Every finding on record at Griggs County Care Center

Based on record review, review of the North Dakota Provider Manual Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 1 sampled resident (Resident #2) reviewed for PASARR. Failure to complete a change in status assessment with a newly diagnosed mental illness may result in the delivery of care and services that are inconsistent with the resident's needs.Findings include: The North Dakota PASARR Provider Manual, revised December 2020, page 13, stated, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC [mental illness, intellectual disability, and conditions related to intellectual disability referred to in regulatory language as related conditions or RC] was not identified at the Level I screen process, and that condition later emerged or was discovered.Review of Resident #2's medical record occurred on all days of survey and identified a PASARR completed on 08/03/23. A provider progress note, dated 02/12/24, stated, . Psychotic disorder with delusions . The patient endorses a history of fixed false thoughts with disruptive behavior, not insightful when redirected by staff or reoriented by staff . Her psychotropic medications will be adjusted today. Discussed new diagnosis . psychotic disorder with delusions . increase quetiapine [an antipsychotic medication] . for psychosis . The record lacked evidence facility staff completed a PASARR related to the new diagnosis of psychotic disorder with delusions. During an interview on 08/06/25 at 3:00 p.m., an administrative nurse (#1) confirmed the facility failed to complete a change in status Level 1 screen for Resident #2.

Based on observation, record review, review of the Long-Term Care Facility Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 13 sampled residents (Resident #4, #26, and #33). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan, and the care provided to the residents.Findings include: SECTION H: BOWEL AND BLADDER The Long-Term Care Facility RAI 3.0 User's Manual, revised October 2024, pages H-1 and H-2, stated, . H0100: Appliances . Coding Instructions Check next to each appliance that was used at any time in the past 7 days . H0100A, indwelling catheter . Observations on all days of survey showed Resident #4 with a foley catheter. Review of Resident #4's medical record occurred on all days of survey. The annual MDS, dated [DATE], identified facility staff failed to code H0100A, indwelling catheter. SECTION K: SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI User's Manual, revised October 2024, page K-4 stated, . K0300: Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in last 6 months. 0, [for] No or unknown. 2, [for] Yes, [and] not on physician-prescribed weight-loss regimen . Page K-10 stated, . Nutritional Approaches . Check all the following nutritional approaches that apply. B. feeding tube (e.g., nasogastric or abdominal (PEG) [percutaneous endoscopic gastrostomy]) . -Review of Resident #33's medical record occurred on all days of survey. The significant change MDS, dated [DATE], showed staff coded K0300 as Code 2, yes, not on physician-prescribed weight-loss. The medical record lacked documentation Resident #33 lost weight. -Review of Resident #26's medical record occurred on all days of survey. A physician order, dated 04/09/2025, stated, . Enteral Feeding: Peg - Tube . The quarterly MDS, dated [DATE], failed to identify a PEG tube. During an interview on 08/05/25 at 2:18 p.m., an administrative staff member (#2) confirmed the facility failed to code the MDSs accurately.

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#1) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During on interview on 07/29/24 at 11:15 a.m., the dietary manager (#1) stated she is currently enrolled in a certified dietary manager course but has not completed it. The facility failed to ensure the dietary manager (#1) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on observation, record review, review of the facility reported investigation, review of facility policy, stand lift Operator's Instructions, resident interview, and staff interview, the facility failed to provide appropriate safety/supervision to prevent accidents for 1 of 1 sampled resident (Resident #1) who sustained a major injury during an EZ stand lift (mechanical sit-to-stand lift). Failure to follow the facility policy for EZ stand transfers and safety interventions resulted in a fracture of Resident #1's left arm. Findings include: Review of the facility policy titled, EZ Stand Lift occurred on 11/29/23. This policy, revised 02/13/18, stated, . Purpose: To lift and transfer resident/patient safely with as little physical effort as possible. Position the EZ stand in front of the resident/patient. Have the resident/patient place his feet (or help as needed) on platform and position his shins into the shin forms. Place leg strap around legs, buckle, and pull the strap to tighten. The EZ Way Smart Stand Operator's Instructions, page 6, stated, . Use of Shin Pad Strap: If a caregiver deems it necessary to keep a patient's shins or feet on the foot plate, secure the shin strap around the patient's legs. Review of Resident #1's medical record occurred on 11/29/23. Diagnoses included paralytic syndrome (weakness/paralysis) following cerebral infarction (stroke) affecting left non-dominant side and contractures of the left hand and left shoulder muscle. A quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The care plan at the time of the incident indicated EZ stand transfers with one assist. The facility reported a fall incident to the state agency on 11/22/23 and immediately started an investigation. The facility's final investigation report stated, on 11/22/23 at 9:00 a.m., . Resident was being transferred via E-Z stand lift. While transferring, resident's knees gave out and went to the side and her arms 'chicken winged' and started to slide out of the lift. A chair placed under the resident and she was assisted via Hoyer lift. Resident later complained of pain to the left shoulder. She was taken to the emergency department and diagnosed with a closed displaced fracture of the left humerus bone received. Resident to not be lifted all the way up in the lift . may have been lifted too high in the lift which caused her left arm to slip out. During an interview on 11/29/23 at 2:58 p.m., when asked about the events that occurred on 11/22/23, Resident #1 confirmed two staff were present during the EZ stand lift transfer, and stated, They [the CNAs] didn't have my feet on the platform properly before they started to stand me up. When asked if staff used the leg straps during the transfer, she stated no and further stated they never do. During an interview on 11/29/23 at 4:11 p.m., the CNA (#1) stated Resident #1's legs went to the side (indicating to the left) as they began to lift the resident. When asked if she used the leg straps during Resident #1's transfer on 11/22/23, the CNA (#1) stated, No. During an interview on 11/29/23 at 4:34 p.m., two physical therapy staff members (#4 and #5) stated they would expect staff to use the EZ stand as ordered and use the leg straps per facility policy. The facility staff failed to strap Resident #1's legs into the EZ stand lift and ensure the resident was not lifted too high during a transfer which resulted in a fracture.

Based on observation, record review, resident and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #32), with a CPAP (Continuous Positive Airway Pressure) machine. Failure of facility staff to clarify physician's order for cleaning a CPAP resulted in staff incorrectly documenting the cleaning method. Findings include: Review of Resident #32's medical record occurred on all days of survey. Diagnoses included dependence on supplemental oxygen and dependence on enabling machines and devices (CPAP machine). Physician orders included, clean and prepare CPAP machine for nightly use - wash with mild detergent and warm water - water well, mask, tubing, head gear. Allow to air dry. Once a day. Resident #32's care plan stated to use the CPAP as ordered. The Administration History report, dated 09/01/23 to 09/13/23, showed facility staff signed the document that they cleaned Resident #32's CPAP mask and tubing with mild soap and water every morning. Observation on all days of survey showed Resident #32's CPAP mask and tubing connected to a sanitizing device and cleaning machine. During an interview on 09/12/23 at 9:30 a.m. Resident #32 stated the CPAP mask and tubing are placed in the sanitizing device every morning. During an interview on 09/12/23 at 4:10 p.m. an administrative staff member (#1) reported he/she is unaware when Resident #32 received the sanitizing device and confirmed staff failed to update the order. Failure of staff to contact the physician for clarification of the order for cleaning Resident #32's CPAP machine resulted in incorrect documentation of the cleaning method for the CPAP.

Based on review of facility policy, observation, record review and staff interview, the facility failed to ensure staff followed appropriate infection control practices for 1 of 1 sampled resident (Resident #9) observed with pressure ulcers. Failure to follow appropriate infection control practices for pressure ulcer care may result in an infection or worsening of the affected area which could cause a delay in healing for the resident. Finding include: Review of the facility policy titled Skin Care Protocol occurred on 04/21/21. This policy, revised February 2021 stated, The facility must ensure . a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing .1. Dress chronic wounds using clean technique. 2. Cleanse wounds using a non-toxic agent prior to making wound assessment and applying new dressing . Observation on 04/19/21 at 10:45 a.m., showed two certified nurse assistants (CNAs) (#3 and #4) removed dressings from Resident #9's left hip, right and left buttocks, right knee, left shin and sacrum. One CNA (#4) called the nurse to the resident's room to change his [CONDITION(S)] bag that was leaking. A licensed nurse (#5) removed the resident's [CONDITION(S)] bag, cleansed the stoma and surrounding area, and applied the new [CONDITION(S)] bag. The CNAs (#3 and #4) then slid the mesh full body sling under the resident's bare buttocks, sacrum and hips without any dressings or protective undergarments between the resident's open, draining, bleeding pressure ulcers and transferred him into the wheelchair via the lift. The cushion of the wheelchair was covered with a disposable pad. The CNAs failed to provide necessary treatment and services to prevent infection to Resident #9. The CNA (#3) stated on Resident #9's bath days the CNAs always remove the old dressings and get the resident up in the wheelchair before lunch. After lunch, staff bathe the resident, lay him back down and then the nurse applies the new dressings. Observation on 04/19/21 at 1:23 p.m., showed Resident #9 lying in bed on his right side. A licensed nurse (#5) applied collagen powder to the resident's left hip and left buttock covering the ulcers with a protective dressing. The nurse (#5) stated she did not need to clean the wounds prior to applying Resident #9's sterile dressings because they are clean from the whirlpool bath. The nurse (#5) confirmed staff used the same mesh full body sling when they transferred Resident #9 from the bed to the wheelchair, wheelchair to the whirlpool tub and whirlpool back to the bed. A CNA (#6) assisted the nurse (#5) with repositioning the resident onto his left side. The nurse (#5) applied new gloves washing hands in between. She then applied disinfectant spray to his right buttock and sacrum and patted in the collagen powder to the ulcers with both hands. With her soiled gloves the nurse touched several sterile unopened dressings, searching for the appropriate dressing. The nurse (#5) then opened a protective dressing and applied it to the resident's sacrum and right buttock ulcers. With the same soiled gloves the nurse again touched several unopened sterile dressings located in a bucket, pulled out several dressings, opened them, and proceeded to dress Resident #9's left shin and right knee. The nurse then removed the soiled gloves and washed her hands. Per facility policy and physician orders the nurse failed to cleanse Resident #9's left hip and left buttock pressure ulcers before applying prescribed powder and new dressings. The nurse failed to sanitize or wash her hands and don clean gloves prior to sorting through unopened sterile dressings and prior to dressing different pressure ulcer sites. Review of Resident #9's medical record occurred on all days of survey and included the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record included the following physician orders: - . SACRUM. CLEANSE WOUND BED, APPLY COLLEGEN [sic] POWDER TO WOUND BED, . then utilize ABD [abdominal gauze pad] pad . - . LEFT BUTTOCK. CLEANSE WITH SKIN INTEGRITY WOUND CLEANSER . cover with abd pad . - . LEFT HIP. CLEANSE WITH SKIN INTEGRITY WOUND CLEANER . and cover with foam dressing or abd pad . During an interview on 04/20/21 at 4:15 p.m., an administrative nurse (#2) stated she expected staff to change gloves and sanitize or wash hands prior to touching unopened dressings and in between different pressure ulcers. During an interview on 04/21/21 at 5:00 p.m., an administrative nurse (#1) stated she expected staff to apply the appropriate protective dressing between Resident #9's open pressure ulcers and the mesh sling to prevent infection and follow facility policy related to infection control and hand hygiene.

Based on observation and staff interview, the facility failed to maintain safe water temperatures at hand washing sinks in the resident bathrooms in 3 of 4 resident units (North, West, and South). Failure to ensure safe water temperatures may result in injuries/burns to the residents and staff. Findings include: Observations on 09/09/19 from 10:50 a.m. to 12:09 p.m. showed the following water temperatures at the hand washing sinks in the resident bathrooms: - North Unit: * room [ROOM NUMBER] - 137 degrees Fahrenheit (F) * room [ROOM NUMBER] - 141.3 degrees F * room [ROOM NUMBER] - 141.6 degrees F * room [ROOM NUMBER] - 138.2 degrees F - West Unit: * room [ROOM NUMBER] - 146.9 degrees F * room [ROOM NUMBER] - 136.4 degrees F - South Unit: * room [ROOM NUMBER] - 132.8 degrees F * room [ROOM NUMBER] - 126.8 degrees F * room [ROOM NUMBER] - 139.8 degrees F On 09/09/19 at 12:15 p.m., after informing an administrative staff member (#9) and an administrative staff nurse (#8) of the hot water temperatures, both stated they were aware of problems with the water temperatures measuring too cold and had been working with the environmental services staff to rectify this concern. The administrative staff member (#9) stated she would inform the environmental service staff (#10) immediately. During an interview on the afternoon of 09/09/19 at approximately 4:30 p.m., the environmental staff member (#10) stated he turned down the temperature on the water boiler system and completed temperature checks in random rooms. The temperatures measured under 110 degrees F during these checks.

Based on observation and staff interview, the facility failed to securely store medications in 1 of 1 emergency medication kit (E-kit) within the medication room. Failure to securely store medications may result in unauthorized access or diversion of medications. Findings include: Observation of the E-kit occurred on 09/11/19 at 11:35 a.m., in the medication room with a certified medication aide (CMA) (#3). The facility secured the E-kit with a numbered tear away lock. The E-kit contained a blister card of [MEDICATION NAME]/[MEDICATION NAME] 5/325 milligram (mg) tablets. It also contained extra numbered tear away locks. During an interview on 09/11/19 at 11:45 a.m., when asked about the process related to E-kit medications, a staff nurse (#4) stated,an order is obtained and then the medication is used from the E-kit. If needed, the medication is re-ordered and when it is received from the pharmacy, the nurse places a new tear away lock on the E-kit and signs the log, documenting the tear away lock number with either another nurse or a CM[NAME] The facility failed to reconcile the numbered tear away lock on the E-kit to ensure there is no unauthorized access or diversion of medications from the E-kit.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #44) observed with topical (skin surface) medications left in his room. Failure to ensure medications are applied as ordered may result in adverse health effects and medication errors. Findings include: Review of the facility policy titled Medication Administration occurred on 09/10/19. This policy stated, SCOPE: RNs (registered nurse), LPNs (licensed practical nurse), CMAs(certified medication assistant). PURPOSE: Medications are administered as prescribed, in accordance with nursing standards of practice. PR[NAME]EDURE: . 2. Medications are administered at the time they are prepared. Review of Resident #44's medical record occurred on all days of survey. A physician's order, dated 09/05/19, stated, Phytoplex with zinc (skin barrier cream): apply topically to tip of penis at catheter site for redness & (and) irritation BID (twice daily) x (times) 7 days . The medical record lacked evidence of Resident #44's ability to self administer medications. Observation on 09/09/19 at 11:16 a.m. showed an unidentified cream in three small plastic medication cups in Resident #44's room. When asked about the cream, the resident stated, I have a yeast infection or something and stated he applied the cream himself, When my mind remembers. Observation on 09/10/19 at 8:59 a.m. showed a licensed nurse (#2) in Resident #44's room and identified the cream in a medication cup located on the window ledge as Phytoplex. During an interview on 09/10/19 at 2:21 p.m., an administrative staff member (#5) confirmed Resident #44 does not self administer medications/creams and on 09/11/19 at 10:16 a.m., stated a nurse needed to apply the Phytoplex because it contains zinc.

Based on observation, record review, and staff interview, the facility staff failed to provide the necessary care and services for 2 of 2 sampled residents (Resident #23 and Resident #287) with orders for continuous oxygen. Failure to provide oxygen as ordered has potential for residents to experience complications related to inadequate oxygen saturation levels. Findings include: - Review of Resident #23's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. Observation on 09/09/19 at 11:44 a.m. showed Resident #23 in bed with oxygen via nasal cannula at two liters per minute. The resident stated she needs to wear oxygen all the time due to shortness of breath. Observation on 09/10/19 at 11:20 a.m. showed a certified nursing assistant (CNA) (#11) assisted Resident #23 with morning cares. The resident sat on the commode without oxygen in place. The CNA stated Resident #23 wears oxygen continously and she has a hard time breathing. Observation showed Resident #23 was short of breath, grunting, and breathing heavily. The CNA assisted the resident with dressing and grooming. A second CNA (#12) entered the room and assisted with a gait belt/pivot transfer to the wheelchair. The CNA (#12) stated Resident #23's portable oxygen tank (located on the back of her wheelchair) was empty and placed the nasal cannula on Resident #23. The CNA (#12) then transported the resident to the oxygen storage area to replace the tank. - Review of Resident #287's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident's care plan stated, Resident has shortness of breath related to (R/T) [MEDICAL CONDITION] . administer oxygen at (sic) as ordered. Observation of morning cares on 09/10/19 at 8:42 a.m., showed a CNA (#7) removed Resident #287's O2, enabling the resident to wash her face. The CNA (#7) assisted Resident #287 with the remaining morning cares. At 9:04 a.m. (22 minutes later), the CNA (#7) re-applied Resident #287's O2 and transported her to the dining room. During an interview on 09/11/19 at 2:30 p.m., an administrative nurse (#8) stated, They should have made sure her oxygen was on her the whole time.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide a system of accountability for controlled medications in 1 of 1 medication room. Failure to provide a system to adequately receive and dispense controlled medications resulted in Resident #29 receiving a lower dose of medication than ordered and has the potential to result in drug diversion. Findings include: Review of the facility policy titled Narcotic Controls occured on 09/11/19. This policy, dated 10/16/2007, stated . Purpose: To ensure adequate control over and storage of narcotic medications in a secure environment . Procedure: 1. Nurses receive narcotics and immediately log the narcotic on the Narcotic Log kept in the locked cabinet (left side) in the Narcotic Cupboard in the Nursing Home Med Room. This log must contain the date the drug was received, and the nurses' names that received the drug. Narcotic count sheets will also be started at the time the medication is logged in to the facility. The nurse initiating the count sheet will ensure that the name of the medication is written on the count sheet, and will ensure that the appropriate number of tabs is written on the form to initiate the count. 2. Narcotics are to be kept in the cupboard until they are put into use at which time they will be signed out on the log by two nurses or a nurse and a CM[NAME] The log book will be kept at the nurse's station. Review of the narcotic storage cabinet occurred on 09/11/19 at 11:35 a.m. with a staff nurse (#2), and a certified medication assistant (CMA) (#3). The cabinet contained several 30-day supply medication punch cards, including a total of nine cards of varying medications and dosages for Resident #29. Review of one [MEDICATION NAME], a narcotic pain medication, as needed (PRN) card for Resident #29, dated 04/04/19, showed it contained 25 half tablets of 50 milligram (mg) tablets available with five tablets punched out/missing. When asked where the missing five tablets were, the nurse (#2) stated a nurse working on 07/15/19 mistakenly removed the card dated 04/04/19 containing 30 half tablets of [MEDICATION NAME] instead of the card containing 30 whole tablets of [MEDICATION NAME]. Review of Resident #29's nacotic log sheet for the PRN [MEDICATION NAME] 50 mg half a tablet showed five administered between (MONTH) 15-29, 2019. The resident's (MONTH) PRN Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. During an interview on 09/11/19 at 1:24 p.m., a nurse (#1) stated Resident #29 received [MEDICATION NAME] 50 mg half a tablet on 07/15/19 at 12:14 p.m. instead of the scheduled dose of [MEDICATION NAME] 50mg (a whole tablet) because the staff member who administered the medication removed it from the wrong card.

Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), the facility failed to ensure the Minimum Data Set (MDS) reflected residents' status for 2 of 13 sampled residents (Resident #15 and #23). Failure to accurately complete Section [NAME] (Behaviors) and Section N (Medications) does not allow each resident's assessment to reflect their current status/needs, and may result in the development of an inaccurate care plan. Findings include: SECTION E: BEHAVIORS The Long-Term Care Facility RAI Manual, revised (MONTH) (YEAR), page E-1 and E-2, stated, . HALLUCINATION The perception of the presence of something that is not actually there. It may be auditory or visual or involve smells, tastes or touch. DELUSION A fixed, false belief not shared by others that the resident holds even in the face of evidence to the contrary. - Review of Resident #15's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified hallucinations and delusions; however, the resident's medical record lacked adequate evidence of hallucinations and delusions during the seven-day look back period. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised (MONTH) (YEAR), page N-6 and N-7, stated, . Steps for Assessment: 1. Review the resident's medical record for documentation that any of these medications were received by the resident during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). - Review of Resident #23's medical record occurred on all days of survey. A significant change MDS, dated [DATE], identified an anticoagulant used on six days of the seven day look back period; however, the resident's medical record lacked evidence of anticoagulant use during that time.

Based on observation, record review, review of facility policy and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 15 of 15 sampled residents (Resident #3, #9, #11, #12, #15, #16, #17, #22, #23, #25, #26, #31, #32, #33, #36). Failure to review and revise the care plan limited the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings include: Review of the facility policy titled COMPREHENSIVE CARE PLANS occurred on 08/09/18. This policy, implemented on 11/28/17, stated POLICY: To develop and implement a comprehensive person-centered care plan for each resident . includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) . will include objectives and timeframe's to meet the resident's needs as identified in the resident's comprehensive assessment . the objectives will be utilized to monitor the resident's progress . alternative interventions will be documented . the physician or professional will inform resident of the risks and benefits of proposed care . the facility will attempt alternate methods for refusal of treatment and document such attempts in the clinical record . Review of the facility policy titled CARE PLANNING AND RESIDENT ASSESSMENT INSTRUMENT (MDS) occurred on 08/09/18. This policy, revised 08/24/09, stated, POLICY: After a change of status is determined . the comprehensive care plan must be reviewed and revised as necessary . all care plans need to be evaluated and revised as the residents condition changes . updates are done quarterly and as needed (PRN) . Review of Resident #3, #9, #11, #12, #15, #16, #17, #22, #23, #25, #26, #31, #32, #33, #36's care plan showed the facility failed to review and revise the targeted goal dates for identified problem-focused areas on the current care plans. Failure to update the target date for specific goals does not allow the facility to monitor the progress made by the residents to achieve their goals. - An observation on 08/07/18 at 9:41 a.m. showed two certified nursing assistants (CNA) (#6 and #8) toileted Resident #9. One CNA (#6) communicated with the resident, via white marker board, not to bear weight on her left foot and pivot on her right foot. The CNA reported Resident #9 had fallen and broken her left hip in the last couple of weeks. With several prompts and extensive assist of two, the resident transferred from the wheelchair to the toilet and back to the wheelchair by pivoting on her right foot. An observation on 08/07/18 at 11:52 a.m. showed two CNAs (#6 and #9) toileted Resident #9. The CNAs used physical cues to remind the resident not to bear weight on her left foot and pivot on her right foot. With several prompts and extensive assist of two, the resident transferred from the wheelchair to the toilet and back to the wheelchair by pivoting on her right foot. Record review for Resident #9 occurred all days of survey. The care plan indicated . Extensive assist of 1 staff with transfers, weight bearing as tolerated to right foot, left foot may touch the floor with no weight bearing. Pivot transfer . The CNA care card stated . Locomotion: Ext (extensive) x 1 . PIVOT TRANSFER ON RIGHT LEG ONLY TO WHEEL CHAIR . During an interview on 08/09/18 at 9:45 a.m., two administrative nurses (#1 and #2) reported it was difficult to transfer Resident #9 as she did not always follow instructions to be non-weight bearing on the left leg. The administrative nurse (#2) further stated she transferred the resident alone, however, it was difficult. She confirmed staff sometimes used two people to transfer due to it being difficult with only one. The care plan was not revised to reflect Resident #9's current need of transfers by two staff. - Observations throughout the survey showed Resident #22 did not wear heel boots while in bed. Observations on 08/06/18 and 08/07/18 showed staff checked and changed Resident #22 and failed to offer a urinal. Record review for Resident #22 occurred all days of survey. The current care plan and CNA care card indicated check and change every 2 hours. to offer urinal every 2 hours . Heel Protectors on in bed . During an interview on 08/09/18 at 9:45 a.m., two administrative nurses (#1 and #2) reported Resident #22 does not wear heel boots or use a urinal and the staff had not updated the care plan or CNA care card. - Observation on 08/06/18 at 11:44 a.m. showed Resident #17 walking independently to the dining room with his walker. He received oxygen via NC from a Helios portable oxygen unit. The Helios unit was set to CF (continuous flow). Observation on 08/06/18 at 2:45 p.m. showed Resident #17 in his room with the oxygen concentrator set at 3L. The resident stated he received 3L from the oxygen concentrator while in his room and set the Helios to CF while ambulating. Review of Resident #17's medical record occured on all days of survey. A physician's order, dated 07/25/18, identified continuous O2 per NC at 3L. The care plan problem list included, . at risk for decreased cardiac output . resident has shortness of breath . Approaches listed on the care plan included . administer oxygen at 2.5L/NC . administer oxygen at (sic) as ordered . During an interview on 08/09/18 at 9:45 a.m., two administrative nurses (#1 and #2) reported staff had not updated the care plan or CNA care card to reflect Resident #17 received 3L continuous oxygen via NC. - Review of Resident #12's medical record occurred on 08/09/18. The current care plan stated, Problem: . Risk for dehydration r/t (related to) diuretic (water pill) use . Resident #12's physician's orders failed to include a diuretic. The facility failed to revise/update Resident #12's care plan to reflect current medications.

Based on record review and staff interview, the facility failed to ensure the medical record for 1 of 16 sampled residents (Resident #9) accurately reflected the resident's Advanced Directive regarding code status. Failure to ensure the resident's medical record accurately reflected her wishes may prevent emergency personnel from knowing the resident's choices in the event of a medical emergency. Findings include: Review of Resident #9's medical record occurred all days of survey. Resident #9's hard copy medical record had a section titled Advance Directive. A document, dated [DATE], titled HCP (Health Care Provider) ORDERS for Life-Sustaining Treatment stated, Cardiopulmonary Resuscitation(CPR): Person has no pulse and is not breathing. Directions on the form indicated to check one of the boxes. The boxes included Attempt Resuscitation/CPR or Do Not Attempt Resuscitation/DNR (Allow Natural Death). The facility failed to choose one of these options. The electronic medical record indicated Do Not Resuscitate. During an interview on [DATE] at 9:45 a.m., two administrative nurses (#1 and #2) indicated they would expect one of the boxes on the HCP Orders to be checked to indicate the resident's wishes regarding CPR. An administrative nurse (#1) provided another document, dated [DATE], titled ADMISSION HEALTHCARE PROVIDER ORDERS. Under the section CODE STATUS, the box for DNR (Do Not Resuscitate) was marked for Resident #9. The administrative nurse (#1) also stated she would expect both forms and the electronic medical record to all be consistent with the same information of code status.

Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services for 1 of 12 sampled resident (Resident #22) related to perineal skin care. Failure to provide skin care according to each resident's care plan has the potential to result in negative outcomes for residents. Findings include: Observation on 08/06/18 at 3:45 p.m. showed two Certified Nursing Assistants (CNA #3 and #4) used pre-moistened wipes to provide perineal care for Resident #22. The resident stated ouch multiple times during cares and observation showed no redness to the penis. Observation on 08/07/18 at 11:09 a.m. showed a CNA (#6) and a licensed nurse (#5) used a cleanser with dry wipes to provide perineal care. Resident #22 said ouch multiple times during the cares and observation showed redness to the foreskin of the penis. The CNA (#6) reported Resident #22's care card stated staff should not use pre-moistened wipes because they cause irritation to the resident's skin. Review of Resident #22's medical record occurred on all days of survey. The CNA care card stated no tenna wipes/use dry wipes. Resident #22's care plan stated . resident is at risk for skin breakdown . keep skin clean and dry as possible . observe skin with cares and report any signs of skin break down (sore, tender, red, or broken areas). Weekly skin assessment by nurse . provide incontinence care after each incontinent episode . use moisture barrier product to perineal area PRN . During an interview with a staff nurse (#7) on 08/08/18 at 10:22 a.m., she stated CNAs are not to use pre-moistened wipes on Resident #22 and she expected the pre-moistened wipes to be removed from the resident's room. An observation at this same time showed pre-moistened wipes in the resident's bedside drawer. During an interview on 08/09/18 at 9:45 a.m., two administrative nurses (#1 and #2) stated they expected the care plan and the CNA care card to match and CNAs perform cares based on the CNA care card. They expected staff to not use pre-moistened wipes and to remove the wipes from Resident #22's room.

Based on observation, record review, staff interview, and review of professional reference, the facility failed to provide the necessary care and services for 2 of 2 sampled residents (Resident #17 and #25) with orders for continuous oxygen. Failure to provide Resident #17 and #25 with continuous oxygen per physician's orders [REDACTED]. Findings include: Berman and Synder, S., Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice, 9th ed., Pearson Education, Inc., New Jersey, page 1397, stated, OXYGEN THERAPY . Like many medications, oxygen is not completely harmless to the client. Clients receive an inadequate amount or an excessive amount of oxygen and both can lead to a decline in the client's condition. An inadequate amount of oxygen ([MEDICAL CONDITION]) will lead to cell death, and if left untreated can ultimately lead to death. - Review of Resident #25's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current care plan stated resident has shortness of breath R/T (related to) [MEDICAL CONDITION], administer oxygen as ordered, monitor oxygen saturation via pulse oximetry as ordered, monitor and report signs of respiratory distress, monitor lung sounds PRN (as needed). The physician order [REDACTED]. The medical record lacked evidence of nursing assessments of lung sounds and oxygen saturations. Observation on 08/07/18 at 10:19 a.m. showed Resident #25 in his room with oxygen at 3.5L per NC. A staff nurse (#7) entered Resident #25's room and stated she was unsure how many liters of oxygen the resident should be on. The staff nurse (#7) left the room, checked the physician's orders [REDACTED]. Observation on 8/08/18 at 9:10 a.m. showed Resident #25 in his wheelchair. A staff nurse (#7) entered Resident #25 room, noticed the flow set at 2L and changed the rate to 3L. During an interview on 8/07/08 at 10:19 a.m., a staff nurse (#7) stated Resident #25 is on Three liters per nasal cannula continuous flow. During an interview on 08/09/18 11:57 a.m., an administrative nurse (#1) stated Resident #25 should be on 3L of oxygen per NC continuous flow per physician orders. The facility failed to consistently provide Resident #25 with oxygen at the ordered flow rate of 3L. - Observation on 08/06/18 at 11:44 a.m. showed Resident #17 walking independently to the dining room with his walker. He received oxygen via NC from a Helios portable oxygen unit. The Helios unit was set to CF (continuous flow). The resident gasped for air and leaned on furniture and his walker. He stopped at the door to the dining room to ask for a chair to be brought to him as he struggled to go further. Observation on 08/06/18 at 2:45 p.m. showed Resident #17's oxygen concentrator set at 3L while in his room. The resident stated he received 3L from the oxygen concentrator while in his room and set the Helios to CF while ambulating. Record review occurred all days of survey for Resident #17. A physician's orders [REDACTED]. The CNA care card stated O2 @ 3L cont. (continuous). In an interview on 08/09/18 at 9:45 a.m., two administrative nurses (#1 and #2) confirmed Resident #17 received 3L continuous oxygen via NC while in his room and while ambulating. They stated Resident #17 had the Helios unit set to CF when ambulating, however, they could not confirm how much oxygen the unit delivered at this setting. After a call to respiratory therapy, an administrative nurse (#1) reported the Helios unit Resident #17 used delivered 2L of oxygen when set to CF. Failure to deliver oxygen as ordered may have resulted in Resident #17 experiencing increased shortness of breath.

HAND HYGIENE/GLOVE USAGE THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 07/20/17. 1. Based on observation, review of facility policy, and staff interview, the facility failed to follow proper hand hygiene and glove usage for 3 of 15 sampled residents (Resident #22, #26, and #36) observed during personal cares and 3 random observations of water distribution. Failure to practice infection control related to hand hygiene/glove usage has the potential for transmission of communicable diseases and infections to residents and staff. Finding include: Review of the facility policy titled Handwashing occurred on 08/09/18. This policy, revised on 01/26/18, stated, . recommended to use hand sanitizer . before and after assisting a resident/patient with toileting . after performing personal hygiene actions . after removing gloves . - Observation on 08/06/18 at 3:45 p.m. showed a Certified Nursing Assistant (CNA) (#4) provided perineal care to Resident #22 after an incontinent bowel movement. The CNA (#4) removed her gloves after perineal care, transferred the resident to his wheelchair, and placed hearing aid in ear. The CNA (#4) failed to perform hand hygiene after removing her gloves and prior to completing other tasks. - Observation on 08/08/18 at 2:15 p.m. showed a CNA (#12) provided perineal care after Resident #26 had a bowel movement. The CNA (#12) removed her gloves and assisted another CNA (#11) to transfer the resident with a mechanical sit-to-stand lift to her wheelchair. The CNA (#12) adjusted Resident #26's clothes, applied foot pedals to the wheelchair, and then performed hand hygiene. The CNA (#12) failed to perform hand hygiene after removing her gloves and prior to completing other tasks. - Observation on 08/08/18 at 2:30 p.m. showed Resident #36 provided her own perineal cares after going to the bathroom. A CNA (#11) assisted the resident off the toilet and into her wheelchair. The CNA failed to prompt or encourage Resident #36 to wash her hands after the resident provided her own perineal cares. During an interview on 08/09/18 at 12:00 p.m., an administrative nurse (#2) stated she expected staff to use hand sanitizer after removing their gloves. - Observations throughout the day on 08/08/18 and 08/09/18 showed three unidentified staff members entered multiple resident rooms with fresh water mugs and exited with the old water mug. The staff failed to sanitize their hands between the handling of clean and dirty water mugs. During an interview on 08/09/18 at 9:45 a.m., an administrative nurse (#2) reported she expected staff members to gather all the dirty water mugs from a wing, sanitize their hands, and then deliver clean water mugs. The administrative nurse (#2) confirmed the staff failed to follow the process of delivering water and proper infection control. ENVIRONMENT 2. Based on observation, review of facility policy, and staff interview, the facility failed to maintain a clean, safe, and sanitary environment in 1 of 1 laundry room. Failure to clean oscillating fans and maintain facility dryers per manufacture's instructions has the potential to result in an unsafe and unsanitary environment. Review of a facility policy titled Maintenance of Alliance Laundry Dryers occurred on 08/09/18. This policy, dated 07/31/17, stated, . follow the attached instructions for maintaining the Alliance Laundry Systems dryers and will follow the instructions in the Alliance Laundry Systems Operations/Maintenance Manual for recommended routine maintenance. These instructions include guidelines for daily removal of lint from the lint compartments. required to sign off on the appropriate daily check off sheets in the department to indicate the lint removal has been done for the day. A tour of the laundry room occurred on 08/09/18 at 12:30 p.m. with a staff member (#10) and an administrative nurse (#2). Observation showed two large dryers and, upon removal of the vent covers, a thick layer of lint laid on the floor of both dryers. When asked how often staff removed the lint from the dryer vents, the staff member (#10) stated it should be done daily. The staff member (#10) referenced the Alliance Drier Daily Check List hanging above each dryer. He stated staff members initial the check list each day the dryers are cleaned. The check list failed to show staff members removed the lint daily. Observation showed a dirty oscillating fan blowing over the clean laundry area. When asked how often the fan was cleaned, the staff member (#10) stated the fan is only cleaned when laundry staff submit a request for cleaning.

1. Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 2 of 3 sampled residents (Resident #2 and #6) observed during cares. Failure to follow infection control practices related to hand hygiene/glove use and perineal cares has the potential to spread infection within the facility. Findings include: Review of the facility policy titled Perineal Care occurred on 07/19/17. This policy, revised in 2010, stated, PROCEDURE: . 2. Wash hands . 3. Put gloves on . 5. Wash perineum . Cleanse anal area . 7. Remove gloves. 8. Wash hands . 12. Wash hands before leaving the room. Review of the facility policy titled Handwashing occurred on 07/19/17. This policy, revised in 2011, stated, PURPOSE: . Proper handwashing helps prevent the spread of infection from person to person or from one part of the body to another. POLICY: INDICATIONS FOR HANDWASHING: . 3. Before and after resident/patient contact (for which hand hygiene is indicated by acceptable professional practice); . 8. Before and after assisting a resident/patient with personal care . 14. Before and after assisting a resident/patient with toileting; . 21. After removing gloves . 22. After completing duty . - Observation on 07/18/17 at 10:25 a.m. showed two certified nursing assistants (CNAs) (#2 and #3) donned gloves and assisted Resident #2 to the toilet. After the resident voided, the CNAs assisted him to his wheelchair and transported him to the solarium. The CNAs (#2 and #3) failed to perform hand hygiene. - Observation on 07/18/17 at 12:00 p.m. showed two CNAs (#2 and #3) toileted Resident #2 in a hallway bathroom. The resident sat on the toilet and voided. Without providing perineal care, the CNAs raised the resident to a standing position using a mechanical lift and pulled up the resident's incontinence pad and pants. The CNAs removed their gloves and left the bathroom without washing their hands. In the hall, one CNA (#3) applied foot pedals and the other CNA (#2) wheeled the mechanical lift to the storage room, disinfected it, and washed her hands. - Observation on 07/18/17 at 12:15 p.m. showed Resident #6 incontinent of a large amount of soft bowel movement (BM) in her brief when toileted by two CNAs (#2 and #3). Both CNAs, wearing gloves, used wipes to clean the resident's perineal area, the backs of her legs, and the seat of the toilet, which was smeared with BM. Next, the CNAs held onto the resident's gait belt and pivot transferred her to the wheelchair. Both CNAs then removed their gloves and one of the CNA's (#3) washed her hands. The other CNA (#2) wheeled Resident #6 into her room, gave her a drink of water from a cup, brushed her hair, and wheeled her to the dining room. The CNA (#2) walked to another table, pulled a resident's chair away from the table, and then left the dining room to wash her hands. - Observation on 07/19/17 at 8:50 a.m. showed two CNAs (#3 and #4) assisted Resident #2 from bed into the bathroom. The CNA (#4) removed the resident's soiled brief (stool), washed her hands, and applied clean gloves while the other CNA (#3) provided pericares. The CNAs dressed Resident #2, removed their gloves, and assisted him to his wheelchair. One CNA (#4) exited the room with the mechanical lift without performing hand hygiene and the other CNA (#3) assisted the resident with his glasses and hearing aid, combed his hair, and obtained the garbage from the bathroom. The CNA (#3) exited the room with the garbage in hand, transported Resident #2 to the dining room, and then washed her hands in the soiled utility room. The CNA (#3) failed to wash her hands after providing pericares and before exiting the resident's room. - Observation on 07/19/17 at 10:45 a.m. showed two CNAs (#3 and #4) assisted Resident #2 to the bathroom. One CNA (#4) removed the resident's soiled brief (stool) and the other CNA (#3) provided pericares. Without changing gloves, the CNA (#3) applied bag balm (a protective ointment) to the resident's reddened scrotum. The CNAs removed their gloves and assisted the resident to his wheelchair. One CNA (#4) applied gloves, disinfected the mechanical lift, and transported Resident #2 to the solarium while the other CNA (#3) obtained the bathroom garbage. Both CNAs failed to wash their hands after providing personal cares for Resident #2 and failed to wash their hands before leaving the room. During an interview on 07/19/17 at 3:45 p.m., an administrative nurse (#1) stated she expected facility staff to perform hand hygiene after bowel movement (BM) cares and before exiting a resident's room. 2. Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 2 of 3 observations of of residents who required blood glucose monitoring. Failure to follow infection control practices related to disinfecting the glucometer has the potential to spread infection to other residents. Findings include: Review of the facility policy titled Equipment Cleaning/Decontamination for Equipment Potentially Exposed to BloodBorne Pathogens occurred on 07/18/17. This policy, revised in 2010, stated, . BLOOD GLUCOSE MONITOR (Assure Pro (brand name)): This monitor is to be cleaned before and after resident use. Observation on 07/18/17 at 11:55 a.m. showed a nurse (#5) opened a storage pouch which contained a glucometer, placed the pouch/glucometer on a tray, and carried it into Resident #11's room. The nurse checked the resident's blood sugar, placed the glucometer back on the opened pouch and tray, and carried it out to the medication cart. The nurse (#5) disinfected the glucometer and the tray with a bleach wipe and placed the glucometer back on the pouch. The nurse failed to disinfect the glucometer prior to checking Resident #11's blood sugar. On 07/18/17 at 12:00 p.m., the nurse (#5) then carried the pouch/glucometer on a tray into Resident #12's room, checked his blood sugar, placed the glucometer back on the opened pouch and tray, and carried it out to the medication cart. The nurse disinfected the glucometer and the tray, placed the glucometer in the storage pouch, and zipped it closed. The nurse (#5) failed to disinfect the glucometer prior to checking Residnet #12's blood sugar. During an interview on 07/19/17 at 3:45 p.m., an administrative nurse (#1) stated she expected nursing staff to carry the glucometer into a resident's room on a tray and not the storage pouch, and to disinfect the glucometer before and after checking a resident's blood sugar. The facility failured to disinfect the glucometer after it laid in/on the pouch and before checking a resident's blood sugar. This practice has the potential to spread infection to other residents.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide activities of daily living (ADL) assistance to 1 of 3 sampled residents (Resident #2) who required staff assistance with pericares. Failure to provide assistance to residents who cannot perform ADLs independently may result in poor hygiene, skin breakdown, and discomfort. Findings include: Review of the facility policy titled Perineal Care occurred on 07/19/17. This policy, revised in 2010, stated, PROCEDURE: . 5. Wash perineum from front to back with disposable wash cloth. Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #2's quarterly Minimum Data Set (MDS), dated [DATE], identified extensive assistance required for personal hygiene. The current care plan stated, Open area to scrotum . Tx (treatment) as ordered. Monitor . The care plan also stated, Problem: Resident is at risk for skin breakdown R/T (related to) incontinence . Approach: . Provide incontinence care after each incontinent episode . Observation on 07/18/17 at 10:25 a.m. showed two certified nursing assistants (CNAs) (#2 and #3) assisted Resident #2 to the bathroom. As the CNAs lowered the resident onto the toilet he dribbled urine. The CNA (#2) stated the resident has a sore on his scrotum. Observation showed redness and drops of urine on his scrotum. The CNA (#2) then pulled up Resident #2's brief and pants. The CNA failed to provide pericares after he voided. Observation on 07/18/17 at 12:00 p.m. showed two CNAs (#2 and #3) toileted Resident #2 in a hallway bathroom. The resident sat on the toilet and observation showed the resident voided. After Resident #2 finished voiding, the CNAs (#2 and #3) raised the resident to a standing position, lifted up the resident's incontinence pad and pants, and transferred him to his wheelchair using a mechanical lift. The CNA's failed to provide perineal care to Resident #2 after he voided. During an interview on 07/19/17 at 3:45 p.m., an administrative nurse (#1) stated she expected facility staff to perform pericares on all residents whether they voided or had a bowel movement.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident and/or family member/legal guardian, and Office of the State Long-term Care Ombudsman, in writing, of a transfer outside of the facility, including the destination and the reason for the transfer, and the resident's right to appeal the action for 2 of 2 sampled residents (Resident #5 and #7) transferred to the hospital. Failure to provide a notice of transfer does not allow the resident or guardian to make an informed choice regarding the resident's rights. Findings include: Review of the facility policy Transfer and Discharge (including AMA (against medical advice)) occurred on 07/20/17. The policy, dated 01/17, stated: This facility . permit(s) each resident to remain in the facility, and not transfer or discharge the resident from the facility . At least 30 days before the resident is transferred or discharged , the Social Services Director will notify the resident and the resident's representative in writing . Emergency Transfers/Discharges - for medical reasons . Nursing should complete and send with the resident a Transfer Form . The policy lacked the requirement to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. - Review of Resident #5's medical record occurred July 18-19, 2017 and identified the resident seen in the clinic and admitted to the hospital on the afternoon of 05/09/17. The record lacked evidence the facility provided the resident and/or the resident's family member/legal guardian a written notice of transfer. - Review of Resident #7's medical record occurred 07/20/17 and identified the resident transferred to the emergency room and admitted to the hospital on [DATE]. The NOTICE OF TRANSFER FOR hospitalization form included an area to document a copy of this notice has been sent to a representative of the Office of the State Long-Term Care Ombudsman on ____________(date). The form within the medical record lacked evidence the facility sent the notice to a representative of the Office of the State Long-Term Care Ombudsman. During an interview on 07/17/17 at 1:30 p.m., a supervisory nurse (#1) stated staff should complete transfer notices when a resident transfers to another facility including the hospital, and confirmed the facility failed to provide the family/legal guardian of Resident #5 a written notice of transfer and discharge. The staff member acknowledged the ombudsman should also receive a copy of the notice.