invasive medication (MOM) on the following days: *05/05/13 - a suppository administered with results. The record showed the last on 05/01/13, 4 days before the suppository, and no MOM given before the suppository. *05/20/13 - a suppository administered followed by 2 BMs. The record showed the last BM on 05/17/13 and no MOM administered before the suppository. *05/26/13 - a suppository administered with results (MOM administered on 05/25/13). *05/27/13 - MOM and a suppository administered even though the record showed the resident had a BM on 05/26/13. The facility failed to administer the MOM and wait for results before administering the suppository. *06/21/13 - a suppository administered with results. The BM record showed the resident had a BM on the 17th, 18th, 19th, and 20th but the facility still administered a suppository (and no MOM) on the 21st. *06/24/13 - a suppository administered followed by 2 BMs. The record showed the last BM on 06/21/13 and no MOM given before the suppository. *06/27/13 - a suppository administered with results. The record showed the last BM on 06/24/13 and no MOM given before the suppository. *07/17/13 - a suppository administered with results. The record showed the last BM on 07/14/13 and no MOM given before the suppository. *08/13/13 - a suppository administered with results. The record showed the last BM on 08/10/13 and no MOM given before the suppository. Failure to notify Resident #1, #5, #7, #8, and 11's physicians and the dietary department regarding their bowel habits and the possible addition of a daily stool softener/laxative and/or additional dietary interventions may have resulted in the residents' experiencing unnecessary discomfort and receiving invasive interventions (suppositories and/or enemas) for constipation. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to manage behavioral and psychological symptoms of dementia (BPSD) for 3 of 6 sampled resident (Residents #1, #2 and #5) identified with behaviors and on psychopharmacological medications. Failure to thoroughly assess the residents' behaviors, implement individualized interventions, including non-pharmacological interventions, and establish on-going monitoring of the behaviors resulted in decreased physical, mental, and psychosocial well-being and negatively impacted these residents' quality of life. Findings include: Review of the facility "Behavioral Causes and Interventions" policy occurred on 09/26/13. The policy, dated October 2009, stated: "Purpose: To aid in determining causes of behavior and appropriate intervention and strategies Behavior Management Issues 1. Cognitively impaired residents who wander with no rational purpose, and are oblivious to needs or safety . . . may benefit from documentation to identify any trend or pattern to behavior. 2. Wandering is random or repetitive locomotion. This movement may be goal-directed . . . or may be non-goal-directed or aimless. Non-goal-directed wandering requires a response in a manner that addresses both safety issues and an evaluation to identify root causes to the degree possible. Moving about the facility aimlessly may indicate that cognitively impaired residents are frustrated, anxious, bored, hungry or depressed. 3. The behavior management team within the center should meet as soon as possible to discuss the resident's behavior and develop individualized interventions to minimize the risk of elopement. Consistent behavior documentation done by all three shifts identifies attempts at elopement as the target behavior, and allows for individualized interventions. Causal Factors of Behavior Try to determine what's causing the behavior. Is the behavior related to the resident's physical or emotional health? . . . environment? . . . communication? . . . tasks? . . . caregiver's approach? . . . Catastrophic Reactions . . . occurs when a situation is too overwhelming for a person with Alzheimer's/dementia, causing the person to react inappropriately. In order to effectively deal with the catastrophic reaction, it is important to analyze and identify the catalyst or underlying cause. Planning and programming should include attention to a resident as soon as there are signs that a catastrophic reaction may occur such as agitation, increased restlessness, facial or body cues of fear or disorientation or distraught moods. Examples . . . Strategies For Addressing Aggressive Behaviors . . . 11. Hand the resident an item to hold while you provide care such as a softball, a soft stuffed animal or doll. 12. Consider wearing a long sleeved gown or shirt while providing care to residents who have a history of pinching or scratching during cares. . . ." Review of the "Documentation of Medication" policy occurred on 09/26/13. The policy, dated March 2011, included codes for "Non-pharmacological Interventions" attempted prior to administration of pain medications; and a "Code sheet for PRN (as needed) Antipsychotics" attempted prior to administration of anti-psychotic medications. - Review of Resident #2's medical record occurred on all days of survey. Resident #2's medical [DIAGNOSES REDACTED]. Resident #2's medication regimen identified orders for [MEDICATION NAME], an antianxiety medication, as follows: * 04/04/12: [MEDICATION NAME] 0.5 mg (milligrams) to one mg by mouth every 4 hours as needed for anxiety; discontinued on 11/02/12 * 04/04/12: [MEDICATION NAME] 0.5 mg one to two tablets by mouth every 6-8 hours; discontinued on 09/07/12 * 09/07/12: [MEDICATION NAME] 0.5 mg to one mg intramuscularly every 4 to 6 hours as needed for agitation; discontinued 11/02/12 On 11/02/12, a psychiatrist ordered Trazadone, an antidepressant, three times a day. A psychiatric progress note, dated 03/15/13, stated, ". . . I discontinued Trazadone 75 mg in the morning and 50 at noon, because she was way too sleepy. Now she has a little problem getting to sleep at night and they are asking if I can review her medication for 6:00 (p.m.). . ." physician progress notes [REDACTED]. . . does have problems with increased irritability and sundowning type symptoms usually into the late afternoon although today is having more problems earlier in the afternoon . . . wheeling herself around in her wheelchair. . . . restless and irritable . . . Dementia with behavioral disturbances, unchanged. . . ."; on 09/06/13: ". . . a bit more irritable at times particularly towards the late afternoon with staff just noticing more sundowning type behaviors. . . . Advanced dementia with sundowning . . . will be followed up by the psychiatry team for further assessment of mood and behavior issues. . . ." Observations of Resident #2 included the following: * 09/23/13 at 4:30 p.m.: Sitting, content, in her wheelchair in the activity room at a table with several visitors and another resident, celebrating that resident's birthday * 09/24/13 at 7:52 a.m.: Sitting in a recliner near a nurse's station asleep. * 09/24/13 at 9:00 a.m.: A certified nursing assistant (CNA) (#6), after assisting Resident #2 with toileting, stated the resident slept through breakfast; the CNA then transported the resident to a Bible study. * 09/24/13 at 10:15 a.m.: Observed in the "chapel." While five other residents sat around the table, Resident #2 slept in her wheelchair. * 09/24/13 at 10:35 a.m.: Remained asleep in the wheelchair. * 09/24/13 in the afternoon: A supervisory staff member (#2) stated Resident #2 never sleeps in her bed, as she would get out; stated the resident went to sleep at 3:30 a.m.; said when Resident #2 is awake she "can just go and go." * 09/24/13 between 2:30 p.m. and 2:50 p.m.: Resident #2 drank a nourishment drink at a desk outside of the nurse's station and then propelled her wheelchair into the nurse's station area. A nurse and CNA in the area visited with the resident with a calm approach; the resident held a comb and one of the staff members encouraged her to comb her hair. Neither staff member offered/provided Resident #2 with an activity to engage in. The staff members exited the nurse's station, and Resident #2 followed them part way out of the nurse's station area. At 3:30 p.m. the resident propelled herself back into the nurse's station, with the comb in her mouth, asking for help * 09/24/13 at 4:00 p.m.: In restorative therapy, Resident #2 told the therapist she wanted to go home. At 4:10 p.m. the resident sat at a desk outside of the nurse's station looking at papers. At 5:20 p.m. Resident #2 propelled her wheelchair over to the medication room door and knocked on the door. * 09/25/13 at 8:10 a.m.: Resident #2 fed herself breakfast in the dining room. At 10:55 a.m. the resident sat, asleep, in her wheelchair next to the nurse's station. * 09/26/13 at 7:30 a.m.: Resident #2 sat in a recliner next to the nurse's station asleep. At 8:10 a.m., Resident #2 sat in her wheelchair asleep. At 9:45 a.m., Resident #2 continued to sleep in the area just outside of the nurse's station in her wheelchair, with a blanket over her. At 11:30 a.m., Resident #2 continued to sleep in this area. At noon, the resident, while sitting in her wheelchair, slept at the dinner table. A quarterly Minimum Data Set (MDS), dated [DATE], and an annual MDS, dated [DATE], identified Resident #2 wandered 4 to 6 times a day, but less than daily. Both MDSs identified this as no change in behavior symptoms; identified Resident #2 with short and long term memory problems; as moderately to severely impaired in daily decision making, and as able to make herself understood and able to understand others. A comprehensive assessment for the annual MDS, dated [DATE], identified the following care areas triggered: * Communication: ". . . is confused d/t (due to) Dx (diagnosis) Dmentia (sic), such that communication is at times not effective. She is alert and able to verbalize. Hearing and vision are not limiting factors. . . . cognition deficits as expected with advanced dementia. She is also restless. Her confusion has been long standing. She continues to require meds (medication) for restlessness, and has varying mood tones from pleasant to aggitiated (sic). She is not showing s/s (signs or symptoms) of adverse side effects. She is on multiple [MEDICAL CONDITION] with adjustment (sic) so is at risk for adverse side effects." * Mood State: ". . . was sleeping the times I attempted to complete my assessments, she has periods where she is sleeping heavily and then will be awake for a long period of time. When she is awake she will propel her wheelchair by herself around the facility. . . ." * [MEDICAL CONDITION] Drug Use: ". . . Resident is on psychoactive medications for her mood and behavior issues. She has mood disorder requiring treatment. . . . Adverse consequences . . . Sedation . . . drowsiness, little/no activity involvement . . . Resident is at risk for falls due to cognition and physical function deficits . . . can be very restless at times. . . ." * Falls: " . . . She does at times wander about in her wheelchair but is generally situated at nurse's station for close supervision. She prefers to be around people. She also becomes restless at times. . . ." Resident #2's current care plan identified the following problems: * "Impaired mobility and potential for falls r/t dementia . . ." with approaches of "Will not sleep in bed. . . ." * "Alteration in mood/behaviors r/t (related to) dementia, [MEDICAL CONDITION], anxiety/agitation, sundowners m/b (manifested by) confusion, restlessness, currently on psychoactive meds (medications), behaviors: verbal, physical and resisting cares with a goal of being free from adverse side effects of psychoactive medication (and) will be free from increased s/s (signs and symptoms) of anxiety and depression. Approaches included monitoring Resident #2's sleep patterns nightly, "Observe/report changes in mood/behavior, Mental Health Referral as needed, Medicate as ordered, monitor for for (sic) adverse consequences, Observe/report s/s anxiety; easily annoyed, irritable, tired, worried, restless, startles easy." The care plan did not provide approaches for the identified verbal, physical, resistance to cares and wandering behavioral symptoms. The care plan also failed to address these behaviors. * "Dependent on others for all leisure needs r/t cognitive status m/b short attention span, Limited interest in leisure activity, memory problems . . . enjoys visiting . . . likes to hold stuffed animals, etc. Has rummage items, needs cues prompts and assistance but may refuse the help" with approaches including " . . . assist, encourage and record activities . . . invite and assist to center activities . . . provide small group activities . . . provide close supervision and redirection when restless, as able, provide stuffed animal or doll to hold as may find comfort in these items, provide items to sort or fold . . ." "Behavior Documentation Notes" (logged into a behavior documentation binder, completed primarily by direct care staff) between 10/15/12 and 08/27/13 included the following staff responses to Resident #2's behavior: * 10/04/12 ". . . very restless. She will not stay seated in her wheelchair or in bed or the recliner. When staff asks resident what is wrong, she starts crying and won't talk. . . ." * 10/09/12 at noon, ". . . Resident was told that the behavior was inappropriate. . . ." * 10/13/12 in morning, ". . . can not be redirected. . . ." * 10/14/12 in morning, ". . . slightly combative at times when trying to redirect." * 10/15/12 ". . . CNA told the resident it was inappropriate behavior . . ." * 10/24/12 at 9:30 a.m., "Resident was going into another resident's room. CNAs told resident that was not her room and tried directing the resident a different direction so CNAs could take the other resident to the bathroom. . . ." This resulted in Resident #2 becoming aggressive with the staff. * 10/27/12, ".. . .restless . . . tried redirecting resident but nothing keeps her occupied long enough. . . ." * 11/16/12, "When CNAs went to toilet resident she was very short tempered. Yelling and saying "I'm going to shoot up (sic) . . . CNA said 'that ain't nice.' . . ." * 11/22/12 and 11/23/12 during the night shift, ". . . She was digging in all the drawers in the nurses station and when I asked her to please not dig in them she told me this was her . . . stuff . . . I told her that it wasn't very nice to talk to someone like that . . . Then she came up to me & started telling me she wants to go to her car and she needs to go home. . . ." * 11/25/12, ". . . Noc (night) nurse reported she did not sleep last noc. . . ." * 11/28/12, ". . . slept for less than 2 hours. . . . was digging in drawers & when I asked not to she (swore). . ." * 12/15/12 at 7:00 a.m., "Res had fallen asleep for an hour or so earlier. She suddenly awoke and tried to climb out of bed. . . . I finally had to use a firm tone of voice/scolding Res. . . ." * 08/27/13 at 9:00 p.m., "Resident entered new residents room tonight & proceeded to tell her to get out . . . Reassurance given to new resident." The "Behavior Documentation Notes" identified no documented behaviors within an eight month period between December 2012 and August 2013. Review of the above identified staff approaches consisted of reprimanding Resident #2, insisting she remain in bed or her wheelchair, and redirection. Specific approaches for redirection were not recognized nor developed. The facility also failed to put measures in place for Resident #2's wandering behavior as identified with her intrusion into other resident's rooms on at l

1. Based on record review, review of professional reference, review of facility policy, and staff interview, the facility failed to provide care and services necessary to prevent [DIAGNOSES REDACTED] for 1 of 3 sampled residents (Resident #10) who received insulin injections. Failure to ensure Resident #10 consumed adequate nutrition to stabilize blood sugar levels after administration of a fast-acting insulin (on 12/07/13 and 12/30/13) resulted in hypoglycemic episodes which required emergency intervention (i.e. glucose gel and IM [MEDICATION NAME]). Findings include: The facility policy titled "Hypoglycemic Incidents," revised August 2013, stated the following: ". . . 2. For blood glucose levels 70 (mg/dL) (milligrams per deciliter) and below, or physician's guidelines, as long as resident is able to swallow . . . Give a rapidly absorbed carbohydrate* such as: 1) 4 oz (ounces) of orange, apple, or grape juice OR 2) 6 oz regular soda . . . b. Repeat blood glucose test after 15 minutes. c. Repeat administration of carbohydrate if necessary . . . 3. For blood glucose levels 45 or below as long as resident is able to swallow: a. Give glucopaste/glucogel/tube per physician's orders [REDACTED]. . b. Repeat blood glucose test after 15 minutes. c. If continues 45 or below, repeat glucopaste or glucogel after 15 minutes from when first given or if resident remains alert to swallow. d. Notify physician immediately. . . . 4. If resident is unable to swallow and has an order for [REDACTED]. [MEDICATION NAME] should be given per physician's orders [REDACTED]. b. Monitor blood glucose levels every 15 to 30 minutes until blood glucose is above 70. . . . 6. Transport to emergency room if [MEDICATION NAME] is ineffective or blood sugar remains below 45 after 30 minutes from the beginning of the hypoglycemic event. . . ." The Nursing 2013 Drug Handbook, page 737, identified the onset of action for subcutaneous [MEDICATION NAME] (a rapid-acting insulin) as 15 minutes, with the peak action in 1-3 hours. Page 741 identified the onset of action for subcutaneous [MEDICATION NAME] (a long-acting insulin) as 1 hour. Page 664 identified intramuscular [MEDICATION NAME]'s (an anti-hypoglycemic) onset of action as 4-10 minutes, peak action as 13 minutes, and duration of action as 12-32 minutes. Review of the manufacturer's instructions for [MEDICATION NAME]occurred on 12/31/13. The instructions stated, ". . . You should eat a meal within 5 to 10 minutes after using [MEDICATION NAME] to avoid low blood sugar. [MEDICATION NAME] is a fast-acting insulin. The effects of [MEDICATION NAME] start working 10 to 20 minutes after injection. . . Do not inject [MEDICATION NAME] if you do not plan to eat right after your injection. . . ." During an interview on the morning of 12/31/13, a nursing staff member (#5) identified meal times as "open breakfast" from 7:30 a.m. until 9:00 p.m., lunch at 12:00 p.m., and dinner at 6:00 p.m. Review of Resident #10's medical record occurred on December 30-31, 2013. [DIAGNOSES REDACTED]. *[MEDICATION NAME] (a long-acting insulin): 22 units subcutaneously (SQ) at 6:00 a.m. *[MEDICATION NAME] (a rapid-acting insulin): 3 units at 8:00 a.m., 12:00 p.m., and 6:00 p.m. *[MEDICATION NAME]: per sliding scale at 6:00 a.m., 11:00 a.m., and 5:00 p.m. *Blood glucose monitoring at 6:00 a.m., 11:00 a.m., and 5:00 p.m. Current physician's orders [REDACTED]. *"Call MD (medical doctor) if blood glucose level 30 or below. . . . Call MD if blood glucose level is 45 (mg/dL) or below and the resident is not responding . . ." *"For a blood glucose level below 60 and the resident is able to swallow, give: 4 oz orange, apple, or grape juice or 6 oz regular soda. . . ." *"[MEDICATION NAME] 15 Gel 40%. Give 15 ml (milliliters) by mouth as needed for low blood sugar . . . For a blood glucose level at 45 and below and the resident is able to swallow, give [MEDICATION NAME] . . ." *"[MEDICATION NAME] Kit 1 mg (milligram). Inject 1 mg intramuscularly (IM) as needed . . . for a blood glucose level below 60 and the resident is unable to swallow give [MEDICATION NAME]: Monitor blood glucose levels every 15-30 min. (minutes) until glucose level is at 60 or above: Transport to emergency room if ineffective . . ." Resident #10's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"location of administration report" (used to identify the time staff administers insulin), and nurses' notes dated 12/07/13 identified the following: *5:14 a.m.: Blood glucose 150 mg/dL *5:34 a.m.: 22 units of [MEDICATION NAME] given *7:28 a.m.: 3 units of scheduled [MEDICATION NAME] given *8:30 a.m.: ". . . Blood sugar 35. 6 oz OJ (orange juice) given. Resident was diaphoretic. . . ." *8:37 a.m.: ". . . Rechecked BS (blood sugar) 38. Gave 3 oz whole milk . . ." *8:43 a.m.: ". . . Rechecked blood sugar after milk was 42 . . ." *9:05 a.m.: ". . . Eating breakfast blood sugar now 74 . . ." Facility staff failed to ensure Resident #10 consumed adequate food/fluids to prevent [DIAGNOSES REDACTED] after receiving fast-acting insulin, and failed to administer [MEDICATION NAME] gel as per physician order/facility policy when Resident #10's blood sugar was less than 45 mg/dL. Resident #10's MAR, blood sugar monitoring record, "location of administration report," and nurses' notes dated 12/30/13 identified the following: *5:27 a.m.: 22 units of [MEDICATION NAME] given *5:41 a.m.: Blood glucose 154 mg/dL. The record identified staff administered [MEDICATION NAME] prior to checking a blood sugar level.*5:41 a.m.: 2 units of sliding scale [MEDICATION NAME] given *7:23 a.m.: 3 units of scheduled [MEDICATION NAME] given *8:00 a.m.: Called MD (medical doctor) on call at SAHC (St. Andrew's Health Center) not there. Faxed info to (provider name) since not in til 1pm . . ." *8:15 a.m.: Blood glucose 27 mg/dL *8:15 a.m.: (per nurse's note) ". . . 1 more tube [MEDICATION NAME] given . . ." A nurse's note, timed at 8:00 a.m., identified staff administered [MEDICATION NAME]; however, the note was later identified as a "documentation error." *8:15 a.m.: The MAR indicated [REDACTED] *8:30 a.m.: (per nurse's note) ". . . [MEDICATION NAME] IM (intramuscular) given Per order for BS (blood sugar) 23 . . ." The MAR indicated *8:43 a.m.: Blood glucose 28 mg/dL *8:43 a.m.: (per nurse's note) ". . . 1 tube [MEDICATION NAME] administered . . ." *8:45 a.m.: (per nurse's note) ". . . Blood sugar now 49 after [MEDICATION NAME] will monitor . . ." *8:49 a.m.: The MAR indicated ineffective." *9:00 a.m.: Blood glucose 49 mg/dL *9:15 a.m.: Blood glucose 69 mg/dL *9:22 a.m.: (per nurse's note) ". . . (provider name) was faxed regarding low blood sugar since he was unavailable til 1pm today. . . ." *10:12 a.m.: (per nurse's note) ". . . Phone call received (sic) from (provider name) regarding low blood sugar and to notify him of upcoming appt (appointment) on Thursday . . ." A fax to the physician, dated 12/30/13 at 9:20 a.m., stated, ". . . Resident had (low) BS this a.m. Gave (2) [MEDICATION NAME] still low. Called on call MD not available. Gave [MEDICATION NAME] 1 mg IM BS (increased) 49. 15 (minutes) later (increased) 69. . . ." When requested, the facility failed to provide evidence of the fax sent to the physician on 12/30/13 at 8:00 a.m. as per the nurse's note. It is unknown why the nurse called the on-call physician. The above fax to the physician identified the nurse administered two tubes of [MEDICATION NAME] gel; however, the MAR indicated ineffective." Resident #10's blood glucose monitoring report identified staff obtained a reading of 49 mg/dL at 9:00 a.m., not 8:43 a.m. as per the nurse's notes. It is unknown why staff administered [MEDICATION NAME] gel (at 8:49 a.m.) if they obtained a blood glucose reading of 49 mg/dL at 8:43 a.m. Another discrepancy exists between the blood glucose monitoring record, which showed a blood glucose reading of 28 mg/dL at 8:43 a.m., and the nurse's notes, which identified a blood glucose reading of 49 mg/dL at 8:45 a.m. (two minutes later). Staff failed to ensure Resident #10 consumed adequate nutrition after receiving rapid-acting insulin in order to prevent a hypoglycemic reaction. Staff also failed to follow physician's orders [REDACTED]. These failures resulted in Resident #10 experiencing low blood sugars for an extended period of time which required emergency intervention (IM [MEDICATION NAME] and [MEDICATION NAME] gel). 2. Based on record review and review of the facility's Plan of Correction (POC), the facility failed to provide the necessary care and services to manage constipation for 4 of 11 sampled residents (Resident #2, #4, #7, and #10) with constipation. Failure to implement appropriate and timely interventions may have resulted in Resident #2, #4, and #7 receiving unnecessary suppositories/enemas. Failure to provide interventions for Resident #10 resulted in no bowel movement (BM) for four days on two separate occasions. Findings include: The facility's POC stated, ". . . The nurses were educated on the Bowel protocol of: No BM in 2 days offer MOM (milk of magnesia) 30 cc (cubic centimeters), No BM in 3 days offer a dulc ([MEDICATION NAME]) suppository, if no BM in 4 days do a rectal check for BM and offer a fleets enema. . . ." - Review of Resident #4's medical record occurred on December 30-31, 2013. [DIAGNOSES REDACTED]. Resident #4's bowel records and prn Medication Administration Records (MARs) showed the following: *A BM on 11/26/13. No interventions provided until 11/29/13 at 6:26 a.m. (Day 3), when staff attempted to give Resident #4 a suppository (the resident refused). At 12:53 p.m., staff attempted to give Resident #4 MOM (the resident refused). Records identified staff failed to attempt interventions on Day 2 without a BM and failed to attempt MOM prior to a suppository as identified in the facility's bowel protocol. *A BM on 11/29/13. No interventions provided until 12/02/13 at 5:58 a.m. (Day 3), when staff administered a suppository. At 1:58 p.m., staff administered MOM, and at 7:48 p.m., staff administered a fleets enema. Bowel records showed a small BM on the evening of 12/02/13. The MAR indicated [REDACTED]. It is unknown why staff administered MOM on 12/03/12 when records identified Resident #4 had a BM on 12/02/13. - Review of Resident #10's medical record occurred on 12/31/13. [DIAGNOSES REDACTED]. A nurse's note, dated 12/16/13 at 7:50 a.m., stated, "Prune juice given for 4 day without BM." The medical record showed Resident #10 had a BM on 12/12/13. Staff failed to provide interventions for constipation prior to prune juice on the morning of 12/16/13. The record also showed Resident #10 had a BM on 12/22/13 and 12/27/13 (5 days later). Staff failed to provide any interventions to help manage Resident #10's constipation. - Review of Resident #2's medical record occurred on December 30-31, 2013. [DIAGNOSES REDACTED]. Review of the BM report and MAR for December 2013 identified Resident #2 had three BM's on the 15th. The facility administered a suppository on December 18th before attempting a less invasive medication. - Review of Resident #7's medical record occurred on December 30-31, 2013. [DIAGNOSES REDACTED]. Review of Resident #7's BM reports and MARs for December 2013 identified the facility administered a suppository on December 4th (before attempting a less invasive medication) even though the resident had a large BM on 12/02/13. The facility failed to provide effective treatment to manage constipation according to the protocol and failed to ensure implementation of the Plan of Correction.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment and services to prevent the occurrence of a facility acquired pressure ulcer for 1 of 1 sampled resident (Resident #7) with a deep tissue injury (DTI) and promote the healing of a pressure ulcer for 1 of 1 sampled resident (Resident #9) with a current pressure ulcer. Failure to provide timely and appropriate interventions and ensure staff consistently implemented existing interventions contributed to the development of Resident #7's new pressure ulcer and has the potential for the deterioration of Resident #9's existing pressure ulcer and the development of additional pressure ulcers. Findings include: Review of the facility policy titled "Pressure Ulcers" occurred on 09/26/13. This policy, revised March 2007, stated, "Policy: . . . a resident entering the center without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable. A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing . . . Ongoing Skin Assessments: Residents at risk for pressure ulcer development and those with pressure ulcers/wounds should be monitored daily for changes in their skin condition. This may occur during the course of the resident's daily care and/or bathing where the CNA should perform a head to toe check of the resident's skin, paying particular attention to: *The surfaces of the skin that come in contact with the bed and chair *Bony prominences (heels . . .) . . . Definitions: . . . *"Suspected Deep Tissue Injury" - Purple or maroon localized (unstageable) area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue . . ." Review of the facility policy and procedure titled "Pressure Ulcers: Skin Assessment and Prevention" occurred on 09/26/13. This policy, revised 01/12, stated: ". . . 1. All residents will be identified for their risk of developing pressure ulcers on admission/readmission . . . using the Braden Scale for Predicting Pressure Sore Risk . . . 2. The registered nurse will complete the Braden Scale for Predicting Pressure Sore Risk . . . on all residents quarterly or when the resident has a change in condition which could affect their risk of developing an ulcer . . . 14. The pressure ulcer should be assessed/evaluated at least weekly and documented on the Wound Flow Sheet . . . with every treatment change. Observation of the ulcer's characteristics may be documented by a licensed nurse and should include at least the following: *Measurements - length, width, depth *Characteristics of the ulcer . . . *Presence of pain *Current treatments . . ." - Resident #7's medical record, reviewed September 23-26, 2013, identified [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognitive skills and extensive assistance for bed mobility, transfers, locomotion, and toileting. The MDS further identified Resident #7 as at risk of developing pressure ulcers, and listed the following skin/ulcer treatments: pressure reducing device for bed/chair and applications of ointments/medications. The Braden Scale for Predicting Pressure Sore Risk, dated 08/19/13, identified, ". . . Total Score 19 (Not at risk of developing a pressure ulcer) . . ." A progress note, dated 09/22/13 at 8:00 p.m., stated, "CNAs (certified nurse assistants) helped (Resident #7) to bed, notified me of discoloration left heel. She has a 2.5 x 4.5 cm (centimeter) purple area on heel, suspected deep tissue injury. Tissue intact, firm, painful. Will place heel lift boot to be worn at all times until resolved." During interview on 09/25/13 at 1:00 p.m., when asked for assistance locating the wound flow sheet, a managerial nurse (#12) stated, "Oh, there is no wound flow sheet for her. Usually the nurse who first sees it writes one up. Facility staff failed to locate the wound flow sheet in Resident #7's chart. During an interview on the morning of 09/26/13, when asked for assistance locating the wound flow sheet, an administrative nurse (#3) located the sheet in her office. The wound flow sheet, dated 09/22/12 at 8:00 p.m., further identified, ". . . Location: . . . Heel L (left) . . . Length: 2.5 cm, Width: 4.5 cm . . . Drainage Amount: None . . . Surrounding Skin: Intact, Undermining/Tunneling: Unknown, Odor: No, Pain: Yes . . ." During an interview on 09/24/13 at 11:10 a.m., when asked if her heel causes her pain, Resident #7 stated, "It's especially painful in the morning when I get up." When asked when she first began experiencing pain in her heel, she stated, "It's been hurting for some time now." She reported experiencing pain prior to staff discovering the wound on her heel. During an interview on 09/25/13 at 8:53 a.m., when asked to explain the procedure for the daily skin checks, a Bath Aide (#21) stated, "I check everything . . . bottom, heels. If I find something, I tell the nurse. If the resident is on the skin sheet, the nurse will check too." During an interview on 09/25/13 at 1:10 p.m., when asked to explain the procedure for the daily skin checks, a CNA (#16) stated, "If the CNA knows their resident, they should know if they (the resident) have an ulcer or (skin) tear. We check during common ADLs (Activities of Daily Living) . . . grooming, dressing . . . We report anything new to the RN (Registered Nurse)." During an interview on 09/24/13 at 3:40 p.m., when asked why the wound on Resident #7's heel had not been identified prior to it measuring 2.5 cm by 4.5 cm in diameter, a managerial nurse (#18) stated, "It looked like a bruise with black, intact skin . . . firm to the touch. It is a deep tissue injury . . . an ulcer. You'd have to hit your foot pretty hard to get a bruise that color. I assume it was there prior . . . on the previous shift . . . the previous day. I'm not sure why the CNAs didn't see it while they were bathing and dressing the resident." A progress note, dated 09/23/13, stated, "PTA (Physical Therapy Aide) Heel lift suspension boot to be worn on (L) (left) foot when supine lying in bed. May use blue heel protector when in w/c (wheelchair) to (L) foot. . . . PTA (and) Nsg (Nursing) conferenced regarding (L) heel deep tissue injury. RA (Restorative Aide) program q (every) ambulation will be placed on hold until DTI (deep tissue injury) is healed. Will update care plan." The current care plan, dated 08/29/13, identified, "Problem: Potential impaired skin integrity . . . Approaches: Pressure relief mattress and chair pad, Bed mobility and repositioning every 2 hrs (hours) or more frequently with assist of 1-2, No massage of reddened boney (sic) prominences, Replace protein to meet daily requirements, Daily skin checks. Report to nurse any red, open, irritated areas daily, Weekly skin evaluations on Thursday, Use lift sheet to move resident if needed to prevent friction and sheer. . . . Problem: Impaired mobility . . . Approaches: . . . Ambulate . . . Hold 09/23/13 (secondary) DTI on (L) heel. . . . Heel lift suspension boot to (L) heel when resident supine lying. Blue heel protector when in w/c." The short-term pressure ulcer care plan, dated 09/22/13, identified, "Problem: . . . left heel suspected DTI . . . Approaches: . . . 2. Monitor status of ulcer, surrounding skin and dressing, 3. Document size and progress on the Wound Flow Sheet . . . 5. Provide support surfaces as appropriate . . . heel lift boot, 6. Monitor for pain; provide non-pharmacological interventions and/or medications/treatments as ordered . . . 8. Notify Dietary for interventions as appropriate . . ." The (undated) nutritional risk notification form identified, ". . . New pressure ulcer . . . Comments: Replace protein not taken in meals, provide sufficient protein to meet healing requirements. . . ." The Treatment Record, dated September 2013, identified the following: * Pressure ulcer documentation of skin assessment flow sheet weekly on Fri (Fridays) by DON (Director of Nursing). * Daily monitoring and documentation of left heel suspected deep tissue injury. 1. Evaluation of the ulcer if no dressing daily. (Staff initialed the treatment record on September 22-24, 2013.) 2. Evaluation of status of dressing daily. 3. Status of area surrounding the ulcer daily. 4. Presence of possible complications daily. 5. If pain is present and adequately controlled. Open to air. See reverse side of wound care sheet for documentation of changes, problems, progress towards healing. *Heel lift boot to left foot at all times until injury resolved. (Staff initialed the treatment record on September 23-24, 2013.) Observations showed the following: * On 09/23/13 at 4:10 p.m. and 09/24/13 at 8:00 a.m. and 12:25 p.m., Resident #7 sat in her wheelchair with a blue heel protector on her left foot. * On 09/23/13 at 4:22 p.m., an unidentified nursing staff member stated, "(Staff) found a blister on her (Resident #7's) heel. She did something to it." * On 09/24/13 at 10:45 a.m., a managerial nurse (#12) assessed the wound on Resident #7's left heel. The managerial nurse (#12) described the wound as "deep purple(/black)" in color, with a "dry, intact" surface and "no drainage." She estimated the wound to be "close (to) 2.5 cm by 4.2 cm" in diameter. She further stated the cause of the injury was unknown as the resident does not self transfer and wears socks and shoes. Prior to leaving Resident #7's room the nurse requested the CNA (Certified Nurse Assistant) obtain another sock for the resident, due to her sock being "snug." She stated, "Get a different sock, one that is not so tight, so it doesn't rub when we're putting it on." * On 09/24/13 at 3:10 p.m., following cares Resident #7 laid in bed with a blue heel protector on her left foot. At 3:40 p.m., a nurse (#18) entered Resident #7's room and instructed the CNAs (#19 and #20) to remove her heel protector and to replace it with her heel boot when she is in bed. The facility failed to: * Identify Resident #7's left heel deep tissue injury/pressure ulcer prior to it being an "intact, firm, but painful, 2.5 x 4.5 cm purple area," * Keep Resident #7's wound flow sheet in her chart, which did not allow staff to document/monitor any changes, problems, progress towards healing, * Protect Resident #7 against adverse effects of pressure, friction and shear ("snug/tight" sock and/or pressure of heels resting directly on mattress while in bed,) * Consistently identify and implement the necessary equipment (heel protector versus heel lift boot), and * Identify the specific dietary interventions to be implemented in order to provide sufficient protein to meet Resident #7's healing requirements. - During the initial tour of the facility on 09/23/13 at 12:05 p.m., observation showed Resident #9 in bed and positioned on his back. A nurse (#15) stated the resident's condition has declined in the past few days and staff no longer get him out of bed. When asked about pressure ulcers, the nurse stated the resident had a pressure ulcer to his coccyx on admission (08/30/13) and now it has healed. Review of Resident #9's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Physician's orders included a [MEDICATION NAME] (a type of wound dressing) to coccyx. The resident's admission MDS, dated [DATE], identified severe cognitive impairment, frequently incontinent of urine, required extensive assistance for bed mobility, transfers, toilet use, and personal hygiene, at risk for pressure ulcers, and a current Stage 2 pressure ulcer. Resident #9's current care plan stated: *"Problem . . . Impaired skin integrity: pressure ulcer R/T (related to) incontinence, decreased mobility M/B (manifested by) Stage II H/O (history of) pressure ulcer coccyx, Braden = 14 (moderate risk for developing a pressure ulcer). . . avoid positioning on the pressure ulcer . . . bed mobility/reposition every 2 hours of (sic) more frequently with assist of 1-2 . . . float heels. *Problem . . . Potential altered (sic) bladder elimination R/T impaired mobility, unable to access toilet independently M/B frequent incontinence . . . Assist of 2 and mechanical lift to toilet with routine cares and on request . . . *Problem . . . Impaired mobility . . . Total mechanical lift assist of 2 medium sling; split leg used for toileting . . ." Resident #9's "Physical Nursing Data" undated assessment identified an open lesion on the resident's coccyx. The assessment provided no description of the lesion. Resident #9's "Wound Flow Sheet," initiated on 08/31/13, identified a 2.0 centimeter (cm) by 2.0 cm Stage II pressure ulcer to the resident's coccyx. Additional assessments, dated September 01-05, 2013 and September 07-11, 2013 showed the nurse(s) failed to document the size of the pressure ulcer. Observations of Resident #9 showed the following: *09/23/13 at 4:55 p.m. - Lying in bed with a pillows placed on both his sides next to his torso. His heels rested directly on the bed. *09/24/13 at 7:55 a.m. - Two CNAs (#16 and #17) checked the resident's brief and placed a pillow under his right buttock and another pillow under his right foot. The resident's right heel rested directly on the pillow and his left foot/ankle rested directly on his right foot. *09/26/13 at 9:20 a.m. - Two nurses (#14 and #18) positioned Resident #9 on his side and removed his brief saturated with urine and feces. The nurse (#14) removed the dressing on his coccyx and stated the pressure ulcer measured approximately 0.2 cm by 0.3 cm. Observation showed Resident #9's buttocks reddened. After the nurses completed the dressing and brief change, they positioned him on his left side and placed a pillow between his lower legs. The nurses failed to float the resident's heels. The facility failed to assess and evaluate Resident #9's pressure ulcer at least weekly and failed to float his heels to prevent additional pressure sores.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to identify and assess and the presence of a pressure ulcer for 2 of 2 sampled residents (Resident #6 and #9) identified by the survey team with facility acquired pressure sores. Failure to identify, assess, and monitor pressure sores limited the facilities ability to implement measures to promote the healing of Resident #6 and #9's Stage II pressure ulcers and further deterioration and/or prevent development of additional pressure areas. Findings include: Review of the facility policy and procedure titled "Pressure Ulcers: Skin Assessment and Prevention" occurred on 12/31/13. This policy, revised 01/12, stated: " PURPOSE: To systematically assess residents with regard to risk of skin breakdown. To accurately document observations and assessments of residents to appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. . . . 5. A systematic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin breakdown . . . Developing an individualized repositioning schedule is recommended based on observation of the resident's skin over a period of time. Individual pressure points are observed for redness or discomfort . . . 7. If a pressure ulcer is identified, cleanse the area prior to observations being made to allow the wound bed and depth to be more accurately observed. The registered nurse should record the type of wound and the degree of tissue damage . . . The licensed nurse records the location of the area, the measurements and the ulcer/wound characteristics. Document the information on the Wound Flow Sheet . . . 8. Notify the physician/practitioner of the ulcer and resident's condition to obtain orders for a treatment. . . . 10. Notify dietary . . . 11. The interdisciplinary teams should determine any modifications that are necessary to the resident's plan of care. . . . 12. When a pressure ulcer is present, daily monitoring . . . should include . . . presence of possible complications . . . Whether pain . . . is adequately controlled 14. The pressure ulcer should be assessed/evaluated at least weekly and documented on the Wound Flow Sheet . . . with every treatment change. Observation of the ulcer's characteristics may be documented by a licensed nurse and should include at least the following: *Measurements - length, width, depth *Characteristics of the ulcer . . . *Presence of pain *Current treatments . . ." - Review of Resident #6's record occurred on December 30-31, 2013. [DIAGNOSES REDACTED]. Review of progress notes identified: * 11/27/13, "Talked with resident and he agreed to sit in a recliner in afternoon. This is to releave (sic) pressure to coccyx. Also possibility for air mattress to bed. . . ." * 12/12/13 at 9:11 a.m., "Weekly skin evaluation resident has pimple on right outer buttock intact no redness to bottom no other new skin issues at present. Will continue to monitor weekly." * 12/23/13 at 4:19 p.m., "Care plan adjusted to show residents receipt and us (use) of 2 inch memory foam cushion, with goal to resume use of ROHO (pressure reducing cushion for a chair) for skin break down." * 12/30/13 at 9:14 p.m., "Resident has open area on right buttock just to the right of buttock crease. Area measured is 1.8 cm (centimeters) (by) 1.4 cm. Duoderm dressing removed had sanguineous drainage. The open area is not deep and appears as if skin has been scraped off. New duoderm applied." Resident #6's progress notes and treatment records failed to identify weekly skin assessments on 12/05/13, 12/19/13, and 12/26/13. A "Report for Quality Committee," dated 11/19/13, for the deficiency at F 314, cited during the standard survey on 09/26/13, identified, ". . . goal . . . to have staff checking pressure points during cares & reporting any unusual areas to the nurses. Summarize your current work . . . they are checking & a few areas were reported to the nurses . . . How have you measured . . . improvement? . . . to continue monitoring skin. What changes or improvements have occurred? Better inspection of the skin. . . . (No) . . . new issue/area for improvement been identified." A "Report for Quality Committee," dated 11/24/13, identified, ". . . (Resident #6) has 2 reports of red coccyx. Will investigate to see when he is repositioned . . . What is the issue/concern? to prevent press (pressure) sores. . . . List possible systems, processes and departments that may be involved in improvement plan. Communication sheet for Bath aides, Educate, Educate, Educate! Do a QA (quality assurance) to check on positions." Review of Resident #6's care plan failed to identify the problem and interventions for the "pimple" identified on 12/12/13 on the "Treatment Administration Record" to the right outer buttocks. The record lacked evidence of weekly skin assessments for the following three weeks. During observation on 12/30/13 at 4:25 p.m., two certified nursing assistants (CNAs) (#2 and #6) provided toileting and performed incontinence cares for Resident #6. Before providing the cares, a CNA (#2) stated Resident #6 had a duoderm dressing on his buttock due to the presence of a sore. A nurse (#8) also reported Resident #6 had an open area. Following cares, observation showed a duoderm dressing on Resident #6's right buttock. The inner edges of the duoderm adjacent to the crevice of the buttock showed evidence of drainage under the duoderm and possible loosening on the edge of the duoderm close to the crevice of the buttock. During interview on 12/30/13 at 4:45 p.m., an administrative nurse (#1) stated Resident #6 "had" an open area, but duoderm is now being used to protect the area. During interview on 12/30/13 between 4:45 p.m. and 5:30 p.m., an administrative nurse (#1) and staff nurse (#7) identified a communication book/Kardex which addressed Resident #6's skin cares. The Kardex included two written communications: dated 11/30/13, "Good pericares and often (sic) as possible when inc (incontinent), Put calmo ([MEDICATION NAME]) on bottom" and on "12-28 Duoderm type drsg (dressing) applied to Rt (right) coccyx." The staff nurse (#7) identified nursing staff completed a weekly "skin check." The staff nurse (#7) stated she observed the resident's buttock on December 12 and December 19 and identified a pimple on the right buttock. The staff nurse (#7) identified the completion of the "evaluation" occurs on the "Treatment Administration Record" and the nurse documents the appearance in the progress notes. The record showed the weekly skin check scheduled for Thursdays in December: December 5, December 12, December 19, and December 26. The administration record lacked evidence an evaluation/assessment occurred on December 5 and December 26. The record lacked documentation of the appearance of the skin on December 19. The staff nurse (#7) stated the "Wound Flow Sheet" is kept by the administrative nurse (#1). On the evening of 12/30/13 at 9:05 p.m., a staff nurse (#3) removed the duoderm dressing and reapplied a new duoderm. The nurse identified a 1.8 centimeter (cm) by 1.4 cm open area with sanguineous (bloody) drainage on Resident #6's right inner buttocks region near the crevice. On 12/31/13 at 8:30 a.m., an administrative nurse (#1) reported talking to the staff nurse (#4) who placed the duoderm on Resident #6's buttock on 12/28/13. The administrative nurse (#1) reported the staff nurse (#4) placed the duoderm on the buttock on 12/28/13 as the area was "just barely" open, and plans were to call the physician for an order on 12/30/13. During interview on 12/31/13 at 8:40 a.m., a staff nurse (#4) reported she did not do an assessment on 12/26/13 as scheduled on the "Treatment Administration Record" and stated on Saturday, 12/28/13, she noted a small open area at the "top" of Resident #6's right buttock. She stated the resident experienced pain so she applied a duoderm and left a note for the administrative nurse (#1) for the following Monday (12/30/13). The staff nurse (#4) provided a copy of the note, dated 12/28/13, which stated, "I put a Duoderm CGF (control gel formula) border 4 x (by) 4 (inch) on (Resident #6's) sore it was draining a little - If its ok or you want something else plz. (please) have (another staff nurse) get an order. Thanks." During interview on 12/31/13, at 9:40 a.m., an administrative nurse (#1) stated no "Wound Flow Sheet" had been initiated regarding the open area on Resident #6's buttock. The "Treatment Administration Record" and progress notes lacked evidence staff completed the scheduled weekly skin assessments. The record lacked an assessment of the area on 12/28/13 prior to the application of a duoderm dressing and lacked evidence of an assessment of the pressure area until 12/30/13. Information request dring the entrance conference on the morning of 12/30/13 failed to identify Resident #6's pressure ulcer. - Review of Resident #9's medical record occurred on 12/31/13. [DIAGNOSES REDACTED]. . ." Review of Resident #9's progress notes identified the following: *12/21/13 - "Small 0.75 cm open area on her coccyx, area was cleansed and dried well and [MEDICATION NAME] applied" * 12/29/13 - "Resolving open area to coccyx area will continue to monitor purple area to lt upper buttock area blanches and no c/o (complaints of) discomfort." The facility failed to assess Resident #9's pressure ulcer and document the findings on a wound flow sheet; failed to notify the resident's physician and obtain a treatment order; and failed to notify the dietary department.

Based on record review, review of policy and procedures, and staff interview, the facility failed to provide supervision and assistive devices necessary to prevent accidents for 1 of 4 sampled residents (Resident #2) who experienced injuries during falls. Failure to develop goals and a plan of care in order to reduce the risk of accidents, implement measures consistent with Resident #2's needs, and evaluate those measures, to prevent falls, all which occurred from a wheelchair, resulted in multiple incidents of injury to Resident #2 and one visit to the emergency room due to unresponsiveness following a fall. Findings include: Review of the facility guidelines for "Prevention and Management of Falls" occurred on September 26, 2013. The policy, dated 04/2011, stated, ". . . In order for a Falls Prevention program to be successful . . . . . . each resident will be evaluated to determine his or her risk for falling. Include the following components for review: . . . ? Identification of environmental hazards and any individual resident risk of an accident, including the need for supervision ? Evaluation and analysis of the hazards and risks related to potential falls ? Implementation of interventions, including adequate supervision, consistent with resident needs, goals, plan of care and current standards of care and current standards of practice in order to reduce the risk of an accident. ? Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice. PREVENTION STRATEGIES Environmental . . . Any hazards discovered should be removed or corrected immediately. Modification of the resident's environment should accommodate his/her individual needs. . . . Medical Management Involvement of the resident's health practitioner is vital. The physician can provide evaluation of medical interventions for any acute and chronic conditions and assess the impact to a resident's fall risk due to the presence of these conditions. . . . Medications Drug regimen reviews . . . should be reviewed for recommendations with specific attention focused on those medications that may increase the fall risk or may have contributed to actual fall. Nursing staff should evaluate the effectiveness, presence of side effects, adverse consequences and the necessity of continued medication usage as part of regular clinical monitoring. Ambulation/Functional Deficits Ongoing evaluation of a resident's level of function is required. . . . decline in physical function may be at increased risk of fall. . . . Activities A program of activities which is geared to meeting the needs of all residents can be used as an intervention to prevent falls. . . . Tracking/Trending A tracking mechanism should be utilized to assist in the evaluation of resident specific information . . . Falls Committee The Interdisciplinary Team should perform an analysis of the precipitating events for individual resident falls and evaluate potential interventions aimed at prevention of future falls. . . . (and) perform ongoing systematic evaluation to determine the effectiveness of the Falls Prevention Program. Quality Improvement . . . should . . . look for trends in Falls location, time and date, risk factor management and potential root cause. . . . to develop an effective action plan or idea . . ." On the morning of 09/23/13, a supervisory nursing staff member (#1) stated Resident #2 doesn't sleep in her bed, but rather sleeps in a Broda chair (a tilt and recline positioning wheelchair/chair) with a chair alarm. Review of Resident #2's medical record occurred on all days of survey. Resident #2's medical [DIAGNOSES REDACTED]. A comprehensive assessment, dated 03/02/13, included the following trigger: * Falls: "Resident has had a fall incident which places her at risk for falls. She also has mobility deficits and is transferred per mechanical lift or sit to stand lift depending upon her compliance status. . . . She used the wheelchair for mobility. . . . had a fall incident which she fell asleep in the wheelchair and slipped out of it. She did substain (sic) a bruise on her forehead from fall. She has safety awareness deficits due to her dementia. . . . She does at times wander about in her wheelchair but is generally situated at nurse's station for close supervision. . . . Proceed to care plan? Yes, Why or why not? To prevent fall and fall related injuries. . . ." Resident #2's current care plan identified the problem of "Impaired mobility and potential for falls r/t dementia, arthritis . . . m/b (manifested by) non-ambulation" with approaches of "Will not sleep in bed. Place in Broda chair or recliner at bedtime. . . . Sit/stand lift and assist of 2 when cooperative; Total mechanical lift and assist of 2 when uncooperative/sleepy . . . Sensor mat to bed and chair. . . ." An interdisciplinary assessment, dated 05/28/12, identified the use of a Broda tilt-n-space chair, and showed the chair in use beginning on 05/22/12. The purpose of the chair being "helps her get restful sleep." An assessment on 08/09/12 identified the Broda tilt-n-space recommended by the physical therapy assistant. A "fall data collection tool," dated 02/20/13, identified the resident at risk for falls, with a fall risk score of 22 (a score of 12 or more indicates high risk). Resident #2's record identified the following falls: * 09/25/12 at 4:15 p.m.: "Slid herself out of w/c (wheelchair) to the floor. No injuries noted." The incident details identified a chair alarm that did not sound because "it slid (with) her and she leaned against it with her back." A comment included "May need to add tab alarm." Observation on all days of survey did not show the presence of a tab alarm. * 10/05/12 at 3:50 p.m., "scooted out of w/c . . . No injury" *10/20/12 between 2:00 p.m. and 4:45 p.m., nursing staff administered "Medication" for restlessness and trying to get out of her chair. At 4:35 p.m., "Resident was found on the floor face down." The incident report identified nursing staff administered Ativan one mg within the four hours prior to the fall. With the fall, nursing staff identified a bruise and contusion on the resident's forehead and began neurological checks, and "Resident became lethargic and fell asleep in wheelchair. Tried to wake resident but she would not wake. Ambulance were called." The resident returned to the facility at 8:50 p.m. and the assessment showed resident with a 2 x 2 cm (centimeter) light purple raised bruise on (left) forehead, 6 x 5 cm non-raised bruise for (sic) (right) forehead from outer (right) eye to scalp-line. . . ." * 11/18/12 at 4:40 a.m., "Staff heard sound et looked to find resident lying face down on floor in front of wheelchair. (Left) side of face against floor." The report identified the fall occurred in the hallway by the nurse's station and staff noted a "lump on (L) outer edge of eye" and neurological checks initiated. An interdisciplinary progress note (IDPN), dated 11/19/12 at 8:00 a.m. stated ". . . Lt (left) eye lid brow et (lower) eye bruising. . . ." * 02/20/13 at 7:30 a.m., fall in hallway by nurse's station, "Sleeping in w/c in hallway - fell forward out of w/c." The report identified the resident sustained [REDACTED]." * 08/02/13 at 7:00 a.m., a fall in the hallway by the nurse's station, "Res (resident) fell asleep in wheelchair, leaning too far to one side & tipped over. (no) apparent injury, denies pain/injury. Neurochecks started." The report identified the resident fell on to her right side, and her "forehead slightly red." * 08/29/13 at 11:50 p.m., "Res was in w/c in commons area by desk. Staff heard chair alarm and res was tipped over in w/c laying on left side. Has pad alarm so did not alarm until w/c was tipped over." The record identified falls occurred on at least two occasions when the chair alarm did not sound. An entry in an IDPN, dated 08/03/13, stated ". . . Sensor mat to chair as resident will physically scoot herself fwd (forward) in chair & has had multiple falls. Note that @ times resident has poor posture in her w/c. Will lean trunk to the (left). Curvature of spine affects positioning of trunk as well as fatigue in her core musculature. Staff encouraged to reposition as often as needed (with assist of two). . . ." During interview on 09/25/13 at 9:10 a.m., a supervisory staff nurse (#2) stated CNAs are informed of cares for residents through a "group list" which identifies "briefly" what the expectation is for CNAs regarding cares. The list identified Resident #2 as a "fall risk." The nurse stated the interventions included a bed/chair sensor and stated that also includes taking the resident to activities and do activities with her. The list did not identify preferred/effective activities for staff to utilize. During interview on the morning of 09/26/13, an administrative nurse (#3) stated she has not done any tracking or trending of Resident #2's falls. The nurse referred the question to another staff member, specifically staff member #4. A staff member (#4) referred the surveyor to the physical therapy department regarding Resident #2 leaning to her left side while her eyes were closed (asleep) in the wheelchair. The facility failed to prevent Resident #2's falls by not assessing, including determining causative factors, implementing measures, and evaluating those measures for effectiveness. This resulted in Resident #2 sustaining falls from a wheelchair which resulted in injuries to the resident's head and a visit to the emergency room due to unresponsiveness following a fall. Observation also showed nursing staff (CNAs) transferred Resident #2 with a sit-n-stand lift verses a total mechanical lift during sleepy periods, placing the resident at risk for additional falls.

Based on observation, record review, review of policies/procedures, review of professional reference, and staff interview, the facility failed to ensure 1 of 13 sampled residents (Resident #5) received the correct dose of medication per physician's orders [REDACTED]. Findings include: "Nursing 2013 Drug Handbook," 33rd edition, Lippincott, Williams & Wilkins, Philadelphia, pages 576-580, identified, "[MEDICATION NAME] . . . CONTRAINDICATIONS & CAUTIONS . . . Use with caution in elderly or debilitated patients. . . . Advise patient not to stop drug abruptly. . . ." Resident #5's medical record, reviewed September 23-26, 2013, identified [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified problems with memory, moderately impaired daily decision making skills, extensive assistance for activities of daily living (ADLs), and use of scheduled and as needed pain medications. The current care plan identified, "Problem: Altered comfort . . . Approaches: Medicate as ordered. Monitor for adverse consequences . . ." The physician's orders [REDACTED]. * 09/22/09, [MEDICATION NAME] 15 mg (milligrams) every two hours as needed for pain * 01/16/10, [MEDICATION NAME] 40 mg twice daily for pain * 01/19/10, [MEDICATION NAME] Patch 150 micrograms (mcg)/hour for pain The physician's orders [REDACTED]. . Change ([MEDICATION NAME] Patch) q (every) 72 hr (hours). Disposal of old patch as follows: Two nurses witness patch wrapped in toilet tissue and flushed down toilet. Both nurses sign off disposal. . . ." Resident #5's progress notes identified the following: * 01/01/13 at 8:30 a.m., "Resident in dining room for breakfast when CNAs (certified nurse assistants) called nurse to table. Resident had 'shakes,' involuntary movement noted. She did not want anyone to touch her during her 'spell.' Began to remove clothing and became very agitated. . . . Resident taken to her room where involuntary movements almost like a [MEDICAL CONDITION]-type continued and worsened - unable to obtain blood pressure due to shaking resident crying and wants to go to 'doctor' . . ." * 01/01/13 at 8:40 a.m., "Unit supervisor notified and CNA stays (with) resident in room meds (medications) not given orally due to shaking as I worried that she could not swallow them properly . . ." * 01/01/13 at 9:00 a.m., "Notified (Hospital) ER (emergency room ) that resident was going to be sent to ER for above symptoms . . ." * 01/01/13 at 11:15 a.m., "Phone call from (Physician) . . . admit to (Hospital) . . ." The (Hospital) Discharge Summary, dated 01/03/13, identified, ". . . HOSPITAL COURSE: (Resident #5) . . . admitted into observation on 01/01/13 after presenting to the ER with altered mental status. Specifically increased agitation compared to baseline. Patient was having trouble sitting still. She would not let anyone touch her to do any kind of assessment. She is complaining of arm and legs and everything hurting. She would also have jerking movements in her arms. . . . It seemed like she would not be able to stop her arms and she would have the jerking for a few seconds and then it would pass for a while. In patient's initial assessment it was noted that she was missing one of her [MEDICATION NAME]es. Patient is on a total dose of 150 micrograms per hour which she receives through one 100 microgram patch in combination with one 50 microgram patch. It was found that she had only her 50 microgram patch on. On the day prior patient had also had nausea and diarrhea. All of the symptoms were suspected to be from narcotic withdrawal. Patient was given initially IM (intramuscular) and later IV (intravenous) [MEDICATION NAME] which did calm her down and relieve symptoms. . . . FINAL Diagnoses: [REDACTED]. . . ." The Physician's Progress Note, dated 01/02/13, identified, ". . . 2. Increased agitation, restlessness, and arm tremor/jerking likely secondary to above." The physician's discharge orders identified the following: * 01/01/13, [MEDICATION NAME] 40 mg twice daily for pain * 01/01/13, [MEDICATION NAME] Patch 100 mcg every 72 hours for pain * 01/01/13, [MEDICATION NAME] Patch 50 mcg every 72 hours for pain The January 2013 MAR, also identified: * " . . . (Handwritten notation) Write site of patch placement: RC (right chest), LC (left chest), RB (right back), LB (left back)." The record failed to identify the site of placement on 01/19/13 and 01/25/13. * " . . . (Handwritten notation) 01/03/13 (start date) Check for placement of [MEDICATION NAME] every shift." The progress notes identified the following: * 01/30/13 at 8:50 a.m., "Resident noted to be missing [MEDICATION NAME] Patch 50 mcg (micrograms) - none found in room - had been applied to Rt (right) upper anterior chest on 01/28/13 . . ." * 01/30/13 at 1:00 p.m., "(Nurse Practitioner) notified - (Registered Nurse) also checked resident's skin with me and no patch found . . . " * 01/30/13 at 2:30 p.m., "Orders received from (Nurse Practitioner) and new patches will be applied today and will follow schedule of (sic) before of two days on and change the 3rd day." The February 2013 MAR, identified, ". . . Change q 72 hr. Write site of new patch placement (right chest, left chest, right back, left back). . . . 12/01/12 Check for placement of [MEDICATION NAME] every shift." The record failed to show the site of placement on 02/08/13. During an interview on 09/25/13 at 8:50 a.m., a managerial nurse (#12) stated, "We started checking for the placement of the patches last year sometime." A progress note, dated 02/18/13 at 9:40 p.m., identified, "Sitting (up) on edge of bed - Tremors of UE's (upper extremities) - c/o (complains of) 'muscle spasms' - severey (sic) anxiety - Rx (Medicated) (with) [MEDICATION NAME] 15 mg (milligrams) po (orally) per prn (as needed) order - unable to (check) vs (vital signs) (secondary to) anxiousness/shaking. - Transferred (sic) to w/c (wheel chair) (and) taken to nurses station to monitor. - Fluids given - unable to calm . . . Also noticed [MEDICATION NAME] (applied 02/17) not on - new Fent ([MEDICATION NAME]) patches (100 mcg (and) 50 mcg) applied (and) covered (with) OpSite to Rt/Lt (left) mid back." Resident #5's narcotic record, dated December 13, 2012-February 22, 2013, also identified the facility failed to verify the correct count of her [MEDICATION NAME] medication on the following days: * December: 14, 17, 20, 21, 22, 23, 25, 26, 28, and 31 * January: 3, 4, 6, 8, 10, 11, 13, 15, 16, 17, 21, 22, 23, 26, 27, 28, and 29 * February: 1, 5, 6, 7, 8, 9, 11, 14, 15, 19, 20 and 21 During an interview on 09/25/13 at 1:30 p.m., an administrative nurse (#3) and a managerial nurse (#15) reported they were unable to locate any investigative reports concerning the three episodes involving the missing [MEDICATION NAME]es. They further reported, "We checked the bedding and the laundry." The facility failed to implement effective interventions following the disappearance of Resident #5's pain medication which resulted in the resident experiencing discomfort and being hospitalized on one occasion for symptoms of withdrawal. They also failed to 1) thoroughly investigate the three episodes (01/01/13, 01/30/13, and 02/18/13) involving Resident #5's missing [MEDICATION NAME]es, 2) identify the site of placement on three occasions between January 19, 1013-February 8, 2013, and 3) reconcile the medication on twenty-two occasions between December 12, 2013-February 22, 2013.

THIS DEFICIENCY WAS NOT CORRECTED AT THE TIME OF THE ON-SITE REVISIT, FOR THE STANDARD SURVEY COMPLETED ON 09/26/2013. Based on record review, review of manufacturer's recommendations, review of professional reference, and staff interview, the facility failed to ensure administration of insulin occurred within the ordered/recommended times and failed to administer scheduled and sliding scale [MEDICATION NAME]in one injection for 2 of 3 sampled residents (Resident #6 and #10) with Type II insulin dependent diabetes. Failure to administer [MEDICATION NAME] (a rapid-acting insulin) at the correct time may result in [DIAGNOSES REDACTED], and failure to administer scheduled and sliding scale insulin resulted in unnecessary pain for Resident #10. These practices may negatively impact all diabetic residents residing at the facility. Findings include: Kozier & Erb's "Fundamentals of Nursing: Concepts, Process, and Practice," 5th ed., Addison Wesley Longman, Inc., California, page 1321, states, ". . . Mixing Medications in One Syringe . . . Frequently, clients need more than one drug injected at the same time. To spare the client the experience of being injected twice, two drugs (if compatible) are often mixed together in one syringe and given as one injection. . . ." Review of the manufacturer's instructions for [MEDICATION NAME]occurred on 12/31/13. The instructions stated, ". . . You should eat a meal within 5 to 10 minutes after using [MEDICATION NAME] to avoid low blood sugar. [MEDICATION NAME] is a fast-acting insulin. The effects of [MEDICATION NAME] start working 10 to 20 minutes after injection. . . Do not inject [MEDICATION NAME] if you do not plan to eat right after your injection. . . ." During an interview on the morning of 12/31/13, a nursing staff member (#5) identified meal times as "open breakfast" from 7:30 a.m. until 9:00 p.m., lunch at 12:00 p.m., and dinner at 6:00 p.m. - Review of Resident #6's medical record occurred on December 30-31, 2013. [DIAGNOSES REDACTED]. Medications included: [MEDICATION NAME] (a long-acting insulin) 50 units subcutaneously (SQ) two times a day, scheduled [MEDICATION NAME] 8 units SQ three times per day, and sliding scale [MEDICATION NAME] three times per day. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Record review for the month of December 2013 identified staff administered Resident #6's sliding scale and scheduled [MEDICATION NAME] between 5:08 a.m. and 6:25 a.m. on 21 different occasions (over an hour before breakfast begins). The record failed to identify any snack given prior to breakfast. Staff also administered Resident #6's sliding scale and scheduled [MEDICATION NAME] between 4:10 p.m. and 4:52 p.m. on 10 different occasions (over an hour before supper begins). The nurse's notes identified a snack of crackers or juice given with the insulin administrations; however, staff do not serve the supper meal until 6:00 p.m. Record review for the month of December 2013 further identified staff administered scheduled and sliding scale [MEDICATION NAME] in two separate injections on 22 occasions prior to the breakfast meal and 8 occasions prior to the supper meal, in addition to Resident #6's twice per day [MEDICATION NAME] and lunch time [MEDICATION NAME] injections. This resulted in Resident #6 receiving up to seven needle sticks per day (on 12/18/13, 12/21/13, 12/22/13, 12/23/13, and 12/24/13). Resident #6's progress notes stated the following: *11/30/13 at 5:25 a.m., stated, ". . . Resident received insulin to the stomach and stated '(expletive)! You (expletive) poke yourself in the stomach!' While nurse was recording Resident's blood sugar outside room nurse heard Resident state '(expletive)! I hate those (expletive) (expletive) needles. Do it to yourself and see how much you like it. . . ." *12/31/13 at 5:42 a.m.: ". . . Resident also was angry this AM when taking his accucheck (blood sugar monitoring) and giving insulin. Resident screamed 'Ow.' . . ." - Review of Resident #10's medical record occurred on 12/31/13. [DIAGNOSES REDACTED]. Current medications included [MEDICATION NAME] (a long-acting insulin) 22 units SQ once per day, [MEDICATION NAME] 3 units SQ three times per day (TID), and sliding scale [MEDICATION NAME] TID. The MAR indicated [REDACTED] Record review for the month of December 2013 identified staff administered Resident #10's sliding scale and scheduled [MEDICATION NAME] between 5:28 a.m. and 6:18 a.m. on 13 different occasions (over an hour before breakfast begins). The record failed to identify a snack given prior to breakfast. Staff also administered Resident #10's sliding scale and scheduled [MEDICATION NAME] between 4:15 p.m. and 4:42 p.m. on 10 different occasions (over an hour before supper begins). The nurse's notes identified a snack of crackers (and occasionally cheese) given with the insulin administrations; however, staff do not serve the supper meal until 6:00 p.m. Record review for the month of December 2013 further identified staff administered scheduled and sliding scale [MEDICATION NAME] in two separate injections on 8 occasions prior to the breakfast meal, 2 occasions prior to the noon meal, and 10 occasions prior to the supper meal, in addition to Resident #10's [MEDICATION NAME] injection. This resulted in Resident #10 receiving up to seven needle sticks per day (on 12/08/13 and 12/30/13). During interview on the morning of 12/31/13, an administrative staff nurse (#5) stated nursing staff provide residents a snack with insulin administration to avoid low blood sugars. Facility staff administered fast-acting insulin over an hour prior to meals and provided residents with snacks rather than meals at those times, which resulted in unstable blood sugar levels for Resident #10 and may result in unstable blood sugar levels for other insulin dependent residents in the facility. Facility staff administered sliding scale [MEDICATION NAME] separately from scheduled [MEDICATION NAME], which resulted in unnecessary needlesticks and/or pain. Refer to F309.

1. Based on observation, record review, and staff interview, the facility failed to provide assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #5) who sustained a femur fracture during a transfer and 1 of 5 sampled residents (Resident #4) observed transported by staff in a wheelchair. Failure to utilize the sit to stand lift per the plan of care resulted in Resident #5 fracturing her leg, causing unnecessary pain, and a decline in the resident's mobility. Failure to apply foot pedals to wheelchairs during staff-assisted transport may result in falls and/or injury to residents. Findings include: - Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #5's annual Minimum Data Set (MDS), dated [DATE], and significant change MDS, dated [DATE], indicated transfer and toilet use with extensive assistance of two or more people. The 04/10/12 MDS indicated the resident walked in the corridor with extensive assistance of two or more people, and the 07/11/12 MDS indicated walking in the corridor did not occur. Resident #5's Interdisciplinary Progress Notes (IDP), dated 06/19/12 at 9:05 p.m., stated, "GSS (Good Samaritan Society) #401 (Incident Report) filled out." The Incident Report, dated 06/19/12, stated, "Alleged nature of incident: Slipped or fell . . . . No injury . . . Comments: Staff attempted to transfer from w/c (wheelchair) to toilet by self, no lift used or gait belt. . . . Staff member given corrective action, and educated. . . ." Resident #5's IDP notes, dated 06/20/12 at 1:05 p.m., stated, ". . . He (doctor) ordered a PT (Physical Therapy) post fall assessment. . . . Resident was not able to extend/assist (with) (left) L/E (lower extremity) for transfer. Resident reports pain (with) motion, swelling . . ." A PT note, dated 06/20/12, stated, ". . . (Resident #5) has an edematous distal thigh and knee on the left. Her passive range of motion is limited to 20 degrees - 80 degrees. Sharp pain at the end ranges. Any dorsinal force on the femur produces pain in the knee and distal thigh. . . . She has pain with any attempted weight bearing. In fact, she cannot even use a sit to stand lift that would limit her weight bearing. She has to use a mechanical lift transfer . . . My recommendation is . . . get further diagnostic studies. . . ." A PT note, dated 06/26/12, stated, ". . . (Resident #5) fell on [DATE] sustaining a distal femoral fracture of the left femur. She had an open reduction internal fixation (surgery) on 06/21/12 and returns to Good Samaritan now with orders to be non-weight bearing on the left. . . ." Resident #5's care plan, dated 04/17/12, identified the following problems: * "Altered bladder elimination r/t (related to) . . . mobility deficits . . . Plans and Approaches: Toilets with assist 2 with sit to stand lift . . ." On 07/03/12 staff updated the plan to read, "Toilets with assist 2 (with) hoyer lift to bed using bedpan . . ." * "Impaired mobility/pot. (potential) falls r/t weakness and deconditioning, balance deficit, m/b (manifested by) unsteady gait, wears foot & ankle support, poor endurance, h/o (history of) falls/high risk for fall. . . . Plan and Approaches: . . . Transfers with sit to stand lift and assist of 2. . . ." On 06/27/12 staff updated the plan to read, "Transfers with total mechanical lift and assist of 2." * "Cognitive loss r/t dx (diagnosis) dementia m/b memory deficit, and lack of judgement in decision making . . . Plans and Approaches: . . . Offer day to day cueing, explaination (sic) of ongoing cares, do not assume understands processes or procedures." During an interview on 09/26/12 at 3:15 p.m., an administrative nurse (#10) stated the certified nurse aide (CNA) (#13) had completed orientation, but answered Resident #5's call light which was on a wing she had not previously worked on. It was determined the facility failed to ensure the CNA (#13) was appropriately trained/educated to provide resident care consistent with the resident's care plan. This lack of training resulted in the resident's fall and fracture. - Review of the medical record for Resident #4 occurred September 24-25, 2012. The facility identified [DIAGNOSES REDACTED]. Resident #4's quarterly MDS, dated [DATE], identified moderately impaired cognition, extensive assistance of one person for transfer and dependence on one person for locomotion on/off the unit. Observation on 09/25/12 at 8:30 a.m. showed a licensed nurse (#2) transporting Resident #4 out of the dining room in her wheelchair. Resident #4 slumped to the side and did not pick up her feet while being transported causing her feet to slide along the hard wood floor of the dining room. When the nurse (#2) reached the carpeted hallway, Resident #4's right foot caught and pulled backward under the wheelchair causing the top of her slipper to slide over the carpet. The surveyor asked the nurse (#2) to stop, indicating the unsafe positioning of the resident's foot. The nurse (#2) asked a CNA (#1) to lift Resident #4's feet while she pushed the resident. The CNA (#1) instead retrieved foot pedals and put them on Resident #4's wheelchair. Observation on 09/26/12 at 8:15 showed a CNA (#14) helping Resident #4 with morning cares. The CNA (#14) identified the resident does not use foot pedals on her wheelchair. At the completion of cares, the CNA (#14) transported the resident to the dining room with the resident's shoes making a brushing noise as they slid along the carpet of the hallway. During an interview on 09/26/12 at 7:55 a.m., an administrative nurse (#10) identified the facility staff would take steps to assure availability of foot pedals when needed by Resident #4. 2. Based on observation, record review, review of facility policy and guidelines, and staff interview, the facility failed to ensure the resident environment remained as free from accident hazards as possible, and failed to determine the resident's ability to safely smoke without supervision for 1 of 2 sampled residents (Resident #9) who smoked independently in an area outside the building. Failure to assess Resident #9's ability to safely smoke and ensure oxygen use is prohibited in the smoking area placed the resident, other residents, staff, and visitors at risk of injury. Findings include: Review of the facility policy titled "Smoking" occurred on 09/27/12. This policy, revised April 2012, stated, ". . . Policy: . . . All clients who smoke or use tobacco products will be assessed. . . . Procedure: 1. . . . The program staff (coordinator) must ensure precautions are taken for the client's individual safety as well as the safety of others in the program. Smoking by clients when oxygen is in use is prohibited. A physician's order should be obtained allowing oxygen to be removed to allow a client to smoke. 2. It is required that all clients who smoke or use tobacco products should be assessed using the Tobacco Use Assessment (GSS #474) for safe use upon admission to the program and when staff members observe a change in safe practices. Each of the nine factors on the assessment should be considered in the care planning process. Care plans are updated as needed. . . ." Review of the facility guidelines titled "Oxygen Use Safety" occurred on 09/27/12. These guidelines, revised March 2011, stated, "Purpose: To administer and store oxygen in a safe manner. Guidelines: 1. . . . There is always a danger of fire when oxygen is used. 2. Be sure to explain the hazards of smoking in the presence of oxygen to residents and families, i.e., resident who goes outside in wheelchair with oxygen. 3. No open flames or smoking in a room where oxygen is being used. . . . 7. Avoid use of flammable materials (. . . smoking . . .) near residents using oxygen. Review of Resident #9's medical record occurred on September 25-27, 2012. The facility admitted the resident from the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #9's admission Minimum Data Set (MDS), dated [DATE], indicated intact cognition, independent locomotion on and off unit, and on oxygen therapy. Physician orders, dated 09/14/12, stated, "Oxygen to keep sats (oxygen saturation) (greater than) 90% (percent)." Resident #9's medication administration record (MAR) for September 14-26, 2012 showed staff charted the resident received oxygen at 2-3 liters per minute (L/M) daily with oxygen saturations of 90-95%. The physician orders failed to address the resident's tobacco habit and oxygen use while smoking. Resident #9's nurses' notes, dated 09/19/12 at 5:00 p.m., stated, "Witnessed resident smoking a cigarette on front porch (with) O2 (oxygen) on per NC (nasal cannula) @ (at) 2.5 L/M. When approached he stated 'I'm going to smoke one no matter what' - I explained that he cannot smoke here (with) O2 running and he asked me to 'turn it off then.' . . . " The facility failed to complete a smoking assessment or develop a care plan and interventions related to smoking after this incident. On 09/25/12 at 09:10 a.m., observation showed Resident #9 wheeled himself down the hall and out the front door. An unidentified resident was in this area smoking, along with two visitors who stopped to talk with the two residents. The resident had oxygen tubing in his nose connected to an oxygen tank with the pressure gauge reading between 1000 and 2000 pounds per square inch. Resident #9 lit and smoked a cigarette. An administrative staff member (#16) and an administrative nurse (#10) were informed of Resident #9's smoking. The nurse administrator stated the resident is supposed to stop at the nurses' station and have a nurse turn the oxygen off before he goes out to smoke. Resident #9's nurses' notes, dated 09/25/12 at 11:00 a.m., stated, "Wanderguard was placed on (name of resident)'s wheelchair so that when he goes outside to smoke, door will alarm so nurses can make sure oxygen is shut off. . . . " The facility failed to complete a smoking assessment to determine whether Resident #9 was safe to smoke unsupervised; failed to obtain a physician order regarding Resident #9's smoking and oxygen use; failed to develop a care plan and interventions related to smoking, oxygen use, and safety issues; and failed to ensure Resident #9 followed safety rules when smoking.

Based on record review, review of information received from the complainant, and staff interview, the facility failed to ensure staff promptly assessed the resident's condition and notified the physician for 1 of 1 closed record (Resident #1) with [MEDICAL CONDITION]. Failure to promptly assess Resident #1's condition and notify the physician resulted in delayed treatment for [REDACTED]. Findings include: The closed medical record for Resident #1, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The record indicated Resident #1 received an anticoagulant (blood thinner) related to his [MEDICAL CONDITION]. Resident #1's Interdisciplinary Progress Notes (IDP notes) identified the resident had long standing "corns" on the 4th and 5th toes of the left foot which staff monitored weekly. The IDP notes identified the following: 12/21/11: (not timed) ". . . Corn pads to 4th and 5th for protecting toes - foot had 'foot drop' often rubs toes there . . ." 12/23/11: "9:30A (a.m.) Lt (left) foot - 4th toe clean/dry (with) hole in center . . . Corn pads left off as seems to irritate areas - cleansed (with) safeclens - will con't (continue) to (check) qd (daily) (no) redness." 01/11/12: (not timed) ". . .Cont (with) 'corns'/scabs on 4th -5th toes L) (left) foot." 01/18/12: (not timed) ". . . monitoring Lt foot 4th et (and) 5th toes, corn areas - dry - (no) redness - scabs - corn pads not used as irritates them (toes)." 01/25/12: (not timed) ". . . Chronic 'corns' to 4th and 5th toes of Lt) foot unchanged . . ." 01/28/12: "PM (afternoon) Lt foot/toes warm, swollen & (and) becoming red. C/O (complained of) slight discomfort." 01/29/12: "10A Lt foot/toes & part way up the shin bone is warm, swollen & red. C/O sl (slight) discomfort. Will have seen by M.D. in AM (morning)." During an interview, on 03/15/12 at 9:40 a.m. a licensed nurse (#1) stated, on 01/28/12, Resident #1's left 4th toe was "purple like a bruise" at the base of the toe. She stated the next day the redness had moved up to just above the ankle. The record lacked evidence the nurse (#1) or other facility staff took appropriate action to address Resident #1's red, swollen left foot on 01/28/12 and the redness and swelling, which extended from the toes to "part way up the shin bone," on 01/29/12. (Refer to F157) Information received from the complainant identified the licensed nurse (#2) on duty on the morning of 01/30/12 received report at approximately 7:00 a.m. identifying "the patient's foot was red and swollen" and at approximately 9:00 a.m. reviewed the appointment book and found a note which stated, "Please make appt (appointment) for (Resident #1) to see (physician's name) for lt foot/leg [MEDICAL CONDITION], redness & warmth -- thanks ?? (question) [MEDICAL CONDITION]." Review of the facility's investigation of "what happened with (Resident #1's) toe" occurred on all days of survey. The investigation, dated 02/02/12, included a statement from a Certified Nursing Assistant (#7) which stated, "Sat (Saturday) Jan (January) 28 - 2012 - about 7:30 AM Took (Resident #1) in for his shower Sat morning as I was bathing him I noticed 4th toe on his left foot was red and slightly swollen. Also had bruise around a corn that started to bleed a little bit. I placed a bandaid on his toes and told nurses (#1 and #5) what I saw . . . Mon (Monday) [DATE]th - 2012 about 7:30 AM Went to get (Resident #1) for his shower Mon AM. When I pulled the blankets off noticed his foot was very red and swollen up to ankle - 4th toe was very swollen, prob (probably) quarter size in diameter, and black and blue, removed bandage when I got him into shower room. Area around corn was greenish in color . . . Did not put Ted hose on because of swelling. I told (Nurse #5) about (Resident #1's) foot - She was going to let (Nurse #2) know when she got back to cart. . . . (Resident #1's) vitals were taken Mon morning everything was good except B/P (blood pressure). I could not get a good reading . . . About 9:45 - 10:00 AM, (Nurse #2) came into shower room to tell me she'd gotten 92/60 for a B/P/" The record lacked evidence the nurse (#2) assessed Resident #1's left foot at the time she obtained this blood pressure reading. Record review identified the nurse (#2) did not assess Resident #1's left foot until 2:00 p.m., seven hours after coming on duty, and five hours after she reviewed the appointment book with the request to make an appointment in the a.m. for possible [MEDICAL CONDITION]. The record identified the staff member assessed Resident #1 after receiving a call from the physician: "01-30-12 1400 (2:00 p.m.) Received T.O. (telephone order) from (physician's name) that pt (patient) is to begin [MEDICATION NAME] (an antibiotic) . . . Pt also scheduled to see (physician's name) @ (at) 4 p.m. to examine foot, which is warm, tender, and swollen (L) (left) 4th toe noted to be dark blue and covered with a bandaid. (unsure who put bandaid on) . . ." "01-30-12 1700 (5:00 p.m.) Received notification from clinic that - pt being transferred to (hospital name) for a surgical consult for possible (L) fourth toe amputation." Review of information from the hospital identified a surgical consultation, dated 01/31/12, which stated, "REASON FOR CONSULTATION: 1. Gangrene of the toe. 2. Acute [MEDICAL CONDITION] of foot. RECOMMENDATIONS: 1. IV (intravenous) antibiotics is (sic) instituted. 2. Once the [MEDICAL CONDITION] is improving, we will recommend toe amputation at that time. . . . PLAN: Do a toe amputation once he has had marked improvement of the [MEDICAL CONDITION], which at this point is beginning and I expect it will be another 24 to 48 hours before [DIAGNOSES REDACTED] will be improved enough to make the toe amputation not complicated by that." A physician's progress note, dated 02/03/12, stated, "(Resident #1) . . . was admitted with left lower leg [MEDICAL CONDITION] and gangrenous left foot. He has also been treated for [REDACTED]. . His bone scan is positive for osteo[DIAGNOSES REDACTED] of his left foot and he is scheduled for amputation of his fourth toe on the left side by (physician's name) today . . . ASSESSMENT: 1. Left lower leg [MEDICAL CONDITION], improving on IV [MEDICATION NAME]. 2. [MEDICAL CONDITION] with positive blood cultures . . ."