Every finding on record at Jourdain Perpich Ext Care Fac

Based on interview, and document review, the facility failed to provide evidence staff were educated on COVID-19 vaccination and ensure records were maintained for 5 of 5 facility staff members (LPN-A, LPN-B, NA-A, NA-B, LA-A) reviewed for COVID-19 vaccination requirements. Findings include:A vaccination education, screening and administration form and/or exemption documentation was requested for the following employees but was not received: licensed practical nurse (LPN)-A, LPN-B, nursing assistant (NA)-A, NA-B and laundry aide (LA)-A.A review of the facility's blank forms identified the following:Religious and/or Spiritual Request for Exemption for Vaccination identified its procedures to implement the requirements of the Employee Immunization Program, Chapter 12, establishing mandatory occupational immunizations for all personnel and providing guidance for requesting medical or religious exemptions consistent with current CDC and Advisory Committee on Immunization Practices (ACIP) recommendations. Employees with an approved religious exemption must comply with facility-directed infection-control measures, including masking and any additional precautions deemed necessary by leadership. Medical Request for Exemption for Vaccination form identified a request for medical exemption may be approved when a licensed independent health care practitioner (LIHCP) certifies that a valid medical contraindication exists which precludes vaccination. Contraindications must align with CDC ACIP 'Contraindications and Precautions to Commonly Used Vaccines' or comparable guidance.Employee Vaccination Screening and Administration form identified the date, name, date of birth , demographic information, illness screening questions and vaccine administration documentation.The Vaccine Information Statement COVID-19 Vaccine: What you need to know dated 1/31/25, identified COVID-19 vaccine can prevent COVID-19 disease. Vaccination can help reduce the severity of COVID-19 disease if you get sick. COVID-19 is caused by a coronavirus called SARS-CoV-2 that spreads easily from person to person. COVID-19 can be mild to moderate, lasting only a few days, or it can be severe, requiring hospitalization, intensive care, or a ventilator to help with breathing. COVID-19 can also result in death.During an interview on 1/7/26 at 1:34 p.m., LPN-B stated she was offered vaccinations every fall, but they were no longer required for employment. LPN-B got really sick from her last COVID-19 vaccine and had chosen not to get another unless things changed. LPN-B stated she received education from her physician but did not recall receiving any education regarding COVID-19 vaccination while at work.During an interview on 1/7/26 at 1:35 p.m., registered nurse (RN)-A stated she was responsible for the facility's Infection Prevention program, but staff vaccinations were done through the clinic. RN-A would provide vaccine education to employees and have employees complete the screening questionnaire but retained no documentation at the facility. During an interview on 1/7/26 at 1:51 p.m., LA-A stated she received her vaccine education and vaccines during a physician visit. My doctor said I couldn't leave until I did it. Stated she did not recall receiving any vaccine education at the facility. During an interview on 1/7/26 at 1:53 p.m., NA-A stated she received COVID-19 vaccine education in 2020. NA-A received her initial COVID-19 vaccine series at the clinic but did not receive a booster this year. They tell us we can get it at the doctor's office. Stated she didDuring an interview on 1/7/26 at 1:55 p.m., LPN-A stated she had not received a COVID-19 booster this year. Stated she had a medical release form signed by her physician that she received in 2020. Stated she had not received any vaccine education at the facility, signed a declination nor provided a copy of her medical exemption for the facility to retain. Stated she was told the facility would provide the vaccine during her new hire employee orientation but that was over a year ago. During an interview on 1/7/26 at 2:01 p.m., NA-B stated he was recently hired at the facility and did receive vaccine education during new hire employee orientation but could not recall what was provided. Stated he had already received his initial COVID-19 series.During an interview on 1/8/26 at 10:44 a.m., the director of nursing (DON) stated she knew the facility did staff vaccinations different than other facilities because staff received their vaccines through the clinic. However, the DON did expect all staff to be educated on vaccines and for the facility to retain documentation as required: either receiving and/or refusing the COVID-19 vaccine. During an interview on 1/8/26 at 11:22 a.m., the administrator stated staff were expected to be educated on vaccines, provided information on how to receive vaccines and it should be documented accordingly. The facility policy COVID-19 Vaccine dated 12/21/20, identified All residents and employees who have no medical contraindications to the vaccine will be offered the COVID-19 vaccination per recommendation to encourage and promote the benefits associated with vaccinations and against COVID-19.

Based on observation, interview and document review, the facility failed to ensure refrigerator temperatures were maintained for 1 of 1 unit kitchenette refrigerator(s); and failed to ensure hairnets were worn effectively when preparing resident meals. This had the potential to affect 23 out of 23 residents who receive meals and snacks from the kitchen and refrigerator Findings include: UNIT REFRIGERATOR: On 1/24/24 at 11:59 a.m., DM-C identified the unit kitchenette refrigerator was stocked with snack food for all the residents. The night shift nursing staff were responsible to check the temperatures of the unit kitchenette refrigerator daily. The refrigerator was observed and contained included the following foods: turkey sandwiches, chocolate pudding made with milk, and an open bottle of hidden valley ranch dressing. The January 2024 fridge/freezer temperature monitoring log identified the unit kitchenette refrigerator temperatures ranged from 32 to 51 degrees Fahrenheit (F), and 12 of the 23 temperatures documented were at 42 degrees F and above. On 1/24/24 at 12:14 p.m., DM-C stated some of the temperature recordings of the unit kitchenette refrigerator were out of range. The temperatures should be between 33-41 degree's F. Storing food at temperatures above 41 degrees F may cause foodborne illness. The current temperature was 40 degree's F; however, DM-C placed a second internal thermometer in unit kitchenette refrigerator to double check the temperature, since there were so many recorded off temperatures. During observation on 1/24/24 at 12:57 p.m., both internal thermometers in unit kitchenette refrigerator read 50 degrees F. During observation on 1/24/24 at 1:48 p.m., both internal thermometers in unit kitchenette refrigerator read 50 degrees F. The facility policy Food Safety Requirements-Resources Information dated 3/4/17, identified a potential cause of foodborne illness was improper storage of food. All food storage refrigerators must be kept at or below 41 degrees F. The United States Food and Drug Administration (FDA) Food Code dated 2022, identified foods requiring refrigeration should be at 41 degrees F or below to prevent food borne illness. HAIRNETS: During observation on 1/23/24 at 11:22 a.m., cook (C)-A was preparing food for lunch. C-A's hairnet was placed about 1.5 inches (in) behind their hairline and about 40 percent of C-A's hair was untucked at the back of hairnet. The untucked hair was hanging about 12 in. down C-A's back. During interview on 1/23/24 at 11:41 a.m., C-A stated she was aware her hair was hanging out of hairnet and that was how she usually wore her hairnet. During interview on 1/23/24 at 11:46 a.m., dietary manager (DM)-C stated she was aware C-A's hair was hanging out of hairnet. DM-C identified it was a long-standing issue and had previously discussed the concern with C-A and C-A's supervisor. On 1/24/24 at 7:12 a.m., C-A was observed preparing food for breakfast. C-A's hairnet was placed about 1 in. behind C-A's hairline and about 25 percent of C-A's hair was untucked at the back of the hairnet. The untucked hair was hanging about 12 in. down C-A's back. During interview on 1/24/24 at 7:17 a.m., cook supervisor (CS)-D stated hairnets were required when preparing and serving food and expected hairnets be worn effectively [all hair contained under the hairnet]. CS-D was aware C-A's hair was hanging out of hairnet and has spoken to C-A about wearing the hairnet effectively and it has been a long-standing issue. During interview on 1/24/24 at 11:10 a.m., DM-C stated it was important to wear a hairnet effectively to prevent food contamination. The facility policy Employee Sanitation Practices dated 3/4/17, identified all kitchen employees should wear hair restraints to prevent hair from contacting exposed food. The United States Food and Drug Administration (FDA) Food Code dated 2022, identified consumers are particularly sensitive to food contaminated by hair. Food employees should wear hair restraints effectively to keep hair from contacting exposed food to prevent food-borne illness.

Based on interview and document review, the facility failed to provide the notice of provider non-coverage (CMS ), or generic notice, upon discontinuation of Medicare part-A services for 2 of 3 residents (R13, R14) reviewed for beneficiary protection notification. Findings include: R13's (skilled nursing facility) Beneficiary Protection Notification Review (CMS- ), completed by the facility, revealed R13's Medicare Part A services started 4/29/19, and the last covered day of Part A service was 5/6/19. The form indicated the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. R13 remained in the facility after 5/6/19. Further record review revealed the facility had provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) (CMS ); however a NOMNC (Notice of Medicare Non-Coverage) (CMS ) had not been provided. R14's CMS- , completed by the facility, revealed R14's Medicare Part A services started 4/17/19, and the last covered day of Part A service was 4/30/19. The form indicated the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. R14 remained in the facility after 4/30/19. Further record review revealed the facility had provided an SNFABN (CMS ), however, a NOMNC (CMS ) had not been provided On 6/4/19, at 2:21 p.m. licensed practical nurse (LPN)-A indicated he had thought the NOMNC form was only required for residents discharged from Medicare Part B so had not given the notice to any of the residents discharged from Medicare Part A services. On 6/4/19, at 3:10 p.m. the director of nursing (DON) verified she would have expected the Medicare notices be provided to residents discharged from Medicare Part A services as required. A policy regarding beneficiary protection notification was requested but not provided.

Based on interview and document review, the facility failed to provide notification to the resident and/or resident representative of the facility's bed hold policy within 24 hours of an emergency transfer on two separate transfers for 1 of 1 resident (R14) who was transferred on both occasions to an acute care facility on an emergency basis. Findings include: R14's Progress Note dated 3/25/19, at 8:22 a.m. indicated R14 had been transferred to the emergency room via gurney, for a spike in temperature and strong urine odor. However, R14's record lacked evidence a bed hold had been offered to R14 and/or R14's representative within 24 hours of the emergency transfer, as required. R14's Progress Note dated 4/6/19, at 8:40 a.m. indicated R14 had been transferred to the emergency room via gurney for an elevated temperature. However, R14's record lacked evidence a bed hold had been offered to R14 and/or R14's representative within 24 hours of the emergency transfer, as required. On 6/4/19, at 11:24 a.m. the bed hold forms were submitted, dated 3/25/19 and 4/8/19, but were not fully completed and were not signed by R14 and/or R14's representative. On 6/5/19, at 9:44 a.m. The director of nursing (DON) confirmed the bed hold policy was to be offered by the nurse at the time of the transfer. Upon review of R14's record, the DON confirmed R14 had not been given a bed hold upon transfer on 3/25/19 and 4/6/19. The Notice of Bed-Hold Policy and Return dated 10/15/2017, indicated the facility was to provide the resident and the resident representative written information about the bed-hold policy at the time of transfer.

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene was completed for 2 of 3 residents (R17, R121) observed during wound care. Findings include: On 6/4/19, at 8:52 a.m. registered nurse (RN)-A was observed to wash her hands, gather supplies and enter R17's room. R17 was seated in a wheelchair, next to the bed. RN-A obtained a garbage bag, opened it, placed it on the bed, and proceeded to set up supplies on the bed. RN-A opened a 2 x 2 gauze package and squirted normal saline from a single use plastic vial into the dressing package. RN-A cut a small piece of [MEDICATION NAME] (a non-adhering dressing) with a bandage scissors and donned clean gloves. Licensed practical nurse (LPN)-B entered the room and assisted by extending R17's right arm while RN-A removed the old dressing from the antecubital (inner elbow) area of R17's right arm and discarded. RN-A removed and discarded her gloves and without performing hand hygiene, donned clean gloves. RN-A observed R17's posterior upper right arm and stated R17 had a posterior blister which was more scabbed than previously observed. The blistered area was noted to be approximately 1.0 inch by 1/2 inch and superficially dried in appearance. RN-A cleansed R17's inner elbow wound with the normal saline soaked 2 x 2 gauze and dried with another dry gauze bandage. RN-A removed her gloves and without performing hand hygiene, donned clean gloves. RN-A measured R17's inner elbow wound using an easy measure grid by placing the transparent grid over R17's wound and traced the wound with a marker. The wound was observed to be closed with a small scab. RN-A placed the small pre-cut [MEDICATION NAME] dressing over R17's wound, held it in place with Kerlix (gauze bandage roll) and taped it in place. RN-A measure R17's posterior blistered area at 2.5 x 1.0 centimeter (cm). LPN-B washed her hands and left the room. RN-A bagged the garbage, brought it to the utility room, washed her hands and cleaned the bandage scissors. On 6/4/19, at 9:15 a.m. RN-A was observed to verify R121's dressing order and obtain wound care supplies. RN-A entered R121's room, washed her hands, obtained a trash bag from the trash can by grasping the trash can with her left hand and pulling a clean trash bag from underneath the trash bag already lining the can. RN-A did not perform handwashing nor use hand sanitizer before placing the trash bag onto the bed to use as a clean surface barrier and placed the clean dressing supplies upon the trash bag. RN-A applied clean gloves, assisted R121 to roll to his left side, assisted to pull down R121's pants, and removed the soiled dressing from R121's ischial (buttock) wound. RN-A stated the wound had filled in nicely and removed and discarded the soiled dressing into the trash can. Without washing her hands or applying hand sanitizer, RN-A applied clean gloves, obtained a sterile 2 x 2 gauze by tearing off top of the package and applied normal saline to the 2 x 2 gauze. RN-A cleaned the wound with the 2 x 2 gauze and normal saline. The wound was noted to be beefy red in color and dry. RN-A dried the wound and surrounding area with a dry 2 x 2 gauze, removed her soiled gloves and discarded them into the trash can and immediately applied clean gloves. RN-A measured the wound using an easy measure grid by placing the transparent grid over R121's wound and traced the wound with a marker. RN-A adhered the easy measure grid onto a worksheet to be kept in the wound book. RN-A proceeded to measure the wound depth by using a sterile cotton swab. After the wound measurements were collected, RN-A removed her soiled gloves, and without washing her hands, placed a small amount of [MEDICATION NAME] (a prescription topical medication used to promote healing of skin ulcers and wounds) into a medication cup. RN-A applied clean gloves and applied the [MEDICATION NAME] to the wound with a sterile cotton swab, covered the wound with a ABD dressing (a thick absorbent gauze pad) that had been cut in half and applied [MEDICATION NAME] tape (a soft, cloth-like surgical tape) to cover the dressing, however, removed her gloves to finish taping due to the tape sticking to her gloves. RN-A dated and initialed the wound dressing, gathered the used supplies and placed them into the trash bag they had been placed on, brought the bagged garbage to the soiled utility room, discarded the trash, and washed her hands in the sink. On 6/4/19, at 9:32 a.m. RN-A verified during the aforementioned wound care observations, she did not perform hand washing nor used hand sanitizer between applying/removing clean and dirty gloves. RN-A proceeded to state her normal routine was to perform hand washing every 2-3 pairs of gloves used or when her hands were visibly soiled. On 6/4/19, at 9:54 a.m. the director of nursing (DON) reviewed the handwashing policy and verified hand washing or hand sanitizer would be expected after removing soiled gloves. The facility's policy titled Handwashing/Hand Hygiene directed staff to perform hand hygiene after removing and disposing of personal protective equipment (such as gloves). The policy further stated the use of gloves did not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare associated infections.

Based on interview and document review, the facility failed implement a program which would include a completed risk assessment to reduce the risk of Legionella (a bacterium) in the facility water system to prevent cases and outbreaks of Legionnaires' disease (a serious type of pneumonia). This had the potential to effect all 25 residents in the facility. Findings include: On 4/27/18, at 10:45 a.m. maintenance director (MD) indicated the facility had not yet developed a water management program or completed a risk assessment. -At 11:13 a.m. administrator confirmed the facility did not have their own water management program. The administrator indicated the nursing facilities water entered through the connecting hospital and was not aware if the hospital had included the nursing facility into their water management program. -At 11:45 a.m. hospital maintenance staff member indicated they were responsible for testing water quality over in the hospital and confirmed the hospital had not included the nursing facility into their water management program. Facility policy Legionella Water Management Program dated (MONTH) (YEAR), included: 1. As part of the infection prevention and control program, our facility has a water management program which is overseen by the water management team. 3. The purposes of water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 5. The water management program includes the following elements: -a detailed description and diagram of the water system in the facility -identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne pathogens -identification of situations that can lead to Legionella growth -specific measures used to control the introduction and/or spread of Legionella (e.g. temperature, disinfectants). -Control limits or parameters that are acceptable and that are monitored -a diagram where control measures are applied -A system to monitor control limits and effectiveness of control measures -a plan when for when control limits are not met and/or control measures are not effective.

Based on observation, interview, and document review, the facility failed to comprehensively assess, analyze, track and trend facility infections so effective interventions could be implemented to help minimize the risk of facility infections for 26 residents who resided in the facility. In addition, the facility failed to ensure hygienic cigarette lighting practices were implemented for 1 of 7 residents (R17) observed to be smoking. Findings include: The facility Infection Control Log's were reviewed for December 2016, January 2017, and February 2017. The logs included resident name, room, dates of treatment, date of onset, date of admission, admitted or acquired, type and site of infection, signs and symptoms, culture results, x-ray results, and antibiotic information. December 2016, Infection Control Log included five infections that were facility acquired but did not list signs and symptoms of the infection or a resolution date of symptoms to determine if the treatment was effective. The infections included a left breast infection, one urinary track infections, one wound infection, and one case of clostridium difficile (contagious bacteria causing severe diarrhea). The December analysis indicated that Tinea Pedis (fungal infection) continued to be a chronic issue for two to three residents who received ongoing treatments. The analysis did not indicate an investigation for the chronic fungal infections, to include environmental cleaning or observation of personal cares to determine potential causal factors. There was no indication of how one resident could have developed a facility acquired breast infection. January 2017, Infection Control Log included eight infections that were facility acquired, but there was no listing of the residents signs and symptoms or a resolution date of symptoms to determine if the treatment was effective. The infections included one case of strep, one breast infection, four urinary track infections and two skin infections. The January analysis did not indicate any trends were identified. However, there was one breast infection in December 2016, with a subsequent breast infection, which developed in January of 2017, these residents were two rooms away from each other, and on the same side of the hallway. Also, the facility had an increase in urinary tract infections and there was no indication that an analysis was conducted as to why there was an increase in infections, or any interventions or surveillance the facility completed to help reduce the incidents of urinary tract infections. February 2017, Infection Control Log included three infections that were facility acquired, but did not identify the signs and symptoms of the infections or a resolution date of symptoms to determine if the treatments were effective The infections included one cellulitis of the feet, one fungal infection and one wound infection. February's analysis indicated no trends. However, the analysis lacked an investigation into the cause of the wound infection and a new onset of a fungal infection, which the facility has already identified as two-three residents having a chronic problem in their December 2016 analysis. During interview on 3/9/17, at 7:41 a.m. the designated infection Preventionist registered nurse (RN)-B stated she obtained infection control information from working on the floor, report and looking at a log when medications were initiated. RN-B stated she tracked the information on the log and made sure the appropriate interventions to monitor resident infections were initiated. RN-B stated she looked for trends in infections on a weekly basis. RN-B stated the form she used didn't leave enough space to track the signs and symptoms of infections, so signs and symptoms were not tracked. RN-B also stated that she tracked the duration of the treatment of [REDACTED]. RN-B stated the only trends noted were in December regarding fungal infections but no investigation or surveillance was conducted to determine why and how to prevent reoccurrences. RN-B stated January's analysis did not identify an increase in urinary tract infections and had not noticed any patterns. RN-B stated the facility had improved their infection control monitoring in the last year but it still wasn't one hundred percent, and it does not get the commitment it deserves because of having numerous responsibilities within the facility. During interview on 3/9/17, at 9:01 a.m. the director of nursing (DON) stated the facility was small and when RN-B worked she then collected the data needed to monitor infections. The DON stated that RN-B does an analysis of the infections and brings the information to the quality assurance meetings. The DON stated infections are to be reviewed for signs and symptoms for each residents and these signs and symptoms needed to be tracked. HYGIENIC CIGARETTE LIGHTING During observation on 3/8/17, at 11:38 a.m. R17 was seated in her wheelchair near the exit door to the courtyard. R17 had a previously smoked butted cigarette in her mouth but it was not lit. The activity aid (AA)-B assisted R17 to zip up her coat and then wheeled R17 out to the courtyard. R17 attempted to light her cigarette multiple times and was unable. AA-B attempted to light R17's cigarette, while R17 held the cigarette in her mouth but was unable to. R17 then handed her butted cigarette to AA-B. AA-B put R17's cigarette in her own mouth, lit it and handed it back to R17 to smoke. When R17 finished the cigarette AA-B pushed R17 in the wheelchair back into the building. During interview on 3/8/17, at 11:58 a.m. R17 stated she had AA-B assist her with lighting her cigarette today because it was so windy. During interview on 3/8/17, at 12:00 p.m. AA-B stated she lit R17's cigarette because it was so windy, and R17 asked her to light her cigarette. During interview on 3/9/17, at 8:04 a.m. RN-B stated staff should not be putting a cigarette in their own mouths and giving it back to a resident to smoke. That's a huge no, no. RN-B further stated staff could have a virus or disease and could give it to the resident. During interview on 3/9/17, at 9:01 a.m. the DON stated staff putting a cigarette in their own mouths and giving it back to a resident to smoke was unacceptable and the staff need to be re-educated. The facility policy Infection Control & Control Program dated 2/2/17, identified the facility would provide, A system of surveillance, designed to identify possible communicable diseases or infections before they can spread to other persons in the facility.

Based on interview and document review, the facility failed to ensure the consulting pharmacist completed a comprehensive review of the medication regimen at least monthly for 5 of 5 residents (R12, R23, R5, R13, and R9 ), reviewed for unnecessary medication use. Findings include: R12's Pharmacist Medication Regimen Reviews, dated 4/20/16 through 3/8/17, identified a column of listed dates in which R12's medication regimen had been reviewed, with each date and Comments/Recommendations, being provided and signed by the consultant pharmacist. The listing identified that R12's regimen had been viewed on the following dates: - 4/20/16, with Recommend d/c (discontinue) hydroxyzine, No use in last month identified; - 6/27/16 (68 days after last review), with No issues, identified; - 8/18/16 (52 days after last review) with No issues, identified; - 9/30/15 with No issues, identified; - 11/23/16 (52 days after last review), with No issues, identified; - 12/20/16, with No issues, identified; - 1/25/17, with, No issues, identified and; - 3/8/17 (41 days after last review) with No issues, identified. R12's medical record lacked any documented evidence R12 had been seen in the periods of missing dates identified on the medication regimen review listing. R23's quarterly Minimum Data Set (MDS) on 01/31/2017 identified a [DIAGNOSES REDACTED]. The facility monthly Pharmacist Medication Regimen Review forms from April 20, 2016 thru March 8, 2017 identified R23 was on medication for [DIAGNOSES REDACTED], depression, pain, diabetes , high blood pressure and atria fibrillation (quivering or irregular heart beat). The monthly pharmacist reviews from April 20, 2016 thru March 8, 2017 identified the pharmacist completed monthly reviews on the following dates: 4/20/16, no issues identified 6/27/16, (68 days after last review), with no issues identified 8/16/16, (50 days after last review), with no issues identified 9/29/16, no issues identified 11/21/16, (52 days after last review), and recommend family care planning for palliative care 12/20/16, comfort care only 1/25/17, no issues, comfort care 3/8/17, (41 days after last review) and recommend increase in pain medication There were no indication in the medical record the pharmacy reviews were completed for the months of May 2016, July 2016, October 2016, and February 2017. R5's Pharmacist Mediation Regimen Reviews dated 1/13/16 through 3/8/17, identified a column of listed dates in which R5's medication regimen had been reviewed with each date and, Comments/Recommendations, being provided and signed by the consultant pharmacist. The listing identified R5's regimen had been reviewed on these dates: - 4/20/16, with No issues, identified; - 6/27/16 (68 days after last review), with No issues, identified; - 8/1716 (51 days after last review), with No issues, identified; - 9/29/16, with No issues, identified; - 11/21/16 (52 days after last review), with No issues, identified; - 12/20/16, with No issues, identified; - 1/26/17, with, Recommend to DC nystatin powder, identified and; - 3/8/17 (40 days after last review) with No issues, identified. R5's medical record lacked any documented evidence R5 had been seen in the periods of missing dates identified on the medication regimen review listing. R13's Pharmacist Mediation Regimen Reviews dated 1/14/16 through 3/8/17, identified a column of listed dates in which R13's medication regimen had been reviewed with each date and, Comments/Recommendations, being provided and signed by the consultant pharmacist. The listing identified R13's regimen had been reviewed on these dates: - 4/21/16, with No issues, identified; - 6/29/16 (69 days after last review), with No issues, identified; - 8/18/16 (50 days after last review), with No issues, identified; - 9/30/16, with No issues, identified; - 11/23/16 (54 days after last review), with No issues, identified; - 12/21/16, with No issues, identified; - 1/25/17, with, GDR attempts for Duloxetine and Seroquel, identified and; - 3/8/17 (41 days after last review) with No issues, identified. R13's medical record lacked any documented evidence R13 had been seen in the periods of missing dates identified on the medication regimen review listing. R9's Pharmacist Mediation Regimen Reviews dated 12/20/16 through 3/8/17, identified a column of listed dates in which R9's medication regimen had been reviewed with each date and, Comments/Recommendations, being provided and signed by the consultant pharmacist. The listing identified R9's regimen had been reviewed on these dates: - 12/20/16, with No issues, identified; - 1/26/17, with, No issues, identified and; - 3/8/17 (40 days after last review) with d/c bubropion, identified. R9's medical record lacked any documented evidence R9 had been seen in the periods of missing dates identified on the medication regimen review listing. During interview on 3/9/17, at 2:37 p.m. the consulting pharmacist (CP)-A stated the tribe had contracted with IHS (Indian Health Service) which was attached to the hospital, to conduct monthly pharmacy medication reviews. After CP-A reviewed the pharmacist medication review records, identified there were a few months of missing reviews. CP-A stated, there were two pharmacists that completed the monthly reviews, and the missed reviews could be due to scheduling issues.

Based on observation, interview and document the facility failed to ensure a comprehensive activity assessment was developed to meet individual needs for 2 of 3 residents (R23, R9) reviewed for activities. Findings include: R23's quarterly Minimum Data Set (MDS) on 1/31/2017, identified a [DIAGNOSES REDACTED]. During interview with R23 on 3/06/2017 at 3:15 pm stated, she periodically gazes at the television, looks outside and listens for the hospital helicopter come in for a landing, (helicopter pad right outside R23's window). She stated that every day she had periods of boredom. During interview on 3/7/17 in the afternoon NA-B stated (R23) likes to play bingo. Staff will ask her to go but it depends on how she feels. She mostly stays in her room but does come out when she wants to, and they do see activity staff in her room, but they were unsure of what they do. During observation on 3/8/17 at 11:41 R23 was in her room in bed with the television on. At 12:50 R23 placed her call light for a drink of water, and at 1:12 p.m. R23 remained in bed in her room. In an interview on 3/8/17 at 1:12 NA-D, stated R23 frequently turns her call light on 20 times a shift for either a drink of water, to be repositioned or to do things in her room. During observation on 3/9/17 at 8:27 a.m. R23 was in bed in her room, asleep. Review of R23's Activity Interview of Daily and Activity Preferences sheet dated, 7/20/16 identified it was very important for R23 to have books and newspapers to read, music, to be around animals, do favorite activities, get fresh air and participate in religious services. There was no indication of what type of music, books, newspaper she preferred, what her favorite actives were, or what religious service she preferred. R23's care plan last revised on 2/15/17 identified resident prefers not to participate in group activities, enjoys playing bingo occasionally and going shopping. The goal was the resident would express satisfaction with the type of activities and level of involvement. Staff were directed to encourage the resident to participate by inviting resident to group activities, modify daily schedule, treatment plan as needed to accommodate activity participation as requested by the resident. Resident needs 1:1 time with activity staff three times a week. Although the care plan identified R23's preferred not to participate in group activities, the care plan directed staff to invite and encourage R23 to attend group activities. Review of the February 2017 JPECC (Jourdain Perpich Extended Care Center) Activity Flow Sheet identified R23 had seven 1:1 visits, and not twelve 1:1 as identified by the care plan. Review of the Activity Progress Notes from the 2/1/17 thru 2/24/17 identified the 1:1 visits consisted of asking how her day was, and the weather. R23's response was she wanted to be moved in bed, wanted a drink, her bathroom door close, and other care requests. Review of the January 2017 JPECC Activity Flow Sheet identified R23 had 13 1:1 visits. Review of the Activity Progress Notes from 1/3 to 1/30/17, identified the 1:1 visits consisted of asking about the residents mood, how her day was, weather, and her family. R23's response was she was fine, complained about not being able to move her arms, and was uncomfortable. She requested staff to reposition her, help her get a drink or do other various things in her room. Review of the December 2016 JPECC Activity Flow Sheet identified R23 had ten 1:1 visits, and not twelve 1:1 visits as identified by the care plan. Review of the Activity Progress Notes from 12/5 thru 12/25/16, identified the 1:1 visits consisted of asking how she felt, how her day was and her family. R23's response was complaining that someone under her bed, burning and fire. The notes also identified R23 did play bingo in the evenings. During interview on 3/9/17 11:40 a.m. Activity Assistant (AA)-A stated R23 does come to some activities but it varies depends on how she is feeling. At 12:00 p.m. AA-B stated she does 1:1 visits with R23, but she was unsure of what her likes, past preferences or what things to talk with R23 about. We ask her how she feels, and then she makes us do thing for her like getting a sip of water, helping her move or doing other things for her in her room. During interview on 3/9/17 at 1:30 Activity Director (AD) stated they use the facility Activity Interview of Daily and Activity Preferences sheet and answered the questions. She stated they do not go into much detail about the areas on the interview sheet that would identify type of music, books, region or what their favorite activities were. AD stated they do not have an assessment that identifies their likes, dislikes or past experiences. They needed to develop something that will help them with their preferences and would assist staff when they do 1:1's with resident. Although the facility activity assessment only identified how important certain aspects were to R23's life. The assessment did not identify R23 preferences, likes, dislikes or what specific things she enjoyed, or any past history which may assist in development of R23's 1:1 sessions with activity staff. Although R23 care plan identified she doesn't like group activities, her care plan directs staff to invite her to group activities. The care plan also identified R23 was to have three 1:1 visits each week, which did were not consistently implemented. R9's annual Minimum Data Set ((MDS) dated [DATE], indicated R9 was cognitively intact and had a [DIAGNOSES REDACTED]. R9's medical record lacked a comprehensive activity assessment. R9's care plan dated 5/28/16, indicated R9 was independent for meeting her emotional, intellectual and social needs. The care plan directed to Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self expression and responsibility. The care plan also indicated R9 preferred activities were: going to the casino, current events, fish fry, movies, bingo, social time, women's group, saging and reading books. During interview on 3/7/17, at 1:10 p.m. R9 stated there were not enough activities offered by the facility during the evenings. During observation on 3/8/17, at 1:23 p.m. R9 was in the day room watching a movie with other residents and eating popcorn. During observation on 3/8/17, at 2:28 p.m. R9 was in bed sleeping, while bingo was going on in the day room. During interview on 3/8/17 at 6:04 p.m. nursing assistant (NA)-C stated at times R9 gets sad and anxious. NA-C stated that R9 enjoys outings to the casino , shopping and movies. There was nickel bingo after six in the evening about three times a week. Nickel bingo used to be everynight of the week, however; due to a lack of activity staff it had been reduced to three times a week. NA-C stated the only activity offered in the evenings was bingo. During follow up interview on 3/9/17, at 7:09 a.m. R9 stated staff invited her to bingo the night before but she declined. R9 further stated the facility only has nickel bingo in the evenings and she didn't like nickel bingo. She didn't like bingo all the time and nothing else was ever offered in the evenings, like a movie or something else. R9 stated in the evenings she ended up watching television in her room or going to bed early, because she got bored. R9 stated she didn't recall anyone asking her, her likes and dislikes regarding activities, upon readmission to the facility in December. R9's progress notes indicated the following: - 2/9/17, at 1:27 p.m. R9 never came to bingo. - 2/14/17, at 6:25 p.m. R9 declined to play nickel bingo. - 2/17/17, at 3:23 p.m. R9 did not want to play prize bingo. - 2/17/17, at 8:00 p.m. R9 declined to play bingo. - 2/19/17, at 8:16 p.m. R9 declined to play bingo. The facility activity calendars were reviewed from December 2016 through March 2017 and indicated the following: - December 2016, included nickel bingo every evening at 6:30 p.m., it did not include any other activities in the evening. - January 2017, included nickel bingo in evening at 6:30 p.m.,for all days except six days, it did not include any other activities in the evening. - February 2017, included nickel bingo in evening at 6:30 p.m.,for all days except seven days, it did not include any other activities in the evening. - March 2017, included nickel bingo in evening at 6:30 p.m.,for twelve days, it did not include any other activities in the evening. During interview on 3/9/17, at 11:41 a.m. NA-D stated the only activity offered in the evening was bingo. During interview on 3/9/17, at 1:49 p.m. the activity director (AD) stated that a comprehensive activity assessment had not been completed on R9, and currently was just completing the activity Activity Interview for Daily and Activity Preferences portion of the MDS, which was not comprehensive. The AD stated that R9's care plan was developed on what activities R9 attended had attended in the past. The AD further stated the only activity being offered in the evening was nickel bingo three times a week. The AD stated that she was hoping to increase activities next month, by increasing the staff numbers.

Based on observation, interview and document review, the facility failed to ensure consistent foot support was provided for 1 of 3 residents (R5) reviewed for wheelchair positioning and whose feet were unsupported. Findings include: R5's quarterly Minimum Data Set ((MDS) dated [DATE], identified R5 had severe cognitive impairment and [MEDICAL CONDITION] (paralysis of one side of the body) with a, Functional Limitation in Range of Motion on one side in her lower extremities. Further, the MDS identified R5 used a wheelchair for mobility and required extensive assistance with locomotion both on and off the unit. R5's care plan dated 2/22/17, identified R5 had, An ADL (activities of daily living) self-care performance deficit, and required assistance to complete her ADLs. The care plan listed several interventions for the staff to implement which included, LOCOMOTION: Resident uses custom wheelchair, staff to wheel her from one location to another. Unable to ambulate. The care plan did not address any specific interventions for R5's positioning in the wheelchair. During observation on 3/6/17, at 5:29 p.m. R5 was seated in a non-reclined position in a high back tilt-n-space wheelchair in the commons area by the dining room watching television. R5's knees were bent at a 90 degree angle and her feet were unsupported causing them to dangle with her left foot pointing downward while seated in the wheelchair. R5 stated her feet were, Sore. When observed on 3/8/17, at 12:26 p.m. R5 was seated in the same high-back wheelchair in a reclined position by the nurses desk. R5's feet remained unsupported and dangling in the wheelchair with her left foot pointing downward. Further, during subsequent observation on 3/8/17, at 6:28 p.m. R5 was seated in her wheelchair in the day area by the nurses desk. However, R5 now had her feet supported with a black colored platform which caused her feet to not dangle. When interviewed on 3/8/17, at 6:39 p.m. nursing assistant (NA)-A stated R5's foot support had, Always been there, since her shift started on 3/8/17, at 2:00 p.m. adding R5's foot support should always be in place when she was in her wheelchair. During interview on 3/8/17, at 6:45 p.m. NA-B stated her, along with other NA staff, had assisted R5 to her wheelchair from bed earlier that day. NA-B stated after R5 was in her wheelchair, the occupational therapist (OT)-A entered R5's room and picked up the black foot support from a sitting chair along the wall. OT-A then placed it on R5's wheelchair. When interviewed on 3/9/17, at 8:25 a.m. licensed practical nurse (LPN)-A stated R5 had used the tilt-n-space wheelchair for the past several months, using the black platform to, Help support her feet. LPN-A stated R5 should be using the platform when she is seated in the wheelchair to, Help prevent her feet from dropping down further than their supposed to be, adding the platform was, Like a supportive device. During interview on 3/9/17, at 12:55 p.m. registered nurse (RN)-A stated a resident should not be left in a wheelchair with their feet being unsupported. When interviewed on 3/9/17, at 1:01 p.m. OT-A stated she was currently working with R5 for orthotic placement (hand splint) and had noticed R5's foot platform was not attached to her wheelchair on 3/8/17, and, Thought it was strange. OT-A stated she found the platform in R5's room and then, Put it back on. OT-A stated R5 should have the foot platform in place when she is in the wheelchair, To my knowledge, adding she had, Never seen it not on, before. Further, OT-A stated residents should, Have their feet supported in some way. An undated facility Repositioning Level II policy identified a purpose of, The evaluation of resident repositioning needs, and To promote comfort for all bed -or-chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. However, the policy lacked any direction or procedures to ensure residents had proper wheelchair positioning including adequate foot support while using their wheelchair. A facility policy on wheelchair positioning was requested, but none was provided.

Based on observation, interview and document review the facility failed to comprehensively assess residents for safe smoking habits while residing in the facility for 2 of 3 residents (R1 and R17), reviewed for safe smoking. Findings include: R1 was admitted to the facility on ,[DATE]. R1's [DIAGNOSES REDACTED]. On 1/12/12, the [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) of 1/17/17 identified that resident was cognitively intact and required extensive assistance with activities of daily living including dressing and mobility. R1's care plan initiated on 9/10/15, and revised on 1/27/17, identified R1 was a smoker and denied desire for cessation. The interventions included staff instruction of resident about the smoking policy on smoking, locations, times, and safety concerns. On 3/7/17, at 2:05 p.m. R1 was observed lighting a cigarette inside the facility, near the activity door. Activity assistant (AA)-A, saw this, gasped, and then quickly assisted R1 outside to the designated smoking area. AA-A returned and stated she has seen R1 light his cigarette inside the building, and they watch residents so they do not do this. AA-A stated she spoke with R1 about not lighting his cigarette, and he understood the need to light the cigarette outside. She would let the nurse know what happened. AA-A went on to state that R1, butted his cigarette out and placed the unused portion of the cigarette back into the package of cigarettes. AA-A stated she had not seen any burn holes or burns on R1 from his cigarettes. On 3/7/17, at approximately 3:15 p.m. administrator (ADM) and director of nursing (DON) informed the survey team they followed up with R1 regarding lighting his cigarette in the facility. The ADM stated, R1 only initiated lighting his cigarette in the facility because of the extreme winds. R1 was aware of the facility policy and if there were ongoing problems, staff would then have to keep the cigarettes and matches on the medication cart. Review of R1's Smoking Safety Screen of 2/8/17 identified the Resident alert and oriented x 3, demonstrates ability to smoke safely and unsupervised. Additional notes on this screen identified R1 has been reminded of designated smoking area but has been witnessed smoking in other areas. Will review if resident continues to smoke in prohibited areas and implement restrictions per smoking policy. The smoking assessment did not identify R1 butted his cigarettes, and placed the unused portion back into the cigarette package. During interview on 3/9/17, at 12:06 p.m. the ADM stated facility staff had noticed residents were lighting cigarettes inside the building before going out to the smoking area. He also added. that cigarettes are to be disposed of in the receptacle with no No butting out. The ADM stated residents were to follow this policy or they would not be allowed independence with their cigarette use. During interview on 3/9/17, at 12:56 p.m. nursing assistant (NA)-D stated R1 has been observed lighting cigarettes before exiting the building on more occasions, Quite often if the weather was cold. NA-D also stated R1 has smoked in front of the building, outside of the designated smoking area, on an almost daily basis. NA-D stated she had observed R1 light his cigarette between the entrance and exit doors when smoking in front of the building, beyond the designated smoking area. During interview on 3/9/17 at 1:16 p.m. NA-E stated R1 had lit his cigarettes in the activity room at least monthly. He opened the door, lights a cigarette, and rolled out to the smoking area. NA-E stated R1 had previously attempted to smoke out in front of the building but had been instructed to only smoke in the designated smoking area. Although R1 had unsafe smoking habits, which the facility was aware of. The facility had not comprehensively assessed R1's smoking habits to ensure he could safely smoke independently. R17's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R17 had moderate cognitive impairment and required limited assistance to areas off the unit. R17's Admission Record (undated) identified [DIAGNOSES REDACTED]. R17's Smoking- Safety Screen- V2, dated 2/7/17, indicated R17 had a cognitive loss and a visual deficit. The smoking screen indicated R17 smoked two to five cigarettes a day at all times of the day. The smoking screen indicated R17 could light her own cigarette and didn't need adaptive equipment or the facility to store the resident's cigarettes and lighter. The screen indicated, Resident refuses to wear smoking apron, has poor eyesight, dementia, fall risk. Is able to light own cigarette, staff continue to monitor resident for burns on clothing/skin. Resident refuses to throw away old clothing with cigarette burns. Encouraged to alert staff when going out to smoke. Resident has right to refuse interventions. Resident able to smoke unsupervised, will review if safety becomes a concern and implement restrictions per policy. R17's care plan dated 4/18/16, indicated The resident is a smoker. Resident is non-compliant with allowing staff to keep cigarettes, will acquire cigarettes without staff knowledge and put them in her purse/bra, non compliant about notifying staff when wanting to go smoke. Resident has been non- compliant and refuses to wear a smoking apron. Resident educated on the risks and benefits of smoking and declines smoking cessation at this time. Resident had clothing with cigarette burns upon admission and refuses to throw out damaged clothes. Trial use of electronic cigarette unsuccessful. Resident used intermittently, when out of regular cigarettes, but verbalizes desire for regular cigarette use. Interventions included were; Encourage resident to store smoking supplies in the south med cart, encourage to let staff know when going out to smoke and encourage to wear a smoking apron, Instruct resident about the facility policy on smoking; locations, times, safety concerns, Observe clothing and skin for signs of cigarette burns q (every) NOC (night) shift and notify charge nurse if noted. Observe for any burns to clothing/skin and report to nurse if noted. R17's undated Visual/Bedside Kardex Report directed staff to Observe for any burns to clothing/skin and report to nurse if noted. During observation on 3/6/17, at 2:50 p.m. R17 told a staff member she was going out to smoke. R17 used the automatic button to the courtyard door and wheeled herself in her wheelchair outside. R17 did not have a smoking apron on. R17 removed a cigarette and lighter from her purse and lit her cigarette. While smoking R17 brushed her hand over her pants several times. She then extinguished her cigarette in the ashtray, and wheeled herself back into the facility. R17 did not have any burn holes in her clothing or signs of ashes on her pants. During observation on 3/8/17, at 11:38 a.m. R17 was seated in her wheelchair smoking in the courtyard with an activity aid (AA)-B, R17 was not wearing an apron. When R17 finished smoking she extinguished the cigarette on her wheelchair wheel and brushed her hands over her pants. AA-B assisted R17 in her wheelchair back into the building. R17's clothing were free from burns and ashes. During interview on 3/8/17, at 11:58 a.m. R17 stated she went out to smoke about three times a day, but butted (process of putting out a cigarette and saving it to smoke at a later time) her cigarettes, because she can't smoke an entire cigarette at a time. R17 stated she has not burned herself with a cigarette while being in the facility, and staff did not always go out with her outside, but some time they did. R17 stated she didn't wear an apron because she doesn't burn herself and kept her cigarettes and lighter on her because she paid for them and they were hers. During interview on 3/8/17, at 12:00 p.m. AA-B stated R17 can smoke independently, but went outside to supervise R17 because it was so windy and didn't want her to get burned, due to the wind. During interview on 3/9/17, at 11:38 a.m. nursing assistant (NA)-D stated the activity staff keep an eye on R17 when she went out to smoke. NA-D stated R17 had bad vision and felt someone should be watching her for safety. NA-D stated that R17 refused to wear an apron, so staff have stopped offering it. They are to observe her for burns and burn holes in her clothes and report any concerns to the nurse, and she has had no burns or injuries from smoking. NA-D stated R17 used to be supervised, but R17 became very upset over staff watching her so they changed her to an independent smoker. If residents violate the facility smoking policy nothing changes with the residents smoking privileges During interview on 3/9/17, at 12:39 p.m. AA-C stated that R17 usually only takes a few drags from her cigarette then butts it and saves it for later. During follow up interview on 3/9/17, at 11: 49 p.m. R17 stated the previous nights she lit her cigarette in the facility before going outside and was told she couldn't do that. R17 also stated that someone had spoken with her today and told her she could no longer butt out her cigarette, which made her mad. She doesn't want to waste her cigarettes and can't smoke a whole one at one time. R17 stated she wasn't sure why staff didn't supervise her while smoking like they used to. During follow up interview on 3/9/17, at 11:53 a.m. AA-C stated that R17 was caught lighting her cigarette inside the building the previous night, and reported the incident to a nurse. AA-C stated the activity department tried to supervise the smoking areas, however; they have not been directed to watch anyone in particular. During interview on 3/9/17, at 11:57 a.m. the director of nursing (DON) stated the leadership team was looking at revising the facility smoking policy due to smoking incidents that have been brought to their attention. The DON further stated that previously when a resident violated the smoking policy, they just talked with the residents but the residents individual smoking privileges didn't change. The DON stated that R17 was previously supervised but showed that she could smoke independently as she had no incidents with burns. The DON further stated that R17's smoking assessment did not include lighting cigarettes inside the facility or assess R17's ability to safely butt her cigarettes for later use. The DON stated that R17 did not need an apron or have her cigarettes and lighter stored on the medication cart and the assessment was confusing. During interview on 3/9/17, at 12:01 the nursing consultant (NC)-A stated that all residents are offered a smoking apron but R17 declined the use of one, and this was not clear in her smoking assessment. NC-A stated the facility met to discuss revising their policy due to residents lighting their cigarettes inside the building, and butting their cigarette and not properly extinguishing the cigarette. NC-A stated although resident input was important, their safety was the facility's main concern. NC-A stated the administrator was talking one on one with the residents who smoke, educating them on a new smoking contract. An undated facility policy, titled Policy and Procedure: Smoking for JPECC (Jourdain Perpich Extended Care Center), identified The facility shall establish and maintain safe smoking practices for residents who smoke while providing consideration for non-smoking residents. The designated smoking area is outlined as the Gazebo, addressed under 4. a Smoking restrictions, addressed under 7 b., indicated If safety is a concern, restrictions may be implemented such as monitoring smoking. Under the outlined under procedure, step 8. identified Restrictions may be increased to the level of not allowing a resident to smoke if safety is deemed to be at a high-risk level as evidenced by resident refusing to allow staff to monitor for safe smoking, excessive falls while smoking, or burning self while smoking.

Based on observation, interview and document review, the facility failed to provide residents/family's with an updated written copy of Federal bill of rights, and have a process to review these rights with residents/family's. This had the potential to affect all 26 residents residing in the facility. Findings include: During interview on 3/7/17, at 1:37 p.m. R16 stated residents had not been updated on the new bill of rights, to his knowledge. Review of the resident council meeting minutes from November 2016, to February 2017, did not identify resident rights were reviewed with residents, or that the rights had been updated. During interview on 3/9/17, at 1:57 p.m. the social services designee (SSD)-A stated she had not incorporated discussing resident rights during the monthly resident council meetings. They had not yet developed a process she was aware of for the facility to review resident rights and to discuss these right with residents and family's. During interview on 3/9/17, at 2:23 p.m. the director of nursing (DON) stated the facility had just received copies of the new updated federal bill of rights to give the residents on 3/6/17. The facility had not reviewed or given these copies to any residents or family's to date. A policy on resident rights was requested and not received.

Based on interview and document review the facility failed to document monthly pharmacy recommendations in the facility medical record for 5 residents (R12, R23, R5, R13, and R9), reviewed for unnecessary medication use. This practice had the potential to affect all 26 residents residing in the facility. Findings include: During review of R12, R23, R5, R13, and R9 medical record, there was no indication that monthly pharmacy reviews were in the facility's medical record for these residents. During interview on 3/9/17, at 8:38 a.m. the consulting pharmacist (CP)-A stated she and the other pharmacist completed the monthly pharmacy reviews, and kept their notes for the residents monthly medication reviews in a notebook. The CP-A stated any pharmacy recommendations are charted in the hospital system for the physician to review and sign, then are printed and given to the facility to place in the residents chart. The monthly pharmacy reviews were not part of the nursing home record, but were kept at the hospital. During interview on 3/9/17, at 2:14 p.m. the director of nursing stated the pharmacy recommendations were filed in the residents facility chart, however; record of the pharmacist monthly review was not maintained in the residents facility medical record for any residents in the facility. During follow up interview on 3/9/17, at 2:37 p.m. the CP-A presented a pharmacy monthly medication review form for residents. The forms were in a three ring binder. The CP-A stated the form was used to document the pharmacist visits and noted if there were recommendations or not. The CP-A stated the form was not currently stored in the residents medical records in the facility. The CP-A further stated it would be easy enough to copy the form and place this in the resident charts in the facility, moving forward. The facility policy Charting and Documentation dated 4/08, indicated, All services provided to the resident , or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.

Based on observation, interview and document review, the facility failed to complete a timely wound assessment, ensure a ROHO pressure redistribution cushion functioned properly and provide every one hour turning and repositioning assistance in order to promote the healing and/or prevent the development and subsequent decline of facility acquired pressure ulcers for 1 of 1 resident (R14) who had acquired pressure ulcers which worsened to stage three ulcers and also became infected. This failure resulted in actual harm for R14. Findings include: R14's [DIAGNOSES REDACTED]. R14's annual Minimum Data Set ((MDS) dated [DATE], indicated R14 had impaired cognition, required extensive assistance of one staff for bed mobility and transfers, and did not walk. The MDS also indicated R14 was at risk for developing a pressure ulcer but did not have a pressure ulcer at the time of the MDS. R14's change of status MDS dated [DATE], indicated R14 had severely impaired cognition, required extensive assistance of two staff for bed mobility and transfers, did not walk, and had pain. The MDS indicated R14 had two stage three (full thickness tissue loss) pressure ulcers and could not verbalize pain but did display non-verbal signs of pain such as crying or moaning, vocal complaints of pain (ouch), facial expressions, and protective body movements. The MDS also indicated R14 did receive pain medication but did not receive any PRN (give as needed) pain medication. R14's Pressure Ulcer Care Area Assessment (CAA) dated 4/26/16, indicated R14 had stage three pressure ulcers to coccyx and right buttock with a history of ulcers, limited mobility, and severe dementia with a history of refusing to reposition. The assessment noted R14 had an air mattress and ROHO (air floatation pressure redistribution cushion) in wheelchair and turning and repositioning done hourly, if resident allowed. The assessment also indicated R14 was being transported to a wound clinic for treatment and was given [MEDICATION NAME] (Protein supplement) twice a day for healing. R14's Tissue Tolerance Observation (assessment to determine the skin's ability to withstand pressure without change) form dated 1/28/16, indicated under the lying observation section, R14 had no skin concerns, did not utilize a pressure redistribution mattress, no redness to skin after lying in same position for two hours. The Sitting Observation section completed 1/21/16, indicated R14 had no skin concerns, utilized a foam, pressure reduction device in the wheelchair and had no skin redness after being seated for two hours. The results section of the form indicated R14 had no skin integrity concerns therefore no turning and repositioning schedule was indicated. -R14's care plan dated 3/24/16, indicated R14 had stage three pressure ulcers on the coccyx and right buttock related to history of ulcers, limited mobility, and severe dementia (refusing to reposition). The plan directed staff administer meds and treatments as ordered, appointments for wound care as ordered, follow facility policy/protocols for the prevention/treatment of [REDACTED]. On 5/10/16 at 3:07 p.m. R14 was observed seated in the wheelchair, next to the nursing station. A ROHO cushion was in place. R14 had just returned from a wound clinic appointment. On 5/11/16, at 7:18 a.m. R14 was observed in bed laying on her right side. -At 7:56 a.m. nursing assistant (NA)-A and NA-D were observed to reposition R14 to her left side facing the door. An air mattress was in place on the bed. NA-D stated R14 was on an every two hour repositioning schedule. -At 9:16 a.m. LPN-A administered R14's oral pain medication ([MEDICATION NAME] 20 mg/ml 0.25 ml). R14 continued to lay on her left side, facing the door. -At 10:37 a.m. (2 hours and 41 minutes since last repositioned)registered nurse (RN)-A and NA-F were observed to reposition R14 and change the wound dressings. RN-A stated R14 had picked the old dressing off so there was no dressing on the coccyx wound. The wound was measured and RN-A stated it was 1.9 cm x 1.1 cm. and 1.8 cm deep. RN-A stated it looked really good, but was deeper. The dressing was removed off the right buttock pressure ulcer which measured 1.0 cm x 0.8 cm. and appeared to be superficial. There was a small amount of drainage noted. The pressure ulcers were treated per physician orders. R14 was then covered and left laying on her right side. During the morning hours on 5/12/16, R14 was observed to be repositioned from side to side every hour. At 9:45 a.m. NA-B and NA-C both stated R14 was supposed to be repositioned every hour. Review of R14's Progress Notes (PN) revealed the following: -On 1/11/16, , 1/18/16, and 1/25/16, indicated R14's skin was intact. -On 2/1/16, at 4:16 p.m. indicated area on coccyx was slightly opened closer to the right gluteal cheek. A&D ointment applied. No other skin breakdown over bony prominences. A reassessment related to the new opened skin area was not completed. -On 2/9/16, wound bed was bright red with some drainage present. Area measures 2.2 centimeters (cm) x 1.0 cm. wound superficial with uneven borders. Area feels slightly firm to touch. Will continue to monitor area and change dressing per orders and as needed to prevent skin breakdown. -On 2/15/16, indicated open area on coccyx measured 1.7 cm x 1.9 cm. Treatment completed as ordered, no other concerns noted at this time. -On 2/17/16, care plan meeting note indicated R14 was at risk for impaired skin integrity, has a pressure reducing cushion in wheelchair and an airbed as R14 refuses to offload when in wheelchair and has history of open areas to buttocks/coccyx. Will continue current plan of care. -On 2/28/16, indicated R14 had three open areas on or near buttocks region. Areas were described as follows: -right buttock, two superficial regions which measured: 1. lower part measured 0.5 cm and 2. middle measured 0.3 cm. Neither had drainage. no pain, A&D applied. -Larger area on coccyx measured 2.3 cm x 1.7 cm with area reddened with white surrounding tissue. Area is tender. R14 has a history of recurrent open area in region and has current order for foam dressing application. Primary care physician updated regarding most recent open areas. No signs/symptoms of infections. Scant clear drainage from coccyx found on old dressing. No active bleeding noted. A reassessment of the additional open areas was not completed in order to determine if current interventions were effective or additional interventions were needed. -On 3/1/16, at 11:03 a.m. indicated large open area on coccyx measured 2.2 cm x 1.5 cm. Area is red and tender with white tissue surrounding open area. Moderate amount purulent drainage present with slight odor detected. Edges of wound are not well defined and broken. Area cleansed and bacterial swab was completed. Will continue to monitor area for any further signs/symptoms of breakdown or infection. -On 3/3/16, a physician order [REDACTED]. -On 3/6/16, at 3:05 p.m. coccyx area 2.0 cm x 2.0 cm. Area is red with white tissue surround open area. Large amount of purulent drainage and strong musky odor noted. Second open area measured 1.7 cm x 1.7 cm with large amount purulent drainage with strong musky odor noted. Both areas felt hard when palpated. -On 3/8/16, indicated results from coccyx open area culture positive [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staph aureus) infection. Orders received to start antibiotic. Continue current wound care and update if no improvement. -On 3/16/16, indicated coccyx wound was a stage three pressure ulcer and possible abscess to right gluteal wound. R14 seen by wound physician. Yellow, stringy tissue was removed from lower right buttock wound and assessed tissue beneath. Wound bed drained fresh blood. No pus or signs/symptoms of infection. Wound not measured, however, large open area with potential tunneling noted underneath. Physician indicated coccyx wound would eventually open up as well and that an open hole will exist. Referral to wound clinic with expectation that wound packing would be involved in the future. At this point the physician would like Duoderm used on each wound and changed every three days and requested R14 remained off of wound bed as much as possible and having R14 up in wheelchair would only exacerbate wound and deny promotion of healing. Physician aware R14 currently utilized an air mattress and was in agreement with continued use. Duoderm applied while at the clinic. R14's physician progress notes [REDACTED]. However, the facility staff did not know how old the cushion was and unsure of where it came from. Facility staff have to pump up the ROHO cushion with air every day to get it back to baseline effective inflation level. The physician indicated he suspected the ROHO cushion was a used one therefore not providing R14 with sufficient pressure abatement. The note further described R14's wounds had necrotic (dead) tissue, wounds debrided and felt the wound to be deep tissue injury. The plan indicated R14 was to stay out of her wheelchair as her ROHO cushion failed to provide adequate pressure relief therefore R14 needed to stay out of the wheelchair as much as possible. On 3/22/16, indicated coccyx wound measured 3.2 cm x 2.0 cm with 85% slough and remaining areas bright red/pink tissue. Tissue surrounding wound was red with distinct, non-intact edges. Moderate amount serosanguineous drainage present on old dressing and drainage had moderately strong foul smell. Wound appears to have declined. Right lower buttock wound measured 2.8 cm x 1.7 cm with possible depth and undermining but unable to determine as R14 uncooperative with assessment. Wound bed has 30% slough and remaining area open with some bright red tissue. Tissue surrounding wound was red and edges were distinct and non-intact. Moderate amount serosanguineous drainage on old dressing and moderately strong foul odor noted. Wound has declined. During dressing change, R14 was agitated and had complained of pain with wound cares but had received pain medication prior to wound cares. Will continue to monitor wounds and apply treatment and dressings as ordered. R14's Clinic Referral form dated 3/23/16, indicated both right coccyx and right buttocks were stage three pressure related ulcers. The wound clinic summary of discharge instructions directed staff to ensure the ROHO cushion was functioning properly, please have cushion checked as age of the cushion was unknown, it is essential R14 rested in bed, off these areas several times a day and off areas while sleeping and to continue the low air loss mattress. Order received to ensure ROHO cushion was functioning properly, to ensure (essential for) R14 to rest in bed off wounds several times a day and is off the wound areas while sleeping and continue the use of low air loss mattress were received. -On 4/5/16, at 11:04 a.m. indicated coccyx wound measured 3.4 cm x 3.5 cm with no tunneling present, 90% slough which yellow/white in color with a slightly darker area in center of wound. Remaining portion of wound bright pink/red. Moderate amount drainage with a strong odor. Wound edges well defined and intact, but very red and inflamed looking. Lower right buttock wound measured 1.3 cm x 1.7 cm with 0.5 cm depth. No tunneling present. 5% yellow slough with remaining portion very red and inflamed looking. Scant amount serious drainage. Wound edges well defined and intact. -On 4/7/16, indicated R14 was seen at wound clinic. Silver [MEDICATION NAME] (debridment) used on wounds, expect some dark/black drainage and wound base. New orders to both wounds. Orders to offload pressure to buttocks at all times. -On 4/12/16, at 2:29 p.m. indicated interdisciplinary team met to discuss significant change MDS completion due to fractured pelvis and two small superficial open areas to buttocks and coccyx. Open areas worsened, culture done which was positive for infection. Wound clinic debrided wounds and classified as stage three pressure ulcers. R14's wound Clinic Referral form dated 4/14/16, indicated R14's ROHO cushion was flat and directed staff to please inflate and have evaluated. R14's Tissue Tolerance Observation form indicated under the lying observation section dated 4/14/16, R14 had skin concerns related to open areas on the right ischial and coccyx, utilized an air pressure redistribution mattress on bed and tissue tolerance ability was not conducted due to current skin condition. The sitting observation section dated 4/14/16, indicated R14 had skin concerns related to the above noted open areas, utilized a ROHO pressure redistribution cushion in the wheelchair and skins toleration to sitting pressure was not assessed due to current skin concerns. The results section of this form indicated R14 would be turned and repositioned per physician order/directive. This assessment was signed by the licensed practical nurse (LPN) on 4/19/16. (five days after the assessment was conducted) -On 4/20/16, care plan meeting note indicated R14 had two superficial open areas on buttocks/coccyx which quickly worsened and infected with subsequent treatment with antibiotics. Wounds debrided at wound clinic and determined to be stage three pressure ulcers. Follow up wound clinic appointments, continued wound care treatments as ordered, turning and repositioning done hourly, ROHO cushion in wheelchair at all times and air mattress to bed. R14 would scratch open areas and pull off dressings often. Medication for pain management. -On 4/26/16, indicated both wounds were stage three which were acquired at the facility. Coccyx wound measured 2.5 cm x 1.2 cm x 1.1 depth with 60% slough and remaining wound bright red/pink tissue, drainage same, no odor but very red and inflamed. Lower right buttock wound measured 1.5 cm x 1.0 cm x 0.3 cm depth. Wound bed bright red with scant drainage, no odor, red and inflamed. -On 5/11/16, at 3:02 p.m. indicated ulcers were acquired at the facility. Coccyx wound measured 1.9 cm x 1.1 cm x 1.9 cm depth with 30% loose slough. R14 had removed the dressing. No signs of inflammation. This wound has remained stable in size but appears to look better from last week. The hard white raised [MEDICAL CONDITION] were not present. -lower right stage three buttock wound measured 1.0 cm x 0.8 cm with superficial depth. wound improved. R14 also had more red areas on left buttock and some superficial scratches that were also red, these areas washed and ointment applied. R14's Medication / Treatment Adminstation form for March 2016, April 2016, and May 2016, revealed the following: -3/4/16, a directive to ensure R14 had a ROHO cushion in wheelchair at all times. -3/7/16, a directive to ensure the air mattress on the bed was working properly every shift. -3/10/16, a N.O air mattress directive directed staff to ensure mattress was working properly. -3/16/16, a directive to ensure R14 remained off wound as much as possible and to limit use of wheelchair. -3/24/16, a directive to ensure ROHO cushion was functioning properly. On 5/11/16, at 11:16 a.m. RN-A stated R14 had a series of falls, developed open areas on the buttock and fractured her pelvis on 3/15, and everything seemed to happen all at once. On 5/13/16, at 9:36 a.m. the director of nursing (DON) and RN-B were interviewed. RN-B stated they had thought the pressure ulcer started as a cyst. The DON confirmed they had problems with the ROHO cushion and had monitored the cushion's inflation and had to keep pumping it up to the appropriate pressure redistribution inflation. The DON stated the facility was finally able to purchase a new ROHO cushion (purchase order dated 3/31/16) but the delivery date was unknown. The DON verified R14's skin issues were identified in February and a reassessment was not conducted timely. A ROHO purchase order revealed the redistribution device was ordered on [DATE], and Direct Supply receipt initialed by a staff member as received on 4/21/16. The policy for Pressure Ulcers/Skin Breakdown-Clinical Protocol revised 2014, indicated the nursing staff and attending physician would assess and document an individual's significant risk factors for developing pressure ulcers. In addition, under the Interventions section of the policy indicated a turning and repositioning program was defined as a specific approach that was organized, planned, documented, monitored and evaluated. The frequency of repositioning a bed or chair bound resident should be determined by type of support surface used, condition of skin, overall condition of resident, response to current repositioning schedule and overall treatment objectives. Residents who were in bed should be on at least every two hours repositioning scheduled and for residents with a stage one or above pressure ulcers an every two hour repositioning scheduled was inadequate. If ineffective, the turning and repositioning frequency would be increased.

Based on observation, interview and document review, the facility failed to complete a timely pain assessment and implement interventions to minimize pain for 1 of 1 (R14) resident who had ineffective pain control following the development of stage three pressure ulcers and a pelvic fracture. This failure resulted in actual harm to R14 due to increased pain without adequate pain management. In addition, the facility failed to provide pain medication prior to ROM exercises for 1 of 1 (R5) resident observed to have pain during the provision of ROM exercises as directed. The facilty failed to ensure renal medications were appropriately adminsitered to 1 of 1 resident (R28) who required phosphorus binding renal medication to be administered with meals. Lastly, the facility failed to ensure adequate foot supports were provided for 1 of 1 resident (R1) observed to with unsupported feet/legs while seated in the wheelchair. Findings include: R14 had sustained a pelvic fracture and acquired two stage three pressure ulcers without effective pain management which resulted in harm to R14. R14's [DIAGNOSES REDACTED]. R14's change of status Minimum Data Set ((MDS) dated [DATE], indicated R14 was severely cognitively impaired, required extensive assistance of two staff for bed mobility and transfers, did not walk and had pain. The MDS indicated R14 could not verbalize pain but did display non-verbal signs of pain such as crying or moaning, vocal complaints of pain (ouch), facial expressions and protective body movements. The MDS also indicated R14 received pain medication but did not receive any PRN (as needed) pain medication. -R14's Cognitive Loss/Dementia Care Area Assessment (CAA) for dated 4/21/16, indicated R14 had impaired cognitive function, a gradual decline in verbalization, was usually very quiet and lacked ability to ask for assistance. The assessment indicated R14 was not able to complete an interview in order to determine mental or pain status. -R14's Pain CAA dated 4/26/16, indicated R14 had chronic and acute pain related to coccyx ulcers, disorder of bone and cartilage, history of closed fracture of femur and recent pelvic fracture from a fall on 3/13/16. The CAA noted R14 exhibited non-verbal signs and symptoms of pain and severe cognitive impairment prevented resident's ability to ask for PRN medications when needed. Staff needed to monitor for signs of pain every shift and to give pain medications prior to completing treatments to coccyx and buttock ulcers. The CAA noted R14 had fallen on 3/13/16, [MEDICATION NAME] 5mg/325 was increased and then changed to 7.5mg/325mg/15ml liquid as resident had difficulty swallowing the tablet form. However, the CAA indicated R14 would spit out the liquid and state that it was too much, therefore not receiving complete/effective pain relief. [MEDICATION NAME] was then changed to MS concentrate 20mg/ml on 4/12/16, 5mg three times a day (TID) and 2.5mg every 4hrs PRN. The CAA also noted R14 appeared to have effective pain relief but showed some non-verbal signs when being transferred into or out of wheelchair and per wound clinic orders resident was to limit time in wheelchair to keep pressure off coccyx. -R14's Pressure Ulcer CAA dated 4/26/16, indicated R14 had two stage three pressure ulcers to coccyx and right buttock, had a history of [REDACTED]. R14's Pain Assessment form dated 2/1/16, indicated R14 had pain in the right hip and bilateral knees. Due to R14's inability to verbalize pain level, a facial diagram was used which scored pain per a six level pain format which ranged from a no hurt level to hurts worst level. R14's pain was identified as hurts even more. Elevating legs and taking time with cares made the pain better. The form indicated R14's pain at it's least was coded as hurts a little bit. Legs in a dependent position for too long, quick sudden movements and increased wandering made the pain worse. The form indicated when pain was at it's worst, R14's pain was coded highest severity of hurts worst. Pain affected R14's social activities, physical activity, mobility and emotions. The effects of pain on R14's sleep and rest, appetite and intimacy was undetermined. The comment section indicated R14 had non verbal signs/symptoms of pain such as crying, moaning, grimacing, wincing, wrinkled forehead, guarding and rubbing body part. Medications/Treatments/Modalities section indicated [MEDICATION NAME] twice a day was used for pain relief. An incident report dated 3/13/16, at 1:31 p.m. indicated R14 rolled out of bed, complained of abdominal pain and was sent to the emergency room (ER) via ambulance for evaluation. R14's ER report dated 3/13/16, indicated R14 was diagnosed with [REDACTED]. The report indicated this type of fracture was very painful and treated with pain medication and by applying ice to the area. (There was no indication in the medical record of any non-pharmalogical interventions attempted or implemented.) R14's progress note (PN) dated 3/13/16, at 9:40 p.m. indicated R14 returned to facility via ambulance. Assist of four staff to transfer R14 from the gurney to the bed. R14 denied pain upon return, however, called out during the transfer and during subsequent cares. R14 appears comfortable as long as no movement was required. Ambulance personnel noted physician at ER wanted staff to be aware R14 had open wounds. Wounds assessed to be inflamed, [MEDICAL CONDITION], and tender to the touch. R14's primary care physician (PCP) to assess resident ulcerations for further treatment options. Further review of R14's March 2016, PN's revealed several entries related to R14's verbal and non-verbal signs/symptoms of pain without effective pain management. R14's PN dated 4/1/16, at 2:54 p.m. indicated non verbal signs of pain noted before scheduled pain med administered. R14 moaning, rubbing hips, cried out when coccyx dressings were changed. -3:55 p.m. PN indicated during dressing change, R14 displayed non verbal signs/symptoms of pain during treatment by crying and moaning out. R14 was pretreated with scheduled pain med which appeared to provide some comfort. R14's PN dated 4/3/16, at 3:08 a.m. indicated R14 complained of pain rated 7 on a 0-10 pain scale but did not specify where the pain was. Non verbal signs noted such as R14 clenching fists and facial grimacing. R14 refused attempts to administer pain med three times. However, the note does not identify any non pharmacological interventions attempted. -at 8:08 p.m. indicated dressings on coccyx changed. Non-verbal signs and symptoms of pain noted during treatment. Patient crying and moaning. Patient was pre-treated with scheduled [MEDICATION NAME] prior to treatment which appeared to provide some pain control. R14's PN dated 4/4/16, (time unreadable) indicated pain med given for complaints of pelvic pain, facial grimacing and clenching of fist. R14 in bed, sleeping. -10:30 a.m. indicated pain med ineffective. A Palliative Care Follow-Up note from the consulting pharmacist dated 4/12/16, indicated the MDS nurse had called requesting different formulation of pain medication. The note indicated R14 was having difficulty with the high volume of [MEDICATION NAME]. The recommendation was to use a more concentrated pain medication with low volume for ease in administration. The plan/order indicated to discontinue the [MEDICATION NAME] and start [MEDICATION NAME] 20mg/ml and give 0.25ml schedule three times a day and then 0.125ml every four hours as needed for breakthrough pain. R14's PN dated 4/12/16, at 2:11 p.m. indicated treatments completed per order, wound bed was bright red with moderate drainage. R14 was pretreated with pain medication prior to the treatments and had vocalized some pain when wounds were being cleansed. -2:30 p.m. PN note indicated decision made by interdisciplinary team that a significant change MDS would be completed instead of a quarterly due to R14 sustaining a fall that resulted in pelvic fracture, had two small superficial open areas to buttocks/coccyx which worsened into stage three ulcers which became infected, and R14's increased pain. MDS Assessment reference date would be 4/19/16. -7:20 pm. PN indicated R14 having difficulty with intake of high volume of [MEDICATION NAME]. New order received to discontinue [MEDICATION NAME] and start [MEDICATION NAME] concentrate 20mg/ml, scheduled doses and PRN for breakthrough pain. R14's PN dated 4/19/16, indicated wound treatments completed per order. Wounds bright red, purulent drainage with strong odor noted. R14 was previously treated with [MEDICATION NAME] prior to dressing change and R14 only had one negative vocalization of coccyx wound hurting while new dressing was changed. Otherwise, R14 was very calm and relaxed during the treatment. The [MEDICATION NAME] was more effective in managing R14's pain. R14's Pain assessment dated [DATE], (completed 31 days following the fractured pelvis) indicated R14's pain site was left iliac crest (pelvis) due to fracture and coccyx due to pressure ulcers. Because R14 was unable to verbalize pain, a facial diagram was used which scored pain per a six level pain format which ranged from a no hurt level to hurts worst level. R14's pain level was hurts a little more. Pain medication appeared to be effective with R14 able to turn and reposition without yelling out. When R14's pain was at it's least, it was coded as hurts a little more. Too much movement and dressing changes made the pain worse with R14 crying out during dressing changes. Pain at it's worst was coded as hurts worst. The assessment indicated pain had not effected R14's sleep/rest, social activities, appetite or intimacy but had an effect on R14's physical activity, mobility and emotions. The comment section indicated R14 was unable to answer the effect of pain questions due to severe cognitive impairment so the above noted effects were noted to have occurred by staff. The Methods/Treatments/Modalities section indicated scheduled MS ([MEDICATION NAME]) 5mg orally three times a day with PRN MS 2.5mg every 4 hrs for breakthrough pain and R14 was to be turned and repositioned hourly. R14's PN dated 4/20/16, at 1:57 p.m. indicated care plan meeting held. Note identified fall with fracture and pressure ulcers as well as pain control. Original [MEDICATION NAME] order was increased and changed several times after fracture but appeared to be ineffective. Scheduled [MEDICATION NAME] was then ordered with better results in pain control. R14 appears to be more comfortable with less signs/symptoms of non verbal pain and resistance to cares. R14's PN dated 4/26/16, 4/29/16, and 4/30/16, revealed improved pain control with the use of the [MEDICATION NAME]. Schedule [MEDICATION NAME] appears to be effective. R14's PN dated 5/9/16, at 12:52 p.m. indicated [MEDICATION NAME] given for left hip pain. -At 1:40 p.m. PN indicated R14 appeared very distressed, crying out when staff attempted to reposition her. Pain med ineffective. Note lacked any non pharmacological interventions attempted. R14's PN dated 5/11/16, indicated wound treatments completed. R14 adminsitered [MEDICATION NAME] prior to with only a few negative vocalizations of the coccyx wound hurting while a new dressing was changed. Otherwise, R14 was very calm and relaxed during the treatment, and having a nursing assistant assisting with R14 helped to reassure R14 during the treatments. R14's Medication Administration Record (MAR) for March 2016, indicated R14 had received routine [MEDICATION NAME] 5-325mg table twice a day since 8/23/15, for pain in joint/lower leg. R14's pain medication regimen had not been increased after the development of the pressure ulcers and not immediately assessed after the pelvic fracture on 3/13/16. -On 3/15/16, R14 was ordered to receive [MEDICATION NAME] 7.5-325mg/15ml every six hours PRN pain. The MAR indicated R14 received 23 doses of the PRN medication in which three doses were ineffective and two doses effectiveness was unknown. This dose was discontinued on 3/24/16. -On 3/24/16, order was changed for R14 to receive 7.5-325mg liquid [MEDICATION NAME] three times a day for pain. No PRN doses of pain medication were administered through the rest of the month, since this order was received. R14's MAR for April 2016, revealed R14 received [MEDICATION NAME] 7.5-325mg/15ml three times a day through 4/12/16. -On 4/13/16, [MEDICATION NAME] 20mg/ml was started (0.25 ml to be administered) three times a day. -On 4/12/16, [MEDICATION NAME] 20mg/ml to give 0.125mg every four hours PRN breakthrough pain was started. However, MAR indicated the first PRN dose was adminsitered 4/25/16. R14 received 4 PRN doses from 4/25/16 through 4/30/16. Of the four doses administered, the medicated was effective once, ineffective once and effectiveness undetermined one time. R14's MAR for May 2016, revealed R14 received [MEDICATION NAME] 0.25 ml three times a day for pain through 5/12/16, and [MEDICATION NAME] 0.125mg PRN five times through 5/10/16. On 5/10/16 at 3:07 p.m. R14 was observed seated in a wheelchair, next to the nurse's station. A ROHO cushion (a specialty cushion that redistributes pressure on the buttocks) was in place. R14 had just returned from a wound clinic appointment. R14's MAR for 5/10/16, revealed the following: -R14 was administered [MEDICATION NAME] at 1:00 a.m., 9:00 a.m. and 5:00 p.m. as scheduled. -At 1:00 a.m. R14's pain level was coded as 7 on a 0-10 pain -At 9:00 a.m. R14's pain level was coded as 7. -At 12:15 p.m. R14's pain level was coded as 4 at which time PRN [MEDICATION NAME] was administered. --At 6:44 pm. R14's pain was coded as 7 at which time [MEDICATION NAME] PRN was administered. On 5/11/16, at 7:18 a.m. R14 was observed in bed laying on her right side. No signs/symptoms of pain noted. -At 7:56 a.m. nursing assistant (NA)-A and NA-D were observed to reposition R14 who shouted out in pain when they rolled her over. R14 continued to say ow, ow, ow. NA-D stated R14's pain was in her leg as she had a previous [MEDICAL CONDITION] and then fractured it again a few months ago when she fell . R14 was repositioned to lay on her left side. R14's MAR revealed R14 was last administered [MEDICATION NAME] at 1:00 a.m. -At 8:27 a.m. licensed practical nurse (LPN)-A was asked if R14 had received pain medication yet this morning. The LPN stated no because another nurse was going to complete the dressing change and they were going to wait to give the medication closer to the time dressing change was to be completed. -At 9:16 a.m. LPN-A administered R14's [MEDICATION NAME] oral pain medication. At the time of the administration, R14's MAR revealed pain level of 0 no pain. -At 10:37 a.m. registered nurse (RN)-A and NA-F were observed to reposition R14 and change the dressings to the two pressure ulcers. RN-A stated they were going to move her slowly because it hurts. During the movement, R14 continued to say no, no. RN-A stated R14 had picked the old dressing off so there were no dressing on the coccyx wound, the wound was measured and RN-A stated it looked really good, but was deeper. The pressure ulcers were treated per physician orders. When RN-A applied the gauze sponge soaked in 25% Dakins (solution containing sodium Hypochlorite (bleach) which kills most forms of bacteria [MEDICAL CONDITION]), R14 flinched and stated ow, ow. R14's wound was covered with dressing and then she was covered with a blanket and left on her right side. R14's May 2016, revealed no PRN doses of [MEDICATION NAME] was administered on 5/11/16. On 5/11/16, at 11:16 a.m. RN-A stated R14 had a series of falls and fracture her pelvis on 3/15/16, and had also developed open areas on the buttocks. RN-A stated everything seemed to happen all at once. On the morning of 5/12/16, R14 was observed to be repositioned from side to side every hour. At 9:45 a.m. NA-B and NA-C stated R14 was supposed to be repositioned every hour. NA-B stated R14 refused to be washed up this morning and stated she yelled ow, ow, every time staff moved her which made NA-B not want to move R14. NA-C stated R14 had been like that since she fell and broke her hip. -At 10:12 a.m. NA-B stated it was time to reposition R14 who was laying in bed on her side. NA-B explained to R14 what was going to happen and asked if she could help roll over. R14 was observed to move herself to her back and when NA-B physically rolled her to the right side R14 said, Ow, Ow, Ow, grimaced, closed her eyes, and brought her knees up in the fetal position. NA-B stated that was the best R14 had ever done for her, normally she yelled very loud. On 05/12/16 at 1:50 p.m. LPN-A stated R14's dressing change had been completed for the day and R14 only complained of pain when the Dankins was applied to the wound because that stings. On 05/12/16, at 2:16 p.m. a loud scream was heard coming from R14's room. NA-G was observed standing between the bed and the wall and another NA was standing next to the other side of the bed. The NAs were tuning R14 from her right side to her left side and both confirmed R14 had screamed with the movement. NA-G stated R14 had pain but was not sure if it was due to the open areas on the bottom or the fracture. -R14's MAR for 5/12/16, revealed R14 was administered [MEDICATION NAME] at 1:00 a.m. at which time R14's pain level was coded as 2 and again at 9:00 a.m with a pain level of 0 no pain. No PRN pain medication was administered 5/12/16. On 5/13/16, at 8:59 a.m. NA-B stated R14 complained of pain when they rolled her over and was not sure if it was due to the open areas on the bottom or the fractured pelvis. On 5/13/16, at 9:36 a.m. the director of nursing (DON) and RN-B was interviewed. The DON verified R14's skin issues began in February, she had a series of falls and fractured her pelvis on 3/13/16. The DON verified a change of status MDS was not started over a month after the fall and the [DIAGNOSES REDACTED]. The DON stated she thought the interventions were in place but maybe it did not look like it on paper. The DON verified R14's medical record did not identify any non pharmacological interventions to be attempted to decrease pain. The DON also stated the physician was notified of the pain but was hesitant of changing the medication for fear of over-medicating R14. The DON also stated R14 was not a morning person, liked to sleep in, but could be seen wheeling around the facility in the wheelchair most evenings and if approached correctly, would be less resistive. RN-B stated the pharmacist had recommended palliative-care. On 5/13/16, at 11:19 a.m. the consulting pharmacist was interviewed and R14's pain medication was reviewed. The pharmacist verified R14's medication regime was reviewed on 3/24/16, and 4/12/16, due to R14's pain and refusing the large amounts of liquid medication. The pharmacist stated there were no hospice services available at the nursing home. The pharmacist stated R14's case was complicated due to the pain felt when being repositioned and requiring frequent repositioning due to the pressure ulcers and then sitting in the wheelchair for so long when going to the wound clinic. Following review of R14's MAR and progress notes to determine effectiveness of pain medication and when asked if R14's pain was being effectively treated, the pharmacist stated, I would say not. The pharmacist stated R14 was not getting any break through doses of pain medication for the breakthrough pain and confirmed R14's PRN doses of pain medication was not utilized. On 5/13/16, at 12:02 p.m. the DON was asked to review R14's nursing notes which described R14's pain with cares and treatments and was asked if R14 had an effective pain management regimen, the DON stated, No, it was not. The facility's Pain-Clinical Protocol revised June 2013, indicated the physician and staff would identify individuals at risk for having pain which included a review of each person's known [DIAGNOSES REDACTED]. R5's pain management interventions were not implemented prior to range of motion exercises. R5's [DIAGNOSES REDACTED]. R5's quarterly MDS dated [DATE], indicated R5 had severe cognitive impairment and required extensive assist of two staff for bed mobility and transfer, total dependence on staff for locomotion on the unit, required extensive assist of one off the unit, and was non-ambulatory. The MDS also indicated R5 had moderate pain occasionally and had functional limitation in range of motion (ROM) of the upper and lower extremities with impairment on one side. Review of the pain assessment interview completed on 3/22/16, indicated R5 had moderate pain almost constantly in the last 5 days. The indicators of pain had not been assessed and frequency of pain had not been assessed. The pain management plan included the following: Scheduled [MEDICATION NAME] 100mg po BID and 300mg at bedtime. Schedule [MEDICATION NAME] 100mg every Tues, Fri and Sunday prior to bath. Non-medication interventions were identified as the following: Splint applied to left hand, repositioning. Under the section for comments the following was identified: Resident has severe dementia, complains of pain to left side of body during transfers, cares and repositioning. Another PAIN assessment dated [DATE], identified R5's pain description as: Left arm and leg r/t (related to) [MEDICAL CONDITIONS](stroke), unable to describe type of pain but states that it hurts often. Current level of pain was not identified. What makes pain better was identified as taking the pain medications. What makes pain worse: transferring, repositioning. The assessment identified pain had no effect on ADL's including physical activity and mobility. The medications and treatment modalities section described all methods of alleviating pain and their effectiveness included: [MEDICATION NAME] 100 mg twice a day, [MEDICATION NAME] 300 mg at bedtime, [MEDICATION NAME] 100 mg on Tues, Fri, and Sun, and as needed [MEDICATION NAME] 50 mg. Splint to left hand, pillow placement under left leg, Biofreeze and massages. Other comments were: Resident has dementia and answers regarding pain will vary greatly. R5's ADL (activities of daily living) Functional/Rehabilitation Potential CAA dated 7/28/15, indicated R5 had an ADL self-care performance deficit related to stroke with [MEDICAL CONDITION], chronic left arm, shoulder, and leg pain. The CAA also indicated possible underlying problems that may affect function included, pain, communication, mood and behavioral symptoms, and recent hospitalization s. R5's care plan revised on 7/28/15, indicated R5 had chronic pain related to stroke with [MEDICAL CONDITION] and complaints of left shoulder, arm, leg and coccyx pain. The plan directed staff to administer pain medications as ordered, anticipate R5's need for pain relief and respond immediately to any complaint of pain. Attempt non-pharmacological interventions such as music, massage/relaxation techniques, other diversional activities or quiet room. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/ record/report to nurse any signs and symptoms of non-verbal pain such as changes in breathing, vocalizations, mood & behavior changes, monitor eye and face movements for non-verbal signs of pain (sad worried, pained, clenches teeth, crying, grimacing). Monitor/ record/report to nurses resident complaints of pain or requests for pain treatment. Notify physician for significant changes in pain characteristics from previous experiences. Review of the PT- Therapist Progress & Discharge Summary indicated R5 started physical therapy on 12/2/15, and the ROM goal included: The patient will tolerate gentle ROM, stretching to maximize joint movement and aide in pain management/improve stiffness with ROM increase five degrees on each plane without increase in pain. The assessment indicated R5 had poor tolerance of ROM due to pain. Review of R5's functional maintenance program (FMP) dated 2/15/16, identified a goal that included: Maintain ROM of bilateral lower extremities three times a week. The approaches included: Really focus on left hip adduction and extension and knee extension with prolonged holds. Patient can be distracted with conversation, it is helpful. Ask Does this feel good? to give her that idea. Stop if she becomes increasingly angry. On 5/12/16, at 8:43 a.m. NA-F stated she had been trained to provide nursing rehabilitation services to the residents including R5. NA-F was observed to start to provide passive ROM to R5's left lower extremity. During the first stretch, R5 said, ouch, ouch, ouch. NA-F attempted to provide stretches to the left lower extremity two more times never attempting to reach or stretch the end point of resistance to the joint movement at any point. R5 complained of pain during each attempt at passive ROM saying ouch and don't do that. R5 was asked by the surveyor if she was having pain and R5 stated, yes. NA-F proceeded to the right lower extremity and started passive ROM exercises (although the FMP identified R5 was supposed to complete active ROM). R5 again complained of pain saying ouch when R5 attempted hip flexion and extension. NA-F completed 2-3 stretches before stopping. No attempt was made on knee, dorsi, and plantar flexion and extension. R5 completed active ROM on the right upper extremity according to the FMP. NA-F removed the splint on R5's left hand/arm and attempted passive ROM on the wrist and fingers, but had not completed exercises on the shoulder and elbow. R5 continued to complain of pain during the exercises saying ouch and R5 stated she was going to kick NA-F. NA-F finished the exercises and placed the splint back on R5's hand. NA-F was interviewed at this time and stated R5 always complained of pain when NA-F attempted ROM. NA-F was asked what her role was in providing interventions for pain for R5, for example does NA-F request pain medications from the nurse for R5 prior to therapy so there is pain medication on board prior to starting. NA-F stated no that it was too hectic in the morning to coordinate with the nurses the time for pain medication in relation to the time ROM was provided. NA-F was asked if she was expected to report R5's symptoms of pain to the nurse and NA-F stated no. When NA-F finished with the ROM exercises a pillow was not placed on the lateral side of the left leg according to the FMP to minimize external rotation of the left lower extremity, and a pillow was not placed under the calf to increase left lower extremity knee extension. On 5/12/16, at 9:11 a.m. LPN-A was interviewed and verified R5 was not provided with pain medication prior to having ROM and stated pain medication had not been requested by NA-F prior to initiating ROM exercises. -At 9:45 a.m. LPN-A stated NA-F had not reported to him R5 had pain during ROM. Physical therapy assistant (PTA)-A was interviewed on 5/12/16, at 3:40 p.m. and stated R5 would sometimes complain of pain during ROM at which time PTA-A would stop the exercises and request a pain medication and return to complete the ROM when the medication was working. PTA-A stated that distraction worked well too when attempting to complete ROM for R5 and included that in the directions for the FMP. On 5/13/16, 11:33 a.m. the DON and RN-B were interviewed together. RN-B stated R5 was on a scheduled pain medication regimen three times a day receiving [MEDICATION NAME] because R5 had pain with movement and the scheduled pain medication was provided so R5 would have pain management interventions on board during ROM exercises. However, when RN-B checked the physician orders [REDACTED]. RN-B stated R5 should have been on a scheduled pain medication regimen to be covered for pain during ROM exercises. The DON stated she would expect NA-F to report to the nurse responsible for R5's care that R5 was experiencing pain during ROM exercises and would expect the care planned pain management plan to be implemented. R28 was not administered renal medication at the appropriate time to ensure maximum efficacy. R28's physicians orders dated 2/19/16, included an order for [REDACTED]. R28's admission MDS dated [DATE], indicated R28 was alert and orientated and had [DIAGNOSES REDACTED]. R28's Nutritional Status CAA, dated 3/1/16, indicated R28 required [MEDICAL TREATMENT] three times a week and was aware of dietary restrictions such as limiting foods high in potassium, sodium and phosphorus. R28's care plan dated 3/1/16, indicated R28 received [MEDICAL TREATMENT] three times a week and directed staff to ensure R28 was monitored for a 1500 cubic centimeter fluid restriction per day. The plan also directed staff how to care for the [MEDICAL TREATMENT] resident, but it did not direct staff as to how to administer medications specifically for the treatment of [REDACTED]. R28's MAR for May 2016, directed staff to administer the calcium acetate at 9:00 a.m., 2:00 p.m. and 9:00 p.m On 5/13/16, at 11:15 a.m. R28 was observed eating lunch in her room. R28 stated when she was at home, she took the calcium acetate medication with her meals, however, while at the facility, staff gave her the medication up to an hour after her meals. She stated she had informed the staff she was to take the medication with meals, but they continued to give the medication after she had eaten. On 5/13/16, at 11:30 a.m. LPN-C stated the only medication R28 received with her meals was insulin. She stated the calcium acetate was to be given at 9 a.m., 2:00 p.m. and 9:00 p.m. LPN-C stated she felt the medication would be more effective if given with food, but she did not have the authority to change the time of administration. On 5/13/16, at 11:45 p.m. RN-B stated the medication was to be given according to the times identified on R5's MAR. Upon further review, RN-B stated the medication was to be given with meals. She stated the MAR would need to be adjusted to ensure the medication was given with meals. On 5/13/16, at 11:45 a.m. the DON verified the medication was to be given with meals to ensure the medication was effective. She stated the medication times were to be changed to 8:00 a.m., 11:00 a.m. and 5:00 p.m. to correlate with the facility meal times. The End-State [MEDICAL CONDITION] policy dated 9/2010, directed staff to be trained in the care and services required for individuals with [MEDICAL CONDITION]. Included in the educational needs was the specific training regarding the timing and administration of medications, particularly those before and after [MEDICAL TREATMENT]. R1 was not provided adequate foot support to prevent feet from hanging while seated in the wheelchair. R1's current care plan dated 10/2015, indicated R1 was diagnosed with [REDACTED]. R1's quarterly MDS dated [DATE], indicated R1 had mild cognitive impairment, required extensive assistance of staff for transferring, bed mobility and locomotion on and off the unit. The MDS indicated R1 did

Based on observation, interview and document review, the facility failed to implement current interventions related to supervision while outside and/or assess and develop new interventions following a fall with a head injury in order to minimize the risk of falls/injury for 1 of 4 residents (20) reviewed who had fallen outside without supervision as directed This resulted in actual harm for R20. In addition, the facility failed to ensure safe smoking practices were followed for 1 of 3 residents (R20) in the sample observed to independently smoke. Findings include: R20's [DIAGNOSES REDACTED]. R20's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R20 had severe cognitive impairment, visual impairment, was independent with bed mobility and transferring, however, required supervision off the unit, had functional limitations with range of motion due to a below the knee amputation on one lower extremity, and R20 was not steady but able to stabilize herself without human assistance when moving from a sit to stand position. In addition, the current tobacco use section had not been completed. R20's Fall Care Area Assessment (CAA) dated 12/15/15, indicated R20 was a fall risk due to R20's below the knee amputation, impaired mobility and eye sight, was cognitively impaired and had difficulty with maintaining balance while seated and during transitions. The CAA indicated R20 was independent with transfers and toileting, utilized a prosthesis however had refused to wear and an order to for a physical/occupational therapy consult was obtained. R20's Fall Risk assessment dated [DATE], indicated R20 had no falls in past 90 days, had moderately impaired vision, was independent with toileting, was non-ambulatory, had unsteady balance while standing, sitting and during transitions which required physical assistance to stabilize and was at risk for falls. R20's care plan dated 9/22/15, indicated R20 had a potential risk for falls related to right below the knee amputation, impaired mobility and impaired eye sight. The plan directed staff to anticipate and meet R20's needs, assure R20's call light was within reach and encourage R20 to use it for assistance, R20 needs prompt response to all requests for assistance, ensure R20 wore appropriate footwear, follow facility fall protocol, physical therapy to evaluate and treat as ordered or when needed, R20 to utilize a high low bed and ensure bed was positioned at knee level while R20 was in bed. R20's care plan revised on 3/26/15, directed staff to assist R20 off the unit as R20 had periods of forgetfulness, macular degeneration, and impaired mobility. In addition, R20 was identified as a smoker and on 4/18/16, the care plan was revised and directed staff to provide supervision and cues while smoking outside and to remind R20 she required supervision when outside smoking. R20's Progress Notes (PN) dated 5/5/16, indicated R20 had sustained an unwitnessed fall on 5/5/16, at 6:00 p.m. The summary of the incident revealed while R20 was outside in the gazebo area, R20 bent down to pick something up from the ground and proceeded to fall out of the wheelchair. R20 was assessed for injury and assisted back into the wheelchair. Injury noted was a scratch above R20's right eye which was cleansed and an antibiotic was applied, At this time, R20 refused to be seen at the emergency room . Vital signs were obtained and R20 denied pain. The If suspected head injury- follow neuro sheet and If Skin Tear or Bruise - Intervention Put Into Place sections were both left blank. (R20 was outside smoking unsupervised at the time of the fall). R20's PN dated 5/5/16, at 6:20 p.m. indicated while R20 was seated in the dining room, R20 became lethargic and unresponsive and was taken to the Red Lake emergency room (ER). R20's emergency room encounter note dated 5/5/16, at 7:00 p.m., indicated R20 had been seated outside and fell out of the wheelchair hitting the right side of her head on the ground. The facility staff reported R20 had been unresponsive. Upon arrival to the Red Lake emergency room R20 was alert and oriented. R20's review of systems included complaints of discomfort at the site of R20's lesion, neuro exam was stable, R20 had about a 2.0 centimeter (cm) by 3.0 cm hematoma on the right eyebrow area with some abrasions. R20's concluded assessment with this emergency room visit was that R20 had sustained a contusion of her forehead, right eyebrow area due to a fall. R20 was discharged back to the facility with instructions for ice packs to be applied and head injury instructions were given. R20's PN dated 5/6/16, at 12:55 p.m. indicated Red Lake ER discharge orders included: apply ice pack as needed to hematoma, monitor R20 for headache, vomiting, difficultly awakening, blurred/double vision, or dizziness. R20's neurological assessments had been completed and revealed the following: -5/6/16, at 10:03 a.m. - R20 complained of a mild headache and mild facial pain, in addition R20's blood pressure was 184/62 (elevated) -5/6/16, at 10:08 p.m. - above R20's right eye was swollen and had an abrasion. All around right eye was black, blue and purple area. -5/8/16, at 2:01 p.m. R20 showed non-verbal signs of pain, grimaced and withdrawals. On 5/9/16, at 6:49 p.m. R20 was observed seated in a wheelchair outside in the gazebo area, smoking a cigarette. No staff were in proximity nor supervised R20 while R20 smoked. On 5/10/16, at 2:04 p.m. R20 was observed seated in a wheelchair in the activity area participating in bingo. R20 had a large black, blue and purple bruise noted on the right side of R20's face. The bruise extended from above R20's right eyebrow to the level of the corner of R20's mouth. R20 had a shoe on her left foot. -At 3:13 p.m. R20 wheeled herself outside in the gazebo area to smoke. R20 was unsupervised while outside smoking. On 5/11/16, at 9:08 a.m. R20 was observed seated in her wheelchair, propelled herself out of her room, down the hall and into the activity area. R20 wheeled herself out the activity door and into the gazebo to smoke. R20 was unsupervised while outside smoking. On 5/11/16, at 11:03 a.m. LPN-A stated R20 was supposed to have supervision when outside smoking, which meant someone should be outside with R20. On 5/11/16, at 11:28 a.m. registered nurse (RN)-B confirmed R20' needed to be supervised when outside smoking. RN-B verified supervision meant a staff member needed to be outside with R20 when R20 smoked. On 5/11/16, at 11:33 a.m. LPN-B stated since R20 had such bad dementia and was forgetful R20 was to be supervised when R20 was outside smoking. LPN-B defined supervised as a staff member being outside with R20 while R20 smoked. On 5/11/16, at 11:57 a.m. nursing assistant (NA)-A confirmed R20 was supposed to be supervised when R20 smoked. On 5/11/16, at 2:20 p.m. R20 was observed seated in her wheelchair outside in the gazebo smoking a cigarette. R20 was unsupervised while outside. On 5/12/16, at 2:18 p.m. R20 was seated in her wheelchair in the activity area participating in bingo. R20's bruise was still evident covering the right side of R20's face. The bruise had started to turn a tinge of yellow and purple in color. On 5/12/16, at 10:52 a.m. licensed practical nurse (LPN)-B confirmed R20 was at risk for falls. LPN-B stated the facility's process following a fall was to first take care of the resident, notify the administrator, director of nursing (DON), physician and family, complete an incident report and then interventions to prevent further falls would be developed. LPN-B reviewed R20's 5/5/16, fall incident, LPN-B confirmed R20 had sustained an injury and been taken to the Red Lake ER for assessment and treatment. LPN-B verified no new or additional fall prevention interventions had been developed and/or implemented following the fall and stated there should have been. On 5/12/16, at 11:22 a.m. the director of nursing (DON) confirmed R20 was identified as at risk for falls and it was her expectation that when a fall occurred, fall interventions would be implemented and put into place to prevent future falls. The DON verified following R20's fall on 5/5/16, no new or additional fall interventions had been developed and/or implemented to prevent further falls and stated there should have been. R20 was identified as an unsafe smoker and was observed to be smoking unsupervised. R20's care plan note dated 3/2/16, indicated R20 had macular degeneration and was cognitively impaired. In addition, R20 was a smoker and was to wear a smoking apron due to R20's poor eyesight and noted cigarette burns in clothing. Due to refusals to wear a smoking apron, R20 must now be supervised when R20 smoked and R20's cigarettes stored in the medication cart. R20's Smoking - Safety screen dated 4/18/16, indicated R20 needed to have the facility store lighter and cigarettes, smoked 5-10 cigarettes a day, had cognitive loss, had dexterity problems, was deemed be safe to smoke with supervision. In addition, the screen indicated R20 refused to wear a smoking apron and burns had been noted in R20's clothing. R20 was unable to see the burns and had cognitive impairments. The rational/conditions identified on R20's smoking screen indicated R20 was to have staff supervision when smoking to ensure R20's safety and to prevent further burns to R20's clothing. In addition, the facility would store R20's lighter and cigarettes as R20 would forget that supervision when smoking was needed. R20's care plan dated 3/26/15, directed staff to assist R20 off the unit as R20 had periods of forgetfulness, macular degeneration, and impaired mobility. In addition, R20 was identified as a smoker and on 4/18/16, the care plan was revised and directed staff to: -Instruct R20 about the facility policy on smoking: locations, times and safety concerns -R20's clothing and skin should be observed for signs of cigarette burns -R20 required supervision and cues while smoking -R20's smoking supplies should be stored in the south medication cart in the narcotic drawer and the number of cigarettes R20 had would be tracked in the narcotic log book R20's care plan dated 4/18/16, identified R20's goals to promote safe smoking as R20 would not smoke without supervision and would not suffer from any unsafe smoking practices. R20's nursing progress note dated 5/6/16, at 10:00 p.m. indicated for staff to ensure R20 be supervised while smoking and that R20's cigarettes were to be kept in the medication cart. Document any noncompliance every shift for safety - R20 refused to give up cigarettes and continued to go out and smoke without staff. R20's nursing progress note dated 5/6/16, at 3:14 p.m. indicated R20 refused to have her cigarettes locked up in the medication cart. On 5/9/16, at 6:49 p.m. R20 was observed seated in a wheelchair outside in the gazebo area, smoking a cigarette. No staff were in proximity nor supervised R20 while R20 smoked. On 5/10/16, at 3:13 p.m. R20 was observed seated in a wheelchair in the activity area. R20 wheeled herself up to the exit door to the gazebo area. R20 pushed the automatic button and the door to the gazebo area opened. This surveyor followed R20 as R20 wheeled herself outside and proceeded to pull a pack of cigarettes out of her purse which was on R20's lap. R20 removed a cigarette from the pack and placed the pack of cigarettes back into her purse. R20 removed a lighter from her purse and attempted to ignite the lighter. R20 was unable to ignite the lighter, placed this lighter back into her purse and started searching for another one. R20 stated I have four lighters in here, you would think I could find one that worked. R20 pulled another lighter out of her purse and attempted to ignite the lighter. On the third attempt R20 was able to light her cigarette. During this time R20 remained unsupervised by staff. -At 3:30 p.m. activity aide (AA)-A entered the gazebo area and sat down on the bench. AA-A stated R20 wasn't supposed to be outside smoking without supervision. R20 continued to smoke a cigarette and at 3:35 p.m. snubbed the cigarette out into the cigarette receptacle. R20's blue, button up the front sweater, which R20 had on, had several burn holes with dark melted fibers around the holes on front panels and sleeves. On 5/11/16, at 9:08 a.m. R20 was observed seated in a wheelchair in her room. R20 proceeded to wheel herself out of her room and down the hall into the activity room and positioned herself directly in front of the exit door by the gazebo. R20 searched in R20's purse, pulled out a cigarette and lighter, ignited the lighter and lit the cigarette up while stationed in the activity room. Smoke permeated into the activity area. R20 placed the lighter in a Styrofoam cup which was attached to the side armrest of R20's wheelchair. R20 pushed the automatic door opener and made her way out into the gazebo area. No staff were in close proximity of R20, nor was R20 supervised while R20 smoked. R20 took three long drags on her cigarette, leaving about an inch long ash. R20 snubbed out her cigarette into the ash tray and without looking at the end of her cigarette, immediately placed the remainder of the smoked cigarette into a Styrofoam cup which held R20's lighter. -At 9:15 a.m. R20 pushed the automatic door from the gazebo area and entered the facility. Once inside, R20 took the lighter and placed it back into her purse and then took the remaining portion of the cigarette R20 had just smoked and placed it into a pack of cigarettes. R20 placed the cigarette pack back into her purse. On 5/11/16, at 11:03 a.m. LPN-A stated R20 had quit smoking for a while, but had started up again. LPN-A confirmed R20's cigarettes and smoking supplies were supposed to be locked up in the medication cart in the narcotic drawer. LPN-A checked the medication cart and confirmed R20 had no cigarettes or smoking supplies locked up in the medication cart. LPN-A stated R20 was supposed to have supervision when R20 went out to smoke, which meant someone should be outside with R20 in case R20 should burn herself. LPN-A stated R20 sometimes hid cigarettes from the staff. LPN-A verified R20 had a sweater which LPN-A had observed to have burn holes in it. LPN-A stated the facility had a smoking apron, however, R20 refused to wear one. On 5/11/16, at 11:28 a.m. RN-B confirmed R20's cigarettes were supposed to be locked in the south medication cart. RN-B was unsure if R20's lighter needed to be locked up. RN-B stated she was aware R20 had some burn holes in R20's sweater. RN-B stated that was why the decision had been made that R20 needed to be supervised when R20 smoked. RN-B verified supervision meant a staff member needed to be outside with R20 when R20 smoked. On 5/11/16, at 11:33 a.m. LPN-B confirmed R20's cigarettes and smoking supplies were to be kept in the locked medication cart. LPN-B stated there had been times when R20 had acquired cigarettes and since R20 had such bad dementia and was forgetful R20 was to be supervised when R20 smoked. LPN-B defined supervised as a staff member being outside with R20 while R20 smoked. LPN-B stated R20 had tried a smoking apron, however with R20's cognitive status R20 would forget she was supposed to wear one, so that was when R20 was changed to needing supervision when R20 smoked. LPN-B confirmed she had seen burn holes in R20's clothing and that too was why R20 needed to be supervised when R20 smoked. LPN-B was not aware of any burns on R20, just R20's clothing. On 5/11/16, at 11:57 a.m. NA-A confirmed R20 was supposed to be supervised when R20 smoked. On 5/11/16, at 12:38 p.m. R20 was observed seated in a wheelchair in the activity area participating in a dice game. R20 had on the blue, button up the front sweater. The sweater had several burn holes noted on the front panels and also the sleeves. One hole on the one side panel was an inch in diameter. All holes had melted black fibers on the perimeter of the holes. On 5/11/15, at 12:41 p.m. the DON confirmed R20's last smoking assessment completed on 4/18/16, deemed R20 safe to smoke with supervision. In addition, R20's cigarettes and smoking supplies should be locked up in the medication cart. The DON stated a smoking apron had been tried with R20, however, R20 would forget to wear the apron, and when R20 would be reminded to put the apron on, R20 refused to wear it. The DON confirmed a lot of R20's clothing had burn holes in them, however, they were unable to determine if they were new burn holes or old. On 5/11/16, at 2:20 p.m. R20 was observed seated in her wheelchair outside in the gazebo area smoking a cigarette. No staff were in close proximity and/or was R20 supervised when R20 smoked. On 5/11/16, at 3:35 p.m. LPN-A verified the last time R20's cigarettes had been tracked in the narcotic log book was 3/16/16. R20's narcotic log for cigarettes from 3/1/16 - 3/15/16, indicated R20's cigarettes had been counted during this time frame, however, no further documentation of R20's cigarettes were found in the narcotic log book since 3/15/16. Smoking Policy-Residents dated 12/2011, indicated safe resident smoking practices would be established and maintained. Any smoking -related privileges, restrictions, and concerns would be noted on the resident's care plan, and all staff would be alerted to these issues. In addition, the facility would impose restrictions on residents at any time, if it was determined the resident could not smoke safely. Any resident with restricted smoking privileges which required monitoring would have direct supervision. Smoking articles for those residents without independent smoking privileges could not have or keep any types of smoking articles including cigarettes except when the resident was directly supervised.

Based on interview and document review, the facility failed to develop and maintain an ongoing, comprehensive infection control program which included investigation, prevention, control, surveillance and reporting of disease and infection. This had the potential to affect all 25 residents who resided in the facility. Findings include: Review of the facility's infection control program revealed a system which lacked a surveillance program with ongoing analysis and interpretation of infections and infection risks. The Infection Control Log for December 2015, January 2016, February 2016, March 2016, April 2016 and May 2016, revealed only infections with prescribed antibiotics were tracked. The facility's tracking system lacked tracking and trending of infections without antibiotics. On 5/13/16, at 2:14 p.m. the facility infection control program was reviewed with registered nurse (RN)-B who was responsible for infection control. RN-B indicated information regarding residents who were prescribed antibiotics was communicated to her via weekday huddles, shift reports, direct report from nursing staff, or she would learn about it first hand if working the floor. RN-B indicated she entered this information onto a monthly Infection Control Log. RN-B provided the Infection Control Log for the months of December 2015, and January, February, March, April and May 2016. Each month had a separate log which included columns for information regarding resident name, room number, dates of treatment, date of onset, date of admission, admit/acquired, type/site of infection and symptoms, culture, X-ray, result of X-ray or culture and antibiotic. Each monthly log also had a floor plan of the facility attached with the location of each infection highlighted. RN-B stated at the end of the month she compiled a report of infection totals broken down by type. RN-B stated this report was reviewed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting where contributing factors were discussed. RN-B stated she mainly clued in on antibiotic use and confirmed she didn't always have the cultures on the logs. RN-B also confirmed date of onset fields were frequently left blank and indicated this occurred due to infections carrying over from one month to the next. RN-B confirmed she did not log viral or other infection symptoms not requiring an antibiotic. RN-B confirmed she had not included a recent discovery of a bed bug in a resident bed in the infection control logs indicating it had not occurred to her to do so. On 5/16/16, at 9:24 a.m. the director of nursing (DON) confirmed all infections should be tracked and trended, not just those infections requiring antibiotics. The DON confirmed the infection control program was lacking and not carried out according to facility policy. The Infection Control Policy and Procedure dated 6/11/14, indicated through ongoing monitoring the facility would take appropriate action to investigate, prevent, control and report disease and infection. The policy directed the tracking and trending of infections by calculating infection rates by period and comparing rates over time to identify patterns, clusters, trends and opportunities for improvement.

Based on observation, interview and document review, the facility failed to ensure care plan interventions for smoking were followed for 1 of 3 residents (R20) observed to smoke without supervision and smoking materials unsecured as directed by the care plan. In addition, the facility failed to ensure restorative nursing services were provided as directed by the care plan for 2 of 3 residents (R5, R3) who required range of motion services; failed to implement pain interventions as directed by the care plan for 1 of 2 (R5) residents reviewed for pain; and failed to provide activities according to the care plan for 2 of 3 residents (R13, R5) reviewed for activities. Findings include: R20 was not provided supervision while smoking nor were R20's smoking supplies secured in accordance with R20's care plan. R20's care plan revision date 3/26/15, directed staff to assist R20 off the unit due to R20's periods of forgetfulness, [MEDICATION NAME] degeneration, and impaired mobility. In addition, R20 was identified as a smoker and on 4/18/16, the care plan was revised and directed staff to: -Instruct R20 about the facility policy on smoking: locations, times and safety concerns -R20's clothing and skin should be observed for signs of cigarette burns -R20 required supervision and cues while smoking -R20's smoking supplies should be stored in the south medication cart in the narcotic drawer and the number of cigarettes R20 had would be tracked in the narcotic log book On 5/9/16, at 6:49 p.m. R20 was observed seated in a wheelchair outside in the gazebo area smoking a cigarette. No staff were in proximity nor supervised R20 while R20 smoked. On 5/10/16, at 3:13 p.m. R20 was observed seated in a wheelchair in the activity area. R20 wheeled herself up to the exit door to the gazebo area, pushed the automatic door button and proceeded to wheel self outside. The surveyor followed R20 as she entered the gazebo area, pulled a pack of cigarettes out of her purse which was on R20's lap, removed a cigarette and lit the cigarette and proceeded to smoke it. During this time R20 remained unsupervised by staff. -At 3:30 p.m. activity aide (AA)-A entered the gazebo area and sat down on the bench. AA-A stated R20 wasn't supposed to be outside smoking without supervision. On 5/11/16, at 9:08 a.m. R20 was observed seated in a wheelchair in her room. R20 proceeded to wheel herself out of her room and down the hall into the activity room and positioned herself directly in front of the exit door by the gazebo. R20 searched her purse, pulled out a cigarette and lighter, lit the cigarette while stationed in the activity room. R20 pushed the automatic door opener and made her way out into the gazebo area. No staff were in close proximity of R20, nor was R20 supervised while R20 smoked. -At 9:15 a.m. R20 pushed the automatic door from the gazebo area and entered the facility. Once inside, R20 took the lighter and placed it back into her purse and then took the remaining portion of the cigarette R20 had just smoked and placed it into a pack of cigarettes. R20 placed the cigarette pack back into her purse. On 5/11/16, at 2:20 p.m. R20 was seated in her wheelchair outside in the gazebo area smoking a cigarette. No staff were in close proximity nor was R20 supervised when she smoked. On 5/11/16, at 11:03 a.m. LPN-A confirmed R20's cigarettes and smoking supplies were supposed to be locked up in the medication cart and R20 was supposed to have supervision when smoking, as directed by the care plan. On 5/11/16, at 11:28 a.m. registered nurse (RN)-B confirmed R20's cigarettes were supposed to be locked in the south medication cart and was to be supervised when smoking as directed by the care plan. On 5/11/16, at 11:57 a.m. nursing assistant (NA)-A confirmed R20 was supposed to be supervised when she smoked. On 5/11/15, at 12:41 p.m. the director of nursing (DON) confirmed R20 was to have supervision when smoking and her cigarettes and smoking supplies should have been locked up in the medication cart as directed by the care plan. Smoking Policy-Residents dated 12/2011, indicated safe resident smoking practices would be established and maintained. Any smoking -related privileges, restrictions, and concerns would be noted on the resident's care plan, and all staff would be alerted to these issues. R5's restorative nursing care plan was not implemented as directed. R5's care plan revised 7/28/15, indicated R5 had an activities of daily living self-care performance deficit related to a stroke with [MEDICAL CONDITION] and pain and directed staff to provide therapeutic exercises as ordered. R5's functional maintenance program (FMP) dated 2/15/16, indicated R5 was to maintain range of motion (ROM) of bilateral lower extremities three times a week and directed staff to provide the following: -gentle passive ROM to left lower extremity -active ROM to right lower extremity and to place pillow or wedge to achieve neutral position and max extension of knee on left. Place heel boot if patient allows. -under the precautions and comments section of the FMP directed staff to really focus on left hip adduction and extension and knee extension with prolonged holds. Patient can be distracted with conversation, it is helpful. Ask Does this feel good? to give her that idea. Stop if she becomes increasingly angry. R5 also had a FMP developed by occupational therapy dated 8/3/15, for R2 to maintain ROM for upper extremities and lower extremities and directed staff to provide: -gentle passive ROM to left upper extremity and hand. -two sets of 10 repetitions each to left shoulder, bicep, wrist and finger flexion and extension. -active ROM to right upper extremity. On 5/11/16, at 9:06 a.m. R5 was observed while in bed and there was no pillow or wedge placed on the lateral side of the left knee as directed by the FMP. On 5/12/16, at 8:43 a.m. NA-F stated she had been trained to provide nursing rehabilitation services to the residents including R5. When R5 was observed laying on her back in bed it was noted that R5's left leg was significantly externally rotated and the left knee was bent and unable to reach neutral position of zero degree's extension. There was no pillow placed on the lateral side of the left knee to achieve neutral position and max extension of knee on left as the FMP had indicated. NA-F provided passive ROM to R5's left lower extremity never attempting to reach or stretch the end point of resistance to the joint movement at any point. NA-F then went to the right lower extremity and started doing passive ROM to the right lower extremity (although the FMP identified R5 was supposed to complete active ROM). No attempt was made on right knee, dorsi, and plantar flexion and extension. NA-F removed the splint on R5's left hand/arm and attempted passive ROM on the wrist and fingers, but had not completed exercises on the shoulder and elbow. When NA-F finished with the ROM exercises a pillow was not placed on the lateral side of the left leg according to the FMP to minimize external rotation of the left lower extremity, and a pillow was not placed under the calf to increase left lower extremity knee extension. On 5/13/16, 11:33 a.m. the DON stated she expected R5's ROM be provided according to the care plan which directed the restorative aide to provide therapeutic exercises according to the FMP. R5's pain management interventions had not been implemented as directed by the care plan. R5's care plan revised on 7/28/15, indicated R5 had chronic pain related to stroke with [MEDICAL CONDITION] and complaints of left shoulder, arm, leg and coccyx pain. The plan directed staff to administer pain medications as ordered, anticipate R5's need for pain relief and respond immediately to any complaint of pain, Attempt non-pharmacological interventions such as music, massage/relaxation techniques and other diversional activities or quiet room and to evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/ record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing, vocalizations, mood & behavior changes, monitor eye and face movements for non-verbal signs of pain (sad worried, pained, clenches teeth, crying, grimacing). Monitor/ record/report to nurses resident complaints of pain or requests for pain treatment. Notify physician for significant changes in pain characteristics from previous experiences. On 5/12/16, at 8:43 a.m. NA-F identified she had been trained to provide nursing rehabilitation services to the residents including R5. NA-F started to provide passive ROM to R5's left lower extremity and during the first stretch R5 said ouch ouch ouch. NA-F attempted to provide stretches to the left lower extremity two more times never attempting to reach or stretch the end point of resistance to the joint movement at any point. R5 complained of pain during each attempt at passive ROM saying ouch and don't do that. R5 was asked by the surveyor if she was having pain and R5 stated yes. NA-F then went to the right lower extremity and started doing passive ROM (although the FMP identified R5 was supposed to complete active ROM). R5 again complained of pain saying ouch when R5 attempted hip flexion and extension and NA-F completed 2-3 stretches before stopping. NA-F removed the splint on R5's left hand/arm and attempted passive ROM on the wrist and fingers, but had not completed exercises on the shoulder and elbow. R5 continued to complain of pain during the exercises saying ouch and R5 stated she was going to kick NA-F. NA-F finished the exercises and placed the splint back on R5's hand . NA-F was interviewed at this time and stated that R5 always complained of pain when NA-F attempted ROM. NA-F was asked what her role was in providing interventions for pain for R5 for example does NA-F request pain medications from the nurse for R5 prior to therapy so there was pain medication on board prior to starting. NA-F stated no that it was too hectic in the morning to coordinate with the nurses the time for pain medication in relation to the time ROM was provided. NA-F was asked if she was expected to report R5's symptoms of pain to the nurse and NA-F stated, no. On 5/12/16, at 9:11 a.m. licensed practical nurse (LPN)-A was interviewed and verified R5 was not provided with pain medication prior to having ROM and pain medication had not been requested by NA-F prior to initiating ROM. LPN-A was again interviewed on 5/12/16, at 9:45 a.m. and stated that NA-F had not reported to him R5 had pain during ROM. On 5/13/16, 11:33 a.m. the director of nursing (DON) stated she would expect NA-F to report to the nurse responsible for R5's care that R5 was experiencing pain during ROM exercises and would expect the care planned pain management plan to be implemented. R3 was not provided ROM services as directed by the care plan R3's care plan dated 9/9/15, indicated R3 had an ADL self-care performance deficit related to [MEDICAL CONDITION] from [MEDICAL CONDITION] and contractures to upper and lower extremities. The plan directed staff to provide therapeutic exercises as ordered. R3's Order Summary Report included the following physician order [REDACTED]. COMPLETE 2-3x WEEKLY: Complete lower extremity passive range of motion (1 set of 15-20 repetitions) --hip flexion and extension --hip abduction and adduction --knee flexion and extension --ankle dorsiflexion and plantar flexion --ankle inversion and eversion --ankle supination and pronation The order indicate little motion in ankles was normal. R3's Order Summary Report included the following physician order [REDACTED]. COMPLETE 2-3x WEEKLY: Passive range of motion (PROM): 1) Elbow extension 3 minutes, wrist and digit extension 5 minutes 2) ROM - reaching for the ball overhead (10 repetitions) --reach for the ball forward (10 repetitions) --ball rolling on table left (L) and right (R) arm ( R to L and L to R 10 repetitions each) --rings over arc - complete each arm with R getting help from L --full arm extension next to chair - yellow theraband 5 repetitions x 2 sets --full arm flexion with 1 pound dowel 5 repetitions x 2 sets On 5/11/16, at 11:10 a.m. NA-F stated she was the restorative aid and worked with R3. NA-F stated she applied a hand splint to his right hand every morning and completed ROM exercises to R3's upper extremities every other day. NA-F indicated she did not provide ROM exercises for R3's lower extremities and indicated lower extremity ROM was provided by the physical therapy aide (PTA). On 5/12/16 from 9:15 a.m. until 9:50 p.m NA-F was observed to provide ROM exercises to R3's upper extremities but did not provide ROM exercises to R3's lower extremities. Review of restorative nursing task documentation from 4/17/16 to 5/12/16 revealed the following: The Task Schedules dated April 2016, and May 2016, indicated lower extremity tasks were documented by NA-F on the following dates: 4/19, 4/21, 4/26, 4/29, 5/3, 5/10 and 5/12. There was no other documentation of lower extremity ROM completed. On 5/13/16, at 9:29 a.m. lower extremity ROM task documentation in the electronic record was reviewed with NA-F. NA-F confirmed she had not performed any lower extremity ROM for R3 since December as she had understood this was done by the PTA. NA-F stated she had spoken with PTA on today and she would now start doing it. On 5/13/16, at 11:01 a.m. the DON confirmed lower extremity ROM had not been provided and indicated there had been miscommunication between therapy and restorative nursing. The DON stated she would have expected the ROM to be done as directed by the care plan. R13 was not provided activities according to the care plan. R13's undated care plan indicated R13 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations and cognitive deficits. The plan directed staff to invite R13 to scheduled activities. The plan indicated R13 required assistance/escort to activity functions, required 1:1 bedside/in-room visits and activities 3x/weekly if unable to attend out of room events and when R13 chose not to participate in organized activities, he preferred to watch television for social and sensory stimulation. The plan further directed staff to engage R13 in simple, structured activities and R13 enjoyed watching sports, westerns and old TV shows. On 5/10/16, at 4:00 p.m. R13 was observed resting in bed with his eyes closed while a card activity was taking place in the activity area. On 5/11/16, the facility activity calendar had Ski ball scheduled at 9 a.m. At 9:25 a.m. R13 was observed resting in bed with lights off. The television was not on and no music played. --At 11:02 a.m. R13 remained in bed with the lights on. No television or music played. --At 12:48 p.m. R13 remained in bed with the lights off. No television or music played. NA-D stated R13 got up once per shift. NA-D also stated the time R13 got up depended on the day. She indicated R13 had refused to get up at 10:45 a.m. but would be getting up later. The facility activity calendar had 7-11 activity scheduled at 1 p.m. --At 1:59 p.m. R13 remained resting in bed with lights off. No television or music played. A dice game was in progress in the activity room On 5/12/16, the facility activity calendar had Red Lake casino scheduled at 10 a.m. No other activities were identified at this time. --At 10:40 a.m. R13 was observed resting in bed with lights off and his eyes closed. A news program played on the television. R13 was positioned on his right side, facing the television. TV on a news channel. --At 11:16 a.m. NA-D stated R13 spent much of his time in bed, however, got up for 2 hours on each shift. NA-D stated R13 liked to watch television, especially football, and also enjoyed watching the news. NA-D indicated R13 was able to indicate yes or no and able to point to indicate his television preferences. Review of R13's Activity Participation Notes from 2/1/16, to 5/13/16 revealed R13 participated in the following: --Month of February: one 1:1 activity and one out of room activity --Month of March: two 1:1 activities and three out of room activities --Month of April: two 1:1 activities and zero out of room activities --Month of May: zero 1:1 activities and zero out of room activities R5 was not provided activities according to assessed need. R5's care plan dated 7/29/15, indicated R5 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive and physical deficits and directed staff to: --Modify daily schedule, treatment plan as needed to accommodate activity participation as requested by R5. --Provide with activities calendar. Notify R5 of any changes to the calendar of activities. --Engage in simple, structured activities such as socialization, casino, baking/cooking, spiritual services, music, cultural events, facility events and outings with activities. --R5 was to receive 1:1 bedside/in-room visits and activities 3x weekly --R5 needed assistance/escort to activity functions. R5 was observed on 5/10/16, from 8:45 a.m. to 4:00 p.m. on 5/11/16, from 7:00 a.m. to 4:30 p.m. on 5/12/16, from 8:35 a.m. to 4:00 p.m. and 5/13/16, from 8:45 a.m. to 4:00 p.m. R5 was not provided activities during any of the aforementioned times. Review of R13's Activity Participation Notes from 2/1/16, to 5/13/16, revealed R13 participate in the following: --Month of February 2016: zero 1:1 activities --Month of March 2016: six 1:1 activities --Month of April 2016: nine 1:1 activities --Month of May 2016: one 1:1 activity On 5/13/16, at 3:36 p.m. the activity director (AD) indicated the activity staff relied on 1:1 visits for residents' who had dementia and could not participate in regular activities. The AD stated 1:1 visits included such things as hand massage and visiting. The AD confirmed documentation regarding activity programs/participation including 1:1 visits were lacking for R13, R14 and R5. On 5/16/16, at 9:20 a.m. the DON indicated she would expect R13, R14 and R5 be provided activities as directed by the care plan. The DON confirmed documentation regarding activity programs/participation for R13, R14 and R5 was lacking.

Based on observation, interview and document review, the facility failed to provide activities to meet the individual interests for 3 of 3 residents (R13, R14, R5) reviewed for activities. Findings include: R13's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R13 was diagnosed with [REDACTED]. The MDS also indicated R12 had severe cognitive impairment, required extensive assist of two persons for transfers, was non-ambulatory and was totally dependent on staff for locomotion on and off of the unit. R13's annual MDS dated [DATE], indicated the interview for activity preferences could not be completed by R13 or family/significant other. The staff assessment of activity preferences indicated R13 preferred reading books, newspapers or magazines, listening to music, keeping up with the news, and participating in favorite activities. R13's Activities Care Area Assessment (CAA) dated 12/8/15, indicated R13 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations and cognitive deficits. R13's Psychosocial Well being CAA dated 12/8/15, indicated R13 had a potential for psychosocial well-being problems related to dementia, limited mobility, inability to speak, and [MEDICAL CONDITION] disorder. The CAA indicated R13 preferred to stay in room and enjoyed watching television. The CAA also indicated R13 would shake head yes/no when asked if he wanted to participate in group activities or watch television in the activity room. The CAA further indicated R13 had 1 on 1 time with activity staff. R13's undated Care Plan indicated R13 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations and cognitive deficits. The Care Plan directed staff to invite R13 to scheduled activities. The Care Plan indicated R13 required assistance/escort to activity functions and required 1:1 bedside/in-room visits and activities 3x/weekly if unable to attend out of room events and when R13 chose not to participate in organized activities, he preferred to watch television for social and sensory stimulation. The Care Plan further directed staff to engage R13 in simple, structured activities and R13 enjoyed watching sports, westerns and old TV shows. On 5/10/16, at 4:00 p.m. R13 was observed resting in bed with his eyes closed while a card activity was taking place in the activity area. On 5/11/16, the facility activity calendar indicated Ski ball was scheduled at 9 a.m. and 7-11 activity scheduled for 1:00 p.m. On 5/11/16, at 9:25 a.m. R13 was observed in bed with lights off. The television was not on and no music played. --At 11:02 a.m. R13 remained in bed with the lights on. No television or music played. --At 12:48 p.m. R13 remained in bed with the lights off. No television or music played. Nursing assistant (NA)-D stated R13 got out of bed once per shift and the time R13 got up depended on the day. She stated R13 had refused to get up at 10:45 a.m. but would be getting up later. --At 1:59 p.m. R13 remained resting in bed with lights off. No television or music played. A dice game was in progress in the activity room. On 5/12/16, the facility activity calendar had Red Lake casino scheduled at 10 a.m. No other activities were identified at this time. --At 10:40 a.m. R13 was observed resting in bed with lights off and his eyes closed. A news program played on the television. R13 was positioned on his right side, facing the television. --At 11:16 a.m. NA-D stated R13 spent much of his time in bed, however, got up for 2 hours on each shift. NA-D stated R13 liked to watch television, especially football, and also enjoyed watching the news. NA-D indicated R13 was able to indicate yes or no and able to point to indicate his television preferences. Review of R13's Activity Participation Notes from 2/1/16, to 5/13/16, revealed R13 was provided the following activities: --Month of February: one 1:1 activity and one out of room activity --Month of March: two 1:1 activities and three out of room activities --Month of April: two 1:1 activities and zero out of room activities --Month of May: zero 1:1 activities and zero out of room activities R14's [DIAGNOSES REDACTED]. R14's significant change MDS dated [DATE], indicated R14 had severe cognitive impairment and required extensive assist of two persons for transfers and locomotion off the unit, limited assist of one person for locomotion on the unit and was non-ambulatory. The Interview for Activity Preferences indicated it was very important to R14 to go outside when weather was nice and participate in religious practices and somewhat important to R14 to listen to music, keep up with news, do things with groups of people, and do favorite activities. R14's Cognitive Loss/Dementia CAA dated 4/19/16, indicated R14 had impaired cognitive function/dementia related to [MEDICAL CONDITION], was alert but not aware of place or time. The CAA indicated R14 had a decline in verbalization and could not speak or respond with a full sentence but could usually respond with a word or two. The CAA further indicated R14 lacked the ability to ask for assistance. R14's Care Plan dated 8/7/14, indicated R14 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to [MEDICAL CONDITION] and dementia. The Care Plan directed staff to: --ensure the activities R14 attended were: compatible with physical and mental capabilities, compatible with known interests and preferences, needs and abilities and age appropriate --invite R14 to scheduled activities. --modify daily schedule, treatment plan as needed to accommodate activity participation as requested by R14. --provide a program of activities that was of interest and empowered R14 by encouraging/allowing choice, self-expression and responsibility --provide R14 with materials for individual activities as desired. The Care Plan indicated R14 liked reading, required assistance/escort to activity functions and required activities which did not involve overly demanding cognitive tasks. The Care Plan further directed staff to engage R14 in simple, structured activities such as outdoor activities, cultural events, music, bingo, cooking/baking. On 5/10/16, at 3:07 p.m. R14 was observed seated in a wheelchair, next to the nursing station. R14 had just returned from a medical appointment. R14 was wheeled into own room and transferred to bed. On 5/11/16, from 7:18 a.m. until 10:37 a.m. R14 was observed to remain in bed. The facility activity calendar indicated a ski ball activity was scheduled at 9:00 a.m. On 5/12/16, at 9:45 a.m. R14 was observed to have remained in bed. At this time, NA-B stated R14 stayed in bed due to open areas on the buttocks and would sit on the edge of bed to eat her meals. The facility activity calendar indicated Red Lake casino was scheduled at 10 a.m. No other activities were identified at this time. On 5/12/16, at 2:16 p.m. R14 was again observed in bed. The facility activity calendar indicated 7 up game was scheduled at 1:30 p.m. and bean bag toss scheduled at 3:30 p.m. No other afternoon activities were identified or indication of activity would be provided to R14. On 5/13/16, at 8:59 a.m. R14 was observed in bed, facing the wall with the privacy curtain pulled. The facility activity calendar indicated Walmart scheduled for 10:00 a.m. No other activities were identified at this time or indication R14 would be provided activities. Review of R14's Activity Participation Notes from 2/1/16, to 5/12/16, revealed R14 was provided the following activities: --Month of February: two activities provided (baking, bingo) --Month of March: three activities provided (balloon volley, ring toss, 1:1 visit) --Month of April: zero activities provided --Month of May: zero activities provided R5's quarterly MDS dated [DATE], indicated R5 was diagnosed with [REDACTED]. The MDS also indicated R5 had severe cognitive impairment and required extensive assist of two for transfer, required extensive assist of one for locomotion on and off the unit and was non-ambulatory. R5's annual MDS dated [DATE], indicated having books, newspapers and magazines to read, listening to music, keeping up with the news, doing things with groups of people, doing favorite activities, going outside, and participating in religious activities were very important and being around animals was somewhat important to R5. R5's Activities CAA dated 7/21/16, indicated R5 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive and physical deficits. The CAA indicated R5 enjoyed going on outings with activities department, but if over stimulated her behaviors increased. R5's Care Plan dated 7/29/15, indicated R5 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive and physical deficits. The Care Plan directed staff to: --Modify daily schedule, treatment plan as needed to accommodate activity participation as requested by R5. --Provide with activities calendar. Notify R5 of any changes to the calendar of activities. --Engage in simple, structured activities such as socialization, casino, baking/cooking, spiritual services, music, cultural events, facility events and outings with activities. --R5 was to receive 1:1 bedside/in-room visits and activities 3x weekly --R5 needed assistance/escort to activity functions. R5 was observed on 5/10/16, from 8:45 a.m. to 4:00 p.m. on 5/11/16, from 7:00 a.m. to 4:30 p.m. on 5/12/16, from 8:35 a.m. to 4:00 p.m. and 5/13/16, from 8:45 a.m. to 4:00 p.m. R5 was not provided activities during any of the aforementioned times. Review of R5's Activity Participation Notes from 2/1/16, to 5/13/16, revealed R5 was provided the following activities: --Month of February: zero 1:1 activities, zero group activities --Month of March: six 1:1 activities, zero group activities --Month of April: nine 1:1 activities, zero group activities --Month of May: one 1:1 activity, zero group activities On 5/13/16, at 3:36 p.m. the activity director (AD) indicated the activity staff relied on 1:1 visits for residents who had dementia and could not participate in regular activities. The AD stated 1:1 visits included such things as hand massage and visiting. The AD stated they completed a Life Story form with each resident to find their past history and interests and if a resident was unable to complete the form they would complete it with the family. The AD confirmed documentation regarding activity programs including 1:1 visits were lacking for R13, R14 and R5. On 5/16/16, at 9:20 a.m. the DON stated she would expect R13, R14 and R5 would have had activities provided based on their assessed need and according to the care plan. The DON confirmed documentation regarding activity programs for R13, R14 and R5 was lacking. An Activities policy was not provided.

Based on observation, interview and document review, the facility failed to ensure a call light was provided to summon assistance for 1 of 1 resident (R5) who was observed asking for assistance but unable to summon assistance due to not having the call light in reach. Findings include: R5's [DIAGNOSES REDACTED]. R5's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R5 had severe cognitive impairment and required extensive assist of two for bed mobility and transfer, was totally dependent on staff for locomotion on the unit, required extensive assist of one off the unit, and was non-ambulatory. On 5/11/16, at 7:24 a.m. R5 was observed seated in the dinning room. There were no staff in the dining room, and there was no way for the resident to summon assistance. From 7:24 a.m. to 7:32 a.m. R5 was observed waving her hand for the surveyor to come to her several times, and when approached R5 stated she needed to use the bathroom. The surveyor found NA-B who assisted R5 to her room to use the bathroom. -At 7:53 a.m. R5 was observed in her room, in bed, partially lying on a bedpan. R5 had been served her breakfast tray in which he was eating while positioned on the bedpan. -At 8:03 a.m. R5 was observed seated in her wheelchair eating breakfast. R5 did not have a call light available within reach. R5 was periodically observed several times asking for assistance stating she wanted to go back to bed. -At 8:48 a.m. the surveyor put the call light on for R5 and at 9:06 a.m. NA-D entered R5's room to assist R5 back to bed. NA-D was asked if R5 could use the call light if it had been available and NA-D stated yes and stated R5 should have had the call light. On 5/13/16, at 11:33 a.m. the DON confirmed R5 should have been provided the call light to summon assistance when staff were not in the residents room. A facility policy regarding call light use or accommodation of needs was requested but not available.

Based on interview and document review, the facility failed to ensure a newly acquired pressure ulcer was assessed, monitored, and provided necessary treatment and services to promote healing for 1 of 4 resident's (R1) reviewed with pressure ulcers. This resulted in actual harm to R1, when R1's pressure ulcer worsened requiring hospitalization . Findings include: R1's medical record revealed diagnoses, which included dementia and diabetes mellitus. A 1/21/15 Brief Interview for Mental Status (BIMS) revealed a score of 10, moderate cognitive impairment. A 1/15/15 Braden scale assessment identified R1 at mild risk for the development of pressure ulcers with a score of 18. A 1/15/15 tissue tolerance test intervention identified to reposition R1 every 2 hours. R1's body audit forms dated 1/21/15, 2/4/15, and 2/25/15 did not identify any skin changes to R1's left upper buttocks.A review of R1's medical record lacked documentation of skin changes to R1's left upper buttocks until 3/4/15.A review of the facility's 24 hour communication board did not identify any skin changes for R1 between the dates of 2/28/15 and 3/5/15.A progress note dated 3/4/15 (not timed) revealed licensed practical nurse LPN(E) identified two reddened areas with no drainage on R1's left upper buttocks measuring "1 x 1." R1 had a temperature of 102.6 and received Tylenol. LPN-E notified the RN. The note lacked further description of the area. A progress note dated 3/5/2015 (not timed) revealed R1's temperature gradually lowered during the night. At 4:40 a.m. R1's temperature was 99.3 degrees. Also at 4:40 a.m. registered nurse RN(H) was alerted by a nursing assistant to assess an open area on R1's left buttock. R1 had two open areas on the left buttock. The lower wound measured ".4/.7 cm." The upper wound measured "1.4 cm." Both areas were "berry-maroon in color." The open areas were encased in a "14 x 11" hardened [DIAGNOSES REDACTED]tous region. The area was warm to touch with uneven edges. The resident did not appear uncomfortable when the area was palpitated. The DON, physician, and family were notified and the resident was sent to the hospital for evaluation. R1's 3/5/15 emergency room physician note assessment identified 1) Fever2) Pressure sore of buttock \ infected 3) [MEDICAL CONDITION] vs abscess. R1 transferred to another hospital for surgical consult and treatment. A clinic referral form dated 3/5/15 identified a left decubitus ulcer with [MEDICAL CONDITION]. The providers orders revealed a 5 cm x 12 cm fluctuant abscess with 2 openings that appear to be fast growing on the upper left buttocks.Hospital records revealed R1 was hospitalized between 3/5/2015 and 3/16/2015 for intravenous antibiotic therapy and wound care for an unstageable pressure ulcer and [MEDICAL CONDITION]. R1 returned to the facility on [DATE]. The facility's "WOUND ASSESSMENT FLOW SHEET" dated 3/17/2015 identified R1's wound site as left upper buttock abscess and identified the type of wound as a " Pressure Ulcer Stage 2". The wound assessment flow sheet defined a Stage 2 pressure ulcer as "Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister."When interviewed on 3/18/2015 at 3:40 p.m. NA-F stated she informed RN-G of R1's skin changes on 2/28/2015. NA-F stated that on the morning of 3/4/2015 she provided cares to R1 and noticed that the area was larger. NA-F was unable to give any further description of the area. NA-F stated that she did not notify the nurse of the change because she had previously reported the skin change and believed that the nurses were monitoring the area. When interviewed on 3/19/15 at 9:00 a.m. RN-G stated that nursing assistant NA(F) informed her of a change to R1's skin on 2/28/2014. RN-G stated that R1 had one area to his upper left buttocks that was the "size of the tip of my thumb," with a pin point white area in the center. "It looked like a pimple." The area was not measured. R1 had no pain at the site and the area was not open or draining. RN-G did not document the skin changes in R1's medical record or write the changes on the 24 hour board for monitoring. RN-G stated that she did not notify anyone of R1's skin changes and did not monitor the area.When interviewed on 3/18/15 at 3:20 p.m. LPN-E stated that the resident had fallen during a shower on 3/4/15 at approximately 8:30 p.m. LPN-E assessed R1 after the fall and observed two 1 cm x 1 cm superficial reddened areas to R1's upper left buttock. LPN-E stated that she was unaware of any prior skin changes to R1's left buttocks. LPN-E stated that areas were not draining and there was no redness to the surrounding tissue. LPN-E administered Tylenol to R1 for a temperature of 102.6 degrees F. LPN-E stated that she notified RN-H of R1's temperature and skin changes prior to the end of her shift and left between 10:00 - 10:30 p.m. LPN-E stated that she did not write the changes on the 24 hour board as only a RN's can document on the 24 hour board. When interviewed on 3/19/15 RN-H stated that LPN-E reported to her that R1 had two superficial wounds to R1's left buttocks as well as a temperature of 102.6 in the evening of 3/4/15. RN-H stated that she monitored R1's temperature during the night, and R1's temperature gradually decreased. At approximately 4:40 a.m. a nursing assistant requested RN-H to assess R1's buttocks sore. RN-H stated that the two wounds were surrounded by a 11 cm x 14 cm reddened hard area that was warm to the touch. RN-H stated that she immediately sent R1 to the hospital and notified the DON, family, and physician of the changes. When interviewed on 3/18/15 at 2:50 p.m. the DON stated that it is the expectation that the DON and physician are notified at the time skin changes are observed. A comprehensive skin assessment and implementation of appropriate interventions are to be initiated. The resident is placed on the 24 hour communication board for monitoring and the nurse documents the progress or changes in the resident's medical record. The DON confirmed that R1's wound was not compressively assessed and interventions to promote healing were not initiated. R1 was not placed on the 24 hour board and R1's wound was not monitored. The DON stated there was confusion when R1 returned to the facility as to whether R1's wound was a pressure ulcer versus an abscess. The DON confirmed that the hospital records diagnosed R1's wound as a pressure ulcer. R1's physician(L) was not available for interview. Physician-L's RN care manager, RN(M) when interviewed on 3/25/15 at 3:25 p.m. stated that she had spoken with physician-L who had not seen R1's wound and deferred to the hospital for diagnosis. The facility's policy dated 11/11/14 titled "Pressure Ulcer Policy and Procedure" included the following: staff to request a treatment order from the physician, initiate weekly wound assessments by an RN every week, initiate and complete a comprehensive data risk collection, a tissue tolerance test, a Braden scale, implement appropriate interventions.

Based on observation, interview and document review, the facility failed to provide repositioning / offloading (pressure relief) to promote healing and prevention for the further development of pressure ulcers as directed by the care plan for 1 of 2 residents (R30) identified with a current stage 4 ( full thickness skin loss with exposed bone, tendon or muscle) pressure ulcer. Findings include: R30's undated Disease Index Report indicated R30's [DIAGNOSES REDACTED]. R30's significant change Minimum Data Set ((MDS) dated [DATE], indicated R30 had intact cognition, was non-ambulatory, required extensive assistance of two+ staff for bed mobility, extensive assistance of one staff member for toilet use, total staff assistance for transfers and had bilateral lower extremity limitation in functional range of motion. The MDS also indicated R30 had one stage 4 and one stage 3 (full thickness tissue loss with possible subcutaneous fat visible) pressure ulcers and also indicated R30 was on a turning and repositioning program. R30's Tissue Tolerance Assessment (a tool used to determine the length of time skin can withstand pressure without change) dated 5/23/14, indicated R30 was to be turned and repositioned every 2 hours while lying and sitting. R30's care plan dated 5/29/14, indicated R30 had impaired skin integrity, was non ambulatory, required total staff assistance for transfer with mechanical lift, had decreased mobility with inability to transfer, turn and reposition nor sit up independently. The plan directed staff to turn and reposition or offload (relieve pressure) R30 every two hours, pressure relieve air mattress on bed, a custom fitted wheelchair cushion and right Prevalon boot while in bed. R30's Sanford Bemidji Medical Center Wound Healing discharge summary signed 7/9/14, indicated R30 had a coccyx and ankle pressure ulcer and instructed staff to continue to limit the amount of pressure and sitting on the coccyx and to continue to offload any pressure on the right ankle. R30's Nurses' Admission assessment dated [DATE], indicated R30 had a coccyx wound which measured 3.0 centimeters (cm) x 3.6 cm x 0.5 cm and a right ankle pressure ulcer which measured 0.8 cm X 1.2 cm. R30's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE], indicated R30 was at moderate risk for pressure ulcers. The attached Checklist Of Skin Risk Factors & Interventions dated 7/28/14, indicated R30 was to be turned and repositioned every two hours. On 8/12/14, at 8:45 a.m. R30 was observed in bed, lying on her back. A pressure relieving mattress was observed on the bed. -At 9:15 a.m. R30 was observed in her own room, seated in her electric wheelchair. R30 stated she has had the coccyx pressure ulcer for two years. A pressure redistribution cushion was observed on R30's wheelchair seat. -At 9:33 a.m. R30 was observed to wheel herself to the common area by the nurses station in her electric wheelchair. -At 10:19 a.m. R30 was observed attending bingo in the activity area. -At 10:50 a.m. R30 continued to play bingo in the activity area. -At 11:19 a.m. R30 was observed to remain in her wheelchair while eating lunch in her own room. -At 11:59 a.m. R30 remained in her room, seated in the wheelchair. -At 12:07 p.m. R30 stated she had been up in her chair since about 9:15 a.m. that morning. R30 stated sometimes her bottom got sore from sitting and said she tolerate sitting up for a couple of hours at a time. -At 12:10 p.m. nursing assistant (NA)-I stated she had worked at the facility for three weeks and wasn't sure how long R30 could sit up and how often she was to be repositioned but stated that information would be in the nursing assistant information book -At 12:24 p.m. NA-J stated R30 would inform staff when she wanted to be repositioned. NA-J also stated R30 could sit up for as long as four hours at a time without repositioning or offloading, or until her hip got sore. NA-J confirmed R30 had been up in her wheelchair since 9:15 a.m. and had not been instructed to encourage R30 to reposition or offload her pressure ulcer. -At 12:36 p.m. NA-I and NA-J were observed to assist R30 into bed via a mechanical lift. R30 remained seated in the wheelchair without repositioning or offloading for three hours and 21 minutes. On 8/12/14, at 12:38 p.m. the director of nursing (DON) confirmed R30 had a healing stage 4 pressure ulcer to her coccyx and verified R30's care plan and skin assessments indicated R30 required every two hour repositioning / offloading. The DON stated R30 should have been repositioned or offloaded every 2 hours as directed. The Prevention of Pressure Ulcers policy dated October 2010, indicated pressure ulcers were usually formed when a resident remained in the same position for an extended period of time causing increased pressure or decrease of circulation to that area and subsequent destruction of tissue. The policy also indicated pressure ulcers were made worse by continuous pressure. The policy directed staff to reposition the resident at least every hour when in a chair and every two hours when in bed or more frequently when needed.

Based on observation, interview and document review, the facility failed to ensure a non pressure related wound was appropriately assessed, monitored or treated for [REDACTED]. This deficient practice caused actual harm for R4. In addition, the facility failed to consistently monitor daily fluid intake for 3 of 3 residents (R46, R61, R59) who had [MEDICAL CONDITION], received [MEDICAL TREATMENT] and were on a prescribed fluid restriction; and failed to monitor 1 of 1 resident (R62) [MEDICAL TREATMENT] access catheter site nor develop a care plan to include interventions related to the monitoring and emergency care of the access site. Findings include: R4 had identified wounds on the right great toe and 3rd toe that had not been appropriately assessed, monitored and treated. R4's Cumulative Diseases Index Report dated 2/12/14, indicated R4's [DIAGNOSES REDACTED]. R4's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R4 had impaired cognition with physical and verbal behaviors that significantly interfered with the resident's care. The MDS also indicated R4 had [MEDICAL CONDITION]. (A quarterly MDS should have been completed by 10/4/14, however, it had not been completed and the data was not available). R4's physician progress notes [REDACTED]. A physician's rounding note dated 9/22/14, did not mention any issues related to open skin wounds. The rounding note indicated R4 had stasis [MEDICAL CONDITION] on bilateral lower extremities with hyperpigmented skin from the stasis [MEDICAL CONDITION]. Review of R4's physician orders [REDACTED]. A&D ointment to bilateral lower extremities twice a day. Left second toe apply [MEDICATION NAME], cover with gauze dressing, change BID (twice a day) until resolved. Wash legs daily apply moisturizing cream BID. R4's nurse progress notes and wound documentation from 9/1/14-10/14/14, revealed the following: -on 9/20/14, licensed practical nurse (LPN)-C documented R4 had two new wounds on toes and one wound on right big toe. The documentation indicated the registered nurse (RN) was to assess. Wounds cleansed and A&D ointment, gauze applied and Koban. The note indicated R4's left plantar toe had a skin tear 3.0 centimeters (cm) in length and 3.0 cm in width, area cleansed, A&D ointment, gauze applied and wrapped with Koban. -on 9/24/14, RN documentation indicated R4's wound dressing was changed, however, the note did not identify which dressing was changed. There was no further documentation related to the foot wounds found in R4's progress notes nor was there an RN assessment of the wounds found in the medical record from 9/20/14-10/14/14. R4's medical record also lacked indication the physician had been notified of the wound on the right great toe, or any indication that a management plan related to the wound had developed. Review R4's Treatment Administration Record (TAR) was reviewed from 10/1/14-10/14/14. The TAR notes revealed the nurse was directed to perform a weekly skin integrity assessment and to provide diabetic nail care. There was no documentation to indicate this task had been completed at all during the month of October 2014. The wound book documentation from 9/1/14-10/14/14, was reviewed and there was no documentation related to R4 having an open wound on any toes, nor any treatment implemented. On 10/13/14, at 3:02 p.m. LPN-B who was responsible for the care of R4, stated R4 still had a foot ulcer on the left foot second toe, however, could not identify what treatment was provided for the wound. At 3:04 p.m. LPN-B stated she was mistaken, that R4 did not have any wounds on either foot and stated all of R4's wounds were currently healed, that nursing staff continued to monitor R4's right great toe, and that if the area on the toe opened up the physician would be notified. LPN-B then again stated R4 did not have any open foot wounds. At 3:06 p.m. R4 was asked if an observation of his feet could be made. R4 became upset and yelled for the surveyor and LPN-B to leave his room. R4's request was honored. On 10/16/14, at approximately 10:50 a.m. RN-B confirmed R4 had a history of [REDACTED]. On 10/16/14, at 10:53 a.m. nursing assistant (NA)-C stated that this past Monday R4 had a sore on his right toe and that the scab had fallen off during his bath. NA-C stated the wound appeared red and had started to bleed "a little bit." NA-C stated she had not notified a nurse regarding the wound. On 10/16/14, at 11:03 a.m. RN-C stated that as of two weeks ago R4's skin was intact and free from sores. RN-C stated she was totally unaware R4 had a new wound on his foot or that any scab had fallen off during his bath. On 10/16/14, at 1:46 p.m. the director of nursing (DON) stated she was not sure when R4's right great toe and third toe wounds had occurred because R4's medical record did not identify any foot related skin issues. The DON confirmed the physician was not notified of R4's right foot wounds so appropriate treatment could be initiated. The DON stated she would have expected the licensed nurses to notify the physician of the wounds. On 10/16/14, at approximately 2:00 p.m. the facility provided a picture of R4's right great toe dated 10/16/14, which revealed an open ulcer the approximate size of a pea on the dorsal surface of the right great toe. On 10/17/14, at 9:33 a.m. R4 was observed seated on the edge of the bed and was interviewed. During the interview R4's right great toe was observed to have a pea size open ulcer and the third toe of the right foot was macerated and bloody. In addition R4's right lower extremity was observed to be purplish in color. There was no dressing on the right great toe or right foot 3rd toe wound. [MEDICAL TREATMENT]: R46 was on a prescribed 1500 cubic centimeter (cc) fluid restriction and his daily fluid intake was not monitored. R46's Admission Face Sheet indicated R46's [DIAGNOSES REDACTED]. R46's physician orders [REDACTED]. R46's care plan last revised on 9/23/14, indicated R46's was on a 1500 cc fluid restriction and was to have 420 cc fluid with each meal, 80 cc with each med pass, no water pitcher at bedside and fluids with meals and evening as fluid restrictions allowed. R46's TAR from 10/3-10/13/14, revealed that daily total fluid intake was not calculated and monitored consistently. R46's total daily fluid intake was not calculated on 10/3, 10/4, 10/5, 10/6, 10/7, 10/8, 10/11, and 10/12/14. On 10/14/14, R4's fluid intake was 1620 cc (120 cc over the fluid restriction). There was no evidence that action was taken related to the excess fluid intake on 10/14/14. On 10/15/14, at 10:30 a.m. the DON confirmed R46's total fluid intake was not totaled and monitored consistently. R61 was on a prescribed 1500 cc fluid restriction which was not consistently totaled and monitored and a plan for delineation of fluid provided by each department had not been developed. R61's Admission Face Sheet indicated R61 was diagnosed with [REDACTED]. R61's physician orders [REDACTED]. R61's care plan dated 8/19/14, indicated R61 had a 1500 cc daily fluid restriction. However, the care plan had not delineated how much fluid each discipline would provide R61 (i.e.. dietary, nursing, activities) and who would be responsible for monitoring the 24 hour total fluid intake. R61's TAR records from 10/3-10/13/14, revealed that daily total fluid intake had not been calculated and monitored consistently. R61's total daily fluid intake had not been calculated on 10/3, 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, and 10/13/14. On 10/15/14, at 12:53 p.m. the DON confirmed R61's daily total fluid intake monitoring had not been completed and the care plan had not delineated how much fluid each discipline would provide or who would be responsible for monitoring the 24 hour total fluid intake. R59 was on a prescribed 1500 milliliter (ml) 24 hour fluid restriction and her 24 hour intake was not consistently totaled or monitored. R59's care plan dated 6/24/14, indicated R59's [DIAGNOSES REDACTED]. The care plan also indicated R59 had a problem with nutrition and a potential for fluid overload. The approaches identified on 9/3/14, included intake and output monitoring and a 1500 ml fluid restriction with delineation of the fluid distribution for 60 ml to be given with medications and 420 ml with each meal. R59's medical record lacked a completed MDS review, however, RN-B provided a Care Area Assessment (CAA) summary dated 6/23/14, which indicated R59 had moderate cognitive impairment and was independent with eating after tray set-up assistance. R59's Physician order [REDACTED]. In addition, R59 had [MEDICAL TREATMENT] three days a week (Monday, Wednesday and Friday). R59's October 2014, TAR indicated R59 was on a 1500 ml / 24 hour fluid restriction. The documentation indicated the following: ? 10/1/14 - lacked documentation for the amount of fluid consumed during the night and the 24 hour total was not completed (the fluid total for the shifts documented equaled 1540 ml - exceeding the fluid restriction for the day by 40 ml). ? 10/2/14 - lacked documentation for the amount of fluid consumed in the evening and the 24 hour total was not completed. ? 10/3 & 4/14 - lacked documentation for the 24 hour fluid intake total. ? 10/5/14 - resident was out on pass. ? 10/6/14- lacked documentation for the amount of fluid consumed on the day shift and the 24 hour total. ? 10/7-9/14 - lacked documentation for the 24 hour fluid intake total (the fluid total for the shifts documented on 10/9/14, equaled 1520- exceeding the fluid restriction for the day by 20 ml). ? 10/10/14 - 24 hour fluid intake documented and totaled (1060 ml) ? 10/11-12/14 - lacked documentation for the 24 hour fluid intake total. ? 10/13/14 - 24 hour fluid intake documented and totaled (1320 ml) ? 10/14/14 - 24 hour fluid intake documented and totaled (1640 ml - exceeding the fluid restriction for the day by 140 ml). The registered dietician's (RD) Medical Nutrition Therapy Notes dated 9/4/14, indicated R59 was on a 1500 ml fluid restriction. The RD's Medical Nutrition Therapy Notes dated 9/30/14, indicated it was difficult for her to ascertain actual intake from the medication administration record. On 10/15/14, at 1:52 p.m. trained medication aide (TMA)-A confirmed any resident on [MEDICAL TREATMENT] should have a 24 hour total fluid intake recorded daily. TMA-A confirmed it was the responsibility of the night staff to total R59's 24 hour total intake and that this total should be documented on her treatment record. TMA-A confirmed for the month of October 2014, R59's total fluid intake had only been tallied on 10/10/14, 10/13/14, and 10/14/14. The total fluid intake on 10/14/14, was 1640 ml, which exceeded the 24 hour fluid restriction by 140 ml for the day. On 10/15/14, at 1:52 p.m. the [MEDICAL TREATMENT] unit RN confirmed she was familiar with R59 and her care. The [MEDICAL TREATMENT] RN verified that on 10/13/14, R59 had come in for her scheduled [MEDICAL TREATMENT] treatment at 70 kilograms which was 5.5 kilograms over her dry weight (the amount of body weight without extra fluid). The [MEDICAL TREATMENT] nurse confirmed R59's dry weight goal was 64.5 kilograms and R59 had routinely come in for her [MEDICAL TREATMENT] treatments around 66 kilograms. The [MEDICAL TREATMENT] RN confirmed the facility should have been monitoring R59's fluid intake and staying within her 1500 ml/day fluid restriction. The [MEDICAL TREATMENT] RN stressed it was very important to monitor R59's total fluid intake and she should never be over four kilograms on fluid (which she was on 10/13/14). This lack of monitoring and exceeding the 24 hour fluid intake restrictions of 1500 ml would place R59 at risk for clinical complications such as congested heart failure, [MEDICAL CONDITION] or [MEDICAL CONDITION]. On 10/15/14, at 2:18 p.m. the DON verified the 24 hour total fluid intake records for R59 where incomplete and that three out of the 14 days for the month of October 2014, the totals had not been tallied. On 10/16/14, at 10:35 a.m. the DON confirmed her expectations were that the staff would follow the individual care plan for R59. The facility's Intake, Measuring and Recording policy (undated), specified as its purpose to accurately determine the amount of liquid a resident consumed in a 24 hour period. The facility's Using the Care Plan policy (undated) indicated the care plan would be developed to meet the resident's daily care needs and that documentation must be consistent with the residents' plan of care. R62 received [MEDICAL TREATMENT] via a right chest portacath (a small medical appliance that is installed beneath the skin in which a catheter connects the port to a vein) and the facility failed to monitor the site and develop a care plan to identify the access site nor the emergency care procedures to be provided should dislodgment and/or bleeding occur. R62's History and Physical dated 10/1/14, indicated R62 was recently started on [MEDICAL TREATMENT] post [MEDICAL CONDITION] onset. R62's 24 Hour-Vital Sign Record indicated R62 was admitted to the facility on [DATE]. R62's Discharge Summary dated 10/2/14, indicated R62's [DIAGNOSES REDACTED]. R62's Admission/Readmission Care Plan was undated and blank. R62's progress note dated 10/2/14, indicated R62 was cognitively alert. The 24 Hour - Vital Sign Record dated 10/2/14, indicated following admission R62 left the facility at 2:30 p.m. for [MEDICAL TREATMENT]. The record further indicated R62 returned from [MEDICAL TREATMENT] at 10:00 p.m., however, the record lacked notation regarding the appearance of the catheter site dressing or how R62 tolerated the [MEDICAL TREATMENT]. The Nurses' Admission assessment dated [DATE], identified R62 had a central line inserted in the right chest. The undated nursing assistant (NA) cheat sheet lacked identification of R62's [MEDICAL TREATMENT] catheter placement nor care of the catheter site. The Physician order [REDACTED]. R62's October 2014, Treatment Sheets identified the right chest portacath for [MEDICAL TREATMENT] access and directed staff to change the dressing as needed if soiled. The staff signature section was blank. The Treatment Sheets lacked indication of monitoring of the access site nor emergency care. R62's October 2014, Medication Administration Records (MAR) lacked indication of monitoring of the portacath site. On 10/15/14 at 1:07 p.m. LPN-A confirmed R62 did not have a temporary care plan developed. On 10/15/14, at 2:39 p.m. RN-B stated an admission/readmission care plan was to be completed as soon as a resident was admitted to the facility. RN-B stated R62 received [MEDICAL TREATMENT], had a left arm access site and was not to have blood pressures taken from the left arm. However, RN-B stated he wasn't sure if the NAs were aware of that or not. RN-B verified he was responsible to complete the care plans, however, stated he did not have "a lot" of information on R62. RN-B confirmed R62's admission care plan was blank and stated it should have been developed to include [MEDICAL TREATMENT], emergency care of the site as well as any restrictions such as no blood pressures on the left arm. On 10/15/14 at 3:00 p.m. R62 was observed in the [MEDICAL TREATMENT] unit of the adjoining hospital receiving [MEDICAL TREATMENT]. The portacath insertion site was observed covered with a clean, white dressing. The [MEDICAL TREATMENT] nurse stated the dressing was changed weekly during [MEDICAL TREATMENT] services. On 10/15/14, at 3:01 p.m. the [MEDICAL TREATMENT] unit RN confirmed [MEDICAL TREATMENT] staff changed R62's portacath dressing weekly and stated there was no nursing home protocol to monitor the access site. However, the RN stated staff should have been monitoring the catheter site for dislodgment and/or bleeding. The RN stated if bleeding occurred, staff should apply pressure and if unable to control the bleeding, R62 would need to be seen in the emergency department. on 10/15/14, at 3:04 a.m. R62 stated no one at the facility had looked at her [MEDICAL TREATMENT]. On 10/15/14, at 3:09 p.m. NA-B verified she occasionally worked with R62 and stated she was not sure where R62's access site was. On 10/16/14, at 7:58 a.m. TMA-A confirmed R62 had a right chest [MEDICAL TREATMENT] catheter in place in which the [MEDICAL TREATMENT] unit staff took care of the dressing. TMA-A stated she monitored R62's catheter site for bleeding three times a day, however, verified there was no documentation indicating such. At 12:00 p.m. the DON stated the facility did not have a policy and procedure related to the development of temporary admission care plans. The facility's [MEDICAL TREATMENT] Access Care policy and procedure dated 5/13, indicated the catheter must be kept clean and dry at all times and to never pull or tug on catheter tubing. The policy also indicated the general nurse should document each shift in the resident's medical record as follows: 1. location of the catheter will be documented in the MAR indicated [REDACTED]. 2. The condition of the dressing and any interventions, if needed. 3. If [MEDICAL TREATMENT] was done during shift. 4. Any part of a report the [MEDICAL TREATMENT] nurse may have provided post-[MEDICAL TREATMENT]. 5. observations post [MEDICAL TREATMENT]. The facility's Using the Care Plan policy (undated) indicated the care plan would be developed to meet the resident's daily care needs and that documentation must be consistent with the residents' plan of care.