Every finding on record at Good Samaritan Society Miller Pointe a Prospera Co

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 19 sampled residents (Resident #3, #37, #65, #73, and #121) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), personal protective equipment (PPE), dressing changes, glove changes, and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 12/30/25. This policy, revised 11/13/25, stated, . all employees . will adhere to the 4 Moments of Hand Hygiene . 1. Entering room [ROOM NUMBER]. Before a clean task 3. After bodily fluid/glove removal 4. Exiting room. PROCEDURE: HCW [healthcare worker] will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: When entering the resident room . After removing gloves regardless of the task completed . After contact with a patient's non-intact skin, wound dressings, secretions, excretions . When moving from contaminated body site to a clean body site during patient care .Review of facility policy titled Standard, Enhanced Barrier, and Transmission-Based Precautions occurred on 12/30/25. This policy, revised 07/07/25, stated, . 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 . Enhanced barrier precautions are also used for residents with chronic wounds . residents with indwelling medical devices . High contact resident care activities include transfers, indwelling medical device care or use . wound care. Post clear signage indicating the type of precautions and required PPE . -Observation on 12/29/25 at 11:26 a.m. showed an EBP sign and a container of PPE supplies outside Resident #73's room. A nurse (#7) applied a gown, gloves, and mask and entered the room. The nurse removed the soiled dressing from Resident #73's left leg wound and, with the same gloves reached into a basket containing clean dressings and scissors, cut a new dressing and applied the dressing to the wound. The nurse then removed the PPE and left the room to obtain gauze. When nurse (#7) returned, he/she placed the gauze package on the PPE stand, applied PPE, picked up the gauze package, and entered the room. The nurse readjusted Resident #73's wound dressing, obtained a scissors from the supply basket, cut the gauze, secured the dressing, and returned the scissors to the basket. The nurse (#7) removed the PPE and without performing hand hygiene, exited the room. The nurse (#7) failed to perform hand hygiene before applying gloves, failed to remove the soiled gloves, perform hand hygiene, and apply clean gloves after removing the soiled dressing, and failed to perform hand hygiene before exiting Resident #73's room. -Observation on 12/29/25 at 11:32 a.m. showed Resident #37 in bed. The certified nurse aide (CNA) (#12) completed hand hygiene, gloved, and gathered supplies for morning cares. The CNA completed bowel incontinence care and without performing hand hygiene or applying clean gloves, completed perineal cares. With the same soiled gloves, the CNA applied a clean brief and the transfer sling under the resident, and finished cleaning the resident. The CNA connected the sling to the mechanical lift, reached into the uniform pocket, called for assistance on the handheld walkie, and then removed the soiled gloves and applied clean gloves. Another CNA (#13) entered the room, assisted the CNA (#12) to transfer Resident #37 to the wheelchair, performed hand hygiene, and exited the room. The CNA (#12) finished dressing the resident, rinsed the dentures and glasses, and handed them back to the resident. The CNA (#12) straightened the bed and room, bagged the soiled linens and garbage, removed one glove, completed hand hygiene on one hand, and exited the room with the bagged soiled linen and garbage in the gloved hand. The CNA (#12) failed to complete glove changes/hand hygiene between tasks. -Observation on 12/29/25 at 1:33 p.m. showed an EBP sign and a container of PPE supplies outside Resident #3's room . Two CNAs (#1 and #2) applied gowns, gloves and face masks and entered the room. The CNAs transferred Resident #3 from the wheelchair to the bed with a full body mechanical lift. The CNA (#1) emptied the urine from foley catheter collection bag. The CNAs removed their PPE, and exited the room. Both CNAs (#1 and #2) failed to perform hand hygiene. -Observation on 12/30/25 at 7:34 a.m. showed an EBP sign and a container of PPE supplies outside Resident #65's room. The CNA (#3) applied PPE and entered the room, transferred the resident from the recliner to the wheelchair, applied the foot pedals to the wheelchair, removed the PPE, and exited the room. The CNA (#3) failed to perform hand hygiene. -Review of Resident #121 medical record occurred on all days of survey. A physician's order, dated 12/24/25, indicated a foley catheter. Observation on 12/30/25 at 8:23 a.m. showed PPE supplies outside Resident #121's room and no EBP sign. Two CNAs (#9 and #10) entered the room, completed hand hygiene, applied gloves, and transferred Resident #121 from the wheelchair to the bed with gait belt assistance. Both CNAs removed their gloves, completed hand hygiene, and exited the room. The facility failed to place proper signage for EBP and the CNAs (#9 and #10) failed to apply gowns. Observation on 12/30/25 at 9:51 a.m. showed an EBP sign and a container of PPE supplies outside Resident #121's room. The CNA (#11) entered the room, completed hand hygiene, gloved, and emptied the urine collection bag. The CNA failed to apply a gown. During an interview on 12/31/25 at 12:25 p.m., two administrative staff members (#6 and #8) acknowledged the infection control issues and stated staff should follow policy and procedures.

Based on observation, record review, review of menus, review of facility policy, and staff interview, the facility failed to serve food according to prepared menus for 3 of 3 sampled residents (Resident #10, #11, and #74) observed during tray line. Failure to serve food according to the portion sizes listed on the resident's menu/tray card may result in inadequate nutrition and weight loss or weight gain.Findings include: Review of the facility policy titled Portion Control . occurred on 12/31/25. This policy, revised 01/28/25, stated, . To ensure that the menu items are served in the planned quantity . The portion sizes listed on the menu extensions or tray cards are followed. Portion sizes are referenced during meal service. Observation of the noon tray line on 12/30/25 showed a dietary staff member (#5) served the following: *Resident #10, one-third cup (c) of pureed stuffed pepper soup and one-third c of mashed sweet potato. The menu identified the serving sizes as one-half c soup and one-half c sweet potatoes. The tray card identified two-thirds c of soup, which didn't match the menu. *Resident #11, a #6 scoop (5.5 ounce [oz] or 2/3 c) of stuffed pepper soup and one-half of a baked sweet potato. The tray card and menu identified a six-ounce ladle of soup and one whole sweet potato. *Resident #74, a #6 scoop (5.5 oz or 2/3 c) of stuffed pepper soup and one-half of a baked sweet potato. The tray card and menu identified a six-ounce ladle of soup and one whole sweet potato. - Review of Resident #10's medical record occurred on all days of survey. The care plan stated, Nutrition: The resident has nutritional problem R/T [related to] underweight and triggering for at risk of malnutrition E/B [evidenced by] low BMI [body mass index] . and hx [history] of weight loss. The dietary staff member (#5) failed to serve Resident #10, #11, and #74 the correct portion size of soup and sweet potatoes, resulting in the residents receiving less food than the menu identified. During an interview on 12/31/25 at 11:20 a.m., a dietary manager (#4) stated she expected staff to follow the ladle or scoop sizes listed on the tray cards.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 1 sampled resident (Resident #100) observed with medications at bedside. Failure to ensure residents take all prescribed medications and document medication administration may result in errors and/or adverse effects for the resident.Findings include: Review of the facility policy titled Medication: Administration Including Scheduling and Medication Aides occurred on 12/30/25. This policy, dated 04/08/25, stated, . Do not leave medications at the bedside or at the table unless there is a specific physician order to do so . if the resident has not been assessed for safety . and there is not a physician order to leave the medication . stay with the resident until the medication is taken and you observed the resident swallow. Review of Resident #100's medical record occurred on all days of survey. A physician's order, dated 10/17/24, stated, please make sure resident is taking medications with each med pass. Observation on 12/29/25 at 10:57 a.m. showed a medication cup containing several pills on Resident #100's bedside table. Review of the Medication Administration Record (MAR) for 12/29/25 identified facility staff administered Resident #100's scheduled morning medications. During an interview on the afternoon of 12/30/25, an administrative nurse (#6), stated she expected staff to ensure Resident #100 consumed all the medications prior to leaving the room and the resident is not appropriate to self-administer medications.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure medication storage for 1 of 6 unlocked and unattended medications cars (Driftwood Lane). Failure to securely store medications may result in unauthorized access to medications by residents, visitors, and staff. Findings include: Review of the facility policy titled Medications: Storage occurred on 12/31/25. This policy, dated 03/04/25, stated, Policy Statement . Medication Storage. medications will be stored in a locked medication cart, drawer, or cupboard . are locked when not in use, . carts used to transport such items are not left unattended if open or otherwise available to others . Observation on 12/29/25 at 5:55 p.m. showed a nurse (#7) walked away from the medication cart on Driftwood Lane and entered a resident room. The nurse (#7) left the medication cart unlocked/unattended and the electronic medical record (Emar) left open with resident information visible to staff, residents, and visitors. Observation showed two insulin pens and a clear bucket containing insulin pens on top of the medication cart. During an interview on 12/31/25 at 1:20 p.m., an administrative nurse (#6) stated she expected staff to lock medication carts and the Emar and store all medications in the cart.

Based on observation, record review, review of the facility reported incident (FRI), review of facility training records, review of facility policy, review of manufacturer's guide, and staff interview, the facility failed to utilize devices necessary to prevent accidents and/or injury for 2 of 2 sampled residents (Resident #1 and #2) observed while in a spa chair. Failure to utilize the spa chair safety belt resulted in Resident #1 experiencing a fall and fracture and placed all residents at risk for falls and/or injury. During the on-site FRI investigation, the surveyor consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 02/23/25. The IJ resulted from the facility's failure to utilize the spa safety belt and the resident sustained a fracture. * 02/27/25 at 9:47 a.m. the surveyor notified the administrator and administrative nurses of the IJ situation, provided them with the IJ template, and requested a plan for removal of the IJ * 02/27/25 at 12:02 p.m., the surveyor and SSA reviewed and accepted the facility's removal plan. The removal plan contained the following: * Assessment and care plan changes for the residents observed, if needed. * Education for all the bath aides as well as skill validations will be completed on 02/27/25 * Plans for auditing the effectiveness of the training. * Reviewed and determination the current bathing policy will remain unchanged. * 02/27/25 at 3:04 p.m., the surveyor verified the implementation of the removal plan. The deficient practice remained at a scope and severity of a G following the removal of the IJ. Findings include: Review of the facility policy/procedure titled Bathing occurred on 02/26/25. This policy, dated 09/03/24, stated, . The use of safety measures and equipment are designed to reduce the risk of injury to resident during a bathing experience. The manufacturer's directions for operating and maintaining equipment should be followed including the use of waist and chest safety belts/straps. Review of the [manufacturer's name] Transfers and Stretcher Safe Operation [and] Maintenance Manual occurred on 02/26/25. This guide, dated 10/16/20, pages 7-10, stated, . 9. All residents must always be securely safety belted at the waist when using any of the . Lift Systems. 22. Once the Transfer [spa lift chair] is clear of the spa, lower the Transfer to the lowest position . 24. Release the safety belts from around the resident and transfer the resident using proper nursing techniques and assistance as required. Review of the FRI, submitted to the SSA on 02/24/25, identified Resident#1 fell from the bath chair and sustained a nasal fracture on 02/23/25. - Review of Resident #1's medical record occurred February 26-27, 2025. The care plan identified the resident required assistance of one staff member for transfers using a mechanical stand lift, dressing, and bathing. Observation on 02/26/25 at 7:56 a.m. showed the certified nurse aide (CNA) (#4) completed Resident #1's bath. The CNA (#4) stood in front of the resident as she dressed him. Resident #1 sat in the spa lift chair without the safety belt in place and his feet approximately 12 inches off the floor. The CNA (#4) failed to follow facility policy and the manufacturer's guide related to safety belt use and the spa lift chair in the lowest position before dressing the resident. - Review of Resident #2's medical record occurred February 26-27, 2025. The care plan identified assistance of one staff for bathing. Observation on 02/26/25 at 8:34 a.m. showed the CNA (#5) assisted Resident #2 on to the spa chair. The CNA (#5) failed to place the safety belt around the resident and raised the spa chair so Resident #2's feet were off the ground. During an interview on 02/26/25 at 12:25 p.m., administrative staff members (#1, #2, and #3) confirmed they expected staff to apply the safety belt and leave it in place while the residents are in the spa lift chair.

1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 3 sampled residents with an indwelling catheter (Resident #163) and 2 of 3 residents (Residents #34 and #89) on transmission-based precautions (TBP). Failure to practice infection control standards related to enhanced barrier precautions (EBP) and TBP has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Standard and Transmission-Based Precautions occurred on 11/07/24. This policy, revised 04/02/24, stated, . Purpose. To explain the use of transmission-based precautions. To assist in determining the appropriate type and duration of precautions for resident, included standard precautions and transmission-based precautions (e.g., contact, droplet and airborne) . Standard precautions should be used by all employees, contract workers . Standard precautions include handwashing, personal protective equipment, cleaning of resident care equipment . Enhanced barrier precautions (EBP) expand the use of PPE [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 MDROs [multi drug resistant organisms] to staff hands and clothing. Enhanced Barrier Precautions are needed for residents . with indwelling urinary catheters. Airborne Isolation. Airborne precautions are needed, as recommended . to appropriate type of precautions for residents/patients known or suspected to be infected with infectious agents . Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE. Gown, Gloves, N-95 or equivalent respirator, Eye protection. Use disposable noncritical resident/patient care equipment . or implement resident /patient dedicated use of such equipment. Observation on 11/05/24 at 11:40 a.m. showed a sign requiring transmission-based precautions on the door of two Covid-19 positive residents. A contract provider (#3) donned an N-95 mask and entered the room. The provider exited the room wearing the N95 mask, walked down the hall and spoke with another Covid-19 positive resident who had entered the hallway in a wheelchair. The provider (#3) touched the resident's arm, and listened to the resident's lungs with a stethoscope (a medical instrument used to listen to someone's heart or lungs). The provider replaced the stethoscope around her neck and proceeded down the hall, wearing the same N-95 mask. The provider failed to apply the recommended PPE consisting of gown, gloves, and eye shield prior to entering a Covid-19 positive resident room, remove the N-95 mask upon exiting the room, don a new N-95 mask and recommended PPE before interacting with another Covid-19 positive resident, sanitize the contaminated stethoscope, and remove the N-95 mask before leaving the resident area. The facility verified the provider removed the N-95 mask and performed hand hygiene before leaving the unit. During an interview on 11/07/24 at 11:20 a.m., an administrative nurse (#4) confirmed contract staff are expected to wear correct PPE and follow facility policy for transmission-based precautions. - Review of Resident #163's medical record occurred on all days of survey. Physician's orders included an indwelling catheter. Observation on 11/05/24 at 8:15 a.m. showed Resident #163 with an indwelling catheter and not placed on EBP. During an interview on 11/05/24 at 8:43 a.m., a nurse (#6) confirmed Resident #163's indwelling catheter and lack of EBP in place. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #26) with an ileostomy (an artificial opening from the small intestine through the abdomen to empty bowels). Failure to practice infection control standards has the potential to spread infection throughout the facility. Review of the facility policy titled Ostomy of the Intestinal Tract occurred on 11/07/24. This policy, revised 03/29/24, stated, . For pouch emptying, Bedpan, toilet or measuring device, Gloves, Tissue . Review of a skills checklist titled Colostomy/Ileostomy Pouch Emptying Clinical Skill Checklist occurred on 11/07/24. This checklist, dated December, 2017, stated, . remove pouch from appliance (closed system) and empty into toilet, bedpan or other measuring device. Review of Resident #26's medical record occurred on all days of survey. Diagnoses included ileostomy status. Physician's orders stated, Empty ileostomy bag every shift and PRN (as needed). The current care plan stated, . Ileostomy . Nursing staff to perform the following cares: empty bag, report to nurse if dressing/skin barrier becomes soiled, keep skin clean and dry around site . Observation on 11/05/24 at 10:17 a.m. showed a certified nurse aide (CNA) (#5) emptied Resident #26's ileostomy bag. The CNA performed hand hygiene, donned gloves, removed the ileostomy bag and wiped bowel movement from around the stoma (artificial opening). The CNA (#5) placed the full ostomy bag under the resident's bathroom sink faucet, filled the bag with water, and carried the bag to the toilet to empty contents three times. After doffing gloves and performing hand hygiene the CNA turned off the faucet, donned clean gloves without first performing hand hygiene, returned to the resident, and cleansed the frontal perineal area. Without removing gloves the CNA took a walkie-talkie (used to communicate with other staff) out of her pocket, and called the nurse. The CNA placed the walkie-talkie on the resident's overbed table and completed cares. The CNA (#5) failed to properly clean an ostomy bag, complete hand hygiene/glove change, and disinfect equipment. During an interview on 11/07/24 at 11:20 a.m., an administrative nurse (#1) confirmed she expected staff to follow the proper procedure for emptying/cleaning an ileostomy pouch and to follow infection control procedures for hand hygiene, cleaning of equipment and resident's items. 31725

Based on record review, policy review, review of staff education, review of facility reported incident, and resident interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell out of a mechanical lift. Failure to safely use the mechanical lift resulted in a fall with injury for Resident #1. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 09/11/24. The facility immediately implemented corrective action and completed corrective action on 09/16/24. Review of the facility policy, Safe Resident Handling Program Overview occurred on 09/17/24. This policy, dated 02/28/24, stated, . Policy: . goal is to maintain a safe living . environment for residents . All caregivers . must receive thorough, documented training prior to conducting mobilization . Care givers will perform a TIME OUT safety stop while the resident is in a sling or harness and still over the surface of the bed or chair to ensure that all straps are secure before moving away from the surface. This is to be competed once the straps are taut, but before the resident leaves a surface. Review of final investigation of the facility reported incident, dated 09/17/24, stated, [name of resident] fell in his room witnessed while being transferred in a total lift by 2 staff. Staff did not loop sling on lower left side and hook to lift appropriately. Assessment completed and nurse noted right knee was swollen and indent noted. Resident was immediately seen by floor nurse post fall and assessment completed. Resident alert and orientated post fall. No concerns of abuse or neglect noted. Staff members that were involved with transfer were immediately interviewed and education provided. Competency completed by registered nurse on 2 staff post incident. Administration reviewed all staff meeting competency and education reviewed at that time. Discussed lift education with those due for annual education. Resident did not have any concerns and did not want to be seen by a provider until his primary was due to round 9/13/2024. On provider visit she discussed getting an Xray and he finally agreed. Preliminary showed fractures of right tibia and fibula. Results of Investigation: Resident was transferred with total lift by 2 staff. One staff member did not loop sling bottom appropriately which resulted in resident falling out of lift. Resident had seen orthopedics and has immobilizer . Final Action Taken: No indication of abuse or neglect. Staff education completed and competency done with 2 staff involved incident immediately. During an interview with Resident #1 on 09/17/24 at 9:00 a.m. regarding the fall from the mechanical lift, the resident stated, it was just an accident, one strap wasn't hooked up right. The resident stated his leg bent behind him, but he didn't have any pain because of his paraplegia. Resident #1 stated he didn't go to the emergency room (ER) right after it happened because there wasn't anything they could do about it anyway. Review of Resident #1's medical record occurred on the morning of 09/17/24. The record identified Resident #1 as cognitively intact and able to make decisions. Review of nursing progress notes identified the following: * 09/11/24 at 12:49 p.m., This nurse was called to residents' room. Resident was on the ground with one strap attached to the Hoyer lift and the left strap was not attached. CNA [certified nursing aide] stated that the strap was not looped into the other strap on the left side. Resident uses a multipurpose sling. Resident was being transferred from his w/c [wheelchair] back into his bed. Resident stated his leg got bent back when he fell to the floor. Residents right knee was slightly swollen and had a small indent on it under the knee. Resident did not bump his head. Resident denied any pain. Resident is a paraplegic. This nurse did ROM [range of motion] on residents left knee. Resident was Hoyer [mechanical lift device] lifted back to bed and vitals were took which were WDL's [within normal limits] for resident. This nurse assessed resident and found no bruising on resident. This nurse had therapy assess residents' knee while back in bed. A note was left for provider and resident will be seen on Friday as resident would like to see [name of provider] PA-C [Physician's Assistant - Certified]. This nurse called residents wife and explained thoroughly everything noted. * 09/12/24 at 3:55 p.m., Fall team met to discuss recent fall, education has been completed including competency with staff present during fall, all staff competency and education reviewed and discussed with those due for annual education. * 09/13/24 at 5:43 p.m., . Resident returned from his x-ray. Resident has 2 fractures in his right knee and was sent to ER. Resident denied surgery and has a splint on his right knee. Resident is suppose [sic] to see ortho in a week but at this time is going to think on it since he is being discharged next week. Resident had no other new orders noted. Residents' wife is aware of all the new orders listed and resident's wife was at ER with resident. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions as follows: * The employees involved in the incident were immediately re-educated on Safe Resident Handling and use of the mechanical lift and slings. * Provider and family notified of the fall and follow up care and treatment provided. * Education provided to all staff members on Safe Resident Handling, including use of various lift devices, types and sizes of slings, and mechanical lift scenarios.

Based on review of the facility reported incident, review of facility policy, and record review, the facility failed to report an incident of potential neglect to the State Survey Agency (SA) for 1 of 1 sampled resident (Resident #1) who fell out of a mechanical lift. Failure to report an event of potential neglect in the required time frame does not comply with regulations established to protect residents. Findings include: Review of the facility policy, Abuse and Neglect, occurred on 09/19/24. This policy, dated 07/22/24, stated, PURPOSE: * To ensure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations in the location .* To ensure that all identified incidents of alleged or suspected abuse/neglect . are promptly reported and investigated. PROCEDURE: . 4. Notification procedures: a. Alleged or suspected violations involving any mistreatment, neglect . will be reported immediately to the administrator. b. In case of absence of the administrator, follow the chain of command for notification (director of nursing services, social worker, etc.). Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency. ii. If there is an allegation that does not involve abuse and there is no serious bodily injury, then it will be reported not later than 24 hours after the allegation is made. Review of the facility reported incident, received by the SA on 09/13/24, indicated Resident #1 fell from a full body lift on 09/11/24. Review of the final investigation report, dated 09/17/24, stated, [name of resident] fell in his room witnessed while being transferred in a total lift by 2 staff. Staff did not loop sling on lower left side and hook to lift appropriately. Assessment completed and nurse noted right knee was swollen and indent noted. Review of the facility reported incident identified the facility reported Resident #1's fall out of a mechanical lift on 09/13/24, two days after the incident occurred. Facility staff failed to report an incident of potential neglect within the required timeline of 24 hours. Refer to F689.

Based on observation, review of professional reference, and staff interview, the facility failed to follow professional standards of practice regarding medication administration for 19 of 20 unidentified residents on the 100 unit. Failure to follow professional standards for safe medication preparation and administration placed the residents at risk of receiving the wrong medication. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 838-840, stated, . Administering Oral Medications . Organize the supplies. Gather the MAR(s) [medication administration records] for each client together so that medications can be prepared for one client at a time. Rationale . reduces the chance of errors. Safety . Label all medications, medication containers, and other solutions . Note: Medication containers include syringes, medicine cups, and basins, Rationale: Medications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have resulted from medications and other solutions being removed from their original containers and placed into unlabeled containers. Observation on 10/16/23 at 4:01 p.m. showed the 100 unit's medication cart with clear plastic medication cups located on top of the cart labeled with numbers 1 through 19. Medications were dispensed in most of the cups. When asked about the medications in the cups, a nurse (#13) stated she was getting her OTC [over-the counter] meds [medications] ready. The nurse (#13) further stated, I always do [pre-dish medications] or I wouldn't get my supper [medications] passed. During an interview on 10/19/23 at 9:04 a.m., an administrative nurse (#14) stated she expected staff not to pre-dish medications.

Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices on 2 of 2 units with Covid positive residents (Unit 500 and 600). Failure to follow infection control practices related to Personal Protective Equipment (PPE) has the potential to transmit infections to other residents, staff, and visitors. Findings include: Review of the facility policy titled Personal Protective Equipment (PPE) occurred on 10/19/23. This policy, dated October 2022, stated, . masks, eye protection or face shields to be worn whenever splashes, spray, spatter or droplets of blood or potentially infectious materials may occur and contaminate the employee's eyes, nose, or mouth . mask or face shield . fit flexible band to nose bridge . fit snug to face and below chin . place over face and adjust to fit . Observations on 10/16/23 showed the following: * 12:13 p.m., a dietary aide (#8) entered Resident #97's room without wearing goggles or a face shield. A Contact Precautions, stating to wear an N95 mask (a particle-filtering face mask), hung on Resident #97's door. * 12:18 p.m., a certified nurse aide (CNA) (#11) entered Resident #71's room without wearing goggles or a face shield. A Droplet Precautions sign hung on Resident #71's door. * 12:50 p.m., a dietary aide (#8) entered Resident #97's room without wearing goggles or a face shield. Observations on 10/17/23 of 500 and 600 units showed the following: * 8:13 a.m., a dietary aide (#9) on the 600 unit prepared food plates in the kitchenette while interacting with residents and staff wearing a surgical mask below his/her chin. * 8:17 a.m., a nurse (#6) on the 600 unit interacted with residents and staff wearing a surgical mask below his/her chin. * 09:36 a.m., a nurse (#6) on the 600 unit interacted with residents and staff wearing a surgical mask below his/her chin. * 11:20 a.m., a dietary aide (#9) on the 600 unit prepared resident food plates in the kitchenette and interacted with staff and residents wearing a surgical mask below his/her chin. * 11:35 a.m., a staff member entered the 500 unit and failed to appy a mask. * 3:20 p.m., a nurse (#6) on the 600 unit interacted with residents and staff wearing a surgical mask below his/her nose. Observations on 10/18/23 of the 600 unit showed the following: * 11:02 a.m., a nurse (#6) interacted with residents and staff wearing a surgical mask hanging from the ear. * 11:23 a.m., a dietary aide (#9) prepared food plates in the kitchenette while interacting with residents and staff wearing a surgical mask below his/her chin. During an interview on the morning on 10/19/23, an administrative nurse (#1) stated she expects staff to wear PPE appropriately when working with COVID positive residents and areas where they reside.

Based on observation, record review, review of facility policy, and family and staff interview, the facility failed to provide assistance with activities of daily living (ADL) for 1 of 17 sampled residents (Resident #81) requiring substantial assistance with dressing or transfers. Failure to dress and assist the resident out of bed may result in decreased self-esteem and quality of life. Findings include: Review of the facility policy titled Activities of Daily Living occurred on 10/19/23. This policy, dated 11/29/22, stated, . Policy. Any resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. ADLs are those necessary tasks conducted in the normal course of a resident's daily life. Included in these are the following: . 3. Dressing: Selecting, obtaining and putting on, fastening and taking off items of clothing . 4. Mobility: Transferring to or from a bed, chair or wheelchair, ambulating inside by . using wheelchair if seated. Review of Resident #81's medical record occurred on all days of survey. Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (condition that causes weakness or paralysis on one side of the body) following cerebral infarction (stroke). A physician's order, dated 04/28/23, stated, If resident is alert and awake at anytime during the day make sure and get him up for a few hours. one time a day for getting out of bed. The current care plan stated, ADL's: The resident has an ADL self care performance deficit . DRESSING/GROOMING: Assist of 2 for ADL . TRANSFER: Assist of 2 and Hoyer [mechanical lift]. Everyday after lunch offer resident to get dressed and out of bed to sit in hearth area or outside if nice. A progress note, dated 05/26/23, stated, . She [family member] was wondering how much her Dad got up . She also brought him up some new clothes. During an interview on 10/17/23 at 11:28 a.m., a family member (#1) stated that she brought clothes to the facility but Resident #81 was in a night gown when she would come to visit. Family member (#1) stated Resident #81 likes to be outside, feel the weather, socialize and be around other people. She expressed concerns that Resident #81 stayed in bed all day and if the resident is left in his room too long, he gets depressed, causing an increase in antidepressants to compensate. Observation on 10/16/23 at 3:30 p.m. and 10/18/23 at 2:13 p.m. showed Resident #81 in bed in a hospital gown. During an interview on 10/18/23 at 3:14 p.m., a nurse (#6) confirmed staff do not document the resident's refusal to get dressed. Facility staff failed to provide care to Resident #81 as ordered by the physician and/or as stated in the care plan.

Based on observation and staff interview, the facility failed to promote privacy and confidentiality of the medication administration records (MAR) on 2 of 6 units (300 and 400 unit) observed. Failure to promote resident privacy and lock computer screens may result in unauthorized viewing of resident records by other residents, visitors, or unlicensed staff. Findings include: Observations of computer screens on 10/17/23 showed the following: * At 8:26 a.m. to 8:37 a.m., an unattended computer at the nurse's station located in the 300 unit with the MAR opened and revealing a resident's picture, name, medications, and dosages. * At 8:42 a.m., a nurse (#4) left an unattended computer at the nurse's station located in the 400 unit with the MAR opened and revealing a resident's picture, name, medications, and dosages. During an interview on the morning of 10/19/23, an administrative nurse (#1) confirmed she expected staff to lock computer screens when unattended. The facility failed to promote privacy and confidentiality of the residents' MARs when unattended by staff. 46477

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and/or the State Long Term Care Ombudsman written notice of transfer for 3 of 5 sampled residents (Resident #30, #47, and #68) with a hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights or inform the Ombudsman of the transfer. Findings include: Review of the facility policy titled Discharge And Transfer occurred on 10/19/23. This policy, dated 12/27/22, stated, Before a location transfers or discharges a resident, the location must: 1. Notify the resident and the resident's representative of the transfer or discharge and the reason for the move in writing . the location must send a copy of the . form to a representative of the Office of the State Long-Term Care Ombudsman . - Review of Resident #30's medical record occurred on all days of survey and identified a hospital transfer on 08/04/23. The resident's medical record lacked evidence the facility provided a written notice/copy of the transfer form to the resident/representative or informed the State Ombudsman of the hospital transfer. - Review of Resident #47's medical record occurred on all days of survey and identified a hospital transfer on 08/07/23. The resident's medical record lacked evidence the facility provided a written notice/copy of the transfer form to the resident/representative or informed the State Ombudsman of the hospital transfer. - Review of Resident #68's medical record occurred on all days of survey and identified hospital transfers on 04/11/23 and 08/03/23. The resident's medical record lacked evidence the facility provided a written notice/copy of the transfer forms to the resident/representative or informed the State Ombudsman of the hospital transfers. During an interview on the afternoon of 10/18/23, an administrative staff member (#1) stated she was unable to produce a copy of Resident #47's transfer form for the hospital transfer on 08/07/23. During an interview on 10/19/23 at 1:52 p.m., an administrative staff member (#12) agreed Resident #30 and #68's medical records lacked transfer forms for their hospital transfers. 40488

Based on record review and staff interview, the facility failed to provide a bed-hold notice to 1 of 5 sampled residents (Resident #30) with a transfer to the hospital. Failure to provide the facility's bed-hold notice does not allow residents or their legal representatives to make informed choices regarding their readmission rights. Findings include: Review of Resident #30's medical record occurred on all days of survey and identified a transfer to the hospital on 06/17/23. The record lacked evidence the facility provided a bed hold notice to the resident and/or their representative. During an interview on 10/19/23 at 1:52 p.m., an administrative staff member (#12) confirmed Resident #30's medical record lacked a bed hold form for the hospital transfer on 06/17/23.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 2 of 25 sampled residents (Resident #39 and #81). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care and safety. Findings include: Review of the facility policy titled Care Plan occurred on 10/19/23. This policy, dated 09/22/22, stated, The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. It will address the relationship of items or services required and facility responsibility for providing these services. The interdisciplinary team will review care plans at least quarterly. Care plans also will be reviewed, evaluated and updated when there is a significant change in the resident's condition. - During an interview on 10/16/23 at 3:29 p.m., Resident #39 expressed concern of having to use a bed pan for toileting and lack of physical therapy, and stated, I have these spells. They say I fall over. Review of Resident #39's medical record occurred on all days of survey. Diagnoses included orthostatic hypotension (excessive drop in blood pressure when an upright position is assumed) and syncope and collapse (fainting/passing out). The record showed Resident #39 as non-ambulatory, discharged from physical therapy on 09/07/23 due to drop in blood pressures with position changes, and use of a bed pan for safety related to syncopal episodes while on the toilet. Resident #39's care plan failed to address a problem, goal, or interventions related to orthostatic hypotension and/or syncope and their effects on the resident's activities of daily living (ADLs) and physical therapy. - Review of Resident #81's medical record occurred on all days of survey. Diagnoses included dysphagia (swallowing disorder). A Speech Therapy note, dated 08/18/22, stated, . Patient now is noted to have improved cooperation, and family is requesting ST [speech therapy] reassessment following bringing dentures to facility. Upper and lower dentures present . The Speech Therapy discharge summary, dated 10/13/22, stated, . Patient additionally consistently spitting out dentures upon placement. The current care plan stated, ORAL CARE: Assist of 2 for ADL. Has some of his own teeth. Observation on 10/17/23 at 9:29 a.m. showed the resident without dentures. During an interview on 10/18/23 at 1:48 p.m., an administrative staff member (#1) stated Resident #81 has a history of taking out the dentures and throwing them. The care plan failed to address Resident #81's dentures. 40488

Based on observation, record review, review of facility policy, manufacturer resources, and staff interviews, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 4 sampled residents (Resident #3) who required a full body mechanical lift with sling for transfers. Failure to ensure staff utilize the proper size sling for each resident placed all residents who transfer with a mechanical lift at risk for accident and/or injury. Findings include: Review of the facility policy titled SRHP-Safe Resident Handling Program Overview-R/S, LTC occurred on 09/14/23. This policy, revised 01/11/23, stated, . This program includes mobility and bathing equipment, program elements to support the use of equipment, employee training and a 'Culture of Safety'. Mechanical lifting equipment and/or other approved resident handling aids must be used to prevent manual lifting . Mobility equipment - Refers to total lift, ceiling lift, sit-to-stand, stand aid and walkers. Includes any device that utilizes a sling or harness and assists a resident with mobilization tasks. Review of FDA Patient Lift Safety Guide at https://ezlifts.com/resources, dated 09/14/23, stated, . Select Patient's Sling Size . SLING TOO LARGE: Patient may slip out . SLING TOO SMALL: Patient may fall out. Review of EZ Way Sling Sizing Chart occurred on 09/14/23. This form, revised 07/31/18, stated, . Beige M [medium] . Burgundy L [large] . Color Coding is used on the binding of slings . Review of Resident #2's medical record occurred on 09/14/23. The current care plan stated, . self care performance deficit R/T [related to] limited mobility/generalized weakness . TRANSFER: Assist of 2 [two] with hoyer [full body mechanical lift]. Medium standard sling. Observation on 09/14/23 at 11:03 a.m., showed two certified nurse aides (CNAs) (#1 and #2) place a white mesh sling with burgundy binding under Resident #3. The CNAs transferred Resident #3 from the bed to the wheelchair with a mechanical lift. The CNA (#1) stated the sling was a large regular, and showed the tag on the sling. The CNAs both explained the kardex/careplan identified the sling size to use for every resident. The CNA (#1) showed the surveyor Resident #3's kardex from the bathroom, which stated, . medium standard sling . During an interview on 09/14/23 at 1:00 p.m., administrative staff members (#3 and #4) confirmed they expected staff to use the correct size sling to transfer residents with mechanical lifts.

Based on information provided by the complainant, record review, and review of facility policy, the facility failed to provide appropriate toileting assistance for 1 of 2 sampled residents (Resident #2) careplanned to be check-and-changed every two-to-three hours. Failure to provide incontinence cares may result in a loss of dignity and place residents at risk of skin breakdown. Findings include: Information provided by the complainant indicated staff failed to toilet residents as scheduled. The complainant indicated he/she observed a resident sitting in his/her wheelchair, soaked in urine. Review of the facility policy titled Bowel and Bladder: Incontinence Program occurred on 01/18/23. This policy, revised 01/10/23, stated, . Resident will be checked for dryness/incontinence every two hours unless otherwise ordered by the physician and/or written in the plan of care. Resident should be kept clean, dry, odor free, with skin integrity maintained . - Review of Resident #2's medical record occurred on 01/18/23. The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as frequently incontinent of urine, always incontinent of bowel, and at risk for pressure ulcers. The current care plan stated, . The Resident has bladder incontinence . Assist of 2 [staff members] for . check and change. Offer ever 2-3 hours . Resident is at risk for alterations to skin integrity . Keep skin clean and dry . Reposition every 2 hours and PRN [as needed] . Resident #2's toileting record, dated December 18, 2022-January 17, 2023, identified the following timespans between check and change and incontinence cares: * greater than (>) 3.5 hours: 23 occasions * > 4 hours: 20 occasions * > 5 hours: 9 occasions * > 6 hours: 6 occasions * > 9 hours: 2 occasions * > 10 hours: 1 occasion * > 11 hours: 3 occasions The toileting records showed facility staff failed to check and change Resident #2 as careplanned 64 times in one month.

Based on record review, review of the facility reported incident investigation, review of facility policy, personnel record review, and staff interview, the facility failed to immediately start Cardiopulmonary Resuscitation (CPR) on 1 of 4 closed resident records (Resident #1) who requested CPR in the event of absence of pulse or respirations. Failure to immediately start CPR may have contributed to Resident #1's death and placed all residents requiring CPR at risk for death. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Advance Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) occurred on [DATE]. This policy, revised [DATE], stated, . PURPOSE: To provide each resident the opportunity to make decisions regarding future medical care . Initiation of Cardiopulmonary resuscitation (CPR): 1. If cardiac arrests [sic] occurs, CPR must be initiated unless the resident has: a. A valid DNR [do not resuscitate] order on file . 2. The resident has obvious signs of clinical death (e.g., rigor mortis [stiffening of the joints/muscles of a body a few hours after death], dependent lividity [settling of the blood in the dependent portion of the body postmortem, causing a purplish red discoloration of the skin.] .) 3. The initiation of CPR could cause injury or peril to the rescuer. Review of Resident #1's medical record occurred on [DATE]. Diagnoses included severe protein-calorie malnutrition, adult failure to thrive, anorexia (eating disorder), interstitial pulmonary disease (group of lung conditions that causes scarring of lung tissue), atherosclerotic heart disease of native coronary artery (hardening of the arteries supplying blood to the heart), COVID-19 (coronavirus disease), and bifascicular block (conduction abnormality of the heart). A physician's order, dated [DATE], stated, ND POLST [North Dakota Physician Orders for Life Sustaining Treatment] (A): CPR/Attempt Resuscitation. The progress notes, dated [DATE], identified the following: * 9:25 a.m., . Level of consciousness: Alert. Verbal. Responds to stimuli. Orientation: Person. Place. Time. Situation. Other circulatory issues: None. Related System: Respiratory Infection is potentially a result of COVID-19. Resident is in isolation Airborne precautions. Contact isolation precautions. Single room isolation . All services are being rendered in the resident's room. All meals are brought to the room and cares are done in the room. Other Notes: Resident takes off oxygen. * 9:28 a.m., . Continues to have moist cough and oxygen dependent. She refuses to keep the oxygen in place. Remains in isolation. * 12:40 p.m., . Informed daughter that resident had stopped breathing and facility staff started CPR. Facility called 911 and will be transported to [name of hospital]. * 1:27 p.m. [staff failed to note entry as a late entry], . RN [registered nurse] called to room via floor staff. Upon assessment resident was not breathing and no pulse noted, body temp warm, CPR started. 911 called. EMS [emergency medical services] arrived LUCAS [automated chest compression system] in place, Artificial airway placed, Line accessed [sic] placed. Paper work given to EMS. Report called to Emergency department. * 4:30 p.m., . Late Entry: Date and time vital signs ceased: 1228 [12:28 p.m.] . Name/date/time Provider/Coroner pronounced death: Time of death 1319 [1:19 p.m.] [Name of hospital] ED [Emergency Department,] MD [medical doctor] notified via phone 1630 [4:30 p.m.] Date, time and details of family/responsible party notification: 1319 via ED staff . The initial report to the State Survey Agency (SSA) Initial Allegation of Mistreatment, Abuse, Neglect, or Theft and Facility Reported Incidents Reporting Form regarding an incident on [DATE] concerning Resident #1 and a nurse (#1) stated, . Briefly describe the alleged incident and/or injury: Registered nurse on duty did not initiate CPR immediately on full code resident. The facility's final report to the SSA stated, . Date and time of the Allegation/Incident: [DATE] 12:23 [p.m.] 8. Briefly Describe the Alleged Incident and/or Injury: C.N.A. [certified nurse aide] found resident unresponsive and called nurse on duty for assistance. Nurse promptly reported to resident room and staff called for additional support. [Nurse #1] directed staff to obtain crash cart. [Nurse #1] did not initiate CPR immediately. Additional staff were called to room, [Nurse #2] initiated CPR immediately upon arrival. Resident left facility with active CPR in progress with EMS staff. Provider and family updated at time of incident. 9. How do you plan to protect all residents during the time you are investigating this allegation? Immediately post incident all staff involved were interviewed. Education on CPR policy was completed on all licensed nurses. Results of Investigation: Nurse [#1] educated on CPR policy and counseled per administration and human resources. Final Action Taken: Nurse [#1] verbalized understanding of immediately performing CPR per policy indicators. Review of the facility's investigation identified the following timeline of events on [DATE] per the unit camera footage: * 12:23 p.m. - [CNA #3] enters room with meal and comes out of room to call for help * 12:24 p.m. - [CNA #4] enters room and [CNA #4] exits room and [CNA #3] waits in doorway * 12:24 p.m. - [Nurse #1] enters room * 12:25 p.m. - [CNA #4] brings crash cart * 12:27 p.m. - [Nurse #1] peaks out of bubble [plastic covering for isolation purposes over Resident #1's room door] and appears to be calling someone for help. * 12:27 p.m. - [Nurse #2] enters the room and initiates CPR * 12:28 p.m. - [Nurse #1] grabs [back] board off crash cart. * 12:29 p.m. - [CNA #3] pushes crash cart into resident room. * 12:31 p.m. - [Administrative staff member #5] take AED into room * 12:36 p.m. - EMS arrives in building [exits building after 11 minutes] The facility's investigation included the following staff interviews completed on [DATE]: * CNA #3 - . [CNA #3] went to [Resident #1's] room walkied [walkie talkie] for nurse as [Resident #1] was not responsive. [Nurse #1] told [CNA #3] that resident had passed after checking pulse. [Nurse #1] did not give any instructions to [CNA #3]. [CNA #3] called [Nurse #2] for assistance. * CNA #4 - [CNA #3] and [CNA #4] were taking resident food trays to those Covid positive residents when [CNA #3] found [Resident #1] unresponsive. [CNA #3] called [Nurse #1] on the walkie to request assistance. [Nurse #1] came to resident room within two minutes. [Nurse #1] did not start compressions. [Nurse #1] told [CNA #4] to grab crash cart. Compressions were started as soon as [Nurse #2] arrived a few minutes later. * Nurse #1 - [CNA #3] called [Nurse #1] in to [Resident #1's] room. [Nurse #1] responded to request within two minutes. [CNA #3] said she thinks [Resident #1] had died . Before [Nurse #1] went in, asked [CNA #4] to get the [crash] cart. [Nurse #1] knew she was a full code. [Nurse #1] did not start compressions initially. [Nurse #1] called 911 as [Nurse #2] started compressions. [Nurse #2] did compressions, followed by [CNA #3] followed by [Nurse #1]. [Nurse #1] stated her mind froze when it came to doing CPR. * Nurse #2 - Responded to a call to room [Resident #1's room number]. When [Nurse #2] got to room, nurse on duty [Nurse #1] told [Nurse #2] this resident was a full code. [Nurse #2] initiated CPR and instructed [Nurse #1] to call 911. [Nurse #2 was assisted by [CNA #3] and [Nurse #1] with the code. During an interview on [DATE] at 9:30 a.m., an administrative nurse (#6) stated Resident #1 tested positive for COVID-19 in the week prior to the incident, and the facility placed the resident and her room in an isolation bubble with plastic sheeting with a zipper opening over her door. Once the nurse (#1) donned personal protective equipment (PPE) and entered the room, she assessed Resident #1 and determined the resident lacked a pulse and respirations and her extremities felt cold. The administrative nurse (#6) stated the nurse (#1) froze and didn't know what to do immediately as she felt the resident had been expired for a while and CPR would be futile. During this time, the nurse (#1) actively sought and called on the walkie for help and the crash cart and activated the EMS protocol. Once the crash cart arrived, the nurse (#1) retrieved the ambu (artificial manual breathing unit) bag and got things ready to start CPR. The administrative nurse (#6) stated when the second nurse (#2) arrived, the nurse (#2) started CPR even though the nurse's (#2) initial assessment and impression was Resident #1 had been deceased for some time. During an interview on [DATE] at 11:34 a.m., an administrative staff member (#5) verified the nurse (#1) checked Resident #1's pulse several times between 12:24 and 12:25 p.m. on [DATE], retrieved items from the crash cart outside the isolation wall, and called for the second nurse and EMS. Staff removed the barrier wall to take the crash cart inside Resident #1's room. The administrative staff member (#5) stated the second nurse (#2) stated during the investigation that starting CPR two or three minutes earlier would not have changed the outcome as the resident was already gone. She stated the nurse (#1) realized afterwards she should have started CPR immediately. At 1:57 p.m., an administrative staff member (#5) stated the camera time stamp included a second hand and showed the nurse (#1) entered Resident #1's room at 12:24:59 p.m., peaked out of bubble to call for help at 12:27:14, and the other nurse (#2) entered and started CPR at 12:27:48 p.m. Review of personnel records on [DATE] identified: * All licensed nurses held current CPR certification, including Nurse #1. * All staff completed annual advance directive education in the past year. * All licensed nurses completed Mock Code Education between May and [DATE]. * The administrator, CNAs, medication assistants, and activities assistants completed Response to an Unconscious Person between April and [DATE]. * Nurse #1's orientation in 2021 included oxygen and supplies, code status, death & dying process, orientation to crash cart, AED, and how to reach EMS services. Based on the following information, non-compliance at F678 is considered past non-compliance. The facility implemented the corrective action for the resident affected by the deficient practice by: * Completing an investigation with interviews of staff who assisted Resident #1 during the incident on [DATE]. * Determining the investigation showed Nurse #1 failed to follow the CPR policy which may have contributed to Resident #1's death. * Providing one-on-one education with Nurse #1 on the CPR policy immediately after the incident. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: * Providing all nurses with face-to-face education on the policy for Advance Directives/CPR following the incident on [DATE]. * Continuing with evaluation of all code situations and/or conducting mock codes a minimum of twice yearly, a practice started in 2020. The facility provided additional training based on outcomes of the mock and real codes (one mock code and four actual codes in the past 12 months). The survey team determined a deficient practice existed on [DATE]. The facility implemented corrective action on [DATE] and completed nursing education on [DATE].

MEDICATION ADMINISTRATION 1. Based on observation, record review, and review of manufacturer's guidelines, the facility failed to ensure staff followed professional standards of practice for 1 of 1 sampled resident (Resident #31) observed receiving an inhaler. Failure to instruct the resident on proper inhalation medication administration has the potential to result in the resident receiving an inaccurate dose of medication and/or experiencing adverse consequences. Findings include: Review of the manufacturer's guidelines for [MEDICATION(S)] Aerosol Powder (Respiratory Combo Inhalant) occurred on 08/30/22. The guidelines, revised September 2020, stated, . While holding inhaler away from mouth, breathe out (exhale) fully. Do not breathe into the mouthpiece. Inhale your medicine. Put the mouthpiece between your lips, close lips firmly around it . Take one long, steady, deep breath in through your mouth . Do not block air vent with your fingers . Remove inhaler from mouth and hold your breath for about 3 or 4 seconds (or as long as it is comfortable for you) . Breathe out slowly and gently . Close inhaler . Rinse your mouth with water after you have used the inhaler and spit it out. Review of Resident #31's medical record occurred on 08/30/22. A physician's order, dated 01/07/2022, stated, [MEDICATION(S)] Aerosol Powder Breath Activated 100-62.5-25 MCG [micrograms]/INH [inhalation], Inhale one puff PO [by mouth] Daily. Rinse mouth after use. Observation on 08/30/22 at 8:30 a.m. showed a medication assistant (MA) (#15) administered the Trelegy Inhaler to resident #31. Resident #31 took six short puffs from inhaler, without any education/instructions from the MA (#15). After six short puffs, Resident #31 swished his or her mouth with water and swallowed. The MA (#15) failed to instruct Resident #31 to take one puff from the inhaler and to rinse and spit out the water. BLOOD GLUCOSE MONITORING 2. Based on record review, review of facility policy, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 5 sampled residents (Resident #53) selected for unnecessary medication review. Failure to notify the physician of abnormal blood glucose levels may result in untreated [CONDITION(S)] (low blood glucose level) or [CONDITION(S)] (high blood glucose level). Findings include Review of the facility policy titled Notification of Change occurred on 09/01/22. This policy, dated 04/26/22, stated, . A facility must immediately . consult with the resident's physician . a need to discontinue or change an existing form of treatment or to commence a new form of treatment. Review of Resident #53's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders identified, . For blood glucose results greater than 400, call provider. Review of Resident #53's blood glucose levels showed facility staff failed to notify the physician of high blood glucose levels on the following dates: 08/13/22 - 406 mg/dl [milligrams per decilitre] 07/08/22 - 443 mg/dl 06/19/22 - 427 mg/dl 05/22/22 - 406 mg/dl 05/08/22 - 437 mg/dl During an interview on 08/31/22 at 9:53 a.m., an administrative nurse (#1) confirmed staff failed to notify the physician of blood glucose levels over 400. OXYGEN 3. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 24 sampled residents (Resident #96) with orders for continuous oxygen. Failure to provide oxygen (O2) as ordered may result in adverse health effects. Findings include: Review of the facility policy titled Oxygen Use occurred on 08/31/22. This undated policy stated, . Oxygen is considered a medication and requires a practitioner's order . Adjust the oxygen flowmeter to the prescribed flow rate . Review of Resident #96's medical record occurred on all days of survey. The record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician's order stated, Oxygen at 2 liters via NC [nasal cannula] continuous. Check SATS [saturation levels] BID [twice daily] . The resident's current care plan stated, . Oxygen at 2 liters via NC continuous. Check SATS BID. Observations of Resident #96's oxygen concentrator occurred on all days of survey. All observations showed the resident's concentrator set at 3 liters rather than the prescribed flow rate of 2 liters. During an interview on 09/01/22 at 11:30 a.m., an administrative nurse (#1) confirmed that the facility failed to ensure the resident's oxygen concentrator was at the prescribed flow rate of 2 liters.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure food is stored, prepared, and served in a sanitary manner for 1 of 1 kitchen (main kitchen) and 1 of 6 dining areas (Unit 600). Failure to properly store thawing raw meat in the cooler and failure to use a barrier when touching ready-to-eat food has the potential to result in cross-contamination and/or food borne illness. Findings include: THAWING RAW MEAT The 2017 FDA (Food and Drug Administration) Food Code, Annex 3 - Public Health Reasons, Section 3.302.11 Packaged and Unpackaged Food - Protection, Separation, Packaging, and Segregation, stated, It is important to separate foods in a ready-to-eat form from raw animal foods during storage . to prevent them from becoming contaminated by pathogens that may be present in or on the raw animal foods. product handling, drippage during the freezing process, partial thawing or incomplete seals on the package increase the risk of cross-contamination from these products. With regard to the storage of different types of raw animal foods . it is the intent of this Code to require separation based on anticipated microbial load and raw animal food type (species). Separating different types of raw animal foods from one another during storage . will prevent cross-contamination from one to the other. The required separation is based on a succession of cooking temperatures . which are based on thermal destruction data and anticipated microbial load. For example, to prevent cross-contamination, fish and pork, which are required to be cooked to an internal temperature of 145 degrees Fahrenheit (F) . shall be stored above or away from raw poultry, which is required to be cooked to an internal temperature of 165 degrees F. due to its considerable higher anticipated microbial load. Review of the facility policy Proper Thawing Methods - Food and Nutrition Services occurred on 08/31/22. This policy, dated 05/16/22, stated, . To maintain food quality/safety during the thawing process. 1. In the refrigerator a. Place raw meats on the bottom shelf in a drip-proof container so that there is no chance of juices splashing on ready-to-eat foods. - Observations of the walk - in cooler in the main kitchen showed the following: 08/29/22 at 7:55 a.m.* Bottom shelf: Tub of thawing raw pork chops, a box of thawing raw ground beef, and a box of cream cheese. * Shelf above the bottom shelf: Pan of thawing raw pork chops, a pan of pre-cooked lasagna, and a container of hard boiled eggs. The facility failed to ensure the raw, thawing meats were stored to prevent cross contamination with ready-to-eat foods (cream cheese, hard-boiled eggs) or other meats which require a lower cooking temperature. 08/31/22 at 2:15 p.m. * Bottom shelf: Pan of thawing raw ground beef.* Shelf above the bottom shelf: Pan of thawing raw turkey. The facility failed to ensure the raw turkey, which requires a higher cooking temperature (165 degrees F) than the ground beef (155 degrees F), was stored on the bottom shelf, or below the ground beef to prevent cross-contamination. BARE HAND CONTACT WITH READY-TO-EAT FOOD - Review of the facility policy/procedure titled Hand Washing and Glove Use - Food Nutrition Services occurred on 09/04/17. This policy, dated 08/11/22, stated, . Employees do not touch any food with bare hands - ready-to-eat or otherwise. Proper utensils such as tissue, spatula, tongs, and single-use gloves should be used for food handling to reduce the risk of cross contamination. . Observation on 08/30/22 at 5:36 p.m. in the 600 unit showed a Food Service Assistant (FSA) (#10) repeatedly reached into a plastic bag of cookies with their bare hand and gave a cookie to each resident who wanted one. The FAS (#10) failed to use a utensil or glove when removing the cookies from the bag. During an interview on 09/01/22 at 9:31 a.m., managerial dietary staff members (#11 and #12) confirmed staff should not touch ready to eat foods with their bare hands.

Based on record review, information from the complainant, review of the facility reported incident investigation, review of facility policies, review of personnel records, and staff interview, the facility failed to immediately start Cardiopulmonary Resuscitation (CPR) on 1 of 1 closed resident record (Resident #1) who requested CPR in the event of absence of pulse or respirations. Failure to immediately start CPR contributed to Resident #1's death. During the complaint survey on [DATE], the survey team determined a potential Immediate Jeopardy (IJ) situation existed. The IJ potential resulted from review of Resident #1's medical record, the facility reported incident investigation, personnel records, and staff interview which showed residents were placed in an immediate dangerous situation due to the delay of CPR. [DATE] at 5:10 p.m. - The survey team contacted the management staff at the State Survey Agency (SSA) to report the findings and to discuss a potential IJ situation. [DATE] at 5:55 p.m. - The survey team notified facility administration of the IJ situation and requested they develop a plan for abatement of the immediate jeopardy. [DATE] at 10:20 a.m. - The SSA notified the regional office of the immediate jeopardy situation. [DATE] at 1:30 p.m. - The survey team determined the IJ situation at a scope/severity of J was abated and reduced to a scope/severity of G. Findings include: Review of the facility policy titled CARDIOPULMONARY RESUSCITATION (CPR) occurred on [DATE]. This policy, revised [DATE], stated, . Cardiopulmonary Resuscitation (CPR) certification is mandatory for all licensed nursing employees. Each location will assign an employee responsible to be sure that all licensed nurses have current CPR certification. This will be reported to the administrator annually. CPR must be initiated unless the resident has a do not resuscitate (DNR) order, the resident has no advance directive on file, the resident does not have a valid DNR on file that includes a medical order issued by a physician or other authorized non-physician practitionerthe (sic) resident has obvious signs of clinical death . Review of the facility policy titled ADVANCE CARE PLANNING AND ADVANCE DIRECTIVES occurred on [DATE]. This policy, revised [DATE], stated, . PURPOSE: To provide each resident the opportunity to make decisions regarding future medical care . Cardiopulmonary Resuscitation (CPR): Any medical intervention used to restore circulatory and/or respiratory function that has ceased. Residents . have the right to make decisions concerning medical care, including the right to accept or to refuse medical or surgical treatment. Review of Resident #1's medical record occurred on [DATE] and identified medical [DIAGNOSES REDACTED]. Resident #1's North Dakota Physician Orders for Life Sustaining Treatment (ND POLST), signed by Resident #1 on admission ([DATE]), identified the following instructions: FIRST follow these orders, THEN call the appropriate medical contact. These medical orders are based on the patient's medical condition and wishes. Any section not completed implies full treatment for [REDACTED]. Resident #1's POLST identified the following: A. CARDIOPULMONARY RESUSCITATION (CPR): CPR/ATTEMPT RESUSCITATION . B. MEDICAL INTERVENTIONS: Patient has a pulse and/or is breathing : FULL TREATMENT - Use all appropriate medical and surgical interventions as indicated to support life. Transfer to hospital if indicated. Includes intensive care.C. ARTIFICIALLY ADMINISTERED FLUIDS AND NUTRITION: . Artificial nutrition and hydration unless it provides no benefit. Review of Resident #1's physician's orders, dated [DATE], stated, ND POLST (A) CPR/Attempt RESUSCITATION. Review of nurses' progress notes identified the following: * [DATE] at 5:38 p.m. - . Met with resident in resident's room to complete admission paperwork. Resident was admitted from (name of hospital) for continues (sic) therapies after being admitted for [MEDICAL CONDITIONS]. * [DATE] at 11:00 p.m. - Resident sitting up on side of bed. He had moderate chunky, food consistency emesis. BP (blood pressure) ,[DATE]; P (pulse) 121; R (respirations) 18; T (temperature) 98.2; O2 (oxygen) 94% RA (room air). Lung sounds clear. Bowel sounds hypoactive. Abdomen distended non-tender. Asked resident if he was feeling like he was going to throw up, resident stated in a clear voice, 'No.' . Resident stated to gag. [MEDICATION NAME] (medication for nausea) applied topically to wrists. Brought [MEDICATION NAME] suppository in and resident turned to his left side. Administered suppository. Resident had moderate soft brown bowel movement. BP ,[DATE]; P 91; R 18; T 98.4; O2 94% RA. * [DATE] at 12:19 a.m. - Approached resident asking if he was alright (sic) still. Resident requested that I take off his wraps on his legs and stated that he was alright (sic). Removed ace wraps from legs. Bowel sounds WNL (within normal limits) all quadrants. Resident safe and secure laying in bed on his back. * [DATE] at 1:24 a.m. - CNA (certified nursing assistant) requested me to come to his room. Apical heart rate not audible. Sternum rub completed without response. (Name of resident's mother) . voice message left at 0126 (1:26 a.m.). CPR initiated immediately. Received follow up report from (nurse) from (hospital) emergency room at 0240 (2:40 a.m.) stated resident deceased . The nurse's documentation of CPR initiated immediately differs from the facility's investigation (timeline and interviews) as listed below. The initial report to the SSA Allegation of Abuse and Neglect, Allegation of Suspected Vulnerable Adult abuse, Neglect, or Exploitation report, dated [DATE], stated, . 8. Briefly Describe the Alleged Incident and/or Injury: Resident ceased breath sounds. CNA (#4) notified nurse (#1). Nurse (#1) checked pulse and did sternal rub. Nurse did not initiate CPR on full code resident immediately. Resident expired. Review of the facility's investigation identified the following timeline of events on [DATE]: 1:04 a.m. (unit camera footage) - CNA (#4) goes to corner of (Unit) where Resident #1's room was located 1:21 a.m. (unit camera footage) - Nurse (#1) goes back to above corner 1:23 a.m. (unit camera footage) - Nurse (#1) goes back to above corner (nurse's progress note stated apical pulse not audible, sternum rub completed and no response) 1:26 a.m. (unit camera footage) - Nurse (#1) returns to nursing station, is on phone/at computer 1:26 a.m. (unit handheld phone) - Call to Resident #1's mother 1:29 a.m. (unit handheld phone) - Call to (another unit) nursing station 1:30 a.m. (unit handheld phone) - Call to Resident #1's son 1:31 a.m. (unit handheld phone) - Call to Resident #1's daughter 1:32 a.m. (unit handheld phone) - Call to (another unit) nursing station 1:39 a.m. (unit desk phone) - Call to on-call provider 1:41 a.m. (unit camera footage) - Nurse (#2) arrives on unit 1:42 a.m. (unit desk phone ) - Call to 911 1:43 a.m. (unit camera footage) - Nurse (#1) returns to above corner (per information from interviews - CPR initiated at this time) 1:44 a.m. (unit camera footage) - Nurse (#3) comes with AED, Nurse (#2) comes with crash cart 1:49 a.m. (camera footage) - EMS (emergency medical system) arrived 1:59 a.m. (camera footage) - EMS leaves building with resident 2:40 a.m. (unit desk phone) - Incoming call from ER The facility's investigation report included the following staff interviews: * Nurse #2 interview - [DATE] . Went down to (unit). (Nurse #1) stated she just lost a patient. (Nurse #2) asked the code status. (Nurse #1) said he was a full code. (Nurse #2) stated that she needed to start CPR. (Nurse #1) stated that she has never done CPR and didn't have the crash cart. (Nurse #1) was trying to call the family. (Nurse #2) stated you are going to learn how to do CPR right now. * Medical Provider #6 interview - [DATE] (Medical Provider #6) did not have a call in regards to (Resident #1) until last evening. (Nurse #1) called the switch board to tell (Medical Provider #6) that Resident #1 had passed away. (Nurse #1) tried to do a sternal rub. (Medical Provider #6) told her (Nurse #1) to start CPR and call 911. (Nurse #1) responded by saying 'okay'. * CNA #5 interview - [DATE] Looking for (CNA #4 and Nurse #1). Went into Resident #1's room. (Nurse #1) said he was dead. (Nurse #1) went to call provider. CPR was not issued right away as (Nurse #1) did not know his code (status). He started CPR 5ish minutes later. (Nurse #2 and Nurse #3) came with crash cart. (Nurse #3) put on AED (Automated External Defibrillator) pads. * CNA #4 interview - [DATE] . She (Nurse #1) checked his pulse. (Nurse #1) called (CNA #5) to room. (Staff #4) cleaned him up. (Nurse #1 and Nurse #2) later started CPR. * Nurse #1 interview - [DATE] at 11:56 AM . Went and checked on him, took wraps off. (Staff #4) in room getting ready to clean him up, fine/still alive, walk out of the room and returned, no heart rate called mom, called (Medical Provider #6), called 911, CPR initiated. EMS arrived quickly and took over, transported to ED (emergency department). Not current on CPR. Says has never dealt with a code before. * Nurse #3 interview - (Nurse #1) called (Nurse #3) to see what to do when you can't get ahold (sic) of a family member when someone passes away. (CNA #4) went into his room and said he was not breathing. (Nurse #1) told (Nurse #3) who it was and he brought him up onto the computer. (Nurse #3) said he's a full code. You need to start CPR, I will be right over. He ran over and pulled the crash cart and grabbed the AED. (Staff (#1)) initiated CPR after being told. AED advised no shock. (Nurse #1) was doing CPR and (Nurse #2) was bagging him. EMS showed up 5 minutes later. (Nurse #3) told (Nurse #1) to document thoroughly. (Nurse #3) expressed that the documentation was not what actually happened. The Final Report Form sent to the SSA on [DATE], stated, . Results of Investigation: Nurse did not initiate CPR until greater than 10 minutes post being alerted of respiratory arrest. Final Action Taken: Termination. During an interview on [DATE] at 2:09 p.m. an administrative nurse (#7) stated all nurses are required to be CPR certified. The nurse (#7) stated they do not have any documentation of CPR certification for the nurse (#1) involved in the incident with Resident #1. When asked about education of staff regarding code status and initiation of CPR, two administrative nurses (#7 and #8) stated the nurses spoke one-to-one with each other regarding the incident. The facility failed to have an educational meeting with nursing staff and confirmed they lacked documentation of nursing staff education. An administrative nurse (#8) stated they are providing education to CNA staff today ([DATE]) regarding location of the crash cart, code book and AED. When asked regarding the discrepancy between the documentation of the nurse's progress note and the investigation timeline and interviews, the administrative nurse (#8) confirmed the nurse's documentation was not accurate. Review of personnel records for all nursing staff on [DATE], identified four (4) nurses lacked evidence of CPR certification. Review of Nurse #1's personnel file lacked evidence of CPR certification. Nurse #1's personnel file identified the following statement from the nurse regarding the incident with Resident #1: When I was visiting with the other staff nurse (he/she) had asked me if I had started CPR. I informed (him/her) I didn't because I didn't think that I needed to due to his heart rate had stopped. (He/she) said Ok then you should contact (name of unit manager), the floor coordinator or physician. I contacted (name of provider) since (he/she) was the on call physician. (He/she) asked if I started CPR. I said no. She told me that I needed to start CPR. So I went and started CPR. Review of the facility's resident code status report identified 22 residents (current census of 116) requested CPR in the event of absence of respirations or heartbeat. The facility nurse (#1) failed to immediately initiate CPR after assessment that Resident #1 did not have an apical heartbeat and no response to a sternal rub. The facility failed to provide documentation of nurses' education regarding location of residents' code status, when to initiate CPR, and to ensure all nurses had current CPR certification. These actions contributed to the death of Resident #1 and the potential for other residents to be affected by the deficient practice.

Based on information provided by the complainant, record review, review of professional literature, review of facility policy, and staff interview, the facility failed to follow professional standards for medication administration for 1 of 1 sampled resident (Resident #1). Failure to administer medications using safe administration practices resulted in a significant medication error which required Resident #1 to be hospitalized . Findings include: Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing Concepts, Process, and Practice", 9th Edition, Copyright 2012 by Pearson Education, Inc., Upper Saddle River New Jersey, page 860-864, stated, ". . . Before administering a medication, identify the client correctly using the appropriate means of identification . . . Errors can and do occur, usually because one client gets a drug intended for another. . . . The Joint Commission's National Patient Safety . . . goal requires a nurse to use a least two client identifiers whenever administering medications. Neither identifier can be the client's room number or physical location. . . . Acceptable identifiers may be the person's name, assigned identification number, telephone number, photograph, or other person-specific identifier. . . ." Review of the facility policy titled "Principles of Medication Administration" occurred on 11/18/14. This policy, revised 09/29/14, stated ". . . Identify the resident prior to administering the medication by checking the picture in the MAR, call the resident by name, or verify with other care center personnel. . . ." The facility policy failed to reflect at least two client identifiers should be used prior to administering medications. Information provided to the State agency indicated facility staff failed to ensure Resident #1 received only her medications per physician order. Review of Resident #1's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and extensive assistance required for Activities of Daily Living (ADLs). The Progress Notes identified the following: * 09/28/14 at 6:00 p.m., "Resident given another resident's medications on top of her own scheduled medications. (Physician) . . . notified with instructions to monitor vitals hourly x 6 hours and to monitor mental status closely." * 09/28/14 at 6:15 p.m., "Resident's initial BP (blood pressure) 81/48 (120/80 systolic/diastolic blood pressure is considered within normal limits) with a HR (heart rate) of 65. Resident brought to her room and laid down with her feet elevated. Staff at bedside to feed resident and monitor BP every 10 minutes." * 09/28/14 at 6:50 p.m., "Resident's BP 70/40 ([MEDICAL CONDITION]: systolic reading consistently between 85 and 110 mm/Hg (manometric unit of pressure)) with a HR of 49 (60 to 100 beats per minute is considered within normal limits). (Physician) . . . notified of BP drop and order received (sic) to send her to (local Hospital emergency room (ER)) to be evaluated and treated. . . . Resident left facility at 7:10 p.m. with EMS (Emergency Medical Services) crew. Report called to (ER). Awaiting update on resident's condition." The hospital history and physical, dated 09/28/14, identified, ". . . accidental administration of medications . . . woman residing in SNF (skilled nursing facility) who was mistakenly given another patient's medications along with her own. She received an extra dose of [MEDICATION NAME] (a pain medication) along with [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) and [MEDICATION NAME] (a medication for hypertension) and [MEDICATION NAME] (a medication for [MEDICAL CONDITION]) and [MEDICATION NAME] (a [MEDICAL CONDITION] medication). Patient was lethargic and hypotensive thus prompting ER visit. . . ." The progress noted, dated 09/29/14 at 2:27 p.m., identified, "Resident returned from hospital . . . ." The medication safety report, dated 09/29/14, identified, ". . . Administering error . . . wrong patient . . . in the dining room . . . Resident sitting in wrong spot, also nonverbal. . . . An error occurred that resulted in the need for treatment or intervention and caused temporary patient harm. . . . Vital signs monitoring initiated . . . Referred to provider . . . ER . . . hospitalization . . ." The report further indicated the nurse received education on the "facility's policy, the rights of medication administration, and alternative identifiers." During an interview on 11/17/14 at 5:00 p.m., an administrative nurse (#1) reported facility staff use the dining room assigned-seating chart, the photos on the MAR (medication administration record), and verbal confirmation to identify residents prior to administering medications. The nurse (who never met either Resident #1 or the new admit) dished the new resident's medications, reviewed the updated seating chart, went to the table identified on the chart, addressed Resident #1 by the new resident's name, and gave her (the new resident's) medications. The nurse felt Resident #1 "looked similar to the person on the MAR," and wasn't surprised when Resident #1 was non-responsive as she had been told the new resident "wasn't very verbal." The nurse used the resident's physical location as an identifier, addressed the resident by name even though she had previous knowledge the resident "wasn't very verbal," and administered the medications even though the resident "looked similar to the person on the screen." Failure to administer medications using safe administration practices resulted in Resident #1 requiring hospitalization .

Based on observation, record review, facility policy review, review of professional literature, and staff interview, the facility failed to provide adequate fluid intake for 1 of 1 sampled resident (Resident #4) dependent on staff for fluid intake and an order for [REDACTED]. Findings include: Review of the facility's policy titled "Hydration Assessment and Maintenance" occurred on 08/28/14. The policy, dated 01/02/09, stated, "POLICY: 1. Residents are provided a fresh supply of water at the bedside unless otherwise contraindicated. 2. Resident's are offered fluids with medications, with cares, during regularly scheduled snack passes and meals, therapy sessions, activities, and PRN (as needed) as requested . . . PURPOSE: 1. To ensure that a resident is offered sufficient fluids based on their individual needs to maintain proper hydration and health. . . ." The Center for Medicare and Medicaid Services (CMA) has outlined the standards of practice regarding hydration. "Sufficient fluid" means the amount of fluid needed to prevent dehydration and maintain health. The amount needed is specific for each resident, and fluctuates as the resident's condition fluctuates. A general guideline for determining baseline daily fluids needs is to multiply the resident's body weight in kg (kilograms) times 30cc (cubic centimeters) (2.2 lbs (pounds) = 1kg). Review of Resident 4's medical record occurred on all days of survey and included [DIAGNOSES REDACTED]. Resident's medications reviewed February 2014 through August 28, 2014 included [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. The quarterly Minimum Data Set (MDS), dated [DATE], identified cognitively intact, extensive assist of at least two staff for bed mobility and transfers, extensive assist of one staff for eating, and a weight of 160 lbs. The Care Area Assessment (CAA), dated 10/18/13, identified Dehydration - Fluid Maintenance for care planning due to constipation, dependant on staff for fluid intake, diuretics, and medications. The current care plan stated, "Problem Start Date: 03/17/2014. Category: Nutritional Status. (Resident is triggering HIGH nutrition risk r/t (related to) . . . swallowing difficulties . . . insufficient fluid intakes at times . . . medications . . . hx (history) UTI . . . on strict I & O (Intake and Output) per MD (medical doctor) ordered . . . Approach Start Date: 10/22/2013 . . . nectar thkn (thickened) liquids . . . Food/fluid intake monitoring per facility . . . limited to extensive assistance with eating & drinking. Encourage food/fluid intakes . . . Problem Start Date: 10/28/13. Urinary: Alteration in patterns of urinary elimination . . . Approach: Monitor for s/s (signs/symptoms) of UTI ie (for example): fever, hematuria, odor, and increased confusion. . . ." During observation on 08/25/14 at 8:20 a.m., a staff member assisted the resident with breakfast. The resident used her right hand to feed herself. The staff member assisted when the resident drank from a cup. Observation at 9:20 a.m. identified a certified nursing assistant (CNA) (#2) emptied the resident's bedpan into the toilet. The CNA failed to measure the urine output. Review of the "Medications Administration History: 02/01/2014 - 02/28/2014" identified Senna Lax 8.6 mg administered twice a day for constipation. Staff administered [MEDICATION NAME] 5 mg tablet PRN for constipation six times in February 2014 before hospitalization on [DATE]. Review of the "Events Report" identified UTIs treated with antibiotics on 01/08/14, 01/27/14, and 07/17/14. Review of Resident #4's progress notes prior to hospitalization identified: * 02/04/14 - "Spoke with (family) regarding . . . condition and behaviors . . . (resident) refused to eat and thrown water at staff . . . (family) request of starting an IV (intravenous) for fluid's to prevent dehydration . . . (staff) would have to consult (physician) . . . (physician) with orders to utilize PRN medication for behaviors . . . continue to monitor. . . ." (The physician did not order IV fluids.) * 02/12/14 - "INFECTION: . . . Resident with recent UTI, treated with [MEDICATION NAME] x7 days . . . (Physician) does not feel it is necessary to obtain a repeat UA/UC (urine analysis/urine culture) . . . behaviors are related to . . . [MEDICAL CONDITION] with bizarre behaviors vs. (versus) UTI. Nursing to continue to monitor . . . New orders for [MEDICATION NAME] 25 mg (milligrams) po (by mouth) Q (every) HS (bedtime). . . ." * 02/18/14 - ". . . NP (nurse practitioner) here . . . New orders received for [MEDICATION NAME] 0.25 mg PO BID (twice daily), increase [MEDICATION NAME] to 0.25mg PO in the morning, [MEDICATION NAME] 0.5 mg prior to noon meal and 0.25 mg prior to pm (evening) meal. . . ." * 02/19/14 - ". . . resident has been sleepy all day and (nurse) believes it is due to the recent medication adjustment of [MEDICATION NAME] . . . new orders received to decrease [MEDICATION NAME] (0.25 mg BID) and [MEDICATION NAME] (0.25 mg at bedtime). . . ." * 02/24/14 - "Resident very lethargic today. Not eating. When spoken to resident stares off and not responding most of the time . . . Heartrate very irregular 107 bpm (beats per minute) . . . O2 (oxygen) applied . . . send to ER (emergency room ) . . . BP (blood pressure) 162/100. . . ." Review of Resident #4's "Treatments Administration History" dated January 2014 identified an order stating, "Strict I & O. Encourage fluids. Frequency TID - Three Times A Day. Start/End Date 10/18/2013 - 03/04/2014 (DC (discontinue) Date). Review of the "Treatments Administration History" dated August 2014 identified an order stating, "Strict I & O. Encourage fluids. Frequency TID - Three Times A Day. Start/End Date 03/10/2014 - Open Ended." Review of Resident #4's "Vitals Report," dated 02/01/14 through 02/28/14 identified an average fluid intake of 334mL (milliliters) per day from 02/01/14 through 02/24/14. According to CMS guidelines a person with a weight of 160 lbs. should have approximately 2181 mL of fluid per day. Staff failed to measure the resident's output in the report, but documented the number of times continent or incontinent. Review of Resident #4's hospital History and Physical, dated 02/24/14, stated, "to the ER due to lethargy and elevated blood pressure and low oxygen saturations . . . is aphasic (non-verbal) . . . Lethargy possibly due to some dehydration . . . Mildly elevated creatinine likely due to dehydration. . . ." The Discharge Summary, dated 03/10/14, stated, " . . . DISCHARGE [DIAGNOSES REDACTED]. . . MEDICATION CHANGES . . . [MEDICATION NAME] . . . discontinued . . . HOSPITAL COURSE . . . A. ([MEDICAL CONDITION]) fibrillation . . . required a [MEDICATION NAME] drip . . . [MEDICAL CONDITION] (elevated sodium level) resulted in a 3-day additional stay for continued monitoring . . . taken off [MEDICATION NAME]-[MEDICATION NAME]. Most likely that medication will promote dehydration. . . so it is avoided . . . acute [MEDICAL CONDITION], resolved . . . [DIAGNOSES REDACTED] (low potassium level) had resolved . . . ." During an interview on 08/28/14 at 10:00 a.m., a nurse manager (#1) indicated the strict I & O order started on admission in October 2013 and was discontinued on 03/04/14. Staff did not currently monitor the resident's I & O. She failed to identify the current order for strict I & O. The nurse manager did not know the reason for the strict I & O admission order. Failure to accurately record and monitor a strict fluid intake and output order with a resident's [DIAGNOSES REDACTED].

Based on observation, record review, review of policy, review of manufacturer's recommendations, and staff interview, the facility failed to re-evaluate the appropriateness, and ensure safe transfer during the use of assistive devices for 2 of 4 sampled residents (Resident #2 and #8) observed during stand lift transfers. Failure to protect Resident #8 from experiencing pain in relation to assessed transfer techniques resulted in repeated episodes of pain during transfers, and placed Resident #2 and #8 at risk of falls due to unsafe transfer techniques in relation to each resident's capabilities. Findings include: Review of the EZ Stand Operating Instructions occurred on 08/28/14. The instructions, dated January 2001, stated ". . . To utilize the EZ Stand, patients must be able to bear some weight. . . . The Seat Strap provides additional support and comfort to patients who have a tendency to quit bearing weight . . . As patients do vary in size, shape, weight and temperament, these conditions must be taken into consideration when deciding if the EZ Stand is suitable for their need. Patients should be able to bear some weight . . . If necessary to keep patients shins or feet on the foot plate, secure the shin straps around the patients legs . . . Lengthen the Seat Strap so that it will slide around and under the patient. . . . slide the Seat Strap around behind the patient and underneath the patient's buttocks. Press the button up again, and release it when the patient is in the standing position. Now adjust the Seat Strap to the desired tension. . . . Position patient's arms on the outside of the harness and have them place their hands on the padded handles. . . ." Review of the facility policy titled "Use of Standing and Total Lifts - General Guidelines" occurred on 08/27/14. This policy, dated 06/19/09, stated, " . . . PURPOSE: 1. Mechanical lifts, either standing or total, are used to transfer a resident from one position to another in a safe, dignified, and comfortable manner . . . PROCEDURE: 1. Nursing associates determine the need for use of a standing lift or a total lift based on the resident's functional and cognitive ability . . . 5. Physical or Occupational therapists are consulted as necessary to determine the appropriate lift to use for a resident based on the resident's functional and cognitive ability . . . 7. Seat straps are used to provide additional support and comfort to residents who have a tendency to quit bearing weight during a transfer. . . ." - Review of Resident 8's medical record occurred on all days of survey and included [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified extensive assist of two or more persons for bed mobility and transfer and moderately impaired cognition. The current care plan stated, " . . . Approach (intervention) Start Date 08/20/13, Transfers: Assist of two and EZ stand. Remove prevalon boots for transfers. Hoyer (total body lift) PRN (as needed) when he refuses to hold on to EZ stand. . . ." Observations of staff transferring Resident #8 with the EZ Stand: * 08/25/14 at 5:15 p.m. - Two certified nursing assistants (CNA) (#2 and #4) transferred the resident from his room recliner to the toilet and then into his wheelchair using the EZ Stand lift. The resident held onto the hand grips as the sling slid up under the resident's arms. The resident appeared to hang in the lift with pressure under his axilla and minimal weight on his legs as his knees remained bent as in a sitting position. Resident #8 stated, "Hurts arms!" One of the CNAs stated, "Sorry. Almost done." The CNAs did not use the Seat Strap. * 08/26/14 at 9:00 a.m. - Two CNAs (#5 and #6) transferred the resident from his wheelchair to his room recliner. The resident did not bear any weight on his left foot and only the toe of his right foot came in contact with the foot plate. The CNAs used the Seat Strap, but it was placed above the buttocks providing no support. The resident moaned as the CNA raised the sling and it slid under his axilla. One of the CNAs asked if that hurt, and the resident stated, "Yes." * 08/26/14 at 11:15 a.m. - Two CNAs (#5 and #6) transferred the resident from his room recliner to his wheelchair. When the CNAs applied the calf strap it slipped under his left foot. They did not readjust it. The resident moaned as the sling raised and slid under his axilla. The CNAs used the Seat Strap, but it was placed above the buttocks providing no support. * 08/26/14 at 1:45 p.m. - Two CNAs (#5 and #6) transferred the resident from his wheelchair to his room recliner. When the CNAs applied the calf strap it slipped around his right ankle. They did not readjust it. The resident moaned as the CNA raised the sling and it slid under his axilla and stated, "Oh! My underarms! Oh God!" Staff positioned the resident quickly into his recliner. The CNAs used the Seat Strap, but it was placed above the buttocks providing no support. * 08/27/14 at 9:25 a.m. - Two CNAs (#8 and #9) transferred the resident from his wheelchair to his bed. The CNAs positioned the Seat Strap appropriately. The resident moaned as the CNA raised the sling and it slid under his axilla and stated, "Stop!" The CNAs did not reposition the Seat Strap to provide more support. The CNA (#8) did not understand what the resident had said and asked him to repeat it, but the resident said nothing more. Review of the progress notes during survey identified the staff had not reported or documented any of the observed pain issues when using the stand lift for Resident #8. During an interview on 08/28/14, a nurse manager (#1) indicated CNAs should report any pain or difficulty with any stand lift transfers to the nurse. - Resident #2's medical record, reviewed August 25-28, 2014, identified [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified intact cognition and extensive assistance of one person for transfers. Resident #2's current care plan stated, "Problem: ADL's (Activities of Daily Living) . . . Approach: Transfers: EZ stand with assist of 2 for transfers. . . . Toileting: . . . EZ stand with assist of 2 to transfer to commode for toileting needs. . . ." The current care plan failed to address Resident #2's weakened right arm. Observation on 08/26/14 at 8:35 a.m. showed two CNAs (#7 and #17) prepared to transfer Resident #2 utilizing a stand lift. The CNAs (#7 and #17) placed Resident #2's feet on the foot plate, secured the shin pad, and attached the harness and seat strap to the stand lift. The CNAs (#7 and #17) then assisted the resident to hold onto the padded handles and transferred her to the commode. Following cares, the CNAs (#7 and #17) transferred Resident #2 from the commode to her bed. Observation showed the resident's knees bent at an approximate 50 degree angle, and the harness pushed up into her axilla causing her shoulders to shrug upward. Her upper right arm (shoulder to elbow) was parallel to the floor and her lower arm (elbow to fingers) hung downward. Staff failed to ensure the resident was able to bear weight, slide the seat strap under her buttocks, and ensure her weakened right arm was held in front of her body during the transfer. Observation on 08/26/14 at 5:30 p.m. showed two CNAs (#23 and #24) prepared to transfer Resident #2 into her wheelchair utilizing a stand lift. The CNAs (#23 and #24) assisted the resident into a sitting position at the edge of the bed, placed her feet on the foot plate, secured the shin pad, and attached the harness and seat strap to the stand lift. The CNAs (#23 and #24) then assisted the resident to hold onto the padded handles, and raised the lift. They attempted, but failed to slide the seat strap under her buttocks. Observation showed the resident's knees bent at an approximate 55 degree angle, the harness pushed up into her axilla causing her shoulders to shrug upward, and her right arm hanging at her side. The CNAs (#23 and #24) lowered Resident #2 back onto the bed after she complained of pain. One CNA (#23) left the room to speak with the nurse. She returned with the Hoyer lift, and stated, "(Resident #2's) sling is in the laundry." Staff failed to ensure the resident was able to bear weight, supported her weakened right arm in front of her body when attempting a transfer, and provided the necessary equipment to accommodate Resident #2's size. During an interview on the afternoon of 08/28/14, an administrative nurse (#1) confirmed residents should be able to bear their own weight when using a stand lift. She also confirmed staff should ensure they have the necessary equipment to accommodate a resident's size prior to attempting a transfer and should ensure a resident's safety during the transfer if they have a weakened/paralyzed limb.

- Review of Resident #8's medical record occurred on all days of survey and included [MEDICAL CONDITION], diabetes, [MEDICAL CONDITION], and a history of pressure ulcers. The quarterly MDS, dated [DATE], identified extensive assist of two plus persons for bed mobility and transfer, moderately impaired cognition, risk for pressure ulcers, frequently incontinent of bowel and bladder, and a pressure reducing device for chair and bed. The current care plan identified an "Approach Start Date: 02/21/2014 Place Roho cushion in recliner chair when resident sits in recliner and then continue to place roho in whatever chair the resident is sitting in . . . Approach Start Date: 08/20/13 . . . Remove prevalon boots for transfers. . . ." Review of Resident 8's progress notes regarding skin issues identify: * 01/10/14 - "Left heel diabetic ulcer healed. Continue [MEDICATION NAME] for 2 weeks. Coccyc (sic) has 2 pin point openings. . . ." * 01/30/14 - "CNA approached this nurse and stated that resident's bottom was really sore and painful during peri-cares. . . ." * 01/31/14 - "Buttocks is healed with only dry skin present. . . ." * 02/07/14 - ". . . moisture fissure to intercocygeal fold that measure 5.5cm x 1.5cm. . . ." * 02/08/14 - "Coccyx area very sore and several open fissures noted . . . having #9 pain to coccyx . . . ." No further documentation until 02/21/14. * 02/21/14 - ". . . no open area noted . . . New orders received to place roho cushion in recliner and then move to each area resident will be sitting." * 03/07/14 - ". . . stage 2 pressure sore to the right gluteal (buttocks) that measures 3.9cm x 2.7cm. . . . MDS: Significant change assessment . . . Braden score is 14 indicating . . . at moderate risk for skin breakdown . . . has a history of healed pressure ulcers. . . ." * 03/14/14 - Right gluteal ulcer measures 2.1 x 1.2cm. No further documentation until 03/21/14. * 03/21/14 - ". . . New orders to D/C (discontinue) [MEDICATION NAME] border to bottom. . . ." * 06/02/14 - ". . . CNA found a pressure sore to residents lateral aspects of residents left foot. . . ." * 06/13/14 - "Changed dressing to left lateral 5th metatarsal head. Wound measures 0.8 x 0.4 cm dark purple and red surrounding painful to touch. . . ." * 06/20/14 - " . . . left foot . . . continue [MEDICATION NAME] for protection and prevention . . . boil on perineum . . . measures .2 x .2 x .6 cm. . . ." * 06/27/14 - ". . . boil measured today: 0.6 x 0.7cm, no open areas noted." No further documentation until 07/11/14. * 07/11/14 - ". . . New order to D/C [MEDICATION NAME] to left lateral foot, wound healed. . . D/C from services." Review of a referral note by a wound practitioner, dated 06/06/14, stated, " . . . PHYSICAL EXAMINATION SKIN: The patient has a left lateral foot area of discoloration over his 5th proximal metatarsal head. It measures 0.4 cm x 0.8 cm. The skin is intact over this area. It does not blanch. I am considering this as suspected deep tissue injury versus a [MEDICAL CONDITION]. . . PLAN: . . . [MEDICATION NAME] border over this area for protection . . . continue to utilize blue foam heel protector boots at all times to patient's feet to help offload the heel, as well as to help protect the left lateral foot area of concern. Continue ROHO cushion to patient's wheelchair and to patient's recliner. . . ." Observations * 08/25/14 at 4:05 p.m. - Resident #8 in his recliner without a Roho cushion. Staff had left the Roho cushion in his wheelchair. * 08/26/14 at 11:15 a.m. - Two CNAs (#5 and #6) transferred the resident from his room recliner which contained no Roho cushion to his wheelchair containing the Roho cushion. The CNAs removed the protector boots leaving the resident's socks on, the calf strap from the EZ Stand lift slipped under the resident's left foot. The CNAs did not readjust the strap during the transfer putting additional pressure on the foot's previous pressure ulcer area. * 08/26/14 at 1:45 p.m. - Two CNAs (#5 and #6) transferred the resident from his wheelchair to his room recliner. The CNAs did not take the Roho cushion from the wheelchair and place it into the recliner. * 08/27/14 at 9:25 a.m. - Two CNAs (#8 and #9) cleansed the resident's coccyx area after an incontinent stool. The resident moaned in pain each time the CNA cleaned the reddened area with a cleansing wipe. Review of Resident 8's progress notes identified staff failed to document the resident's reddened coccyx area or pain during incontinence care. During an interview on 08/28/14, a nurse manager (#1) indicated CNAs should report any pain or reddened areas during incontinence care to the nurse. The nurse should document those issues in the progress notes. Staff should make sure the EZ Stand calf strap is appropriately placed during transfers and not under a resident's foot. Based on observation, record review, review of facility policy and procedure, and staff interview, the facility failed to ensure 2 of 3 sampled residents with current or a history of pressure sores (Resident #6 and #8) received the necessary treatment and services to prevent pressure sores, prevent recurrence of healed pressure sores, promote healing, and prevent infection. Failure to identify, monitor and implement treatment measures resulted in delayed healing and risk of serious harm/injury from delayed healing. Findings include: Review of the facility "SKIN RISK ASSESSMENT, TREATMENT, AND CARE PLAN" policy occurred on 08/27/14. The policy, dated 01/11/13, stated: "The Skin Risk Assessment with Braden Scale (Acuity) Observation is completed: a. On admission . . . b. On a weekly basis for the first three (3) weeks . . . 2. Skin is assessed by the caregiver during routine cares and during baths to identify . . . developing skin condition. . . . PURPOSE: 1. The facility strives to prevent the development of a pressure ulcer(s) in a resident who is admitted without pressure ulcer(s), unless the development is clinically unavoidable. 2. The facility provides necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. . . . Treatment: . . . Obtain and follow treatment orders. . . . Monitoring and Documentation: 1. Documentation of the wound is done weekly and PRN (as needed) when indicated by wound complications or changes in wound characteristics. Documentation includes but is not limited to the following: a. Date b. Length x (times) Width (in cm2) (sic) c. Exudate amount d. Tissue type 1. Necrotic . . . 2. Slough . . . Granulation tissue . . . [MEDICATION NAME] tissue (a stage of wound healing) . . . Closed/Resurfaced . . . Monitoring is done to determine patency of the dressing. Monitoring includes . . . pain . . . status of dressing . . . Edge of peri-ulcer area. d. Presence of possible complications i. Induration ii. Infection iii. Increasing ulceration. . . ." - Review of Resident #6's medical record occurred on all days of survey. Admission [DIAGNOSES REDACTED]. admission orders [REDACTED]. A Minimum Data Set (MDS), dated [DATE], identified one unstageable pressure ulcer on admission with dimensions of 1.6 centimeters (cm) by 2 cm by 0.2 cm (length, width, and depth). The MDS showed Resident #6 required extensive assistance with bed mobility and transfers; with a pressure reducing device for the chair and bed; a turning and repositioning program, and pressure ulcer care. A pressure ulcer Care Area Assessment (CAA), dated 08/04/14, stated: "Braden score is 18 indicating he is at risk for pressure sores and he currently has an unstageable pressure sore to his right lower extremity that was present upon admission. He is receiving treatment with a [MEDICATION NAME] border three times a week. Preventative measures are in place. . . ." Resident #6's current care plan included assist of 1 for positioning; identified the problem of "PRESSURE ULCER: Resident has unstageable pressure ulcer to right lower extremity (present on admission)." Approaches included "Assess and record the condition of the skin surrounding the pressure ulcer. Assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization as ordered by MD (Medical Doctor). . . . Keep bony prominences from direct contact with one another. Keep clean and dry as possible. . . . Observe and report signs of [MEDICAL CONDITION] . . . of osteo[DIAGNOSES REDACTED] . . . [MEDICAL CONDITION] . . . Treatment: As ordered by MD."; and identified the problem of "risk for alteration to skin integrity d/t (due to) impaired mobility . . ." with approaches including ". . . Encourage to elevate legs when in bed; Encourage to lay down twice a day . . . monitor skin and report skin breakdown. . . ." The care plan failed to include the use of a gel mattress to reduce pressure to bony prominences, included on admission orders [REDACTED] During observation on the morning of 08/27/14 a nurse (#15) provided wound cares to Resident #6's right posterior calf ulcer. The area appeared fleshy red in color. Observation showed scabbed areas: over the resident's right heel, distal to the right small toe, and distal to the right great toe. Observation identified no gel mattress in place, as ordered. During interview on the morning of 08/27/14, a nurse (#15), upon entering the electronic Medication Administration Record [REDACTED]. On the morning of 08/27/14, an administrative staff member (#1) stated a speciality clinic provider directing the care of the pressure areas completed the assessment and measurements of Resident #6's pressure ulcer and additional pressure areas/wounds. The staff member stated the speciality clinic orders the pressure ulcer treatment, and required the facility to follow its specific orders for pressure ulcer management. The medical record included provider orders of "Admission Body Observation on admission/readmission and then weekly x (times) 3." The electronic record showed the assessments identified: * July 29: A description of "any additional body marks or sores" stated "Callous with dark spot on right 5th Metatarsal. Callous next left great toe. Ulcer to posterior right leg yellow slough 1.6 x 2 x 0.2 surrounding area dark purple and soft." * August 5: The observation did not include an assessment of the unstageable pressure area to the "right lower extremity" as noted on the admission MDS and CAA. A description of "any additional body marks or sores" stated "Macules distributed throughout the body. [MEDICAL CONDITION] to ankles bilaterally. Bruises to hands bilaterally." * August 12: The observation did not include an assessment of the unstageable pressure area to the "right lower extremity" as noted on the admission MDS and CAA. A description of "any additional body marks or sores" stated "2 pea sized sores top LT (left) foot one scabbed. callous bottom Lt foot by great toe. callous top 3rd toe Rt (right) foot, et lateral side Rt foot by 5th metatarsal with black center, numerous brown marks back" * August 19: The observation did not include an assessment of the unstageable pressure area to the "right lower extremity." A description of "any additional body marks or sores" stated "Right foot 3rd toe red and swollen with a scab, Right lateral great toe has a scab. Bilateral feet swollen." Provider (physician or nurse practitioner) progress notes stated: * 08/04/14 (wound nurse): Visit included measurements of the posterior calf and stated the "Large ulcer to the posterior calf, improving. . . . follow up here at the Wound Clinic as needed. . . ." * 08/06/14: "Follow up right calf ulcer . . . [MEDICAL CONDITION] Reported by staff. Location: upper right calf . . . started 1 week(s) ago . . . [MEDICATION NAME] dressing . . . Right Posterior calf ulcer - Cleanse wound with normal saline moistened gauze, cover with [MEDICATION NAME] border and change 3 times per week . . ." The assessment lacked measurements of the ulcerated area. * 08/13/14: ". . . Skin . . . (Pressure ulcer to right posterior calf. Scabbed area to right upper buttocks.) * 08/20/14: ". . . [MEDICAL CONDITION] Reported by staff. Location: buttocks . . . Couple of days ago; Onset/Timing: abrupt; Context: moisture; Alleviating Factors: [MEDICATION NAME] dressing . . . recently seen and evaluated 8/11/14. At that time we ordered to cover upper buttocks with a [MEDICATION NAME] border and change 3 x/week . . . No further documentation re: (regarding) lesion to buttocks. Right posterior calf ulcer . . . No further nursing documentation re: ulcer to leg. . . . (Pressure ulcer to right posterior calf. Scabbed area to right upper buttocks.). . . . Right posterior calf ulcer . . . continue to have nursing staff monitor with each dressing change and as needed. . . ." Observation on all days of survey showed Resident #6 seated in a wheelchair or on the bed except during the observed dressing change. Failure to implement pressure reduction measures, including a gel mattress ordered upon admission, identify newly developed areas of eschar on Resident #6's right foot; identify the development of a coccyx pressure ulcer as noted in a provider progress note on 08/20/14, and implement preventative (verses treatment only) measures; monitor pressure areas to determine changing characteristics, including size/measurements, appearance, and drainage on a weekly basis as per facility policy; resulted in delayed healing and resulted in the development of additional pressure areas for Resident #6.

SWALLOWING 1. Based on observation, record review, review of professional literature, and staff interview, the facility failed to ensure 2 of 2 sampled residents (Resident #2 and #3) received the care and services necessary to attain the highest degree of safety possible while being fed in their rooms. Failure to ensure a resident with a known risk of aspiration was alert and positioned properly prior to administering medications and/or providing food/liquid resulted in Resident #3 aspirating. Findings include: The facility failed to provide a copy of their policy regarding assessing and/or treating residents with dysphagia when requested. Nancy B. Swigert, "The Source for Dysphagia: Third Edition", LinguiSystems, Inc, 2007, pages 15, 47, 125, 128 and the educational handouts identified, ". . . Signs of pharyngeal dysphagia are coughing or choking during a meal (Observed 08/26/14 during medication administration). . . During the oral intake of medicines, foods and/or liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in a bed or in a chair. . . . Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue (Observed August 25-26, 2014 during cares and medication administration) . . ." - Resident #3's medical record, reviewed August 25-28, 2014, identified [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), dated [DATE], identified intact cognition, and the need for a mechanically altered diet and extensive assistance of one person for eating. The current care plan identified, "Problem . . . hx (history) swallowing difficulty . . . mechanically altered diet w (with)/swallow guide . . . Approach . . . Direct supervision w/meals - follow individualized swallow guide on tray card. . . . Monitor for any increased need for assistance with . . . drinking . . . Speech therapy consult if needed." The individualized swallow guide printed on Resident #3's tray card identified, ". . . SWALLOW GUIDE: direct supervision, sit upright, alternate small sips w/small bites, do not lie down for 30 min (minutes)." The progress notes identified the following: * 08/18/14, "Resident was screened by SLP (speech language pathologist) today - diet changed to: Regular . . . mechanical soft textures w (with)/ground meats/Nectar thickened liquids." * 08/19/14, ". . . Currently on [MEDICATION NAME] and [MEDICATION NAME] for upper respiratory (infection). Lungs clear to diminished. . . ." A video fluoroscopic (modified [MEDICATION NAME]) swallowing study, dated 08/20/14, identified, "There is no evidence of laryngeal penetration or aspiration (when Resident #3 sat in an upright position (90 degree angle)). Premature spillage (premature loss of food over the back of the tongue) (was identified). . . ." The progress noted also identified the following: * 08/20/14, "Resident had video swallow completed today. Report shows no laryngeal penetration of thin liquids at this time. Speech to follow up. . . . . . ." * 08/22/14, "Resident is again okayed per SLP & (and) video study to have thin liquids." Observation showed the following: * 08/26/14 at 9:12 a.m., two certified nursing assistants (CNAs) (#17 and #26) transferred Resident #3 into bed. The CNA (#26) handed Resident #3 a glass of water as she lay in a reclined position (45 degree angle). The resident refused to take a drink and handed the glass back to the CNA (#26). The CNA failed to raise Resident #3's bed to 90 degrees prior to offering her water. * 08/26/14 at 10:00 a.m., a nurse (#28) raised the head of Resident #3's bed (40 degree angle - placing Resident #3 at an increased risk of premature loss of food/liquid over the back of her tongue) and administered her medications. Resident #3 lay on her back with a pillow placed under her shoulders and her neck extended backwards. The nurse (#28) gave Resident #3 a spoonful of medication crushed in pudding, followed by a drink of water. The resident coughed twice (an indication Resident #3 had poor vocal fold closure and secretions had entered her airway). She then gave Resident #3 a sip of liquid medication from a straw. The resident again coughed (an indication Resident #3 had poor vocal fold closure and secretions had entered her airway). The nurse failed to recognize Resident #3's obvious signs/symptoms of aspiration and failed to raise her bed to 90 degrees prior to administering her medications. Prior to leaving the room, the nurse (#28) stated, "She's on this medication, because she has aspiration pneumonia." * 08/26/14 at 4:20 p.m., a CNA (#24) transferred Resident #3 into bed. The CNA (#24) handed Resident #3 a glass of water as she again lay in a reclined position. The resident refused to take a drink and handed the glass back to the CNA (#26). The CNA failed to raise Resident #3 bed to 90 degrees prior to offering her water. During an interview on 08/26/14 at 11:20 a.m., an SLP (#29) verified residents should be able to sit in an upright position before being fed. She also added staff "should not push it" if a resident is fatigued. - Resident #2's medical record, reviewed August 25-28, 2014, identified [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified intact cognition and assistance of one person for tray set-up. The current care plan identified, ". . . Approach . . . Encourage and assist with . . . fluid intakes as needed. Monitor for any increased need for assistance with . . . drinking . . . Speech therapy consult if needed." Observations showed the following: * On 08/25/14 at 2:00 p.m., an unidentified CNA offered Resident #2 a glass of water as she lay in bed (with the head of the bed raised to an approximate 25 degree angle). Resident #2 drank from the glass. The CNA failed to raise Resident #2 bed to 90 degrees prior to offering her water. * On 08/26/14 at 8:35 a.m., two CNAs (#7 and #17) transferred Resident #2 into bed using the stand lift. After repositioning Resident #2, one CNA (#17) offered her a glass of water as the other CNA (#7) raised the head of the bed (to an approximate 75 degree angle). Resident #2 drank from the glass. The CNA failed to raise Resident #2 bed to 90 degrees prior to offering her water. During an interview the morning of 01/09/14, an administrative nurse (#4) confirmed staff are to ensure residents are alert and positioned properly (90 degrees) prior to any feeding attempts. The facility staff failed to recognize Resident #3's signs/symptoms of aspiration (coughing) and failed to position/reposition Resident #2 and #3 as close to 90 degrees as possible prior to offering liquids resulting in Resident #3's aspirating her medication and/or water. CONSTIPATION 2. Based on observation, record review, policy and procedure review, and staff interview, the facility failed to assess and implement an individualized/specific plan of care for management of constipation and lacked evidence of monitoring the effectiveness of an established plan in promoting regular bowel patterns/habits for 4 of 8 sampled residents (Resident #2, #3, #6 and #7) and one discharged resident (#14). This resulted in excessive use of laxatives with accompanying discomfort for for Resident #7. Other residents at risk included Resident #2, #3, #6, and #14, each with [DIAGNOSES REDACTED]. Findings include: Review of the "BOWEL PROGRAM" policy occurred on 08/27/14. The policy, dated 04/12/14 stated: "POLICY: 1. The licensed nurse monitor's resident bowel habits daily and directs the administration of bowel meds (medications) as necessary. PURPOSE: 1. To monitor and assist a resident in maintaining regular bowel habits. PROCEDURE: 1. The licensed nurse checks the resident BM (bowel movement) list daily to determine the need for administration of a bowel med. . . . 2. If the resident offers complaints or demonstrates signs or symptoms of constipation (evidenced by a lack of BM) a licensed nurse completes an assessment. The need for a bowel med is determined by this assessment. a. Absence of adequate BM as evidenced by 2 - 24 hour periods with a small BM or less recorded. i. Day 2 - Begin with a laxative, either in a liquid or tablet form. Utilize medications as listed in Standing Orders or as ordered specific for the resident. May increase to BID (two times a day) if necessary. ii. Day 3 - [MEDICATION NAME] 1 tablet PRN (as needed) daily. May increase to BID as necessary for constipation or [MEDICATION NAME] Suppository 1 rectally PRN daily for constipation iii. Day 4 - consider use of Tap Water or Fleets enema. Contact MD (medical doctor) for specific orders. . . . 4. Nursing . . . document medication administration via eMAR (electronic medication administration record). . . . 6. A resident consistently utilizing a bowel medication on a PRN basis from the standing orders is identified. Resident specific orders are received from the physician. a. Consistently is identified as greater than 5 PRN administration times per month. b. Resident specific bowel program supersedes the bowel meds standing orders. 7. Increased hydration is encouraged. 8. Dietary consult with the LRD (licensed registered dietician) is initiated for those resident (s) identified as consistently using a bowel med. a. Consistently is identified as greater than 5 PRN administration times per month. b. Dietary interventions are initiated to aid in the non-medication management of constipation. c. This includes an increase in fluids where possible. 9. The licensed nurse is responsible to evaluate and update individualized bowel management plans PRN as needed." Review of the facility's "Standing Orders for Medications and Treatment" occurred on 08/28/14. These orders, identified on the morning of 08/28/14 by a facility administrative staff member (#1) specific for Resident #7, stated: ". . . Constipation: a. Milk of Magnesia Regular Strength 30 ml (milliliters) PO (by mouth) Daily . . . b. [MEDICATION NAME] (sic) 10 mg (milligram) suppository 1-2 rectally per day prn c. [MEDICATION NAME] 5 mg 1-2 tablets per day prn constipation d. Senna-Gen ([MEDICATION NAME]) 1-2 tablets po daily & up to TID (three times a day) prn e. Senna-S 1-2 tablets po daily & up to TID prn f. Tap Water Enema prn daily per rectum g. Fleets Enema (Sodium [MEDICATION NAME] or Mineral Oil) per rectum prn daily During an interview on 08/28/14 at 9:30 a.m., when asked how dietary staff are informed of residents experiencing constipation, a managerial dietary staff member (#3) stated, "During an assessment, I look at their diagnoses, and I interview the resident. I review the BM (bowel movement) records, and sometimes the nurse will tell me (if they are constipated.) When asked what types of interventions dietary staff initiate if a resident is identified as experiencing constipation, the managerial dietary staff member (#3) stated, "high fiber liquid mixed with coffee or juice, high fiber powder mixed with mashed potatoes, prunes, prune juice, whole wheat bread, and supplements (Boost Breeze)." She further stated, "We encourage an increase in their fluid intake too." - Review of Resident #7's record occurred on all days of survey. [DIAGNOSES REDACTED]. Current physician orders for laxatives with start dates included: * 10/18/13: [MEDICATION NAME] husk two capfuls daily at 8:45 a.m. * 02/20/14: Initial order as a standing order, [MEDICATION NAME] 10 mg suppository 1-2 rectally per day prn * 05/13/14: [MEDICATION NAME] 17 grams (gm) daily at 8:45 a.m. * 05/23/14: Senna-S one tablet twice a day; scheduled for 8:45 a.m. and 6:30 p.m. * 05/24/14 at 2:50 p.m.: Initial order as a standing order, TWE (tap water enema) prn daily per rectum Physician orders for laxatives following 05/24/14 included: * 06/02/14: Senna S one two times a day; discontinued on 08/08/14 * 06/03/14: [MEDICATION NAME] 5 mg 1-2 tablets per day prn constipation * 08/08/14: Senna S one every evening; and 2 tablets scheduled every day in the morning Resident #7's care plan identified the use of anti-depressant medications (scheduled dose of [MEDICATION NAME] since 10/18/13, [MEDICATION NAME] since 01/15/14 and [MEDICATION NAME] XL since 04/23/14); and use of an antipyschotic medication (scheduled [MEDICATION NAME], since 04/24/14). Additional medications within Resident #7's medication regimen that can cause constipation included three medications for hypertension, two daily doses of a diuretic, and a calcium supplement. Two "Incontinence History and Assessment Form(s)," one un-dated, and one dated, 07/31/14, identified Resident #7 as occasionally incontinent of bladder and continent of bowel. The forms provided no assessment of bowel patterns. During interview on the afternoon of 08/27/14, a staff nurse (#10) stated an assessment of bowel history/patterns is not completed but rather nurses run a report every day to determine who has not had a BM. The nurse did not identify how nursing staff determined resident's bowel patterns from this information. Progress notes included the following: * 05/24/14: "Resident's abd (abdomen) in the LLQ (left lower quadrant) distended and painful to palpation only. Bowel sounds are hypoactive. Resident is on day 5 for BM's. Dulc ([MEDICATION NAME]) tabs (tablets) were given this AM (morning) with no effect. Suppository given just now. Will wait for results, or give enema in 30 minutes. . . ." The eMAR showed on 05/23/14 at 10:27 p.m. nursing staff administered Resident #7 two [MEDICATION NAME] tablets. On 05/24/14 nursing staff administered the three scheduled laxatives and two tablets of [MEDICATION NAME] tablets at 9:27 a.m.; a [MEDICATION NAME] suppository at 1:45 p.m. and a TWE at 3:26 p.m. The record identified Resident #7 then expelled four large and one medium BM between 4:25 p.m. on 05/24/14 and 4:50 a.m. on 05/25/14, over a 12 hour period. * 05/25/14 (Sunday): Nursing progress notes at 12:35 p.m. stated, "Resident's LLQ remains distended today and is slightly more firm than yesterday despite enema and large results of BM x 4 (four times). Dr. (name) was called to make a physician aware of this. Dr. (name) feels that upon description it sounds like a hernia and we are to monitor it and have Dr. (different doctor) assess on Tuesday." * 05/28/14: "VSN (undefined) abdomen ordered by Dr. (name)." * 06/02/14: Resident #7's family refused the request for an abdominal ultrasound. * 06/04/14: "Discussed code status change . . . due to recent refusal of ultrasound for hernia. Family stated that resident has had that hernia for years and Dr. (name) stated that it would be more dangerous to operate on then to keep it as it is. Family decided not to change code status at this time and prefers to wait and re-evaluate when resident starts to decline." Review of physician progress notes [REDACTED]. * 05/23/14: " . . . The patient was seen today and she has been stable. . . . no problem with . . . change in bowel habits . . . reported constipation for which I did start her on [MEDICATION NAME] 17 grams p.o. daily and Senna-S 1 tab p.o. b.i.d." * 05/28/14 (four days after the prn laxative usage): ". . . I was notified by the nursing staff that she has some pain in her left lower quadrant. She does have a history of a ventral hernia. I went in to see the patient. She has no pain now and there was no tenderness as well. Her mass seems to have increased . . . No change in bowel habits. . . . It is not incarcerated. . . ." The note lacked evidence the nursing staff informed the physician regarding the use of multiple laxatives on 05/24/14. Resident #7's eMARs identified in the month of July, nursing staff administered [MEDICATION NAME] tablets for constipation on five occasions, and from August through August 25, 2014 on four occasions. The records identified inconsistencies with when nursing staff administered [MEDICATION NAME] tablets based on the number of days since the last BM (varied between one and four days following a BM). Review of "Nutritional Assessment(s)," dated 10/24/13, 01/17/14, and 04/18/14 failed to address Resident #7's bowel problems including medication management for constipation, and each included an entry to "Continue Current Plan of Care." The 01/17/14 assessment identified medications included "laxatives," the 04/18/14 assessment identified the use of "laxatives - PRN;" and a "Nutritional Assessment," dated 07/18/14 identified the implementation of "Hyfiber" (a liquid fiber substitute) at breakfast. Review of Resident #7's diet/menu card showed the dietary department provided a cardiac diet without any supplements including Hyfiber at breakfast. The menu selection, specific for Resident #7, did not include the option of the Hyfiber for the breakfast meal. The medical record lacked evidence Resident #7 refused the Hyfiber. During observation of meal service on the morning of 08/26/14, Resident #7 received a bowl of bran flakes and ate a few bites. Observation showed no prompting/encouragement by staff to consume the cereal. The presence or lack of Hyfiber could not be determined. During observation on the afternoon of 08/25/14, a certified nursing assistant (CNA) (#11) assisted Resident #7 to the bathroom. When the CNA removed the resident's garment and incontinence product, the product contained light reddish bloody drainage. The CNA stated she had been told earlier about the bleeding, and would tell the nurse also. The record lacked evidence this occurred. During observation of toileting cares at 9:55 a.m. on 08/26/14, Resident #7 expelled a small BM on the toilet. A CNA (#12) stated the rectal area felt like the resident was "impacted" and then stated "constipated." The CNA stated she would let the nurse know. The bowel movement vitals report for 08/26/14 included the documentation of the small BM and one hour later, by a different staff member, a large "Dry/Hard" BM expelled. The facility failed to: * Assess Resident #7's bowel habits and implement a consistent bowel program, and evaluate the effectiveness of the bowel program, in an attempt to lessen the use of scheduled and prn laxatives. * Ensure physician's orders included specific and individualized orders for the use of prn standing orders to avoid inconsistencies in laxative usage by nursing staff. * Implement non-pharmacological measures in an attempt to address Resident #7's history of constipation and excessive use of laxatives. This failure resulted in Resident #7 experiencing distress by frequent elimination episodes following the use of several laxatives on 05/24/14. - Review of Resident #6's record occurred on all days of survey. Resident #6's admission occurred in July 2014. Admission [DIAGNOSES REDACTED]. A "Nutritional Status" Care Area Assessment, completed on 08/04/14, failed to address Resident #6's history/[DIAGNOSES REDACTED]. Review of Resident #6's diet/menu card showed the dietary department provided a "Renal Considerations" diet. Review of the upcoming menu choices for 08/29/14 included no offerings of high fiber foods including whole grains, minimal high fiber vegetables (including cooked), and fresh fruit choices. - Resident #2's medical record, reviewed August 25-28, 2014, identified [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified intact cognition and extensive assistance of one person for toileting. The record lacked evidence the facility completed a bowel assessment for Resident #2. The documentation of Resident #2's BMs from July 8-August 26, 2014 identified the resident failed to have a bowel movement for three days on one occasion, four days on three occasions, and five days on one occasion. The physician's orders identified the following: * 07/18/14 and discontinued 07/28/14, Senna-S 8.6-50 mg three times a day as needed for constipation * 07/31/14, [MEDICATION NAME] Sodium 100 mg twice a day for constipation * 08/04/14, [MEDICATION NAME] 5 mg daily as needed for constipation * 08/10/14, Milk of Magnesia 10 milliliters (ml) as needed for constipation The MAR indicated [REDACTED]. The current care plan failed to address Resident #2's episodes of constipation. The facility failed to assess and implement an individualized/specific plan of care for management of Resident #2's episodes of constipation and lacked evidence of monitoring the effectiveness of an established plan in promoting normal bowel patterns/habits for Resident #2. - Resident #3's medical record, reviewed August 25-28, 2014, identified [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified intact cognition and extensive assistance of two or more persons for toileting. The record lacked evidence the facility completed a bowel assessment for Resident #3. The documentation of Resident #3's BMs from June 28-August 27, 2014 identified the resident failed to have a bowel movement for three days on one occasion, four days on two occasions, five days on one occasion, and eight days on one occasion. The physician's orders identified the following: * 06/24/14 and discontinued 07/08/14, Senna 8.6 mg at bedtime * 07/08/14, [MEDICATION NAME] Suppository 10 mg once a day as needed for constipation * 07/08/14, [MEDICATION NAME] Sodium 100 mg twice a day as needed for constipation * 07/08/14, [MEDICATION NAME] 17 grams once a day as needed for constipation * 08/08/14, Senna with [MEDICATION NAME] Sodium 8.6-50 mg once a day for constipation * 08/10/14, Milk of Magnesia Concentrated 10 ml daily as needed for constipation The MAR indicated [REDACTED]. The current care plan failed to address Resident #3's episodes of constipation. The facility failed to assess and implement an individualized/specific plan of care for management of Resident #3's episodes of constipation and lacked evidence of monitoring the effectiveness of an established plan in promoting normal bowel patterns/habits for Resident #3. - Resident #14's closed medical record, reviewed August 27-28, 2014, identified [DIAGNOSES REDACTED]. The resident's admission MDS, dated [DATE], identified moderately impaired cognition and extensive assistance of two or more persons for toileting. The record lacked evidence the facility completed a bowel assessment for Resident #14. The documentation of Resident #14's eliminations (BM Report) between 03/17/14-05/08/14 identified the resident failed to have a bowel movement for three days on one occasion and four days on another occasion. The physician's orders identified the following: * 03/20/14, [MEDICATION NAME] 5 milligrams (mg) daily as needed for constipation * 03/20/14, Senna-S8.6-50 mg twice a day for constipation The Medication Administration Record [REDACTED]. The current care plan failed to address Resident #14's episodes of constipation. The facility failed to assess and implement an individualized/specific plan of care for management of Resident #14's episodes of constipation and lacked evidence of monitoring the effectiveness of an established plan in promoting normal bowel patterns/habits for Resident #14. ANTI-ANXIETY MEDICATIONS 3. Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to manage behavioral symptoms for 1 of 1 sampled resident (Resident #3) who received as needed (prn) anti-anxiety medication for behaviors prior to attempting non-pharmacological interventions. Failure to attempt non-pharmacological interventions and monitor the effectiveness of those interventions prior to administering an anti-anxiety medication did not allow staff to evaluate what interventions were most effective to manage Resident #3's behavior. Findings include: Review of the facility policy "Behavior Management Program" occurred on 08/28/14. The policy, dated 10/09/13, stated, ". . . The interdisciplinary team . . . determine(s) interventions to be tried resulting in a behavior care plan. . . . The resident specific care plan includes specific interventions to protect staff, resident, and other residents from threatening behaviors as they occur. . . . Staff uses the approaches care planned and documents the resident's response and/or outcome. . . . CNA (certified nursing assistant) staff convey the resident response to interventions to the nurse in charge . . ." Review of the facility policy "Principles of Medication Administration - LTC (long term care)" occurred on 08/28/14. The policy, dated 10/04/12, stated, ". . . When a PRN medication is administered the following documentation is provided . . . symptoms for which the medication was given. . . ." - Resident #3's medical record, reviewed August 25-28, 2014, identified [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), dated [DATE], identified intact cognition and need for antipsychotic and antianxiety medications. The current care plan identified, ". . . Approach . . . Assess if the resident's behavioral/mood symptoms present a danger to the resident and/or others. Intervene as needed. . . . Administer meds (medications) as ordered by MD (medical doctor). Monitor side effects/effectiveness of meds. . . . Attempt non-pharmacological interventions. . . ." The current physician's orders identified the following: * 07/08/14: [MEDICATION NAME] (an hypnotic) 1 milligram (mg) at bedtime as needed * 07/10/14: [MEDICATION NAME] (an anti-anxiety) 0.5 mg every 8 hours as needed * 06/14/14: [MEDICATION NAME] (an anti-psychotic) 12.5 mg at bedtime; monitor behaviors will discontinue if remains stable * 08/23/14: and discontinued 08/23/14, [MEDICATION NAME] (an anti-anxiety) 1 mg one time dose The Medication Administration Record [REDACTED] * 08/04/14, 08/08/14, 08/14/14, 08/17/14, 08/19/14, and 08/22/14, "anxiety" * 08/07/14, "anxious" * 08/15/14, "restless" * 08/18/14, "Anxiety per resident request" * 08/19/14 and 08/20/14, "anxiety, restless" * 08/21/14, "anxiety and restlessness" and "crawling out of bed, looking for other peoplke (sic)" * 08/22/14, "crawling out of bed, restless" * 08/24/14, "anxiety, crawling out of bed" * 08/25/14, "aggitated" The progress notes, dated August 1-25, 2014, also identified: * 08/15/14, ". . . She has been medicated for sleep and also for anxiety which has been effective." * 08/17/14, ". . . Res (resident) requested and received PRN for anxiety . . ." * 08/20/14, ". . . She recieved (sic) medication for anxiety which was effective. . . ." During an interview the afternoon of 08/28/14, an administrative nurse (#1) confirmed she could not locate documentation showing the non-pharmacological interventions staff attempted prior to administering the [MEDICATION NAME]. DIABETES 4. Based on information received from the complainant, record review, policy and procedure review, review of a professional reference, and staff interview, the facility failed to ensure adequate monitoring of blood glucose readings for 1 of 8 sampled insulin dependent diabetic residents (Resident #9), and one discharged resident (Resident #14). Failure to monitor and provide necessary interventions for low and elevated blood glucose levels has the potential to impair function, contributing to accidents, injuries, [MEDICAL CONDITION] and coma. Findings include: Review of the facility policy, "[DIAGNOSES REDACTED], treatment of [REDACTED]. The policy, dated 11/13, stated, ". . . PURPOSE: 1. To provide a consistent treatment procedure for treating [DIAGNOSES REDACTED] . . . POLICY: 1. A licensed nurse who identifies symptoms of [DIAGNOSES REDACTED], follows the procedure for treatment of [REDACTED]. Low blood sugar - any level (less than) 70 mg/dl . . . [DIAGNOSES REDACTED] . . . Insulin reactions can occur at any time and come on quickly. They are most apt to occur: Before meals or if meals/snacks are skipped or delayed. . . . Treatment . . . Give 15 gms (grams) of carbohydrate orally. . . . Recheck blood sugar within 10-15 minutes . . ." The American Diabetes Association (2014 guidelines) defined [DIAGNOSES REDACTED] as "condition characterized by abnormally low blood glucose usually less than 70 (mg/dl) . . . Severe [DIAGNOSES REDACTED] has the potential to cause accidents, injuries, coma and death . . . Treatment: Consume 15-20 grams of glucose or simple carbohydrates; Recheck your blood glucose after 15 minutes; If [DIAGNOSES REDACTED] continues, repeat. Once blood glucose returns to normal, eat a small snack if your next planned meal or snack is more than an hour or two away. . . ." - Review of Resident #9's record occurred on August 27-28, 2014. [DIAGNOSES REDACTED]. Current insulin orders included Humalog insulin 6 units once a day at breakfast time, scheduled for 7:00 a.m.; Humalog 4 units twice a day, scheduled for 11:30 a.m. and 5:30 p.m.; [MEDICATION NAME] 15 units once in the morning, scheduled for 7:00 a.m.; and Humalog insulin according to sliding scale before meals and at bedtime, scheduled for 7:00 a.m., 11:30 a.m., 5:30 p.m., and 8:45 p.m. Current physician's orders included accuchecks/blood glucose monitoring four times a day scheduled for 6 a.m., 11:30 a.m., 5:30 p.m., and 8:45 p.m. The specific orders also stated: "Call primary provider if blood sugar is greater than 400 (mg/dl). If blood sugar is (less than) 80 (mg/dl), treat with 15 gm (grams) carbs (carbohydrates) and recheck in 15 minutes. Repeat until (greater than) 80. Once blood sugar is (greater than) 80, ok to give scheduled humalog. Please chart rechecks in PRN (as necessary)." The orders stated to perform accuchecks PRN as well. The facility's scheduled meal times were: breakfast at 7:45 a.m., lunch at 11:30 a.m., and supper at 5:45 p.m. Review of Resident #9's accucheck results from 08/01/14 through 08/24/14 identified 17 occurrences where nursing staff identified accucheck readings less than 80 mg/dl at the scheduled accucheck times. The electronic Medication Administration Record [REDACTED]. Those 12 readings ranged from 51 to 79 mg/dl. During interview on the afternoon of 08/26/14, an administrative staff member (#1) confirmed Resident #9's medical record lacked interventions implemented by nursing for the hypoglycemic/lower than normal blood glucose readings. During this interview two administrative staff members (#1 and #25) stated nursing staff may not provide the snack for a resident if it occurs prior to the serving of a meal. Information provided by the complainant indicated staff failed to monitor Resident #14's blood sugars. The complainant stated, "Blood sugars way out of control. . . . When high, they would add additional insulin and she would plummet to 40-60's. When we stressed our concerns staff again advised that's how they handle hypo and hyper glycemic issues." - Resident #14's medical record, reviewed August 27-28, 2014, identified [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition and extensive assistance for all activities of daily living (ADLs). The current care plan failed to address Resident #14's episodes of low and/or high blood sugars. The physician's orders identified the following: * 03/17/14, Humalog Insulin 18 units three times a day before meals; 7:30 a.m., 12:00 p.m., 6:00 p.m. * 03/17/14, Humalog Insulin sliding scale: blood suga

Based on record review, review of facility policy, review of the facility's abuse/neglect investigation, and staff interview, the facility failed to provide assistive devices and supervision necessary to prevent accidents for 1 of 1 sampled resident (Resident #1) who received an injury during a Hoyer (a full body mechanical lift) transfer. Failure to follow Resident #1's care plan and ensure adequate assistance and supervision during the transfer resulted in a laceration to Resident #1's lower leg which required emergency medical intervention. Findings include: Review of the facility policy titled "Use of Standing and Total Lifts - General Guidelines" occurred on 04/08/14. This policy, dated, 06/19/09, stated, ". . . Nursing associates identify the need for use of a standing lift or a total lift device. This is specified on the resident's individualized care plan and conveyed to the staff caring for the resident. 2. Physical or Occupational therapists are consulted as necessary to determine the proper lift necessary for use with a resident. . . . Assistance necessary to accomplish a safe transfer is identified on admit, with each MDS (Minimum Data Set), and PRN (as needed) when there is a change in condition. . . ." Review of Resident #1's medical record occurred on 04/08/14. [DIAGNOSES REDACTED]. A Physical Therapy (PT) evaluation, dated 04/03/14, stated, ". . . Transfers . . . (Hoyer in out of bed and EZ stand (a mechanical sit to stand lift) from wheelchair to/from commode.) . . . Clinical impressions: Resident is very weak and has not been up on her feet in about 2 weeks without the use of a standing lift. She wants to be moving and able to use the bathroom again and do some limited walking and get in and out of the wheelchair. These are realistic and atainable (sic) goals that we can work toward even within the limits of her medical diagnosis. . . ." Resident #1's current/initial care plan, dated 04/03/14, stated, ". . . EZ Stand (with) 2 to shower chair from wheelchair. . . . Hoyer in/out of bed to/from w/c . . ." Nurses' notes stated the following: *04/03/14 at 4:20 p.m.: ". . . At this time will be hoyer in/out of bed to/from w/c (wheelchair). EZ stand with 2 assist to commode and shower chair. Place a pillow between knees and lift pad make sure to use leg strap. . . ." *04/05/14 at 5:39 p.m.: ". . . Resident received laceration to left lower leg during transfer . . . received order to send to ER (emergency room ) for evaluation. . . ." *04/05/14 at 11:44 p.m.: ". . . ER staff called for progress of resident and they reported at 2230 (10:30 p.m.) that resident will be admitted to (facility name) hospital. . . ." The Emergency Department (ED) Provider Notes, dated 04/06/14, stated, ". . . Patient is at the Care Center and was being assisted with Hoyer lift out of the bath tub. Somehow her LLE (left lower extremity) got 'caught' in the lift and she sustained a large, gaping laceration of the medial (middle) left calf. This happened just prior to transport here by ambulance. . . . The left lower extremity has a curvilinear (a curved line) laceration measuring maybe 12 inches in length . . . The wound was found to extend into the extensive subcutaneous fat but not to the muscle or fascia. . . . After about 20 minutes of attempting to pull the wound edge together with subcutaneous sutures, I aborted the procedure and decided it might be best to have (plastic surgeon) come in and close this wound. . . . Diagnosis: [REDACTED]. . . Plan: Plastics closure and admission. . . ." The facility's investigation regarding Resident #1's skin tear occurring on 04/05/14 identified the following: *Statement from witness (CNA #2): ". . . (CNA #3) (and) I felt that she was too tired after her shower (and) we felt that she wouldn't be able to tolerate the EZ stand so we used the hoyer instead. There is a lip or shelf getting in or out of the shower (and) we had to use some muscle to get her over the lip of the shower. Her leg split wide open without even hitting a sharp edge on the lift. It was a rounded edge on the hoyer. . . ." *Statement from witness (CNA #3): ". . . After conversing with (CNA #2), it was mutually determined that a hot, steamy, relaxing shower combined with a full day of getting in and out of bed, and visiting with kids and grandkids, had exacerbated an already sick and weakened woman. It was therefore determined that it would be prudent to forgo the EZ Stand in favor of the hoyer lift. Upon lifting (Resident #1) out of the shower chair we had to pull the machine up over the shower threshold. At this point (Resident #1) swung forward just a few inches and her left calf struck the motor casing of the hoyer. . . ." During an interview on 04/08/14 at 12:40 p.m., the CNA (#3) stated Resident #1 used a Hoyer lift to transfer in and out of bed, and an EZ Stand for other transfers. The CNA stated he and the other CNA (#2) decided Resident #1 seemed "weak," and it would be better to use the Hoyer lift to transfer her from the shower chair. The CNA stated Resident #1 "was just too much for the lady who was helping me (CNA #2) to handle, her legs were swaying and hit the left side of the lift." The CNA (#3) further stated they really had to "yank" the lift due to Resident #1's size and the "lip" on the edge of the shower. During an interview on the morning of 04/08/14, a supervisory nurse (#1) stated Resident #1 used a Hoyer lift to get in and out of bed, and a stand lift the rest of the time. During an interview on 04/08/14 at 3:20 p.m., a supervisory nurse (#1) stated PT assesses residents to determine the appropriate transfer method, but nurses can also assess residents if the therapists are not available. The nurse also stated CNAs are taught to communicate with nurses or therapy if they notice a change in the resident's condition. Failure to transfer Resident #1 according to her care plan, failure to inform the nurse of the resident's condition so the nurse could properly assess Resident #1 to determine the appropriate transfer method, and failure to provide for safety and adequate assistance during the Hoyer lift transfer resulted in Resident #1 sustaining an avoidable laceration which required an admission to the ER, and a plastic surgeon to suture the wound.

Based on observation, record review, review of manufacturers recommendations, review of facility job descriptions, and staff interview, the facility failed to provide the necessary assistance to prevent a fall with injury for 1 of 1 closed record (Resident #15) who experienced a fall in the facility van. Failure of the facility to ensure staff transporting Resident #15 had the necessary training resulted in Resident #15 experiencing an unwitnessed fall resulting in a C6-C7 (neck) fracture. In addition the facility failed to ensure a medical assessment was completed by a qualified staff member prior to Resident #15 being moved/transferred to a stationary seat in the van resulting in possible further injury to Resident #15. Findings include: Review of the manufacturers recommendations titled "SURE-LOK Safe and Secure . . . Operation of Lap Belts" occurred on 10/24/12. These recommendations, dated 2005, stated, ". . . Sure-Lok Occupant Restraint Lap Belts are designed to bear upon the bony structure of the body and shall be worn low and snug across the front of the pelvis . . . The shoulder belt shall be properly extended over the shoulder and across the upper chest . . . when connecting it to the lap belt . . . Adjust occupant restraints as firmly as possible . . ." Review of the facility job description titled "Certified Nurse Aide" occurred on 10/24/12. This job description, updated by the facility on 08/19/10, stated, "Supervisor: Assistant Director of Nursing (ADON) . . . Essential Functions: . . . 2. Have knowledge, understanding, and use good judgement in the care and use of equipment . . . 6. Detect and correct situations that have a high probability of causing accidents or injuries to residents . . . 28. Assist with other related duties as requested by the . . . ADON . . ." Review of the facility job description titled "Assistant Director of Nursing" occurred on 10/24/12. This job description, updated by the facility on 08/17/09, stated, "Essential Functions: . . . 10. Supervise, train . . . CNAs . . . 15. Investigates accidents/incidents involving residents and provides immediate interventions . . ." Resident #15's medical record, reviewed October 23-24, 2012, identified [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], idenfied moderate cognitive impairment and extensive assist of one for transfers and locomotion on/off the unit. Resident #15's care plan, dated 06/26/12, stated, "Problem: ADL's: Resident unable to complete own cares due to altered mobility and unsteady gait related to left leg amputation . . . Approach: . . . Locomotion: Wheelchair used for locomotion . . . Assist of 1 to propel longer distances. . . ." The progress note, dated 07/24/12, stated, "Resident had fall in facility van during transfer from appointment to facility. Resident hit head on floor of facility van. Laceration and hematoma noted to back of head with bloody drainage present. Resident pale and unable to answer questions appropriately. (Physician) notified . . . Order received to transfer resident to ER (emergency room ) via ambulance. Resident left via ambulance at 1650. . . ." The "Safety Events - Fall" report, dated 07/24/12, stated, ". . . Location of Fall Other - Facility Van . . . What was resident doing just prior to fall? sitting in facility van chair . . . Does resident . . . complain of pain related to the fall? Yes - head . . . On a scale of 0-10, how does the resident rate intensity of pain . . . 10 Excruciating Pain - Worst Possible . . . Location of Injury back of head Note any injury to the head . . . Bump, Laceration . . . Swelling . . . Level of Consciousness Lethargic/Drowsy - Does not perceive the environment fully; Responds to stimuli appropriately but slowly and with delay . . . Facial Muscle Movement . . . Upper Left Extremity Movement . . . Upper Right Extremity Movement . . . Lower Left Extremity Movement . . . Lower Right Extremity Movement Weak . . . Speech Unclear - Slurred, mumbled words . . . Does the resident exhibit or complain of any the following since the fall? Dizziness/Lightheadedness . . . Does the resident exhibit any of the following as a change in mental status of new onset? Confusion, Slurred Speech . . . Were restraints/adaptive equipment in use at the time of the fall? Yes, seat belt . . ." The "(Hospital) Clinical History and Physical" report, dated 07/24/12, stated, "HISTORY OF PRESENT ILLNESS: The patient is a [AGE] year-old male who presents after had a fall in a wheelchair van. Apparenly he was on his way from (Radiology at hospital campus) where he was at an appointment. He was improperly loaded, therefore his wheelchair tipped over backwards and he struck his head. He is believed not to have any loss of consciousness. He complains of pain throughout his head, neck, back and shoulders . . . There was no true accident; his wheelchair was simply not appropriately secured and therefore tipped over backwards . . . HEENT: . . . He has several abrasions on his posterior occipital area . . . NECK: Supple, but diffusely tender going down throughout the cervical spine and into the shoulders . . . emergency room (ER) COURSE: . . . He was tender in the cervical spine . . . A small subdural along the falx (a fold between the cerebral hemispheres) was noted, in addition there was a small amount of parenchymal blood in the right parietal region. CT (computed tomography) of the C-spine (cervical spine) showed a perched facet (a rounded smooth surface on a bone) at C6-C7 and a facet fracture on the right side of C6 . . . His pain was well controlled on fentanyl and Dilaudid (durogesic or pain medications). An Aspen collar (a device used to restrict motion) was placed . . . ASSESSMENT: Fall from a wheelchair with small subdural hemorrhage and perched C6 facet and C7 facet fracture. . . ." The "Discharge Summary," dated 08/24/12, stated, "discharged to: Hospital . . . Cause of Death or Final Diagnosis: [REDACTED]. . ." During an interview on 10/23/12 at 12:15 p.m., the certified nurse assistant (CNA)/Van Driver (#4) indicated he has transported residents in the facility van for approximately two years. He stated, "Residents should be secured in the van. There is a manual in the van showing how to strap people in. It's been there as long as I've been driving the van." Observation on 10/23/12 at 12:15 p.m. showed a bench placed in the raised position on the left side and near the back of the facility van. A copy of the "Sure Lok" instruction manual hung from the bench. Observation further showed two stationary chairs to the right of the bench. During two interviews on 10/24/12 at 10:15 a.m and 12:15 p.m., the administrative nursing staff member (#1) confirmed the certified nurse assistant failed to properly secure Resident #15 in the facility van prior to transport the morning of 07/24/12. She stated, "He (the CNA) tried to strap him (Resident #15) in, but couldn't get it (the strap) to stay. He propped him by the bench, secured him as best as possible. He put him by the side (of the van) and locked his (wheelchair) breaks. He (the CNA) was worried about side-to-side, not front-to-back (motion). When he (the CNA) accelerated at the stop light, (Resident #15's) chair fell backwards." When asked if/how the driver returned the resident to the facility following the fall, she stated, "He had checked the resident and he seemed fine. He lifted the wheelchair and then pivoted him into a stationary chair. He did call the facility. They told him to bring him back (approximately 14 blocks to the facility)." She further stated upon returning to the facility, the ADON assessed the resident and felt he should be transported to the emergency room . Also during the two interviews on 10/24/12 at 10:15 a.m and 12:15 p.m., when asked whose responsibility it was to assign staff to drive the facility van, the administrative nursing staff member (#1) explained the ADON "asked for volunteers" and then assigned the CNA to transport Resident #15 to his clinic appointment. She confirmed, "He (the CNA #5) had experience driving a van, but not necessarily this one (facility van)." The facility failed to locate documentation indicating the CNA had received training on the proper use of the van equipment prior to transporting Resident #15 to his appointment. The administrative nursing staff member (#1) confirmed the facility's expectation is that staff receive training on the use of the van equipment and that all residents be properly secured in the van prior to transport. The facility failed to ensure Resident #15 received the care and services necessary to attain the highest degree of safety possible while being transported via the facility van. They failed to ensure the CNA had been trained on the proper use of the lap/shoulder belts and was competent to drive the van prior to being assigned to transport residents. They also failed to properly secure the resident in the van prior to transport, and failed to ensure qualified staff assessed the resident prior to moving/repositioning him immediately after his unwitnessed fall.