Every finding on record at Good Samaritan Society - Oakes

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 2 sampled residents (Resident #2 and #4) observed during cares and transfers. Failure to practice infection control standards related to enhanced barrier precautions (EBP), glove use, cleaning/sanitizing surfaces, and catheter and perineal cares has the potential to spread infection throughout the facility. Findings include: Review of the following facility policies occurred on 06/18/26: * Standard, Enhanced Barrier and Transmission-Based Precautions, dated 04/30/26, stated, . Enhanced Barrier Precautions . refer to the use of gown and gloves during high-contact resident care activities . Enhanced barrier precautions are used for residents with . indwelling urinary catheters . High contact resident care activities include transfers . * Bathing, dated 12/22/25, stated, . Bed Bath . Bath and dry resident . in the following manner . wash, rinse and dry face, neck and ears. shoulders, arms, hands, and axillae . chest. abdomen . wash, rinse and dry legs and feet. Refill basin with clean warm water and turn resident on side - wash, rinse, and dry back . Wash genital area last . * Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, Specimen, dated 03/02/26, stated, . Catheter Care- Indwelling . Expose the urethral meatus . Provide perineal care with soap and water . Use a clean washcloth . to clean the perineal area and the portion of the catheter in contact with the . meatus. Use a clean section of the washcloth . for each stroke. Cleanse away from the meatus to remove secretions or encrustation to avoid contaminating the urinary tract. * Hand Hygiene, dated 06/08/26, stated, . When to change gloves and perform hand hygiene . If gloves become soiled with blood or body fluids after a task . * Cleaning of Common Areas, dated 04/02/25, stated, . to maintain a clean, attractive and sanitary building . clean countertops . - Review of Resident #2's medical record occurred on 06/18/26 and identified EBP related to an indwelling catheter. Observation on 06/18/26 at 9:45 a.m. showed two certified nurse aides (CNAs) (#4 and #5) performed hand hygiene, applied appropriate personal protective equipment (PPE) and entered Resident #2's room to provide a bed bath. The CNA (#4) filled a basin with soap and water and placed it on the overbed table. While cleansing the peri area and catheter tubing, the CNA (#4) used the same washcloth and then proceeded to wash the resident's legs with the same washcloth. The CNA (#4) obtained a fresh basin of soap and water, and both CNAs positioned Resident #2 on his side. The CNA (#4) washed the resident's buttocks and, with the same washcloth, washed the resident's back. The CNAs (#4 and #5) removed their PPE, performed hand hygiene, and exited the room. The CNA (#4) failed to cleanse the Resident #2's genital area last, failed to provide catheter cares according to facility policy/procedures, and failed to sanitize the bedside table after removing the basin. These failures may result in cross contamination. - Review of Resident #4's medical record occurred on 06/18/26 and identified EBP related to an indwelling catheter. Observation on 06/18/26 showed a CNA (#3) and a nurse (#7) performed hand hygiene and entered Resident #4's room. The CNA applied gloves, and both the CNA and the nurse utilized a sit-to-stand mechanical lift to transfer the resident from the bed to the wheelchair. The CNA (#3) failed to apply a gown and the nurse (#7) failed to apply gloves and a gown prior to completing the transfer. During an interview on 06/18/26 at 3:48 p.m., an administrative staff member (#1) stated she expected staff to wear a gown and gloves when transferring residents on EBP and confirmed staff failed to use appropriate infection control practices while performing Resident #2's morning and catheter cares. The facility failed to ensure staff followed established infection control practices during personal care.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 14 sampled residents (Resident #4, #6, and #7) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), donning/doffing of personal protective equipment (PPE), and hand hygiene has the potential to spread infection throughout the facility.Findings include: Review of the facility policy titled Standard, Enhanced Barrier, and Transmission-Based Precautions occurred on 01/07/26. This policy, revised 07/07/25, stated, . Enhanced barrier precautions expand the use of personal protective equipment beyond situations . refer to the use of gowns and gloves during high-contact resident care activities . Enhanced barrier precautions are also used for residents with chronic wounds . even if the resident is not known to be infected with or colonized with an MDRO [Multidrug-Resistant Organism] . high-contact resident care activities include . changing briefs or assisting with toileting . and wound care . Review of the facility policy titled Hand Hygiene occurred on 01/07/26. This policy, revised 11/13/25, stated, . All employees in patient care areas . will adhere to the 4 moments of Hand Hygiene . 1. Entering room [ROOM NUMBER]. Before Clean Task 3. After Bodily Fluid/Glove Removal 4. Exiting Room . Gloves are a protective barrier . 2. Hand hygiene should be performed after glove removal. After removing gloves regardless of task completed . After contact with a patient's non-intact skin, wound dressings . when moving from contaminated body site to a clean body site during patient care . - Review of Resident #4's medical record occurred on all days of survey. The current care plan stated, . The resident requires Enhanced Barrier Precautions [EBP] chronic wound E/B [evidenced by] stage 2 pressure ulcer on coccyx . Observation on 01/06/26 at 9:34 a.m. showed an EBP sign on Resident #4's door frame. A certified nurse aide (CNA) (#7) performed a brief change wearing gloves but failed to wear a gown. - Observation on 01/06/26 at 3:03 p.m., showed an enhanced barrier precaution sign and PPE container on Resident #6's door. Outside of the resident's room, a nurse (#2) and a CNA (#1) applied gowns and gloves. The staff members failed to perform hand hygiene prior to applying gowns and gloves and entering Resident #6's room. - Review of Resident #7's medical record occurred on all days of survey. The current care plan stated, . The resident requires Enhanced Barrier Precautions [EBP] E/B indwelling catheter . Observation on 01/07/26 at 8:45 a.m. showed an EBP sign on Resident #7's door frame. A staff nurse (#5) and CNA (#6) performed hand hygiene, donned PPE, and entered Resident #7's room. The nurse (#5) removed the soiled dressings from the buttock's wounds, removed the soiled gloves, and without performing hand hygiene, applied clean gloves to complete the dressing change. During an interview on the afternoon of 01/07/26, an administrative nurse (#3) confirmed she expected staff to wear personal protective equipment (PPE) while performing brief changes while on EBP precaution and to perform hand hygiene before applying gloves and after removing gloves.

Based on record review, review of the hospice agreement, and staff interview, the facility failed to ensure resident records contained the hospice election form for 1 of 2 sampled residents (Resident #6) receiving hospice services. Failure to obtain the hospice election form limits staff's ability to ensure coordination of care between the facility and the hospice agency. Findings include:Review of the facilities Hospice and Nursing Facility Services Agreement, dated 04/17/20, stated, . 3.1.16 Coordination of Services. Hospice shall: . (c) Provide Facility with the following information specific to each Hospice Patient residing at Facility . the hospice election form . Review of Resident #6's medical record occurred on all days of survey and identified election of hospice services on 12/31/25.The medical record lacked the hospice election form.During an interview on 01/07/26 at 2:00 p.m., an administrative staff member (#3) confirmed Resident #6's medical record failed to include the hospice election form.

Based on observation, record review, and staff interview, the facility failed to provide housekeeping services to maintain a safe, clean, comfortable and homelike environment for 1 of 3 sampled residents (Resident #4) on oxygen. Failure to clean personal fans does not provide a safe and clean environment and has the potential to place the residents at risk of illness.Findings include: Review of Resident #4's medical record occurred on all days of the survey. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, chronic bronchitis, emphysema, and chronic respiratory failure. Observations on 01/05/25 and 01/06/25 showed Resident #4 in bed with oxygen administered via nasal cannula and a fan blowing air directly at the resident. Observation showed the cover/grate and blades of the fan covered with dust.During an interview on 01/07/2026 at 1:00 p.m., an administrative nurse (#3) stated she expected staff to clean fans every three days.

Based on record review, review of facility policy, and staff interview, the facility failed to provide services to prevent skin breakdown and/or minimize the development of pressure ulcers for 1 of 3 sampled residents (Resident #2) with pressure ulcers. Failure to ensure the resident received treatments as ordered and reassess wounds in a timely manner may result in delayed healing of current pressure ulcers and/or the development of new pressure ulcers. Findings include: Review of the facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation Requirements occurred on 01/07/26. This policy, dated 12/08/25, stated, . If a pressure ulcer is identified, cleanse the area prior to observations being made to allow the wound bed and depth to be more accurately observed. The registered nurse [RN] should record the type of wound and the degree of tissue damage on the Wound RN Assessment . The licensed nurse records the location of the area, the measurements, and the ulcer/wound characteristics. Notify the physician . of the ulcer and resident's condition to obtain orders for a treatment. The pressure ulcer should be assessed . at least weekly and documented on the Wound RN Assessment . - Review of Resident #2's medical record occurred on all days of survey. Diagnoses included an unstageable pressure ulcer to the right buttock. A Response Request, dated 12/16/25, stated, . This is to let you know that [Resident #2] has an are [sic] located on R [right] buttock . Size: Length 4.8 cm [centimeters], Width: 3.6 cm, Depth: 0 . Wound Bed: Granulation . Drainage Amount: Minimal . Additional Information . Random spots of excoriation within dimensions listed, mild sanguinous drainage, location at R buttocks, cleansed [with] wound cleanser and Mepilex applied. Further guidance? . The physician's response, dated 12/17/25, stated, Agree with above treatment - no new orders. The current physician's orders and treatment administration record (TAR) failed to address the use of the wound cleanser and/or Mepilex dressing. The Wound Assessment reports identified the following:* 12/26/25, . right buttock pressure ulcer . open area and purple discoloration . 100% granulation . minimal drainage . denuded erythematous wound margins . no tunneling . clean with wound cleaner . apply Mepilex dressing .* 01/02/25, . right buttock excoriation . pressure ulcer . progressive healing of area . repositioning/turning . incontinence protection . friction/shear management . wound treatment . continue with current plan of treatment .* 01/03/25, . right buttock excoriation . no drainage . intact pink wound margins . no tunneling . Mepilex changed every 3 days . During an interview on 01/06/26 at 9:40 a.m., when asked where staff document wound measurements, a nurse (#5) stated, on the wound assessment reports. The nurse confirmed Resident #2's record failed to show wound measurements. During an interview on 01/07/26 at 2:20 p.m., an administrative nurse (#3) confirmed facility staff failed to record wound measurements and failed to obtain an order for the wound cleanser and Mepilex dressing.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 2 residents (Resident #40) observed for insulin preparation and administration. Failure to properly prepare and prime an insulin pen may result in contamination of the pen and administration of an inaccurate dose of insulin.Findings include:Review of the facility policy titled Medicine: Insulin Administration, Insulin Pens, Insulin Pumps occurred on 01/07/26. This policy, revised 10/31/25, stated, . Insulin Pen. 7. Wipe the tip of the pen where the needle will attach with an alcohol swab or cotton ball moistened with alcohol . 9. Turn the dosage knob to '2' units to prime the pen. 10. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears.Observation on 01/07/26 at 8:26 and 8:32 a.m. showed a nurse (#4) prepared Resident #40's Lantus and Novolog pens. The nurse applied a new needle to the insulin pens without wiping the tips of the pens with an alcohol swab, dialed the insulin pens to 2 units holding the pens horizontally, and with the needle covers on, primed the pens. During an interview on 01/07/26 at 1:30 p.m., an administrative nurse (#3) confirmed she expected staff to clean the insulin pen with alcohol prior to attaching needle and prime an insulin pen with the needle upright.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 2 sampled residents (Resident #29) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident at risk of receiving unnecessary medications, experiencing adverse drug effects, and possible chemical restraint. Findings include: Review of the facility policy titled Psychotropic Medications occurred on 01/07/26. This policy, dated 12/09/25, stated, . If the attending physician . believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician . evaluates the resident for the appropriateness of the medication. Review of Resident #29's medical record occurred on all days of survey. Diagnoses included anxiety. A physician's order, dated 12/08/25, identified Hydroxyzine (an antihistamine used for antianxiety) 25 mg (milligrams) every six hours PRN for generalized anxiety. The Medication Administration Record (MAR) showed Resident #29 received prn Hydroxyzine on nine occasions between December 23, 2025 and January 5, 2026. The facility failed to ensure the resident's PRN Hydroxyzine was limited to 14 days and reevaluated for continued use. During an interview on 01/07/26 at 2:20 p.m., an administrative nurse (#3) confirmed facility staff failed to ensure the provider limited Resident #29's PRN Hydroxyzine to 14 days and reevaluated for continued use.

Based on record review, review of facility policy, staff interview, and review of a Vulnerable Adult Protective Services (VAPS) report, the facility failed to ensure residents remained free from abuse for 2 of 2 sampled residents (Resident #1 and #2) who experienced nonconsensual sexual contact. Failure to protect residents from sexual abuse placed all residents at risk for psychosocial harm, physical harm, and mental and emotional distress. This citation is considered past non-compliance based on the review of the corrective actions the facility implemented immediately following the incident. During the on-site complaint survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 10/04/25 when Resident #1 entered Resident #2's room, kissed the resident, and laid on his bed. Resident #2 was naked, straddled Resident #1, and put his hand inside her brief. *10/07/25 at 5:45 p.m. The survey team notified the administrator and director of nursing (DON) of the IJ, provided the IJ template, and requested a plan of removal for the IJ.*10/08/25 at 3:55 p.m. The SSA received the removal plan and accepted the plan. *10/09/25. The survey team confirmed by interview and record review the facility removed the IJ on 10/05/25 and corrected the deficient practice prior to the start of the survey on 10/07/25. The deficient practice is considered past noncompliance. The deficient practice remained a G scope and severity following the removal of the IJ.Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 10/07/25. This policy, dated April 2025 stated, . the resident has the right to be free from abuse, . residents must not be subjected to abuse . by other residents . Review of the VAPS report, dated 10/04/25, stated a registered nurse (RN) entered Resident #2's room at approximately 8:00 p.m. and observed Resident #1 lying on the bed, and Resident #2 naked and straddling Resident #1 with his hands down Resident #1's pants.-Review of Resident #1's medical record occurred on 10/07/25. Diagnoses included Alzheimer's disease with psychotic disturbance. The admission Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition. The care plan, at the time of the incident, identified a behavior of wandering in the halls.Resident #1's progress note, dated 10/04/25 at 11:00 p.m., stated, At 2000 [8:00 p.m.], CNA [certified nurse aide] was looking for this resident [Resident #1]. This nurse told CNA to start looking in every room and this nurse would do the same. [Resident #1] often wanders into other rooms and sits there if they allow. [Resident #1] was found in bed with her clothes on with his [Resident #2] hand rubbing her inside her pull up [brief] . This nurse waved for the CNA to come down the hall. CNA took [Resident #2's] hand out of [Resident #1's] pull up and walked with [Resident #1] to the recliner by the nurses station .-Review of Resident #2's medical record occurred on 10/07/25. The admission MDS, dated [DATE], identified severely impaired cognition. The care plan, at the time of the incident identified the following:*Focus: Exhibits inappropriate touching. Intervention: Observe for interactions with female residents, specifically resident (identification number (ID)).*Focus: Displays inappropriate sexual behaviors such as exposing his genitals to staff, fondling himself in front of staff, and interlocked arms and touched the abdomen area of a female resident. Interventions: Observe interactions with female residents, specifically resident (ID number); separate residents if necessary; and provide resident with opportunities for socialization in supervised areas.A faxed request, dated 07/24/25, to Resident #2's provider stated, Resident has been exposing genitalia to female staff, lying on bed fully undressed during night & day hours. Will cover himself when told to but exposes himself again. This started about 1 1/2 weeks ago. May we have a referral to psych [psychiatric] services? The resident's provider responded the same day and stated, referral to psychiatry. Dx: hypersexuality. Resident #2's medical record failed to show a psychiatry visit until 10/08/25, after the incident with Resident #1.Resident #2's progress note, dated 10/04/25 at 11:05 p.m., stated, At 2000 [8:00 p.m.] .this resident and [Resident #1] was found in bed with her clothes on with this resident [Resident #2] hand rubbing her inside her pull up. [Resident #2] was completely naked laying [sic] next to her in bed . [Resident #2] explained she . kissed me 3 times . [Resident #2] has touched other residents in the past but they have not been in bed together .The facility completed the following steps to remove the immediacy and correct the deficient practice:*Assessed Resident #1 and #2 for emotional and psychological distress.*Scheduled psychiatric appointments for Resident #1 and #2 for 10/08/25.*Initiated one to one (1:1) monitoring for Resident #1 when wandering and to redirect and offer a movie or snack on 10/05/25.*Initiated 15-minute checks for both Resident #1 and #2 on 10/05/25.*Updated Resident #1's care plan to reflect 1:1 monitoring, 15-minute checks, and redirection on 10/06/25.*Updated Resident #2's care plan to reflect the incident and for staff to monitor the whereabouts of both residents.*Immediate education provided to all staff working on 10/04/25 and all other staff before the start of their next shift.*Education focused on how to identify/report resident-to-resident sexual abuse and the importance of implementing procedures to ensure resident safety.During an interview on 10/07/25 at 12:30 p.m., two administrative staff members (#1 and #2) stated Resident #1 can be flirtatious with staff and other residents and this was the first time staff witnessed the type of behavior between Resident #1 and Resident #2.

Based on record review, review of facility policy, and staff interview, the facility failed to report an incident of resident-to-resident sexual abuse to the State Survey Agency (SSA) for 2 of 2 sampled residents (Resident #1 and #2) who experienced nonconsensual sexual contact. Failure to report incidents of abuse may result in unwanted physical and/or sexual contact, fear, anxiety, and psychosocial harm. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation Policy occurred on 10/07/25. This policy, dated April 2025 stated, Purpose: To ensure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations . Notification procedures: Alleged or suspected violations involving . abuse . will be reported immediately to . Designated agencies . including the State Survey and Certification Agency . -Review of Resident #1's medical record occurred on 10/07/25. Diagnoses included Alzheimer's disease with psychotic disturbance. The admission Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition.-Review of Resident #2's medical record occurred on 10/07/25. The admission MDS, dated [DATE], identified severely impaired cognition.Progress notes, dated 10/04/25, identified at 8:00 p.m. facility staff found Resident #1 in Resident #2's room fully clothed, and lying on the bed. Resident #2 was naked, straddling Resident #1, and had his hand in the resident's brief.During an interview on 10/07/25 at 9:58 a.m., two administrative staff members (#1 and #2) confirmed the facility failed to report the sexual interaction between Resident #1 and Resident #2 to the SSA.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 2 sampled residents (Resident #2) with a pressure ulcer and 1 closed record (Resident #3). Failure to routinely assess and monitor progression of pressure ulcers has the potential to result in complications. Findings include: Review of the facility policy titled, Pressure Ulcer/Wound Care Resource Packet, occurred on 07/07/25. This policy, revised 07/07/25, stated, . Wound care management may include the management and treatment of surgical wounds, pressure ulcers, diabetic ulcers and skin conditions, as well as arterial and venous ulcers. Promotion of healing . and prevention of complications is extremely important, as well as accurate assessment and documentation. Wound Data Collection UDA [User Defined Assessment] completed by licensed nurse and is required for documenting daily monitoring, is required at least weekly when skin integrity is impaired or open area is present (i.e., pressure ulcer, surgical wound, venous ulcer) and is required to be used daily and with every treatment . Wound RN [registered nurse] Assessment UDA is required at least every seven days and as needed when skin integrity is impaired or open area is present. - Review of Resident #2's medical record occurred on 07/07/25 and identified a diagnosis of peripheral vascular disease (reduced blood flow to the limbs) and a pressure ulcer on the right heel. Review of the Wound Data Collection UDA and the Wound RN Assessment UDA from 12/09/24 to 06/22/25 identified facility staff failed to measure Resident #2's pressure ulcer and failed to consistently document wound characteristics. - Review of Resident #3's medical record occurred on 07/07/25 and identified a pressure ulcer on the sacrum (an area of the lower back near the buttocks), present on admission in September 2024 until discharge in March 2025. Review of the Wound Data Collection UDA and the Wound RN Assessment UDA from October 2024 to February 2025 identified facility staff failed to consistently measure Resident #3's pressure ulcer at least weekly. The documents identified the following: October 2024 - lacked measurements for two weeks (between October 1st and 21st) January 2025 - lacked measurements for 1 week (between January 15th and 28th) February 2025 - lacked measurements for 2 weeks (between February 6 and 27th) Interviews with nursing staff on 07/07/25 identified the following: * 5:30 p.m., A nurse (#3) stated she does not measure wounds and only the registered nurses do the measuring. The nurse stated she is not sure how often wounds should be measured. * 6:10 p.m., A nurse (#2) stated she measures wounds, but is not sure how often they should be measured. The nurse stated the computer alerts them as to when it should be done and the alert can come at any time of the day - on the day shift or the night shift. * 6:20 p.m., A nurse (#4) stated she is not sure how often wounds are measured but it is on the assignment sheet if they need to be measured. During an interview on 07/07/25 at 7:05 p.m., an administrative nurse (#1) indicated nursing staff (registered nurses and licensed practical nurses) are expected to assess and measure pressure ulcers/wounds weekly and confirmed staff are not always completing this assessment.

Based on record review, confidential resident and family interviews, and staff interviews, the facility failed to provide sufficient nursing staff to meet the residents' needs for 4 of 4 confidential residents (Resident A, B, C, and D) and family members (Family member #1 and #2). Failure to provide sufficient nursing staff may result in residents experiencing falls, poor hygiene, incontinence, and skin issues and may negatively affect the residents' physical, mental, and psychosocial well-being. Findings include: - Review of Resident A's medical record occurred on 09/30/24 and identified the resident's most recent Brief Interview for Mental Status (BIMS) scored a 15, indicating intact cognition. The care plan stated, . The resident has a need for restorative intervention due to Limited mobility . Resident will maintain current level of function . Care plan interventions included use of an exercise bike, an arm machine, and static standing (seated wheelchair to standing). The care plan also identified the resident required bathing assistance. During an interview on 09/30/24 at 4:50 p.m., Resident A expressed concern with decrease in bathing from twice per week to once per week and stated, We don't get restorative therapy anymore either, which I liked. I got it every other day. I need it for my leg. I really liked it. It really helped. When asked about these changes, Resident A stated, I was told they don't have enough staff. - During an interview on 10/01/24 at 5:49 p.m., a confidential family member (#1) stated, I wish they had more staff. Sometimes [Resident C] has to sit in his/her poop for a long time. 40489 - Review of Resident D's medical record occurred on 10/02/24. The current care plan stated, . The resident has a need for restorative intervention due to ADL [activities of daily living] self-care performance deficit/limited physical mobility activity intolerance . Resident will maintain current level of function in ADL's . The care plan also identified the resident required bathing assistance. During a confidential family interview on 10/02/24 at 3:18 p.m., Family member #2 expressed concern regarding the facility no longer providing the restorative therapy program for residents and decreased bathing for residents receiving two baths per week to one bath per week as Resident D previously received. When asked about these changes, the family member stated, We were told these cuts were due to staffing, and we don't feel they should be taking things away from residents, especially baths and the restorative program. Isn't that the residents right to have therapy and two baths a week if they choose to? - Review of Resident B's medical record occurred on all days of survey and identified the resident's most recent BIMS scored a 15, indicating intact cognition. The care plan identified the resident required toileting assistance. During an interview the afternoon of 10/01/24, Resident B stated, They don't have enough staff. I've had to wait several times at least 30 to 45 minutes for someone to answer my light when I need to go to the bathroom. A couple weeks ago I had to wet myself in the bed because I couldn't hold it any longer. During an interview on 10/03/24 at 9:51 a.m., an administrative staff member (#1) stated, We decreased staff, decreased the number of baths per week, and discontinued the restorative therapy program around 09/19/24.

40489 Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control practice for 4 of 12 sampled residents (Resident #17, #22, #32 and #39) and 5 supplemental residents (Resident #2, #6, #13, #21, and #31) observed during cares. Failure to follow infection control practices during resident cares related to hand hygiene, glove use, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Standard and Transmission -Based Precautions occurred on 10/03/24. This policy, dated April 2024, stated, Enhanced barrier precautions 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. High-Contact Resident Care Activities include: Transfers . assisting with toileting . Review of the facility policy titled Hand Hygiene occurred on 10/02/24. This policy, dated 03/29/22, stated, . Definitions . Patient Zone . It contains the patient and their immediate surroundings. Typically includes intact skin of the patient and all inanimate surfaces that are touched by or in direct physical contact with the patient. Policy . All employees in patient care areas . will adhere to the 4 moments of Hand Hygiene and 2 Zones of Hand Hygiene. 1. Entering room [ROOM NUMBER]. Before Clean Task 3. After Bodily Fluid/Glove Removal 4. Exiting room [ROOM NUMBER]. Zones: Patient zone . ENHANCED BARRIER PRECAUTIONS: - Review of Resident #22's medical record occurred on all days of survey. The care plan stated, The resident requires Enhanced Barrier Precautions (EBP) R/T [related to] surgical wound to left leg. A sign on the resident's door and a supply cart located in the room identified EBP for Resident #22. Observation on 09/30/24 at 12:48 p.m. showed a certified nurse aide (CNA) (#3) and a licensed nurse (#4) entered Resident #22's room with a stand lift, transferred the resident from the wheelchair to the toilet, provided toileting cares, and transferred the resident back to the wheelchair. The CNA and the nurse failed to wear a gown during the high-contact resident cares. Observation on 10/01/24 at 8:42 a.m. showed two CNAs (#2 and #3) entered Resident #22's room with a stand lift, transferred the resident from the wheelchair to the toilet, provided toileting cares, and transferred the resident back to the wheelchair. The CNAs failed to wear a gown during the high-contact resident cares. - Review of Resident #32's medical record occurred on all days of survey. The care plan stated, .The resident requires Enhanced Barrier Precautions (EBP) R/T open wounds d/t [due to] osteomyelitis [bone infection] on bilateral [both sides], multiple toes. A sign on the resident's door and a supply cart located in the room identified EBP for Resident #32. Observation on 10/01/24 at 5:49 p.m. showed a CNA (#2) entered Resident #39's room with a stand lift, transferred the resident from a wheelchair to the bathroom, provided toileting cares, and transferred the resident to a recliner. The CNA failed to wear a gown during the high-contact resident care. During an interview on 10/03/24 at 11:14 a.m. an administrative staff member (#1) stated she expected staff to wear appropriate PPE during high contact cares for residents on EBP. HAND HYGIENE: - Observation on 10/01/24 at 12:48 p.m. showed two CNAs (#2 and #3) entered Resident #39's room, donned gloves without first completing hand hygiene, and provided the resident personal cares. Both CNAs acknowledged failure to complete hand hygiene upon entering the resident's room and donning gloves. - Observation on 10/01/24 at 1:11 p.m. showed a CNA (#2) provided fluids to Residents #2, #6, #13, #17, #21, and #31 by picking up a water mug located on the resident's bedside table in their room. The CNA (#2) failed to perform hand hygiene after assisting each resident with water and before assisting the next resident.

Based on review of facility policy and resident interview, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity and individuality for 1 of 1 confidential resident (Resident B) who voiced concerns regarding nighttime toileting preferences Failure to honor the resident's choice for toileting does not enhance the resident's quality of life and may result in decreased self-esteem, decreased quality of life, emotional harm and increased pain. Findings include: Review of the facility policy titled Resident Dignity occurred on 10/03/24. This policy, dated November 2023, stated, . PURPOSE . To assist with respecting and ensuring resident rights. will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of her individuality. During a confidential resident interview on 10/01/24 at 2:50 p.m., Resident B stated, I use the sit-to-stand lift during the day and evening, but I compromised with them to use the bedpan at night from 10:00 p.m. to 6:00 a.m. so they wouldn't have to have two CNAs [certified nurse aides] over on this side. I don't want to use the bedpan, I prefer to get up and use the toilet. I also have back problems, so sitting on the bedpan makes that pain worse. The facility failed to treat Resident B with dignity by honoring the resident's preferred method of toileting at night.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or the resident's representative a written bed hold notice for 1 of 5 sampled residents (Resident #35) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy titled Bed-Hold occurred on 10/03/24. This policy, dated 12/07/23, stated, . At the time of . transfer . , the location will provide written information to the resident or resident representative that specifies: 1. The duration of the state bed-hold policy, if any, during which a resident is permitted to return and resume residence. 2. The reserve bed payment policy in the state plan. 3. The location's policies regarding bed-hold periods permitting a resident to return. Review of Resident #35's medical record occurred on all days of survey and identified a hospital transfer occurred on 06/12/24. The medical record lacked documentation the facility provided the resident and/or representative with a written bed hold notice. During an interview on 10/02/24 at 2:03 p.m., an administrative staff member (#1) confirmed staff failed to provide the required bed hold notice to the resident and/or their representative upon transfer to the hospital.

Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a significant change in status assessment (SCSA) for 1 of 3 sampled residents (Resident #26) who experienced a significant change in status. Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facility's ability to accurately assess the resident's status and identity and implement appropriate care approaches. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.18.11), dated October 2023, page 2-24 stated, . A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without staff intervention . 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. and page 2-27 stated, A SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement. Any decline in an ADL [activities of daily functioning] physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning. Review of Resident #26's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as independent with ambulation, personal hygiene, toilet transfer, sitting to lying position, lying to sitting position, sitting to standing, bed to chair transfer, moderate/partial assistance with lower body dressing and taking on/off socks and shoes and toileting hygiene, always continent of bowel and bladder, and did not use a wheelchair. The medical record identified the resident had a fall on 07/09/24 resulting in a right lower leg fracture and hospitalization from [DATE] to 07/12/24. A quarterly MDS, dated [DATE], identified the resident unable to ambulate, required a wheelchair for locomotion, frequently incontinent of bowel and bladder, dependent on staff for lower body dressing and taking on/off socks and shoes, required substantial/maximal assistance with personal hygiene, and partial moderate assistance with toilet transfer, sitting to lying position, lying to sitting position, sitting to standing, and bed to chair transfer. The record lacked evidence facility staff identified and/or completed a SCSA following Resident #26's decline in activities of daily living.

46963 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 12 sampled residents (Resident #25, #32, and #40). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION GG: FUNCTIONAL ABILITIES AND GOALS The Long-Term Care Facility RAI Manual, revised October 2023, pages GG-14 through GG-16, stated, . GG0130 Self-Care . Steps for Assessment 1. Assess the resident's self-care performance based on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident's medical record during the assessment period. Coding instructions . Code 06, Independent: if the resident completes the activity by themselves with no assistance from a helper. Code 05, Setup or clean-up assistance: if the helper sets up or cleans up; resident completes activity. Code 03, Partial/moderate assistance: if the helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Review of Resident #25's medical record occurred all days of survey. A Functional Abilities - Current Performance Assessment, dated 05/30/24, identified the resident required partial/moderate assistance for oral hygiene and walking 50 feet and 150 feet with two turns. The annual MDS, dated [DATE], identified the resident required setup or cleanup assistance for oral hygiene and independent with walking 50 feet and 150 feet with two turns. During an interview on 10/01/24 at 4:36 p.m., an administrative staff member (#1) confirmed staff failed to code the MDS correctly for Resident #25. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages N-6 through N-7, stated, . N0415: High-Risk Drug Classes: Use and Indication . Coding Instructions . N0415A1. Antipsychotic: Check if an antipsychotic medication was taken by the resident at any time during the 7-day look-back period . N0415B1. Antianxiety: Check if an anxiolytic medication was taken by the resident at any time during the 7-day look-back period . N0415G1. Diuretic: Check if a diuretic medication was taken by the resident at any time during the 7-day look-back period . Pages N-12 through N-13, stated, . N0450: Antipsychotic Medication Review . Coding Instructions for N0450A . Code 1, yes: if antipsychotics were received on a routine basis only . - Review of Resident #32's medical record occurred on all days of survey. The Admission/5 day (hospital return) MDS, dated [DATE], identified Section N0415 coded for an antianxiety medication. Review of the medication administration record (MAR) for August 2024 showed Resident #32 received Risperdal (an antipsychotic) during the look back period and lacked evidence the resident received an antianxiety medication. During an interview on 10/04/24 at 4:40 p.m., an administrative staff member (#1) confirmed Resident #32 received an antipsychotic medication, not an antianxiety, and staff failed to code the MDS correctly. - Review of Resident #40's medical record occurred on all days of survey. An admission MDS, dated [DATE], showed Section N coded for a diuretic medication. Review of the July 2024 MAR lacked evidence Resident #40 received a diuretic during the look back period. During an interview on 10/03/24 at 10:30 a.m., an administrative staff member (#1) confirmed Resident #40 did not receive a diuretic and staff failed to code the MDS correctly.

Based on record review, review of facility policy and resident interview, the facility failed to assist in obtaining dental services to meet the needs of 1 of 1 resident (Resident #3) with a lost bottom denture. Failure to promptly refer for dental services and/or assess the resident's ability to eat and drink adequately without a bottom denture may result in decreased intakes, unplanned weight loss, and choking. Findings include: Review of the facility policy titled Denture and Oral Care, Dental Health Assessment, Dental Services occurred on 10/03/24. This policy dated June 2024, stated, . Referral for dental services for lost or damaged dentures must occur within three days of discovery of the lost or damaged denture. If the referral is more than three days, the location must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and document the extenuating circumstances that led to the delay. Review of Resident #3's medical record occurred on all days of survey. A progress note, dated 09/06/24, stated. [Resident #3's name] states she is missing her her [sic] bottom denture. She said she had them on Wednesday night but she couldn't find them on Thursday morning. She said she had staff look for them and they couldn't find them. She is going to call the dentist to see if there is a warranty . During an interview on 10/02/24 at 1:35 p.m., Resident #3 stated, I feel like they [Resident #3's lower denture] got thrown in the garbage by accident. When asked how the this affected her eating Resident #3 said she eats soft foods. The facility failed to refer Resident #3 for dental services within three days after being notified of the resident's missing lower denture and failed to complete an assessment of Resident #3's ability to eat and drink adequately.

Based on review of the daily staffing information, review of the nurse schedule, and staff interview, the facility failed to post daily staffing data for all shifts on 9 of 11 days reviewed (September 22 - October 2, 2024). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift. Findings include: Review of the daily staffing data and the nursing staff schedule from September 22 - October 2, 2024, showed on 11 of the days, staff failed to post the number of staff working on nine day shifts, two evening shifts, and five night shifts. During an interview on 10/03/24 at 10:59 a.m., an administrative staff member (#1) confirmed staff failed to post staffing data for each shift on some days.

Based on information provided by the complainant, record review, review of facility policy, and staff interview, the facility failed to ensure adequate supervision for 1 of 5 sampled residents (Resident #2) who experienced falls. Failure to provide supervision put the resident at risk of falls and/or injury. Findings include: Review of the facility policy titled Fall Prevention and Management - Rehab/Skilled, Therapy & Rehab occurred on 01/04/24. This policy, dated March 2023, stated, . 3. Care plan the appropriate interventions, including personalizing all [sic] areas. 4. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-Hour Report, care plan and Kardex, daily stand-up meeting, and/or Fall Committee meetings. The complainant identified concerns related to resident falls. Review of Resident #2's medical record occurred on 01/04/24. A care plan intervention, dated 09/20/23, stated, Monitor resident every hour. Progress notes identified the resident fell on [DATE] and 10/25/23, and one resulted in a skin tear to the elbow. The facility failed to provide documentation to show hourly rounding occurred. On 01/04/24 at 12:45 p.m., an administrative staff member (#1) confirmed facility staff failed to ensure hourly rounding was being completed and documented.

Based on observation and staff interview, the facility failed to ensure nursing staff were able to locate the necessary equipment and how to operate 2 of 3 suction machines (West Unit). Failure to ensure the suction machines were functional and equipment available placed residents at risk for choking and aspiration. Findings include: Observation on 07/12/22 at 3:36 p.m. showed a supervisory nurse (#3) and two other nurses (#4, and #9) failed to properly set-up and operate the two suction machines located on the West unit. During an interview on 07/12/22 at 3:46 p.m., a supervisory nurse (#3) verified the facility nurses failed to locate supplies and properly set-up the suction machines located on the West unit.

Based on information received from the complainant, record review, and staff interview, the facility failed to provide the necessary assistance to prevent an injury for 1 of 1 discharged resident (Resident #2) whose wheelchair tipped backwards while being transported in the facility van. Failure of the facility to ensure staff properly secured Resident #2's wheelchair in the van resulted in the resident experiencing a widening of a C1 [cervical vertebra near base of skull] anterior arch fracture and the development of a posterior arch fracture. Findings include: The complainant alleged the facility failed to properly secure a resident in the facility van which resulted in a fall with injury during transport. The facility failed to provide copies of their policy regarding transporting residents via the facility van and/or the manufacturer's recommendations for the van's seatbelt/locking mechanism as requested. Review of Resident #2's medical record on 10/25/21 identified diagnoses including dementia and a cervical vertebra fracture. The progress notes identified the following: * 09/14/21 at 5:46 a.m., Resident left with staff for . appointment will meet [family] and then will go . to [health care facility] . * 09/14/21 at 7:55 p.m., Resident returned with [family] from . appointment . * 09/14/21 at 8:05 p.m., Phone call recieved [sic] from . MD [medical doctor] who has talked with radiologist who reviewed x-rays taken this am he noted an Acute neck Fx [fracture] of C1 - calling it a [NAME] unstable fracture [a more severe injury that occur when the [MEDICATION(S)] ligament is also ruptured secondary to the extent of spread of the CI arch] and wants to have resident transferred by ambulance following C-spine [cervical-spine] precautions to . ER [emergency room ] - he relates that resident has had a previous neck fracture and is unsure if what they are noting is a [sic] old or new fracture but doen't [sic] want to take a chance of having it be an issue not further followed up immediately. * 09/14/21 at 8:10 p.m., Resident denies pain in upper back or neck relates it as a 'crackling noise with turning head' - in talking about pain scale he then is calling it a '4 to base of skull' . He is aware that he will be going back to [ER] . by ambulance for evaluation and is tearful . * 09/14/21 at 10:30 p.m., [Hospital] ambulance service is here and . aware to . follow C-spine precautions and transport to [ER]. * 09/14/21 at 1:07 a.m., Spoke to [ER] . resident was admitted by [MD] at this time they have no admitting diagnosis as resident is still in MRI [magnetic resonance imaging] . The hospital reports identified the following: * 09/14/21 at 11:48 p.m., . The patient . was at the [appointment] earlier today when he fell backwards in his wheelchair while in their van. He hit his head but denies any LOC [loss of consciousness]. No changes in vision or hearing. No headache, light headedness or dizziness. He did have some neck pain although it is feeling OK now. He had a CT [computed tomography] head/neck there that saw C1 fx prompting admission here. He also has a hx [history] of cervical spine surgery in the past. * 09/15/21 at 9:32 a.m., . Patient has known anterior arch C1 fracture from July 2021. Call . to neurosurgery for review of images, with recommendation to wear Vista collar [neck brace] when out of bed, get MRI cervical spine and follow up in Neurosurgery clinic, which had not happened. Patient did not wear collar. New cervical CT scan 9/14/21 shows widening of C1 anterior arch fracture, and interval development of left posterior arch fracture. neck tender at dorsal midline . The incident report, dated 09/15/21, identified, . Strap on w/c [wheelchair] in van not fastened tight enough [and] shifted off of stabalizer [sic] bar while driving. Employee . re-instruction . [CNA (certified nursing assistant) (#6)] states she has been fully trained in van use [and] was comfortable [with] transfers. An activity assistant/CNA (#6), who transported Resident #2 to the [appointment], submitted an undated, handwritten statement regarding the incident. It read, . We were on our way to . meet up with [Resident #2's family]. [Resident #2] said he fell backwards and his bottom of neck landed on the ramp. I stop [sic] the van and went to check on resident and help him up. I notice [sic] one of the straps were [sic] loose. I double check the straps before we left again . I told his family of the incident and also when I came back to nursing home I reported it to the nurse. On 09/15/21, an administrative staff member (#2) also submitted a handwritten statement regarding the incident. It read, . [Activity Assistant/CNA (#6)] says she feels the straps were in correctly. She is unsure what caused the strap to loosen. Inservice training/reeducation was provided by her supervisor. [Activity Assistant/CNA (#6)] says there was a red mark across resident's shoulders. She does not feel [at] any time that he hit [at] the base of his skull (C1 area). Resident said 'he hurt a little' but was not in any sort of visible pain . [Activity Assistant/CNA (#6)] placed chair back into position, strapped him back in [and] drove the remaining distance. During an interview on 10/25/21 at 2:05 p.m., a nurse (#3), who was on duty at the time Resident #2 returned from his . appointment, reported being unaware Resident #2's wheelchair had tipped backwards in the van. The nurse (#3) stated she was taken aback when the doctor phoned the facility later that evening and told her about the incident. She indicated the previous nurse had failed to update her regarding the incident during report. During an interview on 10/25/21 at 2:38 p.m., when asked how Resident #2's wheelchair tipped backwards during transport, an administrative staff member (#1) and the supervisory staff member (#4) stated, Basically it was due to operator error. This was [Activity Assistant/CNA (#6)] first transfer out of town. She forgot to put the buttons down, so they [the straps] were not locked. [Resident #2] didn't fall out of the wheelchair. He fell backwards in the wheelchair. He hit the [folded metal loading] ramp. [Activity Assistant/CNA (#6)] told staff of the incident when she got back from dropping him off with [family]. Although the supervisory staff member (#4) reported educating [Activity Assistant/CNA (#6)] prior to the incident, she failed to provide documentation showing the education she provided her staff. The facility failed to ensure Resident #2 received the care and services necessary to attain the highest degree of safety possible while staff transported him in the facility van. The facility failed to ensure: * transport staff received education on securing residents in the van per the manufacturer's recommendations, * transport staff properly secured Resident #2's wheelchair in the van, * transport staff promptly notified the nurse on duty of the incident limiting her ability to make informed decisions regarding Resident #2's medical care, and * nursing staff informed the on-coming shift regarding the incident to ensure continuity of care.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure 2 of 2 sampled residents (Resident #5 and #8) remained free of significant medication errors. Failure to ensure Resident #8 received the correct medications resulted in hospitalization for two days. Failure to administer a [MEDICATION NAME] (pain medication) patch on the correct day and administer a dose of Vancomyocin (antibiotic) intravenous medication to Resident #5 may result in a negative outcome. Findings include: Review of the facility policy titled Medication Errors occurred on 05/24/17. This policy, revised May 2016, stated, . ensure . that residents are free of significant medication errors . Medication errors consist of the following: * Wrong Medication * Wrong Time * Wrong Resident Given the Medication/Unauthorized Medication (drug administered without a physician's order) * Omission of Medication Ordered. Review of the facility policy titled MEDICATION ADMINISTRATION, INCLUDING SCHEDULING AND MEDICATION AIDES occurred on 05/24/17. This policy, revised May 2016, stated, . Medication Errors . An incident report will be completed for all medication errors. - Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition. Review of the progress notes identified the following: * 04/18/17 6:40 p.m. - CNA (certified nursing assistant) summoned nurse into resident's room. Found resident slumped over on bed on her left side. Resident mumbling and very lethargic. Unable to tell me what is wrong . No response when asked if having chest pain . (Physician) notified and orders received to send to ER (emergency room ) for evaluation. * 04/20/17 4:20 p.m. - Resident returned with staff from (hospital) with dx (diagnoses): altered mental status and UTI. * 04/24/17 4:00 a.m. Late Entry - Res (resident) went to the clinic today for a follow-up after recent hospitalization . Family did go along and later afternoon brought to Administrator's attention a lab value of concern. DNS (Director of Nursing Services) called hospital and the lab report was faxed to the facility. Incident report initiated. Resident #8's hospital admission history and physical (H&P), dated 04/18/17, stated, . Quite sedated . Altered mental status, question etiology (cause), assess urine drug screen. The hospital discharge summary, dated 04/20/17, stated, . really seemed that the patient was sedated with some sort of medication, unknown etiology . According to nursing home records and report, the patient was found unresponsive while on rounds . reported to ED (emergency department). At that time though she did have her eyes open not to commands, but was very sleepy and nonverbal . Urine drug screen was ordered, that is still pending. I did have a long conversation with the patient on discharge about possibility of medication mixup at the nursing home as . roommate is on benzodiazepines. Review of the hospital's urine toxicology report, dated 04/19/17, identified Resident #8 positive for Tricyclics (anti-depressant) and Benzodiazepines (anti-anxiety). Review of Resident #8's April 2017 electronic Medication Administration Record [REDACTED]. Review of Resident #10's (Roommate of Resident #8) April 2017 eMAR showed one anti-anxiety medication ordered and administered, but no anti-depressant ordered. During an interview on 05/23/17 at 8:45 a.m., Resident #8 indicated about a month ago she had been admitted to the hospital due to staff administering the wrong medications. During an interview on 05/23/17 at 3:50 p.m. and on 05/24/17 at 8:15 a.m., an administrative nurse (#1) stated the following: * Resident #8's medication error occurred on 04/18/17 * The toxicology report showed Resident #8 received medications not ordered by a physician * Facility staff were unaware of the medication error until 04/24/17 after the resident's family brought the urine toxicology results to the Administrator's attention (Six days after the medication error occurred) * Facility staff failed to review the hospital's admission H&P or discharge summary when the resident returned on 04/20/17 or request the urine toxicology screen * Facility staff failed to investigate to determine whose medication or what medication(s) Resident #8 received * Facility staff completed only one staff interview (certified nursing assistant/certified medication aide (CNA/CMA) on duty during the medication error) * The facility failed to communicate and educate all nurses regarding the medication error The facility failed to thoroughly investigate a medication error requiring Resident #8's hospitalization for 2 days, to identify causative factors including whose medications Resident #8 received to prevent further errors, and educate all nursing staff to prevent additional errors. - Review of Resident #5's medical record occurred on all days of survey. Medications included [MEDICATION NAME] 25 micrograms (MCG) every seventy-two hours and [MEDICATION NAME] 1 gram intravenously every other day (administered by clinic staff). Review of Resident #5's progress notes, dated 02/11/17 at 4:50 p.m., stated, Medication Error: [MEDICATION NAME] scheduled to change today and was changed in error yesterday. resident showed no signs or symptoms of adverse reaction. Review of the investigation report dated 02/11/17 at 4:44 p.m., stated, . Nurse went to sign out res (resident) [MEDICATION NAME] in narc (narcotic) book when she noted a new one had been applied just the day prior. Patch is to be (changed daily every seventy-two hours) . Review of Resident #5's electronic Medication Administration Record [REDACTED]. A faxed note to the physician stated, Resident was to receive IV (intravenous) [MEDICATION NAME] for (urinary tract infection) but did not receive any [MEDICATION NAME] for 12/18/2016. The eMAR showed the medication as administered. The facility failed to complete an incident report. During an interview on the afternoon of 05/23/17, the administrative nurse (#1) stated the staff failed to complete an incident report for the missed dose of [MEDICATION NAME].

Based on information provided by the complainant, observation, record review, review of facility policy, and staff interviews, the facility failed to provide the necessary treatment and services to prevent the occurrence and promote the healing of pressure ulcers for 3 of 3 sampled residents (Resident #1, #3, and #4) identified with pressure ulcers. Failure to provide timely and appropriate interventions and ensure staff consistently implemented existing interventions resulted in the development of new pressure ulcers for Resident #3 and #4. Findings include: Information provided to the State agency indicated facility staff failed to assess Resident #3's skin and were unaware of the development of pressure ulcers to her buttocks. Review of the facility policy titled "Pressure Ulcers" occurred on 11/12/14. This policy, dated September 2012, stated ". . . Based on the resident's comprehensive assessment, the center will use prevention and assessment interventions to ensure that a resident entering the center without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable. . . ." Review of the facility policy titled "Pressure Ulcer Practice Guidelines" occurred on 11/12/14. This policy, revised June 2014, stated ". . . Residents at risk for pressure ulcer development and those with pressure ulcers/wounds should be monitored daily for changes in their skin condition. This may occur during the course of the resident's daily care and/or bathing where the CNA (certified nursing assistant) should perform a head-to-toe check of the resident's skin, paying particular attention to: . . . The surfaces of the skin that come in contact with the bed and chair . . . Bony prominences . . . The surfaces of the skin that come in contact with each other . . . Abnormal findings/changes should be reported to the resident's primary care provider . . . It is recommended that the Wound Data Collection . . . reflects the nurse's observation and management of wounds from a shift-to-shift perspective and with each dressing change. At a minimum, weekly documentation is recommended to provide a review of the pressure ulcer/wound. Weekly documentation should include the date observed and . . . Measurements . . . Presence, type, color, odor, appearance and approximate amount of any exudate, Presence, nature and frequency of pain, Wound bed characteristics . . . Description of wound edges and surrounding skin . . . Once a resident experiences a pressure ulcer, an assessment should take place immediately that determines the severity of injury and treatment interventions necessary. . . ." - Review of Resident #3's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition, limited assistance required for toileting and transfers, at risk for pressure ulcers, nutritional interventions, and dressings. The current care plan further identified: * Pressure Ulcers: ". . . Assess/record/monitor wound healing weekly and prn. Report improvements and declines to the health care provider. treatment per MD (medical doctor) orders. . . . Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. . . ." The progress notes identified the following: * 10/20/14, "Resident's daughter here this evening and expressed concern for L great toe ulcer and for black and blue area at coccyx . . ." Facility staff failed to identify Resident #3's coccyx ulcer until after the resident's family member brought it to their attention. * 10/21/14, ". . . Notified by staff of skin area to coccyx. Area is 6 cm long by 4 cm wide, dark purple color. Area has 3 slits of 0.8 cm. One below the other. Resident complains of some discomfort to area. . . ." * 10/23/14, ". . . Culture from coccyx wound. Oxicillin resistant staphylococcus aureus. Sent to (Nurse Practioner (NP)) for confirmation [MEDICAL CONDITION]." The wound data collection form stated, ". . . Measurements - Required at least once every 7 days. . . ." Resident #3's coccyx ulcer/wound data collection forms were completed as follows: 10/21/14 and 10/30/14 (9 days). * 10/30/14, ". . . Stage 3, open irregular-shaped area on coccyx" which measured "3.75 cm in length, 2 cm in width, and 0.2 cm in depth, with tan drainage, and an odor . . ." The facility failed to provide this surveyor any wound data collection forms for the month of November. Facility staff failed to measure Resident #3's coccyx ulcers with every dressing change or every seven days per policy. Observation on 11/11/14 at 11:15 a.m. showed two nurses (#2 and #3) providing Resident #3's ulcer treatments following her bath (with the CNA #6). Both nurses (#2 and #3) cued Resident #3 to stand. The first nurse (#2) then described the wound on Resident #4's coccyx as a "2.5 cm x 3 cm draining (area) with a white center/core and yellow tissue around (it)," as the second nurse (#3) wrote the measurements on her inner arm. The second nurse (#3) applied a dressing before both nurses (#2 and #3) removed their gloves and exited the bathing room. Following the observation, the second nurse (#3) approached this surveyor and asked "What was 2.3 cm x 1.3 cm? Did you write down the buttocks?" The second nurse failed to accurately document the measurements of Resident #3's coccyx ulcers. - Review of Resident #4's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified severely impaired cognition, extensive-to-total assistance required for toileting and transfers, at risk for pressure ulcers, bed/chair pressure reducing devices, repositioning program, nutritional interventions, and dressings. The current care plan for pressure ulcers further identified, ". . . Treatment to right heel, right great and 1st toe per MD (medical doctor) orders. . . . Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. . . ." The progress notes identified the following: * 09/21/14, "When CNA was dressing resident, noted blood to right foot. Resident pulled away in pain when toes were moved. Nurse cleansed and assessed the wound. Stage 2 pressure ulcer to inner Right great toe. Stage 2 pressure ulcer to medial 1st toe. Orders from (Provider) for meplix dressing and have wound assessed at housecalls." Facility staff failed to identify Resident #4's right toe ulcer until it had reached a Stage 2 (a shallow open ulcer with a red pink wound bed). * 09/24/14, "Wound assessment completed on right great toe and right 2nd toe. . . ." Nursing staff failed to assess (i.e.: measure) the status of Resident #4's toe ulcers for three days after being alerted by direct care staff of their presence. Resident #4's right toe ulcers/wound data collection forms were completed as follows: 09/24/14, 10/01/14, 10/02/14, 10/16/14 (15 days). * 10/02/14, ". . . pressure ulcer between toes" which measured "0.75 cm in length and 0.4 cm in width, with drainage, and an odor. . . ." * 10/16/14, ". . . open area on the lateral portion of right great toe" which measured "1 cm in length and 1 cm in width, with drainage, and an increased odor. . . open area on medial portion of the second toe" which measured "0.5 cm in length and 0.5 cm in width. . . ." The facility failed to provide this surveyor any wound data collection forms for the month of November. Facility staff failed to measure Resident #4's right toe ulcers every dressing change or every seven days per policy. The progress notes identified the following: * 10/16/14, "(Provider) ordered C & S (Culture and Susceptibility) of right great toe wound on 10-17-14, since there has been no improvement and there is drainage and odor." * 10/19/14, "Culture to Toe. Staphylococcus aureus. Susceptibility to follow." * 10/20/14, "Received orders from (Provider) for Bactrim (antibiotic) . . ." * 10/21/14-10/30/14, "Resident on oral antibiotic [MEDICAL CONDITION] infection of right toes without adverse reaction. . . ." * 10/31/14, "Resident received last dose of ATB (antibiotic) [MEDICAL CONDITION] in toe wound at 10am today. . . ." Observation on 11/11/14 at 11:00 a.m. showed two nurses (#2 and #3) prepping for Resident #4's ulcer treatment. As the nurses gloved, one (#2) stated, "It's her right big toe and first toe." The second nurse (#3) countered with, "No, it's her left foot." The first nurse (#2) paused and responded, "Well, the orders are for the right foot." The second nurse (#3) countered with, "I get mixed up." The first nurse (#2) then used a scissors to cut the soiled dressing from Resident #4's right toe, which had been secured with band-aids. She (#2) described one of the wounds on Resident #4's right foot as a "pin-sized, 0.4 x 0.1 cm, circular, open area to the knuckle on the first toe," and the other as a "0.2 x 0.2 cm, pink, circular (wound) between the big and second toe, with no drainage and good tissue around it." She removed her gloves, washed her hands, and regloved. The nurses (#2 and #3) treated Resident #1's right toe ulcers, removed their gloves, washed their hands, and applied new gloves. The first nurse (#2) stated, "Since she has been having issues with the other foot as well, we'll go ahead and look (at it)." The second nurse (#3) cut a dressing into four pieces, removed her gloves, and exited the room. The first nurse (#2) described the wound on the "first toe (of Resident #4's left foot) as a "1 cm x 0.2 cm red area with a darker scab on it, no drainage, and pink surrounding tissue," the wound on the lateral portion of second toe as a "0.1 cm x 0.3 cm scabbed over area, (with) no drainage or infection around it," and the wound between her fourth and fifth toes as a "1.2 cm x 0.4 cm pink area, open, with scant pink drainage." She (#2) further stated, "I'm worried about the top of her small toe. (There is a) small amount of pinkness." The first nurse (#2) removed her gloves, washed her hands, regloved, and treated Resident #4's left toe ulcers. The second nurse (#3) re-entered Resident #4's room and began writing the date on each of the dressings. The first nurse (#2) told Resident #4 they were going to dress her ulcers with [MEDICATION NAME] and paper tape as "the band-aids could cause irritation." She (#2) also stated, "We'll have talk to (the Nurse Practioner) to fix the order." The second nurse (#3) regloved and put Resident #4's socks and blue boots on her feet. Both nurses then removed their gloves, washed their hands, and exited the room. Although the two nurses (#2 and #3) were aware Resident #4 was "having issues with (her left) foot," they failed to assess and evaluate her skin prior to 11/11/14 at 11:00 a.m.; at which time she had three new ulcers and one area of concern on the top of her small toe. The two nurses (#2 and #3) failed to notify Resident #1's physician of the three new pressure ulcers on her left foot and obtain new orders prior to providing treatment/ulcer care. On 11/12/14 at 1:00 p.m., an administrative nurse (#7) confirmed direct care staff were aware of the ulcers on Resident #4's left foot. She stated, "The bath aide forgot to tell someone about (Resident #4's) toes." - Review of Resident #1's medical record occurred on all days of survey. The significant change MDS, dated [DATE], identified intact cognition, extensive assistance required for toileting and transfers, two current Stage 2 pressure ulcers, bed/chair pressure reducing devices, repositioning program, nutritional interventions, and dressings. Resident #1's vertebrae ulcer/wound data collection forms were completed as follows: 08/30/14, 09/09/14 (10 days), 09/17/14 (8 days), 09/24/14, 10/04/14 (10 days), 10/16/14 (12 days), 10/30/14 (14 days). * 10/30/14, "Stage 2 open area at mid spine" which measured "4 cm in length, 2 cm in width, and 0.1 cm in depth, and had scant tan drainage." The facility failed to provide this surveyor any wound data collection forms for the month of November. Facility staff failed to measure Resident #1's vertebrae ulcer with every dressing change or every seven days per policy. Observation on 11/11/14 at 10:30 a.m. showed two nurses (#2 and #3) removing the soiled dressings from Resident #1's back and buttocks. After they finished treating Resident #1's vertebrae ulcer, they placed new dressings over both areas. The two nurses (#2 and #3) failed to assess and evaluate (i.e.: measure) the status of Resident #1's vertebrae ulcer for progress toward healing. On 11/12/14 at 1:00 p.m., an administrative nurse (#7) confirmed staff are to measure wounds on a weekly basis. The facility failed to: * identify Resident #3's coccyx ulcer prior to the resident's family member bringing it to their attention. * measure Resident #3's coccyx ulcer with every dressing change or every seven days per policy. * accurately document the measurements of Resident #3's coccyx ulcer. * identify Resident #4's right toe ulcer until it had reached a Stage 2 (a shallow open ulcer with a red pink wound bed). * assess (i.e.: measure) the status of Resident #4's right toe ulcers for three days, after being alerted by direct care staff of their presence. * measure Resident #4's right toe ulcers with every dressing change or every seven days per policy. * clarify which of Resident #4's feet (right foot) required treatment prior to entering her room. * report abnormal findings/changes to Resident #4's left foot to the supervising nurse * assess and evaluate Resident #4's left foot prior to 11/11/14 at 11:00 a.m.; at which time she had three new ulcers and one area of concern. * notify Resident #4's primary physician of the three new pressure ulcers on her left foot and obtain new orders prior to providing treatment/ulcer care. * measure Resident #1's vertebrae ulcer with every dressing change or every seven days per policy.

Based record review, review of professional reference, review of facility policy and procedure, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #1), identified as having a history of aspiration pneumonia, received the care and services necessary to attain the highest degree of safety possible while in the dining room. Failure to provide services per physician's order, per dysphagia assessment, and per the resident's current care plan resulted in the resident requiring hospitalization for aspiration pneumonia. Findings include: Review of the facility policy "Dysphagia" occurred on 08/28/13. The policy, revised August 2012, stated, ". . . The DDS (Director of Dietary Services) or designee will update the resident' diet card to include the diet order and swallowing interventions and inform dietary staff . . . Dietary staff will provide all thickened beverages for meals, medication pass beverage cart and scheduled snacks . . ." Review of Resident #1's medical record occurred on August 27-28, 2013, and indicated he was admitted to the facility 08/01/13. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognitive skills and supervision/assistance of one person required for eating, coughing or choking during meals or when swallowing medications, and mechanically altered diet. Physician's Orders, dated 08/01/13, identified, ". . . Diet order: Pureed diet (with) honey thick liquids . . . [MEDICATION NAME] (antibiotic) 750 mg (milligrams) QD (daily) . . . x (times) 7 (days) . . ." The care plan, dated 08/01/13, identified, ". . . Problem: Alteration in nutrition . . . Alteration in respiratory status r/t (related to) aspiration pneumonia (and) swallowing difficulty . . . Approaches: ST (Speech Therapy) to evaluate and treat, Honey thick liquids, pureed diet with 1:1 supervision . . . Liquids by teaspoon only, No straws - No cup sips . . . 1:1 supervision to enforce strategies and monitor tolerance . . ." The Nutrition Assessment, dated 08/03/13, identified, ". . . Pureed, Honey thick . . ." The resident's diet card also identified, "Assist Area: (Resident #1) > Honey thick; 4 oz (ounce) honey juice, 4 oz honey water, 8 oz honey milk." The Dysphagia Evaluation and Plan of Treatment, dated 08/06/13, identified, ". . . Transfer with orders and diet/feeding instructions . . . Transfer orders include honey liquids (and) pureed foods . . . spoon fed. . . ." The Daily Skilled Notes, dated August 1-6, 2013, identified the resident received a pureed diet with honey thickened liquids and an antibiotic for aspiration pneumonia. The notes further indicated, ". . . No c/o (complaint of) discomfort . . . No c/o SOB (shortness of breath) . . . Lung sounds are diminished . . . Occ (occasional) non-productive cough . . . Respirations easy (and) regular . . . No s/s of rep (respiratory) distress. . . ." The 08/07/13 note identified, ". . . No c/o . . . SOB. Lung sounds diminished . . . Remains on oral A/B (antibiotic) for pneumonia . . . Resps (respirations) even easy . . . Finished course of [MEDICATION NAME] today . . . Continues on nectar (sic) thick liquids . . ." The 08/08/13 note identified, ". . . Breakfast this am kitchen gave thin liquids. Talked to dietary. He is still on thickened liquids. . ." The Incident Report, dated 08/08/13, identified, ". . . nurse . . . Noticed kitchen had given thin liquids which he consumed. Notified (Dietary staff). Offered thickened liquids. . . ." The Source of Dysphagia, 3rd Edition, 2007, Nancy B. Swigert. "Thin liquids are the hardest thing to control in the mouth and keep together in a bolus. It is easier to aspirate thin liquids because they break apart and some of the liquid can fall into the larynx. Some residents cough when they aspirate, but others are silent aspirators. Aspirated material entering the airway can cause an incomplete expansion or collapse of [MEDICAL CONDITION] alveoli and can alter the mucociliary clearing action of the lungs and predispose a resident to pneumonia." The Fax Communication to Physician, dated 08/08/13, identified, ". . . Was given thin liquids for breakfast instead of honey thickened. Notified dietary. Consult (with) dietian (sic). Changed back to thickened liquids. . . ." The Daily Skilled Notes identified the following: * 08/09/13, ". . . Continues on honey thick liquids . . . res (resident) c/o severe chest heaviness. Notes "It feels like an elephant is sitting on my chest. . . . To Clinic (with) staff via van . . . (Clinic) called res to be admitted to (Hospital) for observation. . . . * 08/16/13, "He arrived from (Hospital) per facility van . . . He's been hospitalized from [DATE] until the present for aspiration pneumonia. . . . Observation/assessment r/t (related to) his tube feeding which was placed on 08/15/13. . . . Resident is NPO (nothing by mouth) and tube feeding 24 hours continuous . . ." During an interview the morning of 08/28/13, when asked how/why Resident #1 received thin liquids, an administrative dietary staff member (#1) stated, "It was a human error. She put a glass with thin liquids on the table (in front of the resident)." She also confirmed the resident's diet had never been upgraded. He remained on honey thickened liquids since his admission to the facility. The facility failed to ensure Resident #1 received the care and services necessary to attain the highest degree of safety possible while in the dining room, which resulted in the resident requiring hospitalization for aspiration pneumonia and may have resulted in the placement of a feeding tube.