Every finding on record at Good Samaritan Society - Lakota

Based on observation, record review, review of facility policy, and staff and resident interviews, the facility failed to provide the necessary care and services for 2 of 15 sampled residents (Resident #22 and #29). Failure to follow physician's orders for wound care (Resident #22) and an implanted vascular access port care (Resident #29), and to address and report low blood glucose levels to the physician (Resident #29) may result in adverse outcomes. Findings include: Review of the facility policy titled Physician/Practitioner Orders occurred on [DATE]. This policy, dated [DATE], stated, . wound care including product to be used . A licensed nurse must provide wound care. Physician/Practitioner orders are a critical component to providing quality care to residents. Review of facility policy titled Intravenous Therapy occurred on [DATE]. This policy, dated February 2024 stated, . IMPLANTED VENOUS ACCESS PORT . It is recommended that the unused implanted venous access port be accessed and flushed at least every 4 weeks or per specific physician order. Review of facility policy titled Hypoglycemic Incidents occurred on [DATE]. This policy, dated [DATE], stated, . PURPOSE To protect from complications of hypoglycemia . For residents with no individual order, the practitioner should be notified when the blood glucose value is less than 70 mg/dl [milligrams per deciliter] . Wound Care Review of Resident #22's medical record occurred on all days of survey. A physician's order stated, Nystatin Powder . Apply to labia/groin topically three times a day related to RASH AND OTHER NONSPECIFIC SKIN ERUPTION . The current care plan stated, . Resident has MASD [moisture associated skin damage] to labia . do excellent peri cares every am [morning] and pm [evening] and prn [as needed], nurse to apply treatment as ordered. During an interview on [DATE] at 12:56 p.m., Resident #22 stated, I have some skin issues on my bottom and feel that the staff don't always follow what my doctor ordered. The resident also stated she felt the lack of treatment had impacted her healing process. Observation on [DATE] at 9:00 a.m. showed a certified nurse aide (CNA) (#13) assisted Resident #22 in the bathroom with peri cares. The CNA cleansed the resident's peri area, and applied powder to the resident's peri area. Observation on [DATE] at 2:28 p.m., showed a CNA (#3) assisted Resident #22 with peri cares. The CNA cleansed the resident's peri area, and pulled up the pants. When asked if Resident #22 had any treatment to the peri area, the CNA stated, yes, showed the surveyor an unlabeled medicine cup containing a powder on the dresser, and went to the treatment room to confirm the name of the Nystatin powder. During an interview on [DATE] at 2:36 p.m., a nurse (#8) confirmed she placed the powder in Resident #22's room and expected the CNAs to call the nurse to apply the powder. She stated, Preferably the nurse applies the treatment but that doesn't always happen, and I place it in there so it's available for the CNAs to apply so the resident does not go without. During an interview on [DATE] at 10:30 a.m., an administrative nurse (#6) confirmed she expected staff to follow physician orders. Port Flushes During an interview on [DATE] at 8:57 a.m. Resident #29 stated she had an implanted catheter port and it should be flushed every two months. The resident stated, Someone in charge of the building tried to flush it but had the wrong needle so they didn't get any blood back. They said they ordered new needles, but that's been a while and I haven't heard anything. It's definitely past due to be changed. Review of Resident #29's medical record occurred on all days of survey and showed an admission date of [DATE]. A physician's order, dated [DATE], stated, . Port flushes with NS (normal saline) 10 ML (milliliters) followed by Heparin 500 units/5ml monthly. On [DATE], the physician changed the order from monthly flushes to every six weeks (45 days). Review of the electronic medication administration record (eMAR) and nurse's notes showed nursing staff flushed Resident #29's port on the following dates: * [DATE] * [DATE] - (75 days later) * [DATE] - Flushed with NS only (49 days later). Heparin expired. * hospitalized in May * [DATE] - (126 days later) Observation on [DATE] at 9:37 a.m. showed the NP (#17) flushed Resident #29's port in the presence of an administrative nurse (#7). The administrative nurse (#7) stated, We could not find the correct needles to flush the port, so we had [NP's name] bring supplies from clinic in [another city]. When asked when nursing staff last flushed the port, the administrative nurse (#7) stated, I don't know, I'd have to check in the record. During an interview on [DATE] at 10:17 a.m., an administrative nurse (#7) when asked why Resident #29's port had not been flushed per orders, stated, We have not been able to get the right supplies for it, we've checked on the internet and could not find the right needles. The facility failed to flush Resident #29's port per physician orders. Blood Glucose Review of Resident #29's medical record occurred on all days of survey and identified a diagnosis of diabetes mellitus. Physician's orders included Lantus (insulin) twice a day and glucagon (used to raise blood glucose) infection for low blood glucose if the resident is unable to swallow. Review of Resident #29's blood glucose record showed a blood glucose reading of 65 milligrams per deciliters (mg/dL) on [DATE] at 7:22 a.m. The medical record failed to show facility staff notified the physician or treated the low blood glucose. During an interview on [DATE] at 11:30 a.m. two administrative nurses (#6 and #7), confirmed Resident #29's medical record lacked documentation the facility contacted the physician and/or addressed the resident's low blood glucose on [DATE]

Based on record review, review of facility policy, review of the resident council meeting minutes, and resident and staff interviews, the facility failed to provide sufficient nursing staff and related services to meet the residents' needs for 3 of 3 confidential residents (Resident A, B, and C) who require staff assistance. Failure to provide sufficient staffing resulted in residents experiencing unmet needs and may negatively affect the residents' physical, mental, and psychosocial well-being. Findings include: Review of the facility policy titled Staffing and Scheduling occurred on 08/26/26. This policy, dated June 2026, stated, . As a manager, or person tasked with scheduling, you want to make sure you have the necessary staff to fulfill the needs of the customers you serve. - Review of Resident A's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified substantial/maximum assistance required with toileting transfers. During an interview on 08/23/26 at 3:14 p.m., Resident A stated, A few months ago, I waited three hours and they told me my call light had fallen down and was broken. Weekends are bad and we need more help. About six weeks ago I pooped the bed waiting for them to answer my light. - Review of Resident B's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified substantial/maximum assistance required with toileting transfers. During an interview on 08/24/26 at 8:57 a.m., Resident B stated, It takes over 30 minutes for them to answer my call light at times. They do not have enough staff, and it depends on who is working, some are good and some are not. I have wet myself waiting for them to answer my call light, but I wear diapers and well today I guess I have a pull up on. - Review of Resident C's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified partial/moderate assistance required with toileting transfers. During an interview on 08/25/26 at 9:05 a.m., Resident C stated, In the evening they are short staffed and it takes half hour or better to get help. Review of the resident council meeting minutes, dated 06/09/26, identified residents voiced concerns related to long call light response times. During an interview on 08/25/26 at 8:25 a.m., when asked if they felt they had sufficient time to meet the needs of the residents, a staff member (#8) stated, We have some days where it's hit and miss. If someone calls in especially on a weekend we usually don't have anyone to call or if we do they cannot come into work. During interviews on 08/25/26 at 3:26 p.m. and 3:32 p.m., two certified nurse aids (CNA) (#2 and #3) indicated they are responsible for approximately 14 residents during a typical shift. They felt they did not have enough time during their shift to complete their assigned duties, and the facility often asks them to come in early or stay late. During an interview on 08/26/26 at 9:55 a.m., an administrative staff member (#1) stated, they had some challenges.

Based on observation, review of facility policy, confidential resident interviews, and staff interviews, the facility failed to ensure sufficient nursing staff to meet resident needs for four confidential residents (Residents A, B, C, and D) who required staff assistance. Failure to provide sufficient staffing and answer call lights in a timely manner does not promote a resident's right to physical, mental, and psychosocial well-being.Findings include: Review of the facility policy titled call lights occurred on 06/16/26. This policy, dated July 2025, stated, . Purpose. To ensure residents always have a method of calling for assistance. To promptly answer resident's call light. When resident's call light is observed/heard go to resident's room promptly. Respond to request as soon as possible. Confidential resident interviews and observations on 06/16/26 identified the following: *At 8:57 a.m., observation showed Resident A's call light on. At 9:09 a.m., an unidentified staff member turned the call light off while picking up meal trays. The staff member told the resident she would be back to help her. At 9:16 a.m., Resident A stated, I have my call light on, and staff should be coming in to help me to the bathroom, and Call light wait time is worse in the morning because they are getting everyone up. They are short on staff here. The resident also stated, There have been a few times I have been incontinent but most of us wear diapers here. At 9:28 a.m., an unidentified therapy staff member brought Resident B (Resident A's roommate) into the room. At 9:29 a.m., Resident B turned the call light on. At 9:31 a.m., a certified nurse aide (CNA) (#4) entered the room and asked who needed help. Resident A stated, We both do, but I have been waiting longer. The CNA exited the room and returned with the stand lift. Resident A waited 34 minutes for assistance. *At 12:57 a.m., observation showed resident B's call light on. During an interview, Resident B stated, The longest wait time is thirty minutes or so. An administrative staff member (#7) then entered the room and asked what they needed (Resident A and Resident B). Both residents stated they needed to use the restroom. Resident B stated, The big man came in about ten minutes ago [approximately 12:47 p.m.] and was going to find someone to help. The administrative staff member then left the room. Resident B stated It is too late for me already. It was me that shit my pants this time, last time it was her [Resident A]. At 1:06 p.m., (approximately 19 minutes after the big guy came into the room) a CNA (#4) entered the room to assist the residents. *At 1:48 p.m. Resident C stated, I sometimes have to wait a long time for help. The longest I have had to wait for help was four hours. Sometimes certain CNAs and staff members enter my room and turn off my call light off without helping me. *At 2:23 p.m. Resident D stated, My roommates bath took a little longer than expected this morning, so my CNA was not able to get me up. At 11:15 [a.m.] I figured there was no point to get up for lunch and I chose to eat lunch in my room. Call light wait times depend upon what's going on. If they are short it takes a while to get help, the longest was maybe forty-five minutes or so. During interviews at 4:33 p.m. and 6:00 p.m., an administrative staff member (#2) stated staff are expected to get residents up at the time requested, answer call lights timely, and it is unacceptable for staff to turn off call lights to find someone else.

Based on observation and record review the facility failed to review and revise care plans to reflect the resident's current status for 2 of 6 sampled residents (Residents #1 and #6). Failure to update care plans limit the staff's ability to communicate residents' needs and ensure continuity of care.Findings Include: - Review of Resident #1's medical record occurred on 06/16/26 and identified a left intertrochanter (hip) fracture. The current care plan stated, . The resident has an ADL [activities of daily living] self-care performance deficit R/T [related to] elzhiemers [sic] E/B [evidenced by] need for staff to anticipate needs and wants. An intervention, revised on 02/09/26 stated, Ambulation: X1 (one person) staff assist, using the standing lift [mechanical sit to stand lift] for all transfers . Resident does not ambulate. During an observation on 06/16/26 at 2:35 p.m., two certified nurse aides (CNAs) (#4 and #5) transferred Resident #1 from the wheelchair to the bed using a full body mechanical lift and not a sit to stand lift as care planned.- Review of Resident #6's medical record occurred on 06/16/26. Physician orders included, . Assure Heel Boots are on at all times and heels are offloaded every shift for Pressure Ulcers to left great and 2nd toes . Prevalon [padded] boots to both feet on at all times . related to pressure ulcer of left heel. The current care plan stated, . The resident has potential for impairment to skin integrity R/T central cord syndrome at C [cervical disc] 5 [five] . Prevalon boots to both feet while in bed .The facility failed to update Resident #6's care plan to reflect heel boots at all times.

Based on observation, record review, review of facility policy, and staff interviews, the facility failed to provide care and services to prevent the development of pressure ulcers for 2 of 6 sampled residents (Residents #1 and #6) with pressure ulcers. Failure to provide repositioning and utilize pressure relief devices appropriately may result in the development/worsening of pressure ulcers. Findings include: Review of the facility policy titled Pressure Ulcers occurred on 06/16/26. This policy, dated March 2026, stated, . will use prevention and assessment interventions to ensure that a resident entering the location 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. Review of the facility policy titled Positioning occurred on 06/16/26. This policy, dated December 2024, stated, . To position residents unable to position/reposition independently in a manner which . maintains skin integrity. - Review of Resident #1's medical record occurred on 06/16/26. Physician's orders included, Frequent repositioning r/t [related to] Buttock skin breakdown. The current care plan stated, . The resident has bladder incontinence R/T loss of ability to identify urinary needs . The resident has existing pressure ulcers R/T need for staff assist will all repositioning . Reposition resident on a routine basis . Observation on 06/16/26 at 8:45 a.m., 11:31 a.m., and 12:35 p.m., showed Resident #1 seated in a reclining wheelchair. At 2:35 p.m., two certified nurse aides (CNAs) (#4 and #5) performed a check and change. The residents brief, pants, mechanical lift sling, and pressure-relieving pad in the wheelchair were saturated with urine. The CNA (#4) stated residents are repositioned every two hours. Facility staff failed to reposition Resident #1 or provide a brief change for almost three hours. - Review of Resident #6's medical record occurred on 06/16/26. Diagnoses include a spinal cord injury and diabetes mellitus. Physician orders included, Assure Foot cradle is on bed and bed blankets are draped over it and the foot board every shift. Assure Heel Boots are on at all times and heels are offloaded. Pressure ulcers to left great and 2nd toes . Prevalon [padded] boots to both feet . related to pressure ulcer of left heel. The current care plan stated, . The resident has potential for impairment to skin integrity R/T central cord syndrome at C [cervical] 5 [five] . inability to reposition self . Reposition with each brief check and change . Foot cradle to foot of bed to keep blankets lifted off the feet . Observations on 06/16/26 at 1:27 p.m. and 4:48 p.m. showed Resident #6 in bed positioned on their left side with blankets draped directly over the resident's feet and not over the foot cradle or foot board. A nurse's progress noted, dated 06/16/2026 at 2:17 p.m., stated, Skin Issues Note: 2 x [by] 2 cm [centimeter] deep tissue injury to back of upper right leg Skin issue education: Change clothing / briefs. Skin issue education: Change / shift positions frequently. Skin issue education: Care of skin issue(s). Skin issue education: Turn every 2 hours. During an interview on 06/16/26 at 4:13 p.m., a nurse (#9) confirmed staff discovered the deep tissue injury during a skin assessment today (06/16/26). During an interview the afternoon of 06/16/26, an administrative staff member (#2) stated she expected staff to reposition residents every two hours, confirmed the facility staff failed to document repositioning, and expected the foot cradle to be used as ordered. The facility failed to ensure the blankets were over the foot cradle and not directly on Resident #6's feet as ordered. Residents #1 and #6's medical records lacked documentation of repositioning every 2 hours.

Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 13 sampled residents (Resident #2, #10, #23, #35, and #36). 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 GG: FUNCTIONAL ABILITIES AND GOALS The Long-Term Care Facility RAI Manual, revised October 2024, pages GG-5 to GG-8, stated, . GG0115 Functional Limitation in Range of Motion: Code for limitation that interfered with daily functions or placed resident at risk of injury in the last 7 days. Coding: 0. No impairment, 1. Impairment on one side, 2. Impairment on both sides . - Review of Resident #23's medical record occurred on all days of survey. The care plan stated, . paralysis to upper extremities and right leg and needs assistance . Observation on 06/02/25 at 10:19 a.m. showed Resident #23's bilateral arms/hands and bilateral legs limp/unable to move. A quarterly MDS, dated [DATE], failed to identify Resident #23's impairments to the upper and lower extremities. During an interview on 06/03/25 at 09:18 a.m., an administrative nurse (#3) confirmed staff failed to code the MDS assessment correctly. SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised October 2024, pages I-5 to I-8, stated, . Active Diagnoses . Coding Instructions: Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status . medical treatments . during the 7-day look-back period . - Review of Resident #36's medical record occurred on all days of survey. An admission provider's note, dated 05/07/25, identified a diagnosis of cancer. An admission MDS, dated [DATE], failed to identify an active diagnosis of cancer. SECTION M: SKIN CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2024, page M-37 to M-39, stated, . Check all that apply in the last 7 days. Coding Instructions: . M1200A/M1200B pressure reducing devices redistribute pressure so that there is some relief on or near the area of the ulcer/injury. The appropriate pressure reducing device should be selected based on the individualized needs of the resident. Review of Resident #10's medical record occurred on days of survey. The care plan stated Roho [an alternating air cushion] cushion to wheelchair seat when up in chair. Observations on 06/03/25 at 8:24 a.m. and 1:29 p.m. showed a Roho cushion on Resident #10's wheelchair and a pressure relieving mattress to the bed. The annual MDS, dated [DATE], showed staff failed to code the use a Roho cushion and a pressure relieving mattress for Resident #10. SECTIONS N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2024, pages N-6 to N-8, stated, . Code all high-risk drug class medications according to their pharmacological classification . N0415K1. Anticonvulsant: Check if an anticonvulsant medication was taken by the resident at any time during the 7-day observation period . - Review of Resident #2's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], showed facility staff coded anticonvulsant use during the seven-day assessment. The medical record failed to identify administration of an anticonvulsant medication during the assessment period. - Review of Resident #35's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], showed facility staff coded anticonvulsant use during the assessment period. The medical record failed to identify an anticonvulsant medication administered in the look-back period. - Review of Resident #36's medical record occurred on all days of survey. An admission MDS, dated [DATE], showed facility staff coded anticonvulsant use during the assessment period. The medical record failed to identify administration of an anticonvulsant medication during the assessment period. During an interview on 06/03/25 at 09:29 a.m., two administrative nurses (#3 and #4) confirmed staff failed to code the MDS assessments correctly. SECTION P: RESTRAINTS AND ALARMS The Long-Term Care Facility RAI User's Manual, revised October 2024, pages P1 to P5, stated, . PHYSICAL RESTRAINTS: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. P0100: Physical Restraints . Coding Instructions: . After determining whether or not an item . is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back or it was used but did not meet the definition. Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period. - Review of Resident #10's medical record occurred on days of survey. The annual MDS, dated [DATE], showed facility staff coded bed rail used daily. - Review of Resident #36's medical record occurred on all days of survey. A Bed Rail Assessment, dated 05/07/25, stated, . Would the side rail be considered a restraint? . 'No.' If no the side rails do not meet the definition of a restraint for this resident. An admission MDS, dated [DATE], showed facility staff coded bed rail as used daily. During an interview on 06/03/25 at 09:18 a.m., an administrative nurse (#3) confirmed the bed rails were not used as a restraint and facility staff coded the MDS's incorrectly.

Based on observation, record review, and review of facility policy, the facility failed to follow standards of infection control and prevention for 4 of 5 sampled residents (Resident #10 #23, #24, and #35) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), perineal care, hand hygiene, and cleaning of a mechanical lift has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Standard, Enhanced Barrier, and Transmission-Based Precautions occurred on 06/04/25. This policy, revised April 2025, stated, . Enhanced barrier precautions expand the use of personal protective equipment [PPE] beyond situations in which exposure to blood or body fluids is anticipated and refer to the use of a gown and gloves during high-contact resident care activities . Enhanced barrier precautions are also used for residents with chronic wounds (i.e., pressure ulcers .) . indwelling medical devices (i.e., indwelling urinary catheters, feeding tubes .) . High-contact resident care activities include transfers, dressings, assisting during bathing, providing hygiene, changing briefs or assisting with toileting . Review of the facility policy titled Hand Hygiene occurred on 06/04/25. This policy, revised March 2022, stated, . To establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms to patients . hand hygiene: a general term that applies to either handwashing or applying hand sanitizer . All employees will . adhere to the 4 Moments of Hand Hygiene and 2 Zones of Hand Hygiene. 1. Entering Room, 2. Before Clean Task, 3. After Bodily fluid/Glove Removal, 4. Exiting Room, 5. Zones: Patient zone and Health-care zone . Review of the facility policy titled Environmental Cleaning Principles occurred on 06/04/25. This undated policy, stated, . Environmental cleaning plays an important role in an infection control program. Multi-use equipment should be disinfected after use. - Review of Resident #10's medical record occurred all days of survey. The care plan stated, The resident requires Enhanced Barrier Precautions [related to] open wound . [Apply] gown and gloves when performing high contact care activities including: . checking and changing . wound care. During an observation on 06/03/25 at 8:24 a.m., two certified nursing assistants (CNAs) (#8 and #9) provided perineal cares for Resident #10. At 1:29 p.m., the CNA (#8) assisted with wound care. During both observations the CNAs failed to wear PPE prior to providing care to a Resident #10. - Review of Resident #23's medical record occurred on all days of survey. The current care plan stated, . requires Enhanced Barrier Precautions (EBP) R/T [related to] indwelling medical device (feeding tube and catheter). Observation on 06/03/25 at 10:19 a.m. showed an EBP sign on Resident #23's door frame and a supply container outside the resident's room containing PPE. Two CNAs (#2 and #5) entered the room, performed hand hygiene, and applied gloves, but failed to wear gowns. The CNA (#5) obtained a wet wipe and cleansed the perineal area from back to front instead of front to back. The CNAs rolled the resident onto her left side and the CNA (#5) cleansed the rectal area, removed the soiled brief, and placed a clean brief under the resident. Without removing the soiled gloves, the CNA (#5) assisted the CNA (#2) with other personal cares. The CNA (#5) then removed the soiled gloves and without performing hand hygiene, obtained mouth swabs and mouthwash and completed oral cares. The CNA (#5) picked up soiled linen on the floor with ungloved hands and exited the room. The CNA (#5) failed to apply gloves and perform hand hygiene. The CNAs (#2 and #5) failed to apply gowns before providing cares. The CNA (#5) failed to provide appropriate incontinence cares, failed to remove soiled gloves and perform hand hygiene before applying clean gloves, handled soiled linen without gloves, and failed to perform hand hygiene before exiting Resident #23's room. - Review of Resident #24's medical record occurred on all days of survey. The current care plan stated, . has an ADL [activities of daily living] self care performance deficit R/T impaired cognition, mobility E/B [evidenced by] assist of 1-2 for cares . TOILETING USE: . requires assist of 2 and full lift. has bladder incontinence R/T impaired cognition E/B urinary incontinence . Observation on 06/01/25 at 2:57 p.m. showed two CNAs (#7 and #8) entered Resident #24's room, performed hand hygiene, applied gloves and transferred the resident from the wheelchair to the bed with the full body mechanical lift. The CNA (#7) completed perineal cares, placed a new brief under the resident, and removed the soiled gloves. Without performing hand hygiene, the CNA (#7) completed personal cares for the resident. The CNA (#8) performed hand hygiene, exited the room with the mechanical lift, and placed it in the hallway. The CNA (#8) failed to sanitize the lift prior to exiting the resident's room. - Review of Resident #35's medical record occurred on all days of survey. The current care plan stated, . requires Enhanced Barrier Precautions (EBP) R/T indwelling medical device (Foley catheter) . Observation on 06/02/25 at 1:25 p.m. showed two CNAs (#2 and #5) entered the resident's room, performed hand hygiene, applied a gown and gloves and transferred the resident from the wheelchair to bed. The CNA (#5) performed catheter cares, cleansed the rectal area, discarded the soiled brief, and placed a clean brief under the resident. Without removing their soiled gloves and performing hand hygiene, the CNA (#5) completed other personal cares for the resident.

Based on record review, review of facility policy, and staff interviews, the facility failed to provide the necessary services for 1 of 13 sampled residents (Resident #10) and 2 supplemental residents (#11 and #12) who required staff assistance with bathing. Failure to provide bathing as scheduled may result in poor personal hygiene and decreased self-esteem. Findings include: Review of the facility policy titled Bathing occurred on 06/03/25. This policy, dated September 2024, stated, To promote cleanliness and general hygiene . To assist resident with personal care . During an interview on 6/02/25 at 8:28 a.m., a certified nurse aide (CNA) (#2), indicated he/she normally does baths, however, since the facility was working short staffed today he/she was working on the floor instead of giving resident baths. - Review of Resident #10's medical record occurred all days of survey. The care plan stated, . BATHING: Resident requires assist of 1 with bathing in whirlpool. Review of the bathing record from May 5 through June 3, 2025, showed the facility staff failed to bathe the resident from May 19 to June 3, 2025, (15 days). - Review of Resident #11's medical record occurred on 06/03/25. The care plan stated, . resident has an ADL [Activities of Daily Living] self care performance deficit. Review of bathing records from May 5 through June 3, 2025, showed the resident refused a bath on May 5, received a bath on May 12 and May 19. The facility failed to bathe the resident from May 20 to June 3 (15 days). - Review of Resident #12's medical record occurred on 06/03/25. The care plan stated, . BATHING: Resident requires moderate assist of 1 staff with bathing. Review of bathing records from May 5 through June 3, 2025, showed the resident received a bath on May 5 and May 20, and refused a bath May 30. The facility failed to bathe the resident from May 6 to May 19 (13 days). During an interview on 06/03/25 at 6:40 p.m., an administrative staff member (#1) confirmed Resident #10, #11 and #12's medical record lacked documentation staff provided bathing as scheduled.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment and services to promote healing of a pressure ulcer for 1 of 2 sampled residents (Resident #10) with a pressure ulcer. Failure to provide wound treatment as ordered may result in delayed healing, wound infection, and worsening or development of a new pressure ulcer. Finding include: Review of the facility policy titled Wound Dressing Change occurred on 06/03/25. This policy, dated 11/01/24, stated, . Check the physician's order . Identify date and initials on dressing/tape. Chart dressing change . Review of Resident #10's medical record occurred on all days of survey. A physician's order, dated 04/02/25, stated, Decubitus Ulcer Coccyx [an open wound on or near the tailbone] Cleanse with Wound Cleanser, apply Collagen [a protein] Pad and cover with Bordered Gauze daily. every night shift for Decubitus Ulcer Coccyx. Observation on 06/03/25 at 8:24 a.m. showed two certified nurse aides (CNAs) (#8 and #9) assisted Resident #10 with a brief check and change. The dressing located on the resident's coccyx area showed a date of 05/31/25. During an interview on 06/03/25 at 10:50 a.m., a nurse (#10) stated the dressing is changed nightly and checked the treatment administration record (TAR). Documentation identified dressing changes completed on 05/31/25, twice on 06/01/25, and the resident refused on 06/02/25. Observation on 06/03/25 at 1:29 p.m. showed a nurse (#10) and the CNA (#8) completed a dressing change for Resident #10. The nurse (#10) confirmed the date written on the old dressing removed was 05/31/25. Review of the TAR for the month of May 2025 showed staff failed to complete/document dressing changes on 05/11/25, 05/20/25, and 05/24/25. The medical record did not indicate the resident refusal on these days.

Based on record review, review of facility policy, and resident interview, the facility failed to provide necessary services and assistance for 1 of 1 confidential resident (Resident A) who voiced concerns related to toileting assistance. Failure to provide toileting assistance in a timely manner may result in a loss of dignity and placed the residents at risk for incontinence, skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries. Findings include: Review of the facility policy titled Bowel & Bladder occurred on 06/03/25. This policy, dated May 2025, stated, . PURPOSE To achieve a comfortable voiding schedule with the least amount of incontinent episodes . Review of Resident A's medical record occurred on all days of survey. The care plan identified the following, . TOILET USE: Resident requires 1 staff assist. The current Minimum Data Set, identified required substantial/maximal assist for toileting and always continent of bladder. During an interview on 06/01/25 at 4:21 p.m., Resident A stated he/she has been incontinent of urine due to waiting for staff assistance with toileting. The resident stated when he/she uses the call light for staff assistance it often takes 15-45 minutes. Review of Resident A's toileting log, dated May 4 through June 2, 2025, showed staff failed to toilet the resident for 4-11 hours on four occasions and resulted in urinary incontinence. The facility staff failed to provide the necessary services and assistance for Resident A to maintain urinary continence.

Based on record review, review of facility policy, and resident and staff interviews, the facility failed to provide respiratory care in accordance with professional standards and the plan of care for 1 of 1 sampled resident (Resident #25) with a diagnosis of severe obstructive sleep apnea. Failure to obtain or check on the status of a Continuous Positive Airway Pressure (CPAP) device may result in cardiovascular issues, daytime fatigue, impaired cognitive function and affect overall quality of life. Findings include: Review of the facility policy titled Non - Invasive Respiratory Support occurred on 06/03/25. This policy, dated October 2024, stated, . PURPOSE . Provide the most effective treatment option . for those suffering with respiratory insufficiency. Review of Resident #25's medical record occurred on all days of survey and included diagnoses of severe sleep apnea and acute respiratory failure with hypoxia. During an interview on 06/01/25 at 4:41 p.m., Resident #25 stated, I had a home sleep study in January and I'm supposed to have a CPAP, but they haven't gotten it for me yet. A home sleep test report, dated 02/22/25, identified Resident #25 had severe obstructive sleep apnea and indicated the need for a CPAP device. The medical record included an order request for a CPAP device to a medical equipment supplier on 02/27/25 and an order request to another medical equipment supplier on 05/23/25. During an interview on 06/03/25 at 2:38 p.m. an administrative staff member (#6) confirmed staff failed to order Resident #25's CPAP device until 05/23/25. The facility failed to follow up on obtaining a CPAP device for Resident #25 for over 3 months.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure posting of staff information on 2 of 3 days of survey (June 1-2, 2025). Failure to post staffing data does not allow residents and visitors information related to the number of licensed and unlicensed staff on duty each shift. Findings include: Review of the facility policy titled Nursing Staff Daily Posting Requirements occurred on 06/03/25. This policy, dated December 2024, stated, . post daily the staffing and resident census at the beginning of each shift . Observation on all days of survey showed a Nurse Staffing Posting Information form posted on a board in the hall by the residents' dining room. Review of the staffing information posted on 06/01/25 showed the data posted for 05/30/25. Review of the staffing information posted on 06/02/25 showed the data posted for the previous day. The facility failed to post current staffing information for June 1 and 2, 2025. During an interview on 06/03/25 at 6:40 p.m., an administrative staff member (#1) confirmed staff failed to post the appropriate staffing form for June 1-2, 2025.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to promote the healing or prevent the development of pressure ulcers for 2 of 3 sampled residents (Resident #1 and #2) identified with pressure ulcers. Failure to apply pressure relieving devices as ordered, complete weekly assessments with measurements of pressure ulcers per facility policy, may result in new pressure ulcers, the deterioration of existing pressure ulcers, and delayed healing. Findings include: Review of the facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation Requirements occurred on 01/08/25. This policy, dated April 2024 stated, . The pressure ulcer should be assessed/evaluated at least weekly . and should include at the least the following: Measurements - length, width, depth . Review of the Wound Data Collection form occurred on 01/08/25 and stated, . Measurements - Required at least every once every 7 days . - Review of Resident #1's medical record occurred on 01/08/25. Diagnoses included a history of urinary tract infections (UTIs), and clostridium difficile (inflammation of the colon caused by bacteria that can result in frequent diarrhea). The record identified a total of seven wounds, including two unstageable pressure ulcers and one stage two pressure ulcer. Physician's orders included weekly skin assessments, initiated 07/02/24; weekly registered nurse assessments, initiated 11/12/24; and wound care-right thigh, left gluteal fold, right gluteal fold - cleanse with wound cleanser, apply anasept gel (an antimicrobial skin and wound cleanser), with hydrogel gauze, cover dressings with border gauze every day shift and every one hour as needed for dislodged or soiled dressing, initiated 12/11/24. An initial assessment to Resident #1's left thigh wound, dated 11/07/24, measured 0.5 centimeters (cm) length x (by) 1.0 cm width x 0.1 cm depth. A second assessment, dated 11/19/24 (12 days later), failed to include measurements. Record review showed staff failed to complete weekly assessments and measurements after 11/19/24. An initial assessment to Resident #1's right thigh, dated 11/07/24, indicated an unstageable pressure ulcer and failed to include wound measurements. A second assessment dated , 11/13/24, showed a measurement of 2.5 cm x 4.0 cm. A third assessment dated , 11/19/24, showed a measurement of 3.0 cm x 2.8 cm x 0.2 cm. A fourth assessment dated , 12/06/24, indicated a stage two pressure ulcer with a measurement of 1.8 cm x 1.8 cm. Record review showed staff failed to complete weekly measurements after 12/06/24. An initial assessment to Resident #1's right gluteal fold, dated 12/07/24, indicated an unstageable pressure ulcer and showed a measurement of 0.7 cm x 1.6 cm. A second assessment, dated 12/11/24, showed a measurement of 8.2 cm x 5.5 cm x 0.1 cm. Record review showed staff failed to complete weekly wound measurements after 12/11/24 even though the resident's wound increased in size. An initial assessment to Resident #1's left gluteal thigh, dated 11/19/24, indicated a stage two moisture related pressure ulcer and measured 0.8 cm x 0.5 cm x 0.1 cm. A second assessment, dated 12/06/24 (17 days later), stated . open wound with necrosis [irreversible death of body tissue) at the center. and measured 2.0 cm x 1.7 cm. A third assessment, dated 12/07/24, indicated an unstageable pressure ulcer with a measurement of 1.6 cm x 1.0 cm. Record review showed staff failed to complete weekly wound measurements after 12/07/24. An initial assessment to Resident #1's right buttocks, dated 12/06/24, indicated an unstageable pressure ulcer with a measurement of 3.0 cm x 2.5 cm. Record review showed staff failed to complete weekly wound measurements after 12/06/24. An initial assessment to Resident #1's coccyx wound, dated 11/19/24, failed to include measurements and stated, . multiple areas to coccyx/peri area have moisture related first layer of skin removed. Record review showed staff failed to complete weekly assessments with wound measurements after 11/19/24. An assessment to Resident #1's left buttock wound, dated 11/20/24, stated, . red area with scattered small open areas . and measured 11.1 cm x 9.0 cm x 0.1 cm. Record review showed staff failed to complete weekly assessments with wound measurements after 11/20/24. Review of nursing progress notes showed Resident #1 had multiple loose incontinent stools throughout the day and received loperamide (an anti-diarrheal) as needed for the loose stools. The electronic treatment record showed the facility staff completed dressing changes as ordered and as needed due to the loose incontinent stool. - Review of Resident #2's medical record occurred on 01/08/25. A significant change Minimum Data Set, dated dated dated [DATE], indicated two unstageable pressure ulcers. A physician's order, dated 12/19/24, stated, . Bilateral heel check for wound condition, offloading and heel protector boot placement BID [twice a day]. Bilateral heels must remain raised offloaded in bed and chair. Keep heel protector boots on at all times. Observation on 01/08/25 at 10:04 a.m. showed Resident #2 in the recliner in his room, with a pillow under his knees and his heels resting directly on the foot rest of the recliner, without protector boots in place. Observation on 01/08/25 at 12:00 p.m. showed Resident #2 in the recliner in his room, with bilateral heels resting over the edge of the recliner's foot rest, without protector boots in place. The facility failed to follow pressure relief interventions as identified by the physician's orders. Assessments of Resident #2's right heel pressure ulcer showed the following: * 11/24/24 - 2.2 cm x 3.1 cm. * 12/07/24 - 3.0 cm x 3.5 cm., (13 days later) * 12/19/24 - 1.1 cm x 1.6 cm., (12 days later) * 12/25/24 - 1.0 x 0.6 cm. * 12/30/24 - 1.0 cm x 1.0 cm * Record review showed staff failed to complete weekly wound measurements. Assessments of Resident #2's left heel pressure ulcer showed the following: * 12/07/24 - 2.0 cm x 2.5 cm. * 12/19/24 4 cm x 5 cm., (12 days later) * Record review showed staff failed to complete weekly wound measurements after 12/19/24 and showed the resident's pressure ulcer increased in size. During an interview on 01/08/25 at 1:30 p.m., and administrative staff member (#1) verified the facility failed to ensure interventions were being followed and the medical record lacked weekly wound measurements. The facility failed to complete weekly assessments with measurements to monitor Resident #1 and #2's pressure ulcers to determine further treatments and interventions to prevent the deterioration of the pressure ulcers.

Based on record review and staff interview, the facility failed to ensure appropriate care and services for 1 of 1 sampled resident (Resident #1) with an indwelling urinary catheter. Failure to obtain a physician order for an indwelling urinary catheter, and provide catheter care may result in urinary tract infections (UTI's), unnecessary discomfort, unnecessary skin issues, and/or sepsis. Findings include: Review of Resident #1's medical record occurred on 01/08/25. Diagnoses included retention of urine, pressure ulcers, resistance to multiple antimicrobial drugs and recurrent UTI's. The quarterly Minimum Data Set, dated dated [DATE], identified a urinary catheter. The care plan stated, . indwelling medical device (foley catheter) . Review of the medical record included a nurse practioner's note dated 12/18/24 and stated, . Patient returned to nursing home [from hospital] on 11/18/2024. A trial off the foley catheter occurred shortly after return with noted urinary retention. She has a urology consult 2/12/2024 (sic) for urinary retention and recurrent UTIs. Review of Resident #1's progress notes included the following: * 11/19/24 at 3:07 p.m. catheter draining yellow urine. * 12/25/24 at 4:14 p.m.Indwelling foley catheter replaced today with 16fr [french] Cathether (sic). The facility failed to obtain a physician order for an indwelling foley catheter and how often to change the catheter. During an interview on 01/08/24 at 1:20 p.m., an administrative staff member (#1) confirmed Resident #1's medical record lacked an order for the catheter.

1. Based on observation, record review, review of facility policy, and staff and resident interview, the facility failed to provide care and services to maintain the resident's highest level of well-being for 1 of 1 sampled resident (Resident #30) with a change in health status followed by a transfer to the hospital. Failure to monitor and assess the resident's condition on an on-going basis resulted in worsening respiratory symptoms, a delay in treatment, and an admission to the hospital. Findings include:Review of the facility policy titled Notification of Change occurred on 06/19/24. This policy, dated 12/04/23, stated, . A facility must immediately inform the resident, consult with the resident's physician . when there is: . A significant change in the resident's physical, mental or psychosocial status . A need to alter treatment significantly . Observation on 06/17/24 at 11:12 a.m. showed Resident #30 ambulating in her room with oxygen in place via nasal cannula. The resident stated she was good, except I can't breathe. The resident was noticeably short of breath and sat in her recliner. The surveyor asked if the resident would like a staff member to come in, and the resident stated, No, they know, and indicated the doctor would be at the facility that day. The resident identified she has been feeling more short of breath and planned to speak with the doctor about it. Resident #30 stated she has needed increased oxygen in the last five days or so, and was now receiving 3 liters per minute (lpm) of oxygen. The resident also stated she had blisters on her leg and thought they were infected. Observation on the morning of 06/18/24 showed Resident #30 in her recliner with oxygen via nasal cannula at 3 lpm. Resident #30 stated she was still experiencing shortness of breath, and the doctor did not come to see her yesterday. Resident #30 stated she was very disappointed, but was told the doctor would be at the facility today (06/18/24). Review of Resident #30's medical record occurred on all days of survey. Diagnoses included chronic obstructive pulmonary disease (COPD), pulmonary heart disease, and congestive heart failure. Current physician's orders included: *Supplemental oxygen (O2) at 2 lpm *Ventolin HFA (hydrofluoroalkane) (used to treat or prevent bronchospasms) Inhalation Aerosol Solution, 2 puffs inhale orally every 4 hours as needed for shortness of breath (SOB), wheezing. Resident #30's nurses' notes identified the following: *06/14/24 at 5:06 a.m.: . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB, wheezing. coughing with moist cough, inspiratory wheeze . *06/14/24 5:23 a.m.: . Ventolin HFA Inhalation . PRN [as needed] Administration was: Effective . *06/14/24 at 8:15 p.m.: . Entering resident's room and noted a dry hacky cough. She states that she has increased pain to the right mid back. With ascultation [sic] [listening to lung sounds with a stethoscope], noted moderately loud rhonchi [coarse, loud sounds caused by constricted airways] to all lobes on the right and the left was clear. Vitals taken and WNL [within normal limits]. noted that there are 5 intact fluid filled blisters to her RLL [right lower leg] and the left is more red. This was noted when taking off her thigh high ted hose. There was weeping fluid from an opened blister. Xeroform [a wound dressing] place [sic] and covered with gauze and kling [a type of gauze] until provider could be notified. Do [sic] review her weights and noted a 2.5# weight gain in a week and a 9# weight gain over the past month. Did request her ventalin [sic] inhaler to help her with her coughing and feeling winded. 02 is on a [sic] 2L/NC and sats are 96%. Wull [sic] continue to monitor and report to the oncoming shift to notify provider. The record lacked evidence of physician notification. *06/15/24 at 4:19 p.m.: . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB, wheezing. CN [charge nurse] notified . The record lacked evidence of a respiratory assessment or vital signs. *06/15/24 at 5:40 p.m.: . Resident did not go to dining room for her supper because she stated she wasn't feeling well. She has rhonchi in right upper and lower lobes. SOB with any exertion. left lower leg has erythema [redness] 10 x 9 cm [centimeters]. Has oxygen at 3 LPM NC due to increased SOB. Resting in recliner with legs elevated . *06/15/24 at 8:54 p.m.: . Ventolin HFA Inhalation Aerosol Solution . PRN Administration was: Effective no longer wheezing . *06/15/24 at 9:20 p.m.: . LATE ENTRY . States her cough is better tonight. Lung sounds are notably clearer with only a few rhonchi heard. Still turns 02 up to 3 liters with any activity and states this helps. *06/16/24 at 7:20 a.m.: . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB, wheezing. Per CN . The record lacked evidence of a respiratory assessment or vital signs. *06/16/24 at 8:58 a.m.: . Ventolin HFA Inhalation Aerosol Solution . PRN Administration was: Effective . *06/16/24 at 3:32 p.m.: . Right lower leg with 3 large fluid filled blisters and dark red around. Left leg is lighter red with no open areas. She has expiratory wheezes thoughout [sic] all posterior lung fields and left upper lobe. Also has rhonchi to left lower lobe anteriorly. Has had trays today in room. She is short of breath at rest. [Provider name] said she will see Resident tomorrow . *06/16/24 at 8:42 p.m.: . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB, wheezing. The record lacked evidence of a respiratory assessment or vital signs. *06/17/24 at 12:00 a.m.: . Wraps applied at HS [bedtime] tonight after dressing change because they measure bigger than the day shift. Still has a harsh cough but the ventalin [sic] helps her breath [sic]. 02 is on at 3L/nc [nasal cannula] because she feels she breathes better on this. Lung sound still have rhonchi and an audible wheeze noted with activity. Provider will be seeing her this afternoon she states . *06/17/24 at 12:09 a.m.: . Ventolin HFA Inhalation Aerosol Solution . PRN Administration was: Effective less coughing . *06/17/24 at 4:34 p.m.: . received order for Mucinex [used to loosen mucus in the airways and clear congestion] 600mg [milligrams] BID [twice a day] x 1 week. Will see resident at facility tomorrow. *06/17/24 at 9:48 p.m.: . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB, wheezing. The record lacked evidence of a respiratory assessment or vital signs. *06/17/24 at 10:51 p.m.: . Ventolin HFA Inhalation Aerosol Solution . PRN Administration was: Effective . *06/18/24 at 3:28 p.m.: . late entry for 0930 today. This Resident was having difficulty breathing and had wheezes throughout all lung fields. Her lower legs and feet has [sic] 4 PE [pitting edema] and bright red. I asked her if she wanted to go to the hospital and she said yes that she did. (11 [sic, 911] was called and the [NAME] Ambulance was called and they arrived at 10:00 am and transported Resident to [hospital name] . *06/18/24 at 3:55 p.m.: . called [hospital name] and Resident was admitted to the hospital. The medication administration record (MAR) identified Resident #30 received five doses of PRN Ventolin from 06/14/24 to 06/17/24, and had not used the Ventolin prior to this during the month of June. The medical record and interview with Resident #30 identified increasing respiratory distress, pitting edema, lower leg blisters, weight gain, need for continuous oxygen at 3 lpm (versus 2 lpm as ordered), and use of PRN inhalers. The facility failed to report and act on Resident #30's complaints of respiratory distress and increased oxygen needs in a timely manner, assess and monitor the resident's respiratory status on an ongoing basis, and notify the medical provider until the afternoon of 06/16/24. These failures resulted in a delay in treatment and subsequent hospital admission. During an interview on the afternoon of 06/19/24, an administrative nurse (#2) stated staff should complete an assessment when they notice a change in condition. 45873 2. Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure staff provided care and services for 2 of 12 sampled residents (Resident #1 and #16) care planned for a positioning device and physician orders for devices for pain/swelling to an arm. Failure to apply a positioning device and to follow physician's orders for devices to control edema (swelling)/pain may result in poor posture, increased pain, worsening of edema, and other complications. Findings include: Review of the facility policy titled Positioning occurred on 06/19/24, This policy, dated 02/28/24, stated, . Purpose: To provide proper body alignment for residents in wheelchairs. Position . Resident is upright positioning and weight-bearing equally at hips (does not lean to one side). - Review of Resident #1's medical record occurred on all days of survey and included a diagnosis of dementia and osteoporosis. The current care plan stated, . The resident is at risk for falls R/T [related to] cognition deficit E/B [evidenced by] history of falls. Interventions: . Resident is to use an Evolution chair/Broda chair [reclining wheelchair]. Does tend to slide down in chair, at times. Monitor for sliding in chair at all times. Monitor resident for significant changes in mobility, positioning device, sitting balance and lower extremity joint function. Observations showed Resident #1 in a Broda wheelchair, with her body and head leaning to the left, and no positioning device present at the following times: *06/17/24 in the dining room at 12:02 p.m. in the TV room at 12:31 p.m. and in the dining room at 5:15 p.m. *06/18/24 in the TV room at 9:40 a.m. and 1:30 p.m. When asked if the resident had anything to keep her body and head upright, a certified nurse aide (CNA) (#7) stated, No, but she should have something as she always leans to that [left] side. *06/18/24 at 2:00 p.m. The CNA (#7) assisted Resident #1 to the toilet and laid her on the bed stating, she needs to lay down so she's not leaning. She is tired. *06/18/24 in the TV room at 3:20 p.m., asleep and with her body and head tilted to the left. The CNA (#7) stated the resident was restless and wouldn't stay in bed so she got her up again. *06/19/24 in the TV room at 8:15 a.m. During an interview on 06/19/24 at 1:10 p.m., an administrative nurse (#2) stated the positioning device in Resident #1's care plan is for an L-shaped pad that is supposed to be on the resident's left side in the wheelchair. The administrative nurse agreed the positioning pad should have been in the resident's wheelchair. The facility failed to assess Resident #1's positioning needs. - Review of Resident #16's medical record occurred on all days of survey. A physician's order dated 05/14/24 stated, Apply geri-sleeve [a compression device for edema/swelling and geri-sling [strapped sling] to left arm for swelling. Apply in the morning and remove at hs [hour of sleep] . for swelling to left arm. The care plan stated, . Apply geri-sleeve and geri-sling to left arm for swelling. Apply in the morning and remove at hs . Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, . Carrying Out a Physician's Order . Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. It is the nurse ' s responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Clarification from any other source is unacceptable and regarded as a departure from competent nursing practice. Observations of Resident #16 occurred on all days of survey and showed edema to the left hand and no geri-sleeve or geri-sling present. During an interview on 06/18/24 at 4:00 p.m., a nurse (#2) stated she assisted Resident #16 that morning and forgot to apply the geri-sleeve and sling. She also stated the sleeve and sling are for swelling and he had quite a bit when they got the order. The facility failed to follow the physician's order to apply Resident' #16's geri-sleeve and sling daily.

Based on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 1 of 1 food-preparation sink (main kitchen) observed. Failure to provide the required air gap for a food-preparation sink has the potential to allow contamination of the sink in the event of sewer back up and bacterial migration. Findings include: Review of the 2018 North Dakota Plumbing Code, Section 801.2 Air Gap, or Air Break Required, stated, Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. Where a drainage air gap is required by this code, the minimum vertical distance as measured from the lowest point of the indirect waste pipe or the fixture outlet to the flood-level rim of the receptor shall be not less than 1 inch (25.4 mm). Section 801.3.3 Food-Handling Fixtures, stated, Food-preparation sinks, steam kettles, potato peelers, ice cream dipper wells, and similar equipment shall be indirectly connected to the drainage system by means of an air gap. Bins, sinks, and other equipment having drainage connections and used for the storage of unpackaged ice used for human ingestion or used in direct contact with ready-to-eat food, shall be indirectly connected to the drainage system by means of an air gap. Each indirect waste pipe from food-handling fixtures or equipment shall be separately piped to the indirect waste receptor and shall not combine with other indirect waste pipes. The piping from the equipment to the receptor shall be not less than the drain on the unit and in no case less than 1/2 of an inch (15 mm). Observation on 06/17/24 at 10:30 a.m., showed a continuous drainage pipe passed into the wall with no visible air gap for the main kitchen food-preparation sink. During an interview on the afternoon of 06/17/24, an environmental services director (#12) lacked an air gap.

Based on observation, review of facility policy, and staff interview, the facility failed to prepare, store, and serve food in a sanitary manner in 1 of 1 main kitchen and 1 of 1 resident nutrition center. Failure to label food with date/time, to discard expired food, clean soiled equipment, and use outdated test strips all have the potential to affect food quality/preparation, improper sanitation, and may result in the spread of foodborne illness to residents, staff, and visitors. Findings include: Review of the facility policy titled Date Marking - Food and Nutrition occurred on [DATE]. This policy, dated [DATE], stated, . PROCEDURE . 2. When TCS [time, temperature control for safety] food has been opened but remains in storage, employees: a. Ensure ready-to-eat TCS foods opened at the locations are clearly date-marked for: 1. The date/time the original container is opened. 2. The date or day by which the food shall be consumed on the premises, sold, or discarded. 4. A food item is discarded when: c. The container or package does not bear a date or day. d. The TCS item is beyond the use by date. Review of the facility policy titled Safe Handling of Personal Food, Outside Food - Food and Nutrition occurred on [DATE]. This policy, dated [DATE], stated, POLICY: Location ensures safe and sanitary storage, handling and consumption of foods brought to the resident by family or other visitors for personal consumption. Personal food is stored separate from the location's food. Employees remove foods deemed unsafe for consumption . PERSONAL FOOD STORED IN COMMON AREAS: . Employees monitor common food storage areas . remove unsafe foods. *Observation of the main kitchen occurred on [DATE] at 10:30 a.m. with a nutrition services director (#11). Observations showed the following: Walk-in Cooler: - Individual servings of mandarin oranges (whole & puree) uncovered and undated sitting on a three-tiered cart. - One large container of blended shredded cheese not in the original container and lacked an open date/time. - One gallon of lemon lime juice (half full) lacked an open date/time. - One gallon of fat free Italian dressing (half full) lacked an open date/time. - One large container of picante sauce (half full) lacked an open date/time - One container of discolored cut up broccoli covered in saran wrap dated [DATE]. Walk-in Freezer: - Packages of meatballs and sausage links (in an unsealed bag), and not in original containers lacked the date/time the original packages were received and lacked an open date/time. - One large bag of breaded chicken breasts with visible ice crystals in an unsealed package in the original opened box. The chicken lack lacked an open date/time. - Observation showed a section of pipe covered with a large chunk of ice that dripped water onto an unopened box of food below it. The box showed water damage and had ice accumulated on top of it. Ice/Water Dispenser: - Ice and water dispenser panel and drip/drainage pan covered in of buildup of mineralization and debris. Chemical Test Strips: - Test strips used to test cleanser solution expired on [DATE]. - Chlorine test strips used to test the chlorine level for the dishwasher expired on [DATE]. *Observation of the resident nutrition center refrigerator/freezer occurred on [DATE] at 3:50 p.m. and showed the following: Resident Nutrition Center Refrigerator contained cheddar cheese dip lacked an open date/time. Resident Nutrition Center Freezer: - An open box of pizza rolls with original bag twisted closed. The box/bag lacked an open date/time. - Carmel delight ice cream (half full) lacked an open date/time. - Neapolitan ice cream (half full) lacked an open date/time. - Six ice packs. - Several packages of lemon mouth swabs. During an interview on [DATE] at 3:34 p.m., the nutrition services director (#11) confirmed the open food items lacked an open date/time and stated, I expect staff to follow policy and procedures. During an interview on [DATE] at 4:00 p.m., an administrative staff member (#2) stated, these [ice packs] should not be mixed with food.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician of a change in condition for 1 of 1 sampled resident (Resident #137) with missed blood tests. Failure to notify the physician of unsucessful blood draws may have prevented the physician from altering the treatment/care provided to the resident. Findings include: Review of the facility policy titled Notification of change occurred on 06/19/24. This policy, reviewed 12/04/23, stated, . A facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with her or her authority, the resident representative(s) when there is . A need to alter treatment significantly - a need to discontinue or change an existing form of treatment or to commence a new form of treatment. Review of Resident #137's medical record occurred on all days of survey. Diagnoses included chronic kidney disease. The physician's orders included a BMP [basic metabolic panel blood test] for 06/11/24 and 06/18/24. A hospital discharge summary , 05/27/24, stated, . Monitor labs and electrolytes, frequently has Hypokalemia [low potassium]. A Progress note, dated 06/11/24 at 5:37 p.m., stated, Lab draw this morning was unsuccessful, several staff attempted. Unable to find vein in upper extremities. The medical record lacked documentation the facility notified the provider regarding the missed BMPs on 06/11/24 and 06/18/24. During an interview on 06/19/24 12:55 p.m., an administrative nurse (#2) confirmed staff were unable to obtain blood samples on June 11th and 18th for the ordered lab work due to inability to find a vein. The administrative nurse stated the facility would notify the provider on next rounds.

Based on record review and staff interview, the facility failed to provide the State Long Term Care Ombudsman a notice of transfer for 1 of 1 sampled resident (Resident #9) reviewed for hospital transfers. Failure to provide a copy of the transfer notice does not allow the ombudsman to be aware of facility practices regarding transfer and discharge or advocate on the resident's behalf. Findings include: Review of Resident #9's medical record occurred on all days of survey and identified hospital transfers on 01/21/24, 02/17/24, and 03/03/24. The resident's medical record lacked evidence the facility provided a copy of the transfer notices to the ombudsman. During an interview on the afternoon of 06/19/24, an administrative staff member (#5) confirmed the facility failed to send the notices to the ombudsman prior to 06/19/24.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents (Resident #2 and #9). 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: The Long-Term Care Facility RAI User's Manual, revised October 2023, page A-32, stated, . A1500 . Code 1, yes: if PASRR [Preadmission Screening and Resident Review] Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Page K-6 of the RAI manual stated, . K0300 Weight Loss . Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. Section A: - Review of Resident #9's medical record occurred on all days of survey. Diagnoses included schizoaffective disorder, bipolar type; generalized anxiety disorder; and personality disorder. A PASRR Level II Outcome, dated 12/06/23, stated, . You fall in the category of having a diagnosis that the PASRR program was designed to assess. That diagnosis is: A mental health condition. Resident #9's annual MDS, dated [DATE], identified a no response under Section A1500, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? During an interview on the afternoon of 06/18/24, a social services staff member (#1) confirmed facility staff coded Section A1500 incorrectly. Section K:-Review of Resident #2's medical record occurred on all days of survey. A significant change MDS, dated [DATE], identified weight loss; however, record review failed to identify Resident #2 experienced a 5% or more weight loss in 30 days or a 10% or more weight loss in 180 days. - Review of Resident #9's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified weight loss; however, record review failed to identify Resident #9 experienced a 5% or more weight loss in 30 days or a 10% or more weight loss in 180 days.

Based on observation, record review, review of facility policy, staff interviews, and information from a complainant, the facility failed to ensure resident safety for 1 of 1 resident (Resident #1) closed record reviewed for smoking safety. Failure to ensure the safety of a resident who smoked placed the resident at risk for adverse events, serious injury, and death. Findings include: Review of the facility policy titled [Facility Name] Smoking Procedure for Residents, Employees and Visitors occurred on [DATE]. This policy dated [DATE] stated, . Smoking and tobacco use in the location is not permitted. On [DATE], all locations of the [Facility Name] implemented a procedure to establish a smoke-free environment. This policy applies to residents, employees, and location visitors. As of [DATE], [Facility Name] does not allow smoking on facility grounds. These procedures are in addition to the Smoking and Tobacco Use - Rehab/Skilled and Outpatient Therapy Policy (dated [DATE]) endorsed by [Facility Name] and [Facility Name] locations. Resident Smoking Procedure. Per [Facility Name] Policy, we do not condone resident smoking. However, if that resident should choose to forgo our recommendations, and they have were [sic] a current resident and smoking before [DATE], they have that right. The outdoor garden space to the west of the building is our designated resident smoking area for those that were a current resident and smoking before [DATE]. Review of Resident #1's medical record occurred on [DATE] and showed the following: * Sustained an injury on [DATE] while outdoors smoking. * Current care plan stated, Focus: The resident has impaired cognitive function/dementia or impaired thought processes . E/B [evidenced by] slight memory impairment, poor judgment skills & safety awareness, and impaired decision-making abilities . Revision on: [DATE]. Focus: The resident uses tobacco products E/B use of cigarettes. Goal: Resident will safely use tobacco products in designated area. Interventions: . Monitor resident via cameras at nurses' station or where easily visible while out in the garden. Revision on: [DATE]. * A smoking assessment, completed on [DATE], stated, . Cognitive Loss . [marked as modified independence] . Physical Limitations . [marked as no] . * admitted to the facility as a smoker in 2019. * Grandfathered in to smoke on the property per facility policy. * On [DATE] only skilled nursing facility smoker. Observation of the facility's main nurses' station on [DATE] at 9:25 a.m. showed a surveillance monitor screen scrolling through views of indoor hallways and outdoor areas, including the designated smoking area. No staff were present in the nurses' station at this time. Observation on [DATE] at 11:00 a.m. with an administrative staff member (#1) showed an interior locked door with a numbered keypad. A code needed to be entered to exit to and enter from the facility's designated smoking area. No alarm sounded when code was entered, or when the door opened. Interviews occurred on [DATE] from 12:39 p.m. to 2:30 p.m. Questions asked: Were the monitors at the nurses' station on at the time of the incident? Were any staff in the nurses' station when Resident #1 went out to smoke? Where/what were you doing during the time of the incident? * Staff (#2) had been in the nurses' station at the start of shift, could not recall if surveillance monitors were on, and was not in the nurses' station when Resident #1 was out smoking. Staff #2 was walking down the hallway carrying a clean soaker pad on the way to a resident's room. A resident walking in the hall told this staff member it smelled like something was burning. Staff member went down the hall and saw the resident in the vestibule, opened the door, tried to assist the resident, called the charge nurse on walkie talkie, smoke alarm went off, and maintenance and charge nurse responded. * Staff (#3) had been in the nurses' station earlier in shift, and the surveillance monitor was on. Staff #3 was in another resident's room when Resident #1 was out smoking, and the fire alarm sounded. * Staff (#4) does not routinely use the nurses' station and does not know if surveillance monitor was on. Staff #4 heard the fire alarm and responded to the area. * Staff (#5) had not been in the nurses' station, does not know if surveillance monitor was on, and was not in the nurses' station when Resident #1 was out smoking. Staff #5 heard the fire alarm while working in the kitchen. * Staff (#6) had been in the nurses' station throughout the morning, and the surveillance monitor was on. Staff #6 was in another resident's room when Resident #1 was out smoking, and the fire alarm sounded. During an interview on [DATE] at 2:45 p.m., when asked how facility staff monitor cameras at the nurses' station if no one is present, an administrative staff member (#1) stated, There is a doorbell that alerts at the nurses' station when that door opens. I don't know if it was on that day. It makes a sound; you can choose ring tones. On [DATE] Resident #1 sustained injury from fire, was transported by ambulance to the hospital, and later to a burn center where the resident died . The facility failed to monitor Resident #1 while smoking in the designated smoking area and ensure an alarm sounded/alerted staff when the resident left the building.

Based on information provided by the complainant, record review, policy review, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 2 of 9 sampled residents (Resident #1 and Resident #3) and 1 closed record resident (Resident #4) reviewed for advanced directives. Failure to ensure all methods of communication and/or documentation of code status accurately reflected the resident/resident representative wishes has the potential to limit his/her access to life-sustaining services or unwanted treatment, and did result in unwanted treatment for Resident #4. Findings include: Information provided by the complainants indicated that residents expressed different wishes for code status than what were ordered in the residents medical record resulting in unwanted treatment. Review of the facility policy titled Advanced Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) - Rehab/Skilled occurred on [DATE]. This policy, revised [DATE], stated, . Residents have the right to formulate advance directives.1. If cardiac arrests occurs, [sic] CPR must be initiated unless the resident has: a. A valid DNR [Do Not Resuscitate] order on file that includes the medical order issued by a physician or other authorized non-physician practitioner.Procedure: Admission/Re-Admission Advance Directive 1. At the time of admission or re-admission, social services or designated staff member asks the resident/healthcare decision-maker whether the resident has prepared an advance directive such as a living will, durable power-of-attorney for healthcare decisions . 2. The designated staff member will meet with the resident/healthcare decision-maker to answer questions and determine if the resident/healthcare-decision maker wish to develop or amend advance directives. 4. As necessary, physicians will be contacted for orders that reflect the resident's wishes.Procedure: Quickly Identifying Resident CPR status in the SNF [skilled nursing facility] . 2. When PCC [Point Click Care, electronic medical record] is available, the nurse may choose to access the code status on the dashboard. During an interview on [DATE] at 3:45 p.m., a staff nurse (#3) stated she verified resident code status by looking at the banner in the electronic medical record. The staff nurse (#3) accessed Resident #1's medical record and looked at the banner. No code status displayed. She stated I would treat this resident as a Full Code. She indicated that is how she was trained as a nurse and did not recall if she received any specific training to code status on orientation. Review of Resident #1's medical record occurred on all days of survey. A physician's order, dated [DATE], stated Full Code. The electronic medical record failed to display Resident #1's code status in the area direct care staff would access prior to providing life sustaining treatment. Review of Resident #3's medical record occurred on all days of survey. A physician's order, dated [DATE], stated Full Code. A social service progress note, dated [DATE], stated, . reviewed his advance directives with resident, and it continues to be DNR, DNI [Do Not Intubate], no tube feeding, Do hospitalize, and use antibiotics . The electronic medical record lacked an updated physician's order reflecting the resident's wishes for code status and failed to display Resident #3's code status in the area direct care staff would access prior to providing life sustaining treatment. Review of Resident #4's closed record occurred on all days of survey. A physician's order, dated [DATE], stated, Full Code. A social service progress note, dated [DATE], stated, . Advance directive was reviewed on admission, and it continues to be DNR, DNI, tube feeding only on a trial basis. He also agreed to the use of antibiotics. POLST [Physicians Order for Life Sustaining Treatment Form] will be sent to his primary for orders. Review of nursing progress notes for Resident #4 showed the following: * [DATE] at 10:14 p.m., stated, At approximately 2030, CN [charge nurse] and CNA [certified nursing assistant] heard residents bed alarm going off. CN went in to check on him and he was on his knees with his torso laying over the bed. CN called for CNA to come assist him back into bed. As we were in the process of trying to get him back into bed, he slumped over and we lowered him the rest of the way to the floor. CN noted that he was cyanotic [bluish coloring of the skin due to lack of oxygen], eyes were glazed over and CN could not find a pulse. CN started CPR and did it over about a minute when resident started to gasp for air and started looking around. In the process CN yelled for CNA to call 911 and report a transfer for a resident who was unresponsive. CN told med aid to go grab an O2 [oxygen] concentrator and start oxygenating him. We got the O2 on him and his color started coming back. Resident still was not responding, but was looking around and would occasionally make a moaning sound. Ambulance showed up and transferred resident to the [critical access hospital] ER [emergency room ]. resident was currently intubated. [Physician name] (ER doctor) stated that they were going to air lift resident to the [acute care] hospital where he would be admitted to the ICU [intensive care unit]. * [DATE] at 12:03 p.m., stated, Rec'd [received] signed POLST from MD [medical doctor]. The facility failed to obtain an updated physician's order reflecting the resident's wishes for code status in a timely manner resulting in Resident #4 receiving CPR. The electronic medical record failed to display Resident #4's code status in the area direct care staff would access prior to providing life sustaining treatment. During an interview on [DATE] at 8:45 a.m., two administrative staff members (#1 and #2) confirmed the medical records lacked updated physician's orders for Resident #3 and Resident #4, the physician's orders present in the medical record did not match the documented conversations, and Resident #4 received CPR per facility policy. They confirmed the electronic medical records for all three residents failed to display the code status in an area direct care staff would access prior to providing life sustaining treatment. The administrative staff members (#1 and #2) identified the facility failure to obtain revised physician's orders for code status and provided meeting minutes that showed implementation of a new admission process that began on [DATE]. Education to nursing staff began on [DATE].