Every finding on record at Kadoka Nursing Home

Based on observation, interview, kitchen task checklist review, and policy review, the provider failed to ensure standard food safety practices were followed regarding two of two observed freezers in the kitchen galley with food items in them that were not stored and labeled according to the provider's policy and one of one ceiling fan in the kitchen where residents' food was prepared that was on and not clean to prevent food contamination.Findings include:Observation on 7/21/26 at 10:30 a.m. in the kitchen galley revealed there were two freezers. Inside the freezers, there were clear, unlabeled, and undated plastic bags that contained diced chicken, rhubarb stalks, and hot dogs. There were two additional unlabeled and undated plastic bags containing unknown food items. Another plastic bag was labeled Spanish Rice, and was not dated. 2. There were four clear plastic storage containers in the freezer closest to the kitchen entry. One container was labeled Beef Stroganoff with a date-mark of 7/10/26 written on it. It was overfilled, and the container lid was not on the container, but rather sat on top of and touching the food inside that container. The lids of the other three plastic storage containers were date-marked and labeled Chicken Ala King, Roast, and Ham. The lids of those containers did not fit securely on the containers. When the containers were moved, the lids easily slid on top of or off the containers. 3. Observation on 7/21/26 at 11:30 a.m. of [NAME] C in the kitchen revealed that cook C was plating the residents' noon meals. There was a metal countertop beside the steam table. Metal containers inside the steam table held the hot foods for the noon meals. There was a ceiling fan directly above the metal countertop. [NAME] C stood beneath that running ceiling fan and cut pork chops and cooked beets into bite-sized pieces for the residents who required a modified textured diet. The cleanliness of the fan was not seen while the fan was running. 4. Observation and interview on 7/22/26 at 12:10 p.m. with cook D in the kitchen revealed the ceiling fan was not running. Gray dust build-up was visible along the sides of the fan blades and on the surface of the blade that faced the metal countertop. [NAME] D stated the cooks were responsible for ensuring that kitchen tasks listed on a checklist were completed and documented each day. That list was composed of cleaning and other kitchen-related tasks that were to be completed either after each meal, daily, or weekly. Interview and kitchen task checklist review on 7/23/26 at 10:00 a.m. with dietary director (DD) B revealed she acknowledged the above observed findings regarding the contents in the two galley freezers. She stated that all foods stored inside the freezers were expected to be labeled and marked with the date that they were placed in the freezers. She acknowledged that the poorly fitting food storage container lids potentially compromised the quality and palatability of the food stored in them. DD B stated that an unclean ceiling fan blowing air in the food preparation and serving area increased the risk of food contamination.DD B stated it was the responsibility of the cook to ensure each day that all food was properly stored and labeled, and that the kitchen ceiling fan was cleaned weekly, according to the kitchen task checklist. She was aware that labeling and date-marking of foods and the cleaning of the ceiling fan were not consistently occurring. On 2/3/26, she educated the kitchen staff regarding kitchen cleaning expectations, which included the ceiling fan. On 5/26/26, she conducted a mock kitchen survey exercise with her staff. That exercise included identifying and managing unlabeled food and food that was not date-marked. It also re-addressed ceiling fan maintenance expectations.The 7/19/26 through 7/25/26 kitchen task checklist indicated that on 7/21/26, cook D initialed that she had ensured all food was labeled, and the ceiling fan blades were dusted. DD B confirmed that those tasks were not completed. DD B did not regularly audit the kitchen task checklist for task completion, but she thought she should. 5. Review of the provider's revised 3/25/24 Food Serving policy revealed that, 4.b. All leftover foods stored in the freezer shall be placed in food-grade containers with tight-fitting, secure lids or wrapped and sealed to protect the food from contamination, moisture loss, and freezer burn. Each container must be labeled with the [food] product name and preparation date.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, observation, and policy review, the provider failed to review and revise one of one sampled resident's (1) care plan (personalized plan that addresses a resident's care needs, goals, and interventions) after the resident eloped (left the facility without staff knowledge).Findings include:1. Review of the provider's 3/9/26 SD DOH FRI revealed that on 3/8/26 at 2:10 p.m., resident 1 opened the front entrance door of the facility causing the door's alarm to sound. Certified nurse aide (CNA) F responded to the alarm. She saw the front door closing behind resident 1. CNA F redirected the resident back inside the facility and settled her back into her room. At 2:30 p.m. that same afternoon, the door alarm sounded again. CNA G responded to the alarm. He found resident 1 standing in front of the open front door entrance. The resident wanted to go away for a while. She was redirected away from the front entrance by CNA G. 2. Review of the provider's 3/22/26 SD DOH FRI revealed that on 3/21/26 at 9:32 p.m., the door alarm sounded. Registered nurse (RN) H and CNA I checked the facility's doors, which were all closed. An internal search of the facility revealed that resident 1 was unaccounted for. She was not found inside the facility or on the facility's grounds. Her family member and law enforcement were notified of the resident's absence. Resident 1 was last seen in her bed by the staff.At 9:38 p.m., en route to the facility, resident 1's family member saw resident 1 lying on the ground approximately 30 yards away from the facility. After resident 1 returned to the facility, she was assessed by the nursing staff for any injuries. Resident 1 had a small hematoma (collection of blood under the skin caused by injury) below the crown of her head. Neurological checks (assessment of nerve function, reflexes, coordination, motor skills, sensation, and mental status) were initiated. They were within normal limits. Resident 1's physician was notified of her elopement and injury.3. Review of resident 1's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with agitation, irritability, and depression. Her 4/26/26 Brief Interview for Mental Status (BIMS) assessment score was 8, which indicated her cognition was moderately impaired.Resident 1 received psychiatric services. A 5/5/26 psychiatric progress note indicated that resident 1 had moments of delusion (false beliefs and distorted view of reality) and agitation. [Resident 1] believes she can go home and live independently. She has poor safety awareness and is at risk for falling. The resident was prescribed Seroquel (an anti-psychotic) and Zoloft (an antidepressant). There were no recent changes to those medications.The resident's initial 2/2/22 Elopement Risk Assessment score was 17, which indicated that resident 1 was a high risk for eloping related to her cognitive impairment, poor decision-making, her desire to leave the facility, and her ability to ambulate. Her 4/28/26 Elopement Risk Assessment indicated that the resident remained a high risk for eloping.Her 4/24/26 Wandering Risk Scale assessment score was 13. An assessment score of 11 or higher indicated a resident was at high risk for wandering. Resident 1's 4/28/26 through 5/26/26 Wandering UDA (user-defined assessment) revealed she wandered 18 of those 30 days. Resident 1's revised 5/27/26 care plan did not mention her wandering, exit-seeking (a behavior in persons with dementia, characterized by attempts to leave a secure area of a facility), or eloping.4. Interview on 5/27/26 at 1:35 p.m. with laundry staff J revealed she had worked at the facility for about three years. She knew resident 1 sometimes forgot to use her walker when she walked, and stated she wanted to go home, and would walk towards the front door. She was verbally redirected by the staff when that happened.5. Interview on 5/27/26 at 1:40 p.m. with CNA K revealed she had worked at the facility for about four years. She knew resident 1 was confused and would pack a bag because she had a baby boy at home. At those times, the resident might walk towards the front entrance as if to leave the facility. She was monitored closely by the staff. Resident 1 usually responded to reassurance from the staff when she was told that the boy was fine. The resident also wandered into other residents' rooms. At times, the staff had resident 1 talk with a family member on the phone to calm her. The resident's family members also came to the facility to support the resident.CNA K knew all the door entrances would alarm if they were opened by someone other than an employee. There were cameras positioned at the facility entrances, and a television monitor by the nurses' station showed views of those entrances.6. Observation and interview on 5/27/26 at 1:30 p.m. with resident 1 revealed that she sat in a chair near the nurses' station with her walker in front of her. She was neatly dressed, smiling, and calm. She felt fine, but she had a corn on her right foot.7. Observation on 5/27/26 at 3:20 p.m. revealed resident 1 was in an activity room seated next to another resident. Two young family members were playing nearby. At 3:30 p.m., resident 1 approached administrator A and asked her about going out to the rodeo that day. Resident 1 accepted administrator A's explanation that it was too hot to be outside that day, and the rodeo may be over.Resident 1 commented that she had been up working since 8:00 a.m. that day anyway. 8. Interview on 5/27/26 at 1:45 p.m. with Minimum Data Set (MDS) Nurse D revealed she worked one day per week at the facility. She completed residents' MDS assessments, updated resident care plans, and attended resident care conferences. MDS Nurse D acknowledged that resident 1's care plan did not address her wandering, exit-seeking, or elopement risk, even though she knew resident 1 demonstrated those behaviors. 8. Interviews on 5/27/26 at 2:20 p.m. and 3:00 p.m. with administrator A revealed that all staff were made aware of the above FRIs regarding resident 1 after those incidents occurred. They were reminded how wandering and exit-seeking behaviors, and elopements were expected to be managed. On 4/28/26, the facility conducted a mock elopement drill. Administrator A stated that high winds the night of resident 1's 3/21/26 elopement may have awakened her, causing her to get out of bed and leave her room. The resident was also being treated for a urinary tract infection, which may have increased her confusion at that time.The facility's door alarm sounded properly when it was opened by resident 1, the staff responded to that alarm as they were expected to, and reacted properly when resident 1 was not able to be accounted for. 9. Interview on 5/27/26 at 3:30 p.m. with administrator A, MDS Nurse D, director of nursing (DON) B, assistant DON C, and RN/social services director (SSD) E revealed resident 1's sundowning (increased confusion, anxiety, agitation that peaks in the late afternoon or early evening) correlated with her wandering and exit-seeking behaviors. The resident was more inclined to wander and exit-seek after she returned from outings with her daughter, when she showed signs and symptoms of a potential urinary tract infection, when she verbalized a desire to go home, and when she packed a bag to go home. Interventions that were implemented when resident 1 wandered and sought out facility exits included staff supervision, limiting the resident's off-grounds outings, verbal redirection, family phone calls or visits, anticipating the resident's needs for thirst, hunger, continence care, or physical exercise, and individualized diversion activities for the resident to engage in. The above staff acknowledged that all of the above information related to resident 1 should have been in her care plan. Administrator A, DON B, ADON C, and RN/SSD E, in addition to MDS Nurse D, were also responsible for ensuring that resident 1's care plan was revised to reflect her individualized needs.10. Review of the provider's revised 4/11/26 Elopement of a Resident policy revealed that following a resident elopement, The care plan should be updated with additional approaches being implemented.

Based on observation, record review, interview, and policy review, the provider failed to ensure: *One of one low-temperature dishwasher consistently met the required minimum wash and rinse temperatures for proper sanitation. *Temperature monitoring and documentation was completed consistently for one of one dishwasher temperature logs. Findings included: 1. Observation on 4/14/25 at 12:35 p.m. in the kitchen revealed: *The mechanical dishwashing machine had a label on it that read: -Wash Temperature 120 degrees F [Fahrenheit] minimum. -Rinse Temperature 120 degrees F minimum. *The logs for the dishwasher temperatures for April 2025 were on the counter and included: -Columns to record Wash/Rinse Temp/IN [initials] for each of the three mealtimes listed as Breakfast, Lunch', and Supper. -Each column had only one recorded temperature. -Those temperatures ranged from 111 to 134 degrees F. --Fifteen of those recorded temperatures were not at the minimum wash/rinse temperature of 120 degrees F. *Review of additional dishwasher temperature logs revealed: -For March 2025: - Columns to record Wash/Rinse Temp/IN for each of the three mealtimes Breakfast, Lunch', and Supper. -Each column had only one recorded temperature. -Those temperatures ranged from 103.7 to 132.3 degrees F. --Twenty-four of those recorded temperatures were not at the minimum wash/rinse temperature of 120 degrees F. *For February 2025: -Columns to record Wash/Rinse Temp/IN for each of the three mealtimes Breakfast, Lunch', and Supper. -Each column had only one recorded temperature. -Those temperatures ranged from 97 to 130.5 degrees F. --Eighteen of those recorded temperatures were not at the minimum wash/rinse temperatures of 120 degrees F. *For January 2025: -Columns to record Wash/Rinse Temp/IN for each of the three mealtimes Breakfast, Lunch', and Supper. -Each column had only one recorded temperature. -Those temperatures ranged from 85 to 137.8 degrees F. --Twenty-five of those recorded temperatures were not at the minimum wash/rinse temperatures of 120 degrees F. 2. Observation and record review on 4/14/25 at 12:45 p.m. in the kitchen revealed: *The dishwasher temperature monitoring sheets had several unrecorded temperatures that included: -April 2025 had 7 unrecorded temperatures out of 40 opportunities. -March 2025 had 15 unrecorded temperatures out of 93 opportunities. -February 2025 had 36 unrecorded temperatures out of 84 opportunities. -January 2025 had 32 unrecorded temperatures out of 93 opportunities. 3. Interview on 4/14/25 at 12:53 p.m. with dietary manager (DM) E revealed: *She had been employed with the facility as the DM since 7/29/24. *She knew about the low temperatures of the dishwasher since she had started as the dietary manager. *She had called the service department from whom they leased the dishwasher, he came to the facility four times to service the dishwasher and was able to get the rinse and wash temperatures to a minimum of 120 degrees F. -He had been coming to the facility to service the dishwasher and had told the facility they needed a holding tank. -She was unsure of when maintenance had installed the holding tank. *She agreed there were several unrecorded temperatures on the dishwasher temperature logs. *She had tried to check the dishwasher temperature logs monthly but had gotten busy and forgotten to check them. 4. Observation and interview on 4/15/25 at 8:13 a.m. in the kitchen with dietary staff G revealed: *She stated she was running the dishwasher to see what the thermometer read. -It had read 117 degrees F for the wash temperature, she did not wait for the thermometer to read the rinse temperature. *She stated she had to run the dishwasher again to get the thermometer to read 120 degrees F or above. *On the second cycle, the wash temperature was 123 degrees F, and the rinse temperature was 127 degrees F. 5. Interview on 4/15/25 at 8:25 a.m. with maintenance manager F revealed he had installed the holding tank on 1/7/25. 6. Interview on 4/15/25 at 9:20 a.m. with chief operating officer (COO) A regarding the low dishwasher temperature readings revealed: *She thought the holding tank that was installed on 1/7/25 had fixed the problem. *She expected the kitchen staff to have notified the DM of the dishwasher low temperature readings. *She had talked to the service department that they leased the dishwasher from, and they discussed options if the temperature problem did not resolve. *She confirmed there had been no gastrointestinal outbreak in the facility. 7. Interview on 4/15/25 at 4:45 p.m. with dietary staff H regarding the low dishwasher temperature readings revealed she: *Had written temperatures on the dishwasher temperature log below 120 degrees F. *Stated she knew the dishwasher temperature needed to be 120 degrees F or above. *Did not notify the dietary manager of the low dishwasher temperature readings. 8. Review of the provider's 11/1/23 Dish Machine Temperature Log policy revealed: OBJECTIVE: Dishwashing staff will monitor and record dish machine temperatures to ensure proper sanitizing of dishes. Procedure: *1. The dishwashing staff will be provided a log for daily temperature tracking. *2. The food service manager will train dishwashing staff to monitor [the] dish machine temperature throughout the dishwashing process. *3. Staff will be trained to record dish machine temperatures. *4. Dishwashing staff will be trained to report any problem with the dish machine to the food service manager as soon as they occur. *5. The food service manager will assess any dish machine problems and take action to assure sanitation of dishes.

Based on observation, interview, record review, and policy review, the provider failed to adhere to professional standards of care by not ensuring medications were taken by four of four observed residents (3, 9, 14, and 19) at the time those medications had been administered by one of one unlicensed medication aide (UMA) (I) and one of one licensed practical nurse (LPN) (J). Findings include: 1. Observation and interview on 4/14/25 with resident 14 in the dining room revealed: *At 5:30 p.m. a blue, oval-shaped pill, and a round salmon-colored pill were in a medication cup on the dining table in front of the resident. *Resident 14 sat between two female residents at that table. -The table was located near the entrance to the kitchen and around the corner from the medication cart. *At 5:45 p.m. the above medications remained in the medication cup. -Resident 14 stated she wanted to eat something first before she had taken those pills. *At 6:05 p.m. the medication cup was empty. 2. Continued observation in the dining room of resident 9 revealed: *At 5:35 p.m. UMA I placed a powdered substance in the resident's cup of thickened juice, and stirred it using a straw. -The powdered substance had not dissolved in the thickened juice and small clumps of the powder were seen inside the cup. *UMA I encouraged resident 9 to drink the contents of the cup, then walked back to her medication cart and continued with other residents' evening medication administrations. *At 6:15 p.m. the above juice glass was mostly empty. Small bits of clumped powder were seen along the inside and bottom of that cup. 3. Continued observation in the dining room and interview with resident 19 revealed: *At 5:50 p.m. resident 21 leaned over from her dining room chair and picked up a white pill from the floor. -She handed that pill to resident 19, who then placed it into her mouth and swallowed it. *Resident 19 stated that pill was just a calcium pill. 4. Observation and interview on 4/15/25 at 7:35 a.m. with resident 3 in the dining room revealed: *She had picked up a medication cup on the table in front of her and drank the clear-colored substance inside that cup. -She had not known what she had drunk from that cup, but she thought it was medicine. 5. Review of residents 14, 9, 19, and 3's electronic medical records revealed: *Resident 14's 1/23/25 Basic Interview for Mental Status (BIMS) assessment score was a 9. That indicated she had moderate cognitive impairment. *Resident 9's 2/28/25 BIMS assessment score was 14. That indicated he was cognitively intact. *Resident 19's 1/25/25 BIMS assessment score was 15. That indicated she was cognitively intact. *Resident 3's 2/27/25 BIMS assessment score was 9. That indicated she had moderate cognitive impairment. *None of the above residents had a physician's order or an assessment completed that supported their ability to have self-administered their medications. Interview on 4/15/25 at 3:20 p.m. with UMA I and LPN J regarding the above medication administrations revealed: *UMA I confirmed having left residents 14 and 19's medication cups on their tables without having ensured that those residents had taken the prescribed medications in those cups. *The powder UMA I had added to resident 9's thickened juice was a physician-ordered fiber supplement. -The resident was unable to drink the entire cup of thickened juice at one time, so she observed the juice cup periodically during the meal service to ensure the contents had all been consumed by the resident by the end of the meal service. *UMA I and LPN J had known resident 9 took his fiber supplement in a gummy form in the past. They felt that allowed staff to confirm the supplement was taken at the time of its administration. *LPN J confirmed having left resident 3's fiber supplement on the table for the resident to have taken on her own. -She stated she was expected to have watched the resident take the medication at the time she administered it and she should not have walked away from the resident when the medication had not yet been taken. Interview on 4/16/25 at 7:46 a.m. with director of nursing (DON) B regarding the above observations revealed: *It was her expectation that UMAs and licensed nursing staff were to have observed and confirmed residents had taken their prescribed medications at the time they were administered. -A physician's order and a completed medication self-administration assessment were required for a resident to take their medications unsupervised. Review of the provider's revised 3/11/24 Administration of Medications policy on 4/16/25 at 7:46 a.m. with DON B revealed: *The policy had indicated: 14. No medications will be left in the resident's room unless a Self-Administration of Medications Assessment has been documented by the medication nurse and a special order by the attending physician is in place. -DON B confirmed the above would have also applied to leaving medications on a dining room table.

Based on observation, interview, record review, and facility assessment review, the provider failed to ensure: *One of one sampled resident (20) had been screened for post-traumatic stress disorder (PTSD) upon being admitted to the facility. *The implementation of a trauma informed care program. Findings include: 1. Observation and interview on 4/15/25 at 10:00 a.m. with resident 20 in his room revealed he: *Was a well-groomed, heavy-set man who sat in his wheelchair during the interview. *Was never married, but he had a sister who was involved with his care. *Had lived in the facility for about 18 months. He wanted to live on his own again or in an assisted living facility. *Had a history of health conditions that included heart disease, a stroke that had affected his left side, and a fall that had caused a brain bleed. -Had a new diagnosis of leukemia, but he was not certain what his treatment course was. -Had breathing issues he attributed to the inhalation of jet fumes while he was in the military. *Had served during the Vietnam War on an aircraft carrier. -Had seen planes land on that carrier with visible signs of having been shot at by enemy fire. -Had not given his mother any details regarding his military assignment to protect her from worrying about him. -Was not recognized for his military service with a parade or a celebration when he was discharged from the service. *Confirmed he had anxiety and depression mostly related to his loss of independence. He denied the need for counseling services, but he was taking medication for those conditions. Review of resident 20's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *He was taking an anti-depressant medication once daily and an anti-anxiety medication twice daily. *In addition to the above diagnoses reported by the resident, he also had a history of suicidal ideations diagnosed on [DATE]. *His 2/22/25 Brief Interview for Mental Status assessment score was 15. That indicated his cognition was intact. *Social services designee (SSD)/registered nurse (RN) D's 2/24/25 progress note indicated: he [resident 20] does have a history of being verbally abusive to staff and mocks other residents, this behavior has improved and this behavior is monitored. He has had occasional outbursts with staff when he becomes frustrated, none in this assessment period. [Resident 20] has been counseled and redirected with this negative behavior. -Resident 20 had refused mental health services. There was no mention of his past military service or potential trauma. On 4/15/25 at 1:50 p.m. a trauma-informed care assessment for resident 20 was requested from director of nursing (DON) B, assistant DON C, SSD/RN D, and Minimum Data Set (MDS) coordinator K. *They confirmed there was no such assessment completed for resident 20. They did not have a process to have assessed residents for trauma history. -They agreed resident 20 may have been at risk for trauma related to his military service. *The provider had no Trauma-Informed Care policy. Review of the provider's Facility Assessment last reviewed and updated in November 2024 revealed: *Part 2: Services and Care We Offer Based on our Residents' Needs: -Specific Care or Services had included: Manage medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as trauma/post-traumatic stress disorder (PTSD) .

Based on observation, interview and policy review the provider failed to ensure: *One of one kitchen was maintained in a clean and sanitary manner. *Food was stored and labeled safely. Findings include: 1. Observation and interview on 12/18/23 at 10:15 a.m. with dietary manager E while in the kitchen revealed: *A large, thick, white, and brown circle under the dishwasher. *The gas stovetop and burners had dried, burnt food particles on it. *The space between the stovetop and the grill had grease build-up and burnt food particles. *Under the stove and the prep table the floor had a thick build-up of dust, grease and visible chunks of food. *The front of the stove had splattered grease covering the surface. *The stovetop was cleaned weekly every Monday. *The kitchen had been deep cleaned two and a half weeks ago. *The floors were mopped nightly. *The cleaning list was to have been posted on the refrigerator and staff were to place a check mark when completing the task. *She had not kept any logs of past cleaning lists. Observation on 12/18/23 at 4:30 p.m. in the kitchen revealed: *The back of the stove had grease build-up, dust, and spider webs on it. *The floor in the back of the stove had thick dust build-up with visible food particles around the stoves floor outlet. *The back of the stove had a layer of thick dust and cobwebs. *Under the three-compartment sink there was a bucket placed on a serving tray, under a drain that had unidentified overflowing white sludge. Interview on 12/19/23 at 9:45 a.m. with chief operating officer A revealed: *She agreed the items above were dirty and unsanitary. *Dietary manager E should have kept a log of the past cleaning lists. *The mops used to clean the floor in the kitchen, were hard to get under the stove and prep table. *She was unaware of the bucket that was on a serving tray under the drain of the three-compartment sink. Review of provider's undated Cleaning Instructions: Ranges policy revealed The range will be cleaned after each use. Spills and food particles will be wiped up as they occur. Review of provider's undated Cleaning Instructions: Floor, Tables and Chairs policy revealed: *Procedure: -1. Kitchen floors will be swept and cleaned after each meal. A thorough cleaning using a disinfectant will be done at least twice a week. Major appliances will be moved at least once a month (as appropriate) in order to facilitate cleaning behind and underneath them. Review of provider's undated Sanitation of Dining and Food Service Areas policy revealed: *The food service staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. *The food service manager will record all cleaning and sanitation tasks needed for the department. 49695 2. Observation on 12/18/23 at 10:00 a.m. in the kitchen revealed: a. Inside the dry food storage room there was the following: *Unsealed and undated opened bags of pretzels, rice, and crackers. *An unlabeled and undated can of coconut flakes. *An unlabeled and undated jar of dried parsley that was opened to the air. *Multiple bags of unlabeled and undated bags of dried pasta that had been removed from their original packaging. b. Inside the chest freezer there was the following: *Opened bags of unlabeled and undated frozen chicken, frozen pork chops, and frozen garlic toast. *A bag of unlabeled and undated frozen hamburger patties that was opened to the air. *Multiple bags of unlabeled and undated frozen vegetables, poultry, breads, and meat that had been removed from their original packaging. c. Inside the refrigerator there was the following: *Undated and unlabeled plastic containers of prepared Jell-O cups and fruit cups with lids. *Undated and unlabeled pitchers of prepared tea. Interview on 12/18/23 at 10:15 a.m. with dietary manager (DM) E regarding the above-mentioned food items revealed: *She confirmed the food items were not dated, labeled, and sealed when they were opened. *She was unsure when the Jell-O cups, fruit cups, and pitchers of tea were prepared. *It was her expectation that staff stored opened food items in sealed containers and label them with open dates. Interview on 12/19/23 at 9:45 a.m. with chief operations officer (COO) A revealed it was her expectation that food packages and containers would be sealed and have an opened date on them to ensure the quality and freshness of the foods. Review of the provider's undated and untitled Food Storage and Labeling policy revealed: *Previously cooked or prepared foods were to be labeled with a discard date. *Foods that were made with previously cooked foods in-house were to be labeled with the discard date of the previously cooked items. *Leftover foods stored in containers were to have tight-fitting lids and clearly labeled with the date and time the food was first prepared. *If foods were stored in a zip-top plastic bag, the air was to be pushed out of the bag before it was sealed. *All ready-to-eat foods that were prepared in-house were to have been stored for a maximum of 7 days. -After 7 days, those food items were to have been thrown out to prevent bacteria from growing to unsafe levels. Review of the provider's undated and untitled Food Service policy revealed food stored for future serving was dated and stored in sealed containers then discarded based on the shelf life of the individual food item.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled residents (27) physician's order (PO) for weight monitoring and physician notification of weight changes outside the specified parameters was followed. Findings include: 1. Observation and interview on 12/18/23 at 11:31 a.m. and again on 12/19/23 at 3:00 p.m. with resident 27 revealed he: *Was admitted in August 2023 and his diagnoses included a stroke history, heart disease, diabetes, and a brain bleed. -Was wearing compression socks to help maintain his blood flow and reduce leg swelling. -Weighed less than he had in the recent past. Review of resident 27's electronic medical record (EMR) revealed: *A 9/4/23 PO that included the following instructions: -Weigh the resident daily. -Notify the cardiologist if the resident has a three lb (pound) weight gain overnight or a five lb weight gain in one week. *An 11/28/23 Nutritional Assessment indicated the resident's weight was 288.8 lbs. -That was an increase of 17.2 lbs in 30 days and a 13.8 lb increase since his admitted . Interview on 12/19/23 at 9:30 a.m. with registered nurse G regarding resident 27 revealed: *He was administered a daily diuretic medication (a medicine that helps reduce fluid build-up in the body) for heart failure. *His weight was taken and documented daily. *A physician was notified if the resident's weight fluctuated outside the parameters outlined in the PO referred to above. -Nurse communication with the physician regarding those weight changes was documented in the resident's EMR. *She had not: -Ever had to notify a physician for a weigh gain outside of the parameters referred to in the above PO. -Been aware of any nurse who needed to contact a physician regarding the resident's weight having been outside of those physician-ordered parameters. Interview on 12/19/23 at 1:30 p.m. with director of nursing (DON) B revealed: *Resident 27's weight was taken no later than 9:00 a.m. each day and documented on the Daily Weight Sheet form. *The nurse was responsible for the following: -Signing the bottom of the Daily Weight Sheet form each day indicating the weight information was reviewed. -Determining if resident 27's weight for the current day was three lbs greater than his weight that was documented for the previous day or if the current days weight was five lbs greater than his weight documented one week prior. -Notifying the physician of weight fluctuations outside of the parameters in the 9/4/23 PO. -Documenting the outcome of the physician notification in the resident's EMR. Continued interview with DON B and review of resident 27's 11/19/23 through 12/17/23 Daily Weight Sheet forms and his EMR revealed she confirmed: *There were no documented weights on 11/19/23, 11/30/23, 12/7/23, 12/13/23, and 12/16/23. *Overnight weight gains of greater than 3 lbs occurred on the following days: -Between 11/18/23 (273 lbs) and 11/20/23 (282 lbs). -Between 11/20/23 (282 lbs) and 11/21/23 (288 lbs). -Between 11/28/23 (283.6 lbs) and 11/29/23 (287.8 lbs). -Between 12/4/23 (280.4 lbs) and 12/5/23 (285.6 lbs). -No nurse progress notes between 11/19/23 and 12/17/23 regarding the weight changes referred to above had been communicated to the physician. Review of the undated Physician's Orders policy revealed [Physician's] orders are verified and coordinated by a nurse.

Based on review of the Consultant Pharmacist Review reports for 2023, record review, interview, and policy review, the provider failed to ensure a physician's order (PO) included a specific duration of time for an as needed (PRN) psychotropic medication for one of one sampled resident (26) who received a PRN psychotropic medication. Findings include: 1. Review of resident 26's electronic medical record (EMR) revealed: *Two POs for PRN Ativan (psychotropic medication). -One had instructions for administration with seizure activity and the other had instructions for administration with agitation. -The PO for Ativan 0.5 mg every 6 hours PRN for agitation was started on 6/19/23. *Consultant Pharmacist Review 2023 monthly notes completed by pharmacist D that reviewed the resident's EMR for identification of medication irregularities revealed: -Only the PRN PO for Ativan administered with seizure activity had been reviewed. -There was no documentation of the PRN PO for Ativan administered for agitation. *Medication administration records from 6/19/23 through 12/19/23 revealed the PRN Ativan for agitation was administered three times in November 2023. Interview on 12/19/23 at 3:49 p.m.with pharmacist D regarding resident 26's PRN Ativan for agitation revealed he: *Had monitored the resident's use of PRN Ativan administered for seizure activity but had not monitored the use of the PRN Ativan administered for agitation. -That was an oversight on his part. *Had known PRN orders for the use of psychotropic medications were limited to 14 days unless the physician documented a rationale to extend the use of that medication. -Should have requested a standing order for re-evaluation of the use of that medication every 14 days, requested the medication had been administered on a scheduled basis, or requested the medication had been discontinued. Interview on 12/20/23 at 9:21 a.m. with director of nursing B regarding resident 26's PRN Ativan administered for agitation revealed: *The resident's admission orders included multiple PRN Ativan orders for agitation. -She had thought all those POs had been discontinued. Review of the July 2022 Psychotropic Medication Use policy revealed 12. a. PRN orders for psychotropic medications are limited to 14 days. Review of the undated Physician's Orders policy revealed: *6. The ADON/SSD [assistant director of nursing/social services designee] will print and verify the physician's orders at least every 60 days to provide a clean (recap) copy. *7. The physician will review the recap. The physician, then, will sign and date the recap, stating that it is correct. *8. The charge nurse will review the recap of orders, enacting all new orders, then noting the recap by signing 'noted', signing, and dating it when the process is completed.

Based on observation, interview, and policy review, the provider failed to ensure: *Medications in one of one medication refrigerator were securely stored. *One of one sampled residents (20) had her prescription insulin medication accurately labeled. Findings include: 1. Observation on 12/18/23 at 2:36 p.m. of the medication refrigerator revealed: *It was unlocked on a counter in an alcove near where the north/south and east/west residential hallways intersected. *Inside of the refrigerator was the following: -One syringe of Ativan (psychotropic medication) in a clear plastic container secured by a zip tie. -Multiple stacked boxes of residents' insulin. -A tuberculin vial. *Staff entered and exited that alcove to access residents' paper charts and to use a handwashing sink. Interview on 12/18/23 at 2:54 p.m. with registered nurse (RN) G regarding the medication refrigerator revealed: *It was unsecured. -The key used to lock it had not worked for a few months. -I would have to think someone reported this issue to management. *The medications in the refrigerator were accessible to anyone who entered that alcove. -Missing medications would not have been noticed until shift change when they were counted by the nursing staff. Interview on 12/19/23 at 1:30 p.m. with director of nursing (DON) B regarding the unsecured medication refrigerator revealed she: *Was unsure how long the refrigerator key had not worked. -Had known the key worked at the end of the preceding week. *Expected nursing staff to notify her or another member of the management team upon discovering that the refrigerator key was not working. -The refrigerator could have been secured by another means until a new key was made or the lock was replaced. 2. Observation and interview on 12/19/23 at 11:30 a.m. with RN G during a medication administration pass revealed: *She referred to resident 20's medication administration record (MAR) for the physician's order (PO) and instructions regarding the administration of her insulin (Lantus) medication. -That order was for ten units of Lantus to have been injected subcutaneously daily for diabetes. *She removed the prescription labeled Lantus insulin pen from the medication cart. -Without comparing the instructions on the prescription label to the MAR she prepared and primed the insulin pen. -Dialed the number of units of insulin to administer to ten. -Locked the medication cart and turned towards the resident's room to administer that insulin dose. *RN G was asked by the surveyor to read the prescription label on the insulin pen. -It instructed five units of Lantus to be injected subcutaneously daily. *She had not noticed the discrepancy between the amount of insulin on the MAR that was to have been administered compared to the amount of insulin on the prescription label that was to have been administered. -She was expected to compare them and reconcile any differences before drawing up the insulin for resident 20. Interview on 12/19/23 at 11:45 a.m. with DON B revealed RN G was expected to: *Compare the prescription label of resident 20's insulin against the PO for insulin on her MAR before preparing the medication for administration. *Place a See MAR sticker on the prescription label to alert other nursing staff to the discrepancy between the prescription label on the insulin pen and the PO for insulin on the MAR. Review of the undated Compliance of Medications policy revealed 7. Resident's medications must be properly labeled and stored in a locked cabinet at the nurse's station.

Based on observation, interview, and record review, the provider failed to ensure one of one dietary manager (DM) (E) had completed a State-approved training program for feeding assistants prior to providing two of two observed residents (20 and 26) feeding assistance during one of one observed meal service. Findings include: 1. Entrance conference interview on [DATE] at 10:30 a.m. with chief operating officer (COO) A revealed the facility had no paid feeding assistants. Observation and interview on [DATE] at 5:07 p.m. with DM E in the dining room revealed: *She sat at one of the dining room tables in between residents 20 and 26. *Resident 20's meal was served on a three-compartment plate. -The consistency of her food was moist-looking and had been modified to a soft texture. *DM E verbally cued and physically assisted the resident to eat her meal. *Resident 26 used a modified spoon to scoop his food and bring it to his mouth to eat. *DM E held a cup to the resident's mouth for him to drink fluids. *She helped feed residents to support her co-workers. *She was not a certified nurse aide (CNA) and had not been provided any specialized feeding training. -She thought the only requirement for feeding residents was having cardio-pulmonary resuscitation (CPR) certification. Review of resident 20's electronic medical record (EMR) revealed: *An [DATE] speech therapy daily treatment note: Patient continues to present with moderate to severe dysphagia characterized by needing a modified diet, pocketing food, anterior loss with cup and residue within oral cavity. Review of resident 26's EMR revealed: *A [DATE] speech therapy daily treatment note: Patient presents with mild to moderate dysphagia characterized by oral residues, pocketing, deficits from stroke, and no use of left side as well as safety precautions d/t [due to] patient being at an increased risk for aspiration. Interview on [DATE] at 1:00 p.m. with COO A revealed: *She had known DM E helped assist residents with their meals without having CNA training or having completed a State-approved training program for feeding assistants. *Neither resident 20 nor resident 26 were appropriate to have been assisted by a feeding assistant based on their diagnoses, the speech therapy recommendations referred to above, and DM E's lack of specialized training for residents who required feeding assistance. A Feeding Assistance Program policy was requested from COO A on [DATE] at 3:00 p.m. She confirmed there was no policy.

Based on observation, interview, and policy review, the provider failed to ensure an in-room call light system was accessible for one of one sampled resident (13). Findings include: 1. Observation and interview on 12/18/23 at 11:46 a.m. with resident 13 in his room revealed: *He was in bed underneath his bedding wearing a hospital gown. -Individual packets of lip balm and packages of mouth swabs sat on his bedside table. *His television was on, and his call light was lying on top of the bed covers near his feet. -He used his hands to feel on top of his bedding for the call light but was not sure where it was. -He would have tried to get the attention of someone passing by his room if he had needed help. Observation on 12/18/23 at 2:26 p.m. of resident 13 in his room revealed: *He was in bed asleep with the television on. -His call light lay on the floor at the foot of his bed. Interview on 12/18/23 at 2:30 p.m. with certified nurse aide (CNA) I revealed: *Resident 13 was hospitalized about a month ago. -He received end-of-life care and had chosen to remain in bed most of the time. *Staff had been in the resident's room no less than every two hours to reposition, check, and change his incontinence brief. Observation on 12/18/23 at 3:25 p.m. of resident 13 revealed maintenance manager F stood in the resident's doorway and asked How are you, [resident 13]? without noticing the call light was on the floor. Interview on 12/19/23 at 8:05 a.m. with maintenance manager F regarding the 12/18/23 observation referred to above revealed he had not noticed the resident's call light on the floor. Observation and interview on 12/19/23 at 7:40 a.m. of resident 13 revealed he: *Was in bed and would have been better if he had coffee. -Was unable to make his needs known because his call light was between his legs below his knees and was unable to be seen or reached by the resident. Interview on 12/19/23 at 10:20 a.m. with CNA J regarding resident 13 revealed she: *Provided care for the resident at 7:30 a.m. that morning. -Had not noticed the resident's call light was not accessible to him. *Thought the call light might have been unintentionally displaced by the resident when he moved around in bed. -Had known other residents whose call light had a clip on it that could be attached to their clothing or bedding so it remained in place. Interview on 12/19/23 at 1:30 p.m. with director of nursing B regarding resident 13's call light revealed: *Staff were in and out of his room at routine intervals to provide end-of-life care. -They were expected to ensure the resident's call light was accessible anytime they were in his room or passed by and looked into his room. *A modification to the resident's call light should have been made so it remained in place and accessible for the resident to activate. Interview on 12/20/23 at 9:30 a.m. with assistant DON C revealed call light competencies were completed annually for all caregivers and included ensuring residents always had access to a call light. On 12/19/23 at 4:45 p.m. chief operating officer A stated there was no policy that specifically addressed call light accessibility.

Based on observation, interview, and policy review, the provider failed to ensure appropriate hand hygiene and glove use to prevent cross-contamination in the handling of ready to eat foods during one of one meal service with one of one cook (E). Findings include: 1. Observation and interview on 12/27/22 from 4:33 p.m. through 5:20 p.m. of the supper meal revealed: *Beginning at 4:33 p.m. with gloves on completed the following food preparation tasks, he: -Used gloved hands obtained a knife from drawer and started cutting a grilled cheese sandwhich. -Placed the grilled cheese sandwhich on plate and with same gloved hands adding crackers and cookies to plate. -Used utensils to serve soup and dish up cauliflower out of a pan and placed on same plate. -Handed the plate to his co-worker. -Looked out to the dining room to see who to serve next as he leaned on countertops and top of the microwave with gloved hands. -Touched drawers to get utensils out, used a pen to write on a sticky note and touched his mask. -Continued to touch the grilled cheese sandwiches, cookies and crackers with the same gloved hands along with utensils for soup and cauliflower to serve the residents. -Served 5 more plates then got tongs out for the grilled cheese sandwiches. -Opened the microwave and placed two small containers of pureed cauliflower in it with same gloved hands. -Touched the controls on the microwave to heat the containers. -Removed the containers and placed them on the plate. -Grabbed another bowl to heat the pureed soup in. -Touched the microwave controls to heat the soup. -Removed soup from the microwave. -Grabbed a bowl and used a utensil to fill it with soup. -Placed it on a plate and handed it to a co-worker. -Leaned on countertops and top of the microwave to look out into the dining area. -Continued to use the same gloves to serve cookies, crackers and plates until all residents were served. -Removed the gloves he had used from start of serving the meal, touching objects, removed the gloves without washing his hands. Interview with Cook E on 12/27/22 at 5:20 p.m. revealed: *He was hired in March of 2022. *His dietary trainings were completed upon hire. *He agreed, by nodding his head and verbilizing he should not have touched contaminated surfaces and then continue to serve food without sanitizing and changing his gloves. Review of Cook E's training records revealed he: *Completed Competencies for Food and Nutrition Services Employees on 9/8/22. *Completed Hand Washing Competency on 10/18/22. *Was working towards getting Servsafe certified. Interview on 12/29/22 at 4:06 p.m. with Chief Operations Officer (COO) A revealed: *The Dietary Manager (DM) was on vacation. *Trainings for dietary staff included Relias and Association of Nutrition & Foodservice Professionals (ANFP) upon hire and annually. *Monitoring of staff included the DM and COO overseeing. *Discussion in Quality Assurance Performance Improvement (QAPI) from DM and any individual training that was needed. *COO A agreed Cook E should not have continued to use soiled gloves to serve food to the residents. Review of the Facility's undated Hand Hygiene and Glove use in the Kitchen policy revealed: *Objective: To ensure that all residents, residents' family or friends, and staff are receiving ready to eat food under sanitary conditions. To reduce as possible transmission of harmful bacteria to any resident, residents family or friends, or staff that may eat in the facility. *Procedure: -Policy for Glove use: --1. Wash hands properly before and after wearing or changing to a new pair of gloves ---b. If gloves become contaminated or visibly soiled dispose of properly and re glove following the proper steps of hand washing --4. When wearing gloves work from clean surfaces to dirty surfaces

Based on observation, interview, and policy review, the provider failed to ensure one of one controlled medication in one of one refrigerated emergency kit was accounted for. Findings include: 1. Observation and interview on 9/28/21 at 9:00 a.m. and 11:50 a.m. with registered nurse (RN) C and chief operating officer (COO) A regarding the locked emergency kit in the locked refrigerator in the medication storage room revealed: *The refrigerator and emergency kit required separate keys to unlock them. *The emergency kit contained a one dose vial of lorazepam (controlled antianxiety medication) two milligrams per milliliter. *RN C stated lorazepam was part of the emergency kit and was not a part of the controlled medication count. *The contents of that emergency kit was reviewed monthly by the pharmacist for expired medications. *RN C and COO A agreed if lorazepam was missing there was no system in place for reconciliation and accounting of that medication. Interview on 9/28/21 at 9:00 a.m. with director of nursing B revealed she agreed with the above findings. Review of the provider's revised 8/15/11 Emergency Medical Kit policy revealed there was no process to account for the controlled medication in the emergency kit. Review of the provider's undated Medication Narcotics Policy revealed: *Objective: To provide adequate record or administration of narcotics and other controlled drugs, proper accounting and storage for the same.

Based on observation, record review, interview, and policy review, the provider failed to ensure care plans for five of thirteen (3, 4, 20, 25, and 28) sampled residents' had been updated to reflect resident changes in health care needs. Findings include: 1. Observation of resident 4 on 10/21/19 at 4:30 p.m. revealed he: *Was alert and sitting in a recliner in his room. *Was confused to place and time. *Was unable to effectively participate in a conversation. Review of resident 4's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED]. Interview on 10/22/19 at 11:12 a.m. with the director of nursing and review of resident 4's Incident reports revealed: *The resident had fallen multiple times since his admission. -He was adjusting to his loss of independence. -They had noted he became more agitated and confused towards evening and most of his falls occurred in the evening. *He had dementia and was having a difficult time adjusting to this placement. -They encouraged him to use his call light, but he did not remember to do that. -They had placed a fall mat near his bed to prevent injuries if he did fall. -There was a sign in his room to remind him to use his call light. *When he first came in he was having difficulties with urinary urgency. -Since his admission they had started him a two different medications to treat the urgency. *On 6/26/19, he fell twice trying to get to the bathroom with no injury. *On 7/12/19, he was found on the floor of his room. He reported he was trying to transfer from the wheelchair to his recliner and missed the chair. *On 7/21/19 he was found on the floor of his room trying to get to the bathroom. *On 8/3/19 at 8:00 p.m., he was trying to transfer from his wheelchair to the recliner to make a phone call and missed the chair. *On 8/9/19, he was reaching for his call light and slid out of his bed to the floor. *On 8/17/19, he had returned to his room after supper, tripped on his slipper, and fractured his hip. -He was hospitalized and returned on 10/9/19. -Since that incident they had noted he was more confused. -He was now going to therapy three times a week. *In reviewing his above falls they were related to his needing to go to the bathroom and forgetting to use the call light. Review of resident 4's 6/18/19 care plan revealed: *Focus: The resident is at risk for fall r/t (related to) [MEDICAL CONDITION] and dementia. *Goal: The resident will be free of falls. *Interventions included anti-roll back brakes, and physical therapy to evaluate and treat as ordered or needed. -Other interventions were non-specific to this resident. *The care plan did not address: -He had numerous falls. -That most of his falls occurred in the latter part of the day. -That one of the falls had resulted in a [MEDICAL CONDITION]. -How his care needs changed as a result of that fracture. -The recommendations by therapy. -What staff were doing to monitor his safety when he was out of sight in his room. Further interview at the above time with the director of nursing (DON) regarding resident 4 revealed: *She confirmed the care plan did not address: -The resident had several falls. -The resident had a significant injury of a fracture. *She concurred the care plan should have been updated. 2. Observation and interview on 10/20/19 at 3:37 p.m. with resident 20 revealed she: *Had various stages of healing bruises to her forehead, the outside corners of her eyes, the bridge of her nose, and on both of her cheekbone areas. *Stated she had fallen in the early morning after using the bathroom. -Was unable to state the date of the fall. *Had been sitting on the four wheeled walker (4WW) and using it as a wheelchair to go from her bed to the bathroom and back. *Had fallen forward off of the 4WW seat and hit her face on the frame of her bed. *Stated she only used a wheelchair now. Review of resident 20's interdisciplinary progress notes revealed on: *9/17/19 4:18 p.m.: Resident was found on the floor this morning by CNA (certified nursing assistant) (initials) when she entered resident's room to answer her call light. This nurse was called to resident's room. She was sitting on the floor, on her bottom, facing her bed. She was CAOx3 (conscious, alert, and oriented times three). She had a large laceration to the middle of her forehead the was bleeding. She had a smaller laceration beside the right eye. The corner of her left eye, right next to the tear duct has a small tear with bleeding. Her left forearm had a large skin tear as well. Resident's right knee was bruising. Resident had a full body exam and extremities were checked for range of motion. Resident was carefully picked up and placed in her recliner where vitals were taken and neuro (neurological) checks were started. Resident was cleaned up and a change of clothes put on by CNA's while this nurse called resident's family and made arrangements to have her transported to (town name) ER (emergency room ) for more appropriate treatment. Resident's son (name) notified this nurse that he would come and take his mother to the ER. While waiting, this nurse cleaned up resident's left forearm and placed steri-strips to the skin tear. Resident's family arrived and loaded resident in POA (power of attorney) at 0720 (7:20 a.m.) This nurse notified ER and doctor on call that resident was en-route. Resident returned to facility around 10:30 (a.m.) with her son. Resident has steri strips to forehead, side of right eye. She is encouraged to use ice for swelling. Will CTM (continue to monitor) and continue neuro checks. *9/18/19 at 3:56 p.m.: Resident is a f/u (follow-up) fall from yesterday morning. Resident denies any pain r/t (related to) recent fall. Steri strips to forehead remain intact. Resident has bruising to her face and a light bruise to her left knee. She is assist with all transfers at this time due to unsteady gate (gait) and resident fear. She has been staying in her room today, however, she has a great attitude. Resident is monitored frequently. Neuro checks completed this am and all are within normal range. *9/28/19 at 5:33 p.m.: Resident began [MEDICATION NAME] 1600 (4:00 p.m.) for UTI (urinary tract infection). Will monitor resident for and (any) adverse reactions. *10/4/19 at 11:38 p.m.: Resident denies concerns with urination, no adverse reaction noted [MEDICATION NAME] (treatment), will finish up last coarse of antibiotics in the a.m. Review of resident 20's last revised 9/19/20 care plan revealed she had interventions for her problems of: *Resident is at risk for UTI's r/t incontinence. -That had last been revised on 8/28/18. There had been no updates to the care plan related to her recent UTI. *The resident is at risk for decline in ADL (activities of daily living) function r/t history of decline in ADL function r/t acute pain from fall. -That had last been revised on 8/28/18. -A 2/21/19 intervention included: She usually wants staff to push her down to meals on her four wheeled walker though she ambulates in her room. *The resident is at risk for falls r/t poor vision from [MEDICATION NAME] degeneration and history of fall. -That had been last revised on 8/18/18. -A 8/20/19 intervention included: Educate resident to use brakes appropriately on 4WW when using it as a seat/WC (wheelchair). -A 9/18/19 intervention included: (Resident used a 4 wheeled walker for ambulation, but do (due) to fall is not ambulating independently at this time. Resident also uses it as a wheelchair at times with staff assist. *There had been no updates related to her most recent fall for her facial bruising and lacerations. 3. Observation on 10/20/19 at 4:45 p.m. of resident 25 revealed she was seated in her recliner. There was a thick foam mat under the foot rest of the recliner. She had oxygen by a nasal cannula. That oxygen came from an oxygen concentrator, and a bottle of water to provide moisture was attached. She also had a pressure alarm under her in the seat of the recliner. She was transferred with a sit-to-stand lift from her recliner to the toilet and then to her wheelchair by certified nursing assistant (CNA) [NAME] Review of resident 25's interdisciplinary progress notes revealed on: *6/27/19 at 11:42 a.m.: Resident fell this am at 0635 (6:35 a.m.)while oncoming day shift was in report. Report late this am due to busy night for night shift. Resident found by night CNA with alarm sounding. Resident lying next to bed on her left side on safety mat in fetal position with her head facing the east towards the head of the bed. Resident transferred self from bed trying to go to the bathroom. Resident denies hitting her head and denies pain. She has ROM (range of motion) to all extremities. Assessment completed and then resident assisted X3 (times three) with use of gaitbelt into wheelchair. VS (vital signs) obtained and B/P= 175/87, P=68, R=20, T=97.6, O2= 97% on 4 liters and then titrated down to 2 liters. Small 1/2 (inch) skin tear noted to Left elbow, site cleansed and 2 steri-strips applied and then covered with [MEDICATION NAME]. Son (name) notifed (notified) at 1120 (11:20 a.m.) and Dr. (name) notified at 1130 (11:30 a.m.) at (name) Clinic. Reisent (resident) is scheduled to see Dr. (name) today for a visit. Will continue to monitor and report. *6/27/19 at 9:30 a.m. a late entry progress note: This nurse in to assist CNA with toileting resident. This nurse and CNA assisted resident from WC to toilet with use of gait belt. Resident very weak and unable to stand for long periods of time. Resident denies any pain. Upon assessment, dark purple bruising remains to left knee. Area appears slightly swollen. Resident denies pain to area. Resident straightens left leg with no problem or noted pain. Entire left leg palpated up to left hip and resident has no pain s/s (signs or symptoms). Resident also has purple bruising to left side of face, right arm to hand and right knee that remains from previous fall on 6/16/19. Plan is to have resident assessed by PCP (primary care provider)today re: (regarding) increased need for assistance with transfers, multiple recent falls and Left knee swelling. *6/27/19 at 2:41 p.m.: Resident had labs (blood tests) drawn today. This RN notified that residents Na+ (sodium) was critical at 117. Dr. (name) notified as well of critical lab value. Resident seen this afternoon by Dr. (name). Assessed Left knee and resident has patella tendon rupture and possible patella fracture. Orders to transfer to hospital. *8/1/19 with Dx (diagnosis) of Left knee patella tendon rupture-questionable fx. (fracture) Critical Na of 117. It was repaired. Had pneumonia when in SB (swing bed). *10/8/19 at 3:47 p.m.: This nurse spoke with resident's primary physician via telephone re: low sodium level, elevated K+ (potassium) and resident's increased behaviors. Also discussed that resident has been hollering out more, seems more confused and has been crying uncontrollably. Informed physician that resident continues to be [MEDICATION NAME] a UTI. Orders received to stop [MEDICATION NAME], add salt to meals, re check BMP (basic metabolic panel) on 10/10 and have physician assess resident at clinic visit on 10/10/19. Charge nurse notified. Review of resident 25's care plan revealed: *A focus area revised on 8/15/19: The resident has risk for an ADL self-care performance deficit r/t history of falls and oxygen dependency and recent left patellar fracture. Interventions included: -Brace needs to remain on left knee when bathing or showering. -If resident does ambulate, use gait belt with 2 person assist. Brace to be on left leg at all times. It needs to be locked when ambulating. I (it) can be unlocked when she is sitting in chair. -Resident is using wheelchair for locomotion for longer distances such as to the dining room. -Sit to stand lift and 2 person assist for transfers and toileting. *A focus area revised on 4/15/19: for her [MEDICAL CONDITION]. Interventions included: -OXYGEN SETTINGS: O2 (oxygen) via NC (nasal cannula) @ (at) 1-4 liters continuously. (MONTH) titrate to keep oxygen saturations at 90% (percent) or above. *A focus area revised on 8/15/19: The resident is at risk for falls r/t history of falls and recent patellar fracture and repair. Interventions included: -Easy-stand with transfers. Revised on 8/29/19. -Res. (resident) no long ambulates. Revised on 9/18/19. The care plan did not match what her actual care and conditions were. She was no longer ambulating, did not have a left knee brace, and had humidity added to her oxygen. 4. Observation on 10/20/19 at 4:23 p.m. of resident 28 revealed she was transferred from her recliner to the toilet and then to her wheelchair. She had oxygen delivered by an oxygen concentrator at two liters via a nasal cannula. She also had a bottle of water attached to the oxygen for humidity. Review of resident 28's interdisciplinary progress notes revealed on: *10/1/19 at 6:25 p.m.: COMMUNICATION - with Physician Situation: O2 sats around 80% low grade fever crackles bilaterally coughing Background: Assessment (RN)/Appearance (LPN): Recommendations: [MEDICATION NAME] 1gm IM daily X 5 Z-Pak F/U with (physician name) on 10/03/19 O2 PRN (as needed). *10/1/19 at 6:29 p.m.: Resident receiving [MEDICATION NAME] and [MEDICATION NAME] for URI (upper respiratory infection). No adverse reaction noted at this time. *10/3/19 at 3:59 p.m.: COMMUNICATION - with Physician Situation: F/U for URI Background: Assessment (RN)/Appearance (LPN): Recommendations: [MEDICATION NAME] TIB (TID three times a day) Finish antibiotics. 10/5/19 at 2:52 p.m.: Resident takes her last doses of [MEDICATION NAME] and [MEDICATION NAME] today. No adverse reactions (hives/rash, increased difficulty breathing or facial swelling) noted at this time. Will continue to monitor this shift and report. 10/17/19 at 11:35 a.m.: SSD (social service designee) Note Text: Resident has severe dementia and is hardly understood or is unable to follow conversation. Resident is alert to self. Resident is able to talk, but hardly ever makes sense or follows the conversation. Resident requires extensive to total assist on all ADL's. Resident has been on O2 supplementation due to a recent cold. She is still recovering from this. Resident isn't able to ambulate. She utilizes a wheelchair for locomotion. She is able to use her feet to propel herself throughout facility and she does wander at times. Resident usually is pushed by staff in her wheelchair. Resident does utilize the sit-to-stand lift for transfers and toileting. Resident does participate in restorative therapy. Resident passively participates in activities occasionally, depending on her energy level. She does get one-on-ones. She also does music and memory. Staff report that resident doesn't seem bored. Resident is put in her recliner to rest in afternoon. Family visit her on occasion. Staff deny her appearing sad or depressed. Staff report that resident has a good appetite and usually eats all of her food/drink. Staff report that she sleeps good at night. However, it is reported that she is tired most days and requires a nap. Staff report that resident is well mannered and doesn't get agitated easily. Staff report that resident does have difficulty concentrating and can't follow conversations or activities. Staff report that resident appears comfortable here. Review of resident 28's last revised 4/23/19 care plan revealed no focus area, goal, or interventions related to her recent URI. There was no mention of her oxygen use or her recent decline related to the URI. 5. Interview on 10/22/19 at 3:00 p.m. with the director of nursing (DON) and the Minimum Data Set assessment coordinator confirmed the care plans had not been revised or updated to reveal resident's 20, 25, and 28's current condition. They had provided education in the last month to the charge nurses to update the care plans. She agreed that had not happened as it should have. They had not reviewed the care plans to ensure revisions were completed. 6. Review of resident 3's medical record revealed: *He was admitted on [DATE]. *He had a [DIAGNOSES REDACTED]. *He had an order for [REDACTED].>-Give 5 mg by mouth one time a day every Mon, Wed, Fri for A-Fib. -Give 7.5 mg by mouth one time a day every Tue, Thu, Sat, Sun for A-fib. *His International Normalized Ratio (INR), a test that measures the time for blood to clot, was done on 10/15/19. -The results were in a therapeutic range, and the physician did not adjust his [MEDICATION NAME] dose. -The next INR was ordered to be done in one month. Observation and interview on 10/21/19 at 8:27 a.m. with resident 3 revealed: *He had a small bruise on his knee. *He took a blood thinner every day. *He reported he had taken the blood thinner for many years. *The nurses drew his blood at least monthly. Review of resident 3's 9/23/19 quarterly Minimum Data Set (MDS) assessment revealed he had received seven days of an anticoagulant medication. Review of resident 3's revised 10/3/19 care plan revealed [MEDICAL CONDITION] and [MEDICATION NAME] had not been addressed on it. Interview on 10/21/19 at 4:30 p.m. with the MDS coordinator regarding resident 3 revealed: *[MEDICAL CONDITION] was not something she would have added to the care plan. *Monitoring for side effects of [MEDICATION NAME] was not something she would have added to the care plan. Review of the provider's 9/15/17 Administration of Medications policy revealed: Residents will be observed for adverse reactions to medication(s). Review of the provider's 11/19/18 Comprehensive Care Plan policy revealed: *It is the policy of this facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. *It must include initial goals, MD (medical doctor) orders, diet orders, social services, therapy services, and PASRR (Preadmission Screening and Resident Review) recommendations. *An interdisciplinary team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident. *The comprehensive care plan has been designed to: -Incorporate identified problem areas. -Incorporate risk factors associated with identified problems. -Build on resident's strengths. -Reflect treatment goals and objectives in measurable outcomes. -Identify the professional services that are responsible for each element of care. -Prevent decline in the resident's functional status and/or functional levels. -Enhance the optimal functioning of the resident by focusing on a rehabilitative program. *The resident's comprehensive care plan is developed within seven (7) days of admission and revised/updated after the completion of the resident MDS 3.0 assessment or within twenty-one (21) days after the resident's admission (admitted plus 20 calendar days), whichever occurs first. *Care plans are revised as changes in the resident's condition dictates. Reviews are made thirty (30) days after the resident's admission, sixty (60) days after admission, ninety (90) days after admission and at least quarterly thereafter. Care plans are reviewed upon return from the hospital, within 14 days.

Based on observation, interview, record review, and policy review, the provider failed to ensure 3 of 13 sampled residents (21, 27, and 28) had their care plans updated and revised to reflect their current status and care needs. Findings include: 1. Review of resident 27's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *The physician had written orders: -On 5/1/18 for [MEDICATION NAME] 50 milligrams (mg) every 6 hours as needed for pain. --She had frequently requested [MEDICATION NAME] in the evening for pain that was located in various areas of the body. -On 9/6/18 for her to have received Tylenol Extra Strength 1,000 mg three times a day for discomfort from arthritis. Review of resident 27's 8/23/18 comprehensive care plan revealed no focus area to support the resident had a problem with chronic and acute episodes of pain. Random observations on 10/23/18 from 8:10 a.m. through 11:45 a.m. of resident 27 revealed she: *Had been alert with good memory recall. *Had been observed either sitting in her room in the recliner or in the dining room for meals. *Was capable of ambulating throughout the facility without staff support and the use of a wheeled walker (w/w). *Had not appeared in any distress or discomfort. Observation and interview on 10/24/18 at 8:22 a.m. with resident 27 revealed: *She had been in her room sitting in a recliner. *When asked if she was having any pain she had stated: -I always have pain. -What they give me for meds works just fine. -You can leave now. Interview on 10/24/18 at 2:00 p.m. with the director of nursing (DON), assistant director of nursing (ADON), and chief operating officer regarding resident 27 confirmed the resident had a history of [REDACTED]. They would have expected the care plan to have been updated to support the resident's [DIAGNOSES REDACTED]. 2. Review of resident 21's medical record revealed: *He had [DIAGNOSES REDACTED]. *He had orders for scheduled oral and topical pain medications. -He did not have orders for medications for breakthrough pain. *He was seen by his primary care provider on 8/9/18 who ordered knee injections to be administered at the clinic on 8/16/18. Review of his 6/25/18 and 9/17/18 Minimum Data Set (MDS) assessments revealed: *His mental status was severely impaired. *He had frequent, mild pain. *He had received scheduled pain medications. Observation of resident 21's restlessness on 10/23/18 revealed at: *1:42 p.m. he was shuffling through drawers in his nightstand. He retrieved his electric razor and attempted to stand but was unable to. *1:47 p.m. he shaved his face with the electric razor while seated in his recliner. *2:05 p.m. he stood up and attempted to ambulate. His chair alarm went off. Staff came to his room and assisted him to his bed. *2:11 p.m. he stood at his bedside and used his wheelchair for support. He then ambulated with small shuffled steps to his recliner dragging his wheelchair behind him. He sat in his recliner and positioned the wheelchair beside him. He sat for a short time. He then stood up and ambulated behind his wheelchair toward his door. His chair alarm went off. Staff entered his room and assisted him back to his recliner. Staff asked him if he needed help with anything and offered to put his feet up, but he declined. The call light was given to him, and staff instructed him to ask if he needed anything and left his room. *2:36 p.m. he was in his recliner with his eyes shut, his right foot elevated on the arm of his wheelchair, and his call light within reach. Review of his 10/23/18 care plan revealed: *The resident has [MEDICAL CONDITION] affecting speech and gait. *The resident will remain free of further s/sx (signs and symptoms), discomfort or complications related to [MEDICAL CONDITION]. *Give medications as ordered by the physician. Monitor/document side effects and effectiveness. *There were no further focus areas or interventions that specifically addressed his pain. *It did not specifically address his restlessness. Interview on 10/24/18 at 4:14 p.m. with the MDS coordinator regarding resident 21 revealed she agreed: *His periods of restlessness could have been an indication of pain. *His care plan did not specifically address his pain or how to manage it. 3. Observations, record review, and staff interviews related to resident 28 during the survey revealed he had frequent weight changes and an overall weight loss since his admission. Refer to F658, finding 1. Review of resident 28's last revised 10/3/18 care plan revealed: *A focus area for his [MEDICAL CONDITION]. -All interventions had been initiated on 6/21/18 with no changes made after that date. *A focus area for a potential for nutritional problem related to dementia. -Most interventions were initiated on 6/21/18 with the exception of: --On 8/27/18 a yogurt was offered three times daily. -There was no mention of his weight loss, significant weight changes, or his [MEDICAL CONDITION] concerns. Interview on 10/24/18 at 1:27 p.m. with licensed practical nurse C regarding resident 28 revealed: *His care plan had not mentioned his concerns with [MEDICAL CONDITION] and fluid retention and had not been updated related to those concerns. *The charge nurses did not update care plans. *The MDS assessment coordinator updated residents' care plans. Interview on 10/24/18 at 1:50 p.m. with the MDS assessment coordinator regarding resident 28 revealed: *She confirmed his care plan had not been updated to reflect his significant weight changes or overall weight loss. *The assistant DON, DON, and her primarily updated all residents' care plans. -Charge nurses could have updated them also. Interview on 10/24/18 at 3:08 p.m. with the DON regarding resident 28 confirmed his care plan had not been updated and revised to reflect his concerns with [MEDICAL CONDITION] and interventions related to that. 4. Review of the provider's 8/25/17 Care Plan policy revealed: *It is the policy of this facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. *Care plans are revised as changes in the resident's condition dictates. *Any nursing staff aware of changes to resident's care plan may add and/or revise care plan to be accurate to resident's current status and include initiation or revision dates.

Based on observation, interview, record review, and policy review, the provider failed to follow professional standards of practice for documentation for 4 of 13 sampled residents' (21, 28, 29, and 79) health status related to their weight changes, admission to the facility, return to the facility from the hospital, and discharge from the facility. Findings include: 1. Observation on 10/22/18 at 3:43 p.m. of resident 28 in his room revealed: *He was sitting in his wheelchair and appeared tall and thin. -Pictures in his room indicated he had been tall and average-sized for weight. *He was wearing Ted hose stockings to both legs and had specialty shoes on. -His lower legs and feet appeared swollen. *There was no swelling noted to his arms or hands, but his hands were a bluish color and felt cool to the touch. Observation of resident 28 on 10/22/18 during the evening meal and on 10/23/18 during breakfast revealed he sat at an assisted dining table. But he was able to feed himself. He ate and drank well for both those meals. Observation and interview on 10/23/18 at 8:37 a.m. with certified nursing assistant (CNA) A during resident 28's morning care revealed:*He had dressings in place to both his lower legs. *CNA A stated: -He had sores on his legs from the swelling and the nurses took care of that. -His legs had been so swollen they sometimes leaked fluid. *Both his lower legs and feet were visibly swollen. -The left leg was worse than the right, and his skin appeared tight. *She said he always had swelling in his legs. -Some days it looked worse, and some days it looked better. -Sometimes his hands and arms were swollen too. *She put on his thigh high Ted hose stockings and assisted him with the rest of his morning care. Review of resident 28's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *At the time of his admission he had: -Orders to wear Ted hose stockings every day. -Venous wounds on his lower legs with treatment orders for them. -No orders for diuretic medications. *On 6/23/18 there was an order to do daily weights. *On 6/29/18 he started [MEDICATION NAME] 3.125 milligrams (mg) twice daily for his [MEDICAL CONDITION]. *On 7/3/18 a nutritional supplement twice daily was started. *On 7/6/18 he started [MEDICATION NAME] 12.5 mg every morning for his swelling. *On 7/10/18 he started taking a protein supplement twice daily, and the other nutritional supplement was discontinued. *On 7/13/18 the [MEDICATION NAME] was increased to 25 mg, and [MEDICATION NAME] 20 mg every morning was added for his swelling. *On 7/19/18 the wound treatment to his legs was changed, and his [MEDICATION NAME] was increased to 6.25 mg twice daily for heart failure. *On 8/2/18 his [MEDICATION NAME] was increased to 40 mg daily. *On 8/10/18 potassium chloride daily was started for his heart failure after he was found to have a low potassium level. *There were no further order changes related to his [MEDICAL CONDITION], heart failure, or wounds. Review of resident 28's weights and vitals summary from his admission on 6/21/18 through 10/23/18 revealed: *He was getting weighed daily starting on 6/23/18. *His weights were variable and included the following:-On 6/23/18, 186.7 pounds (lb). -On 7/2/18, 195.3 lb. --That was up 9.4 lb in nine days and was a 5.1% increase. -On 7/11/18, 205.9 lb. --That was up 19.2 lb since 6/23/18 and was an 8.4% increase. -On 8/2/18, 208.5 lb. --That was up 21.8 lb since 6/23/18 and was an 11.7% increase. -On 8/7/18, 206 lbs, and on 8/8/18 he was 197.7 lb. --That indicated he had lost 8.3 lb in one day. -On 8/20/18, 188.4 lb. -That was only 1.7 lb up from his 6/23/18 admission weight. -His weights continued to vary daily and started trending down in (MONTH) and October. -On 10/19/18, 158.7 lb. -On 10/20/18, 163.4 lb. -On 10/21/18, 164.2 lb. -On 10/22/18, 157.5 lb. -On 10/23/18, 156.4 lb. --There were frequent significant changes in his weights. *Those weight changes caused automated system warnings that: -Indicated he had weight changes of greater than 5%, 7.5%, and 10%. -Occurred for every weight other than 6/23/18 through 7/1/18 and 7/3/18. Interview on 10/24/18 at 7:28 a.m. and again at 2:29 p.m. with the dietary manager regarding resident 28 and residents with nutrition concerns and weight changes revealed:*All dietary documentation should have been documented in the electronic progress notes. *She had just started as dietary manager in (MONTH) and was still learning. *She had not done any type of nutrition or dietary assessments for residents. -She talked to residents after they were admitted and periodically after that. *She monitored residents' weights and intakes weekly, but she typically had not documented anything about that in their medical records. *She was aware of resident 28's weight being down recently. -She thought his weight loss and weight fluctuations were related to his fluid and swelling problems. -He ate well, and dietary gave him protein supplements twice daily. Review of resident 28's dietary and nutrition notes from his admission on 6/21/18 through 10/24/18 revealed: *There were notes on 7/5/18, 7/24/18, 8/27/18, 9/11/18, and 9/13/18 only. *The only mention of weight changes was on 9/11/18, and it stated: - .weight is 187 pounds, 30 day weight was 205. weight loss/gain percentage is 10% decrease in 30 days. resident is offered protein BID (twice a day). *There was no mention of his swelling, fluid concerns, or significant weight fluctuations. Review of resident 28's weight change notes by nursing from his admission through 10/24/18 revealed only one note on 7/4/18 that stated: Resident noted to be up #5 (pound) from yesterday. Does have continual drainage out of bilateral lower legs related to [MEDICAL CONDITION]. No increase in SOB (shortness of breath) noted. Will continue daily weights. Review resident 28's monthly pharmacist consultant reports from July, August, and (MONTH) (YEAR) had no mention of swelling, fluid, or weight change concerns. Review of resident 28's nutritional assessments revealed: *On 6/22/18 an Initial Nutritional History/Assessment Data Collection Form had been done. -That form had no signature or name of who completed it. -There was no mention of his swelling or fluid concerns. *On 7/3/18 an Initial Nutritional History/Assessment Data Collection form had been done by the registered dietitian (RD). -That had mentioned weeping lower legs and [MEDICAL CONDITION]. *The only other RD documentation was on 9/4/18 and stated: -Weight loss. This is not due to a nutritional aspect; it is due to his [MEDICAL CONDITION] fluid retention with a weight loss now felt to be due to fluid [MEDICATION NAME] by increasing his [MEDICATION NAME] from 20 mg to 40 mg on 8/3/18. He also had an additional [MEDICATION NAME] added in July. Review of resident 28's nursing admission screening, assessments, and progress notes from his admission on 6/21/18 through 10/24/18 revealed: *His 6/21/18 nursing admission screening had included: -His general appearance was well-nourished. -There was no mention of any swelling or to what degree that swelling would have been. -His [MEDICAL CONDITION] was not mentioned as a relevant diagnosis. *Overall there was minimal nursing documentation related to his swelling and weight changes. *When significant changes occurred during his daily weights there was little or no documentation to support: -He had been assessed by the nurse. -What his current health condition had been. -If the physician had been updated. Interview on 10/24/18 at 1:23 p.m. with CNA B regarding resident 28 and his weight revealed: *He was weighed daily by the CNAs. *They wrote down his weight and gave it to the nurse. *If the weight was different than the day before they let the nurse know. Interview on 10/24/18 at 1:27 p.m. with licensed practical nurse C regarding resident 28 revealed:*Since he was admitted he had a lot of swelling and problems with retaining fluid. *Most times his swelling was in his lower body and especially his legs. -His legs were so swollen they would leak fluid at times. *Sometimes his swelling would get so bad he had it in his arms and private areas too. *He had medication changes related to his swelling, and his weight loss was related to that. -He ate well so his weight changes were not related to his nutrition. *He was weighed daily. *If his weight was significantly different than the previous weight the nurse should have:-Had him re-weighed to see if it was accurate. -Assessed him for potential health concerns. -Documented that assessment. -Notified the physician of the nursing assessment and weight change. *She confirmed there was minimal nursing documentation in resident 28's medical record to support: -His swelling concerns. -The appropriate nursing care, assessments, and documentation. -Notification to his physician when significant weight changes occurred. Interview on 10/24/18 at 1:50 p.m. with the Minimum Data Set assessment coordinator regarding resident 28 revealed:*She confirmed: -There were minimal nursing assessments and documentation to support his weight changes were related to his swelling. -There was a lack of documentation by nursing the physician had been updated regarding his weight changes and the response from the physician. *She was unsure what the RD involvement should have been. Interview on 10/24/18 at 2:15 p.m. with LPN/chief operating officer regarding resident 28 revealed she confirmed the lack of nursing documentation related to his weight changes. Interview on 10/24/18 at 3:08 p.m. and again at 4:33 p.m. with the DON regarding resident 28 revealed:*He had been admitted with a significant amount of swelling in his lower body and arms. *They had updated the physician and made changes in his medications to decrease his swelling several times since he was admitted in (MONTH) (YEAR). *She confirmed there was a lack of nursing assessments and documentation in his record related to his swelling problems. *She expected the nurse to assess him when those weight changes occurred and to document their assessments in his medical record. -If there was a significant weight change the physician should have been notified with documentation to support that had been done. *They had no professional standards of reference in the building for nursing standards of practice. -They would have followed their policies. Review of the provider's 9/6/16 Weight policy revealed: *Notify the doctor in a timely fashion of weight gain or loss unless there is a doctors order for intentional weight loss or gain. *Any weight loss or gain of over three lb a day or 5 lb a week with symptoms should have been reported to the doctor. *3. Document any weight loss/gain in point click care. Also note reweigh to prove significant weight loss/gain, relating diagnosis, and if resident is symptomatic or if there is underlying reason for weight loss/gain. 2. Review of resident 21's medical record revealed: *On 1/28/18, health status notes he had: -Fallen in his room and had been transferred to an emergency room . -Been transferred to a hospital for surgical repair of a [MEDICAL CONDITION]. *On 1/31/18, a restorative program note: Resident is currently in Hospital. *On 2/22/18, a social services designee (SSD) note: MSW (masters in social work) consult with SSD regarding this resident. *On 3/23/18, a behavior note: Resident was assisted to bed at 2045 (8:45 p.m.) and has been resting comfortably since then. *No documentation in the progress notes regarding when he had returned to the facility, what his health status was, or what his needs were at that time. Interview on 10/24/18 at 4:31 p.m. with the DON regarding no documentation of resident 21's return to the facility revealed: *She agreed there was no nursing documentation in the his electronic medical record upon his return to the facility. *She would have expected documentation regarding his current health status and needs at that time. *A nursing assessment form was completed on 3/22/18. -She would have expected a summary of the assessment in the progress notes. 3. Review of resident 29's closed medical record from 8/1/18 through 10/16/18 revealed: *On 10/15/18: -The physician had written orders for her to discharge to another facility. Her medications were to have been sent with her. -She had been discharged to another long term care facility. *There was no documentation to support: -When the facility had been aware of that discharge. -What and how many medications had been sent with her. Interview on 10/24/18 at 4:30 p.m. with the DON and ADON revealed: *A week prior to 10/15/18 the ADON had received a call from the family notifying them the resident would be discharged to another facility. *They confirmed there was no documentation to support: -When and if that phone conversation had occurred with the family. -What and how many medications had been sent with the her. *They agreed the above information should have been documented in and a part of the resident's medical record. 4. Review of resident 79's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She was alert and oriented to self only. *She had been dependent upon the staff to assist her with all activities of daily living. *On 10/17/18 the admission note failed to support their policy and procedure of: -Date and time of admission. -How she was transferred to the facility. -Where she had been admitted from, and who accompanied her. -The mental and status from both a subjective and objective overview. -Her vital signs including her height and weight. -Review of her skin assessment. -The disposition of her clothing and valuables. -What her allergies [REDACTED]. -Physician's name. -A nurse's note on all pertinent information noted upon assessment. Interview on 10/24/18 at 2:15 p.m. with the DON, ADON, and chief operating officer confirmed the above information should have been a part of her admission documentation. Review of the provider's 5/29/14 Medications, Compliance of policy revealed: A notation concerning their disposition shall be made on the resident record, to include RX (medication) # (number), name of medication and amount. Review of the provider's 8/5/16 Charting and Documentation policy revealed: *There was no process in place to support a process for when the resident discharged from the facility. *The same procedure as listed above for when a resident was admitted to the facility. *A complete clinical record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has adequate plans of care, and provides sufficient evidence of the effects of the care provided. Documentation should provide a picture of the resident's progress, including response to treatment, change in condition, and changes in treatment . *Documentation should have included: -Resident's response to new orders or treatments. -Change in vital signs and significant changes. -Physician notifications including time and situation of which the physician was notified.

Based on observation, interview, record review, policy review, and procedure review, the provider failed to prevent pressure ulcers from forming while in the facility for two of two sampled residents with pressure ulcers (5 and 7). Findings include: 1. Observation on 8/29/17 at 3:37 p.m. of resident 7 during the dressing change to her lower right leg pressure injury revealed: *She had significant [MEDICAL CONDITION] to both of her lower legs. *She had an anti-embolism stocking (TED hose) on her left leg and no stocking on her right leg. *The wound was located about three inches above her right ankle in a crease. *She had the same crease noted on her left leg, and the stocking was tight around the crease like a rubber band. Review of resident 7's skin observation documents revealed: *On 8/11/17 Small open area to front of lower R (right) leg. Possibly from TED hose. Duoderm put on after cleaning area. *On 8/18/17 Small open area in the crease between her right lower leg and foot, new Duoderm applied. Review of resident 7's 8/23/17 wound care measurement and assessment revealed: *It had been classified as a stage two pressure injury. *The measurements were 0.5 centimeter (cm) by 1.0 cm with approximately half of the wound opened and the other half with redness. *There had been a slight odor with a scant amount of serosanguineous drainage. Review of resident 7's interdisciplinary progress notes revealed: *On 8/17/17 R leg has breakdown in crease of leg, new duoderm put into place. *On 8/24/17 Resident was seen today by (physician), right shin and left eye brow was examined. Watch for drainage and right shin ulcer, continue wound care protocol Aerobic and Anaerobic culture if any foul drainage. *No documentation was found her family or dietary had been notified of her pressure injury. *The first documented notification to her physician had been on 8/24/17. That was thirteen days after the pressure injury had been found. Interview on 8/29/17 at 4:00 p.m. with licensed practical nurse (LPN) A after resident 7's dressing change revealed: *She had thought it was a skin tear. *She agreed the TED hose were very tight on the resident's left leg also in the same crease. *The resident had previously worn the same TED hose on her left leg. Review of resident 7's 8/23/17 care plan revealed: *Focus area: Skin ulcer to R shin from TED hose. *Goal: Skin ulcer will be healed or show signs of healing within 2 weeks. *Intervention: Wound care per protocol. 2. Observation and interview on 8/30/17 at 7:55 a.m. with LPN A and the director of nursing (DON) during resident 5's dressing change revealed: *A stage two pressure injury to the left rib area. *The pressure injury had been caused by a shoulder immobilizer resident 5 had used following a right shoulder injury. Review of resident 5's skin observation and wound care measurement and assessment documentation revealed: *On 8/4/17: Small open area to L (left) rib area with bruising due to immobilizer. No measurements had been completed. *On 8/9/17: Breakdown on the left lateral skin from immobilizer. No measurements had been completed. *On 8/23/17: the left rib area pressure injury was measured. It was 2.5 cm by 1.0 cm. It had a slight odor and a moderate amount of serosanguineous drainage. The following was also documented on the above date: -The resident's physician had been first notified on 8/17/17. -The resident's family was notified on 8/23/17. -The pressure injury had been acquired on 8/4/17. *On 8/28/17: the wound weekly observation documentation included: -The resident's physician was updated on 8/28/17. Spoke with (physician) via telephone re: unstageable wound to resident's left side. Discussed (name) from AMT wound care suggestions. Orders received from (physician) to change wound care orders. Wound care done. -Resident notified of changes. -Date acquired 8/15/17. -Original stage was a stage two pressure injury. -Currently the pressure injury was unstageable. -Overall impression was the wound was worsening. -The wound measured 7 millimeters (mm) by 20 mm. Review of resident 5's 8/15/17 care plan revealed: *Focus area: The resident has risk for skin breakdown r/t (related to) impaired mobility, urinary urgency, incontinence, [MEDICAL CONDITION], obesity and need for assistance with ADLs (activities of daily living). *Goal on 8/15/17: Res (resident) has pressure ulcer stage II to L lateral side. *Goal on 8/28/17: No unstageable to left lateral side. *Interventions on 8/15/17: Wound care per orders. Stage and size weekly. Interview on 8/29/17 at 4:40 p.m. with the DON, assistant director of nursing, and the Minimum Data Set coordinator revealed: *They were not aware of which residents had pressure injuries when the survey team had entered on 8/29/17. *There was communication issues with the nurses on the floor. *They had put out communication sheets to have been read by all the nurses. Those communication sheets included: -On 8/8/17: Nurses: Please report any sores to (dietary manager) and the front office. (Dietary manager) needs to report ulcers to a dietician within 72 hours and it needs to be changed on the care plan immediately. -On 8/22/17: Attention Nurses If and when OPEN AREAS are found on a resident, follow the instructions below; 1) Stage and size area immediately a. Use Wound Measuring Guide clear sheet to trace wound size. b. Chart findings under Assessments tab; Wound-weekly observation tool in PCC (computer program) 2) Initiate Standing Orders per Protocol-see attached Policy a. Write S.O. in physician's orders [REDACTED].> 1, Standing Orders must be written as is on the policy-DO NOT make your own orders. 3) Write Orders on MAR (medication administration record) 4) Make Wound Care Bucket with supplies and store in locked cabinet at nurses station 5) Write Nurse's note in Point Click Care Progress notes 6) Schedule appointment with clinic for provider to see wound on next available clinic day 7) Notify management and dietary manager ASAP 8) Make sure to report wound details to the next nurse until wound is healed Review of the provider's undated Pressure Ulcer-Prevention policy revealed:*All bed/chair bound resident should have been turned and repositioned a minimum of every two hours unless contraindicated. *If a resident was at risk for skin break down place a pressure relieving air or foam layered mattress to the resident's bed. *A record of any reddened area, rash, or breaks in the skin should have been: -Reported to the charge nurse. -Initiation of care to the area. -Document the size, depth, drainage, location, type of skin compromise, and care given in point click care. -Update care plan of resident to reflect current treatment. Review of the provider's undated Pressure Ulcer Assessment policy revealed: *All pressure ulcers were to have been assessed by a registered nurse weekly. *The assessment would have included the size, depth, stage of the wound, and signs or symptoms of infection. *Also included in the documentation would have been healing progress, condition of the wound bed, and physician notification.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *An effective infection control program was in place that included the trending of all infections in the facility. *Alcohol foam rub in rooms throughout the facility were not outdated. *Dirty alcohol foam rub plastic holders had been cleaned. *Seven random wheelchairs with cracks and tears in the vinyl armrests had been repaired. *Handwashing and glove use had been correctly performed during two of two dressing changes for residents (5 and 7) by one of one observed licensed practical nurse (LPN) (A). *One of one observed LPN (A) had correctly disposed of a dropped medication during one of three medication passes. *Towel racks had been designated for each resident in seven of seven shared randomly observed residents' rooms (1, 3, 5, 7, 9, 11, and 15). Findings include: 1. Review of the provider's infection control monitoring records from 1/1/17 through 7/31/17 revealed: *Residents, diagnosis, symptoms, antibiotic, dosage, start and end dates, and organism was recorded each month. *January 2017 there had been five urinary tract infections (UTI), two upper respiratory infections (URI), and one eye infection. Three UTIs had a culture and sensitivity completed; two were for the same resident. *February 2017 there had been eleven UTIs, seven URIs, and two cellulitis infections. Twenty-two residents had been treated [MEDICATION NAME] for influenza A. Four UTIs had a culture and sensitivity completed. Two residents each had two UTIs; only one of those residents had one that had been cultured and one had not. *March 2017 there had been two UTIs and two skin infections. Neither UTIs had been sent for a culture. *April 2017 there had been one UTI, one skin cellulitis infection, and one eye infection. No culture had been sent in on the UTI. *May 2017 there had been one UTI, one wound infection, one URI, and one tooth infection. There had only been a culture completed on the wound infection. *June 2017 there had been six UTIs, one URI, and one tooth infection. No cultures had been completed for the UTIs. *July 2017 there had been three UTIs. Only one UTI had a culture completed. *For each of those months a floor plan of the building had noted where each infection had been located. *There was no documentation if any of those infections had been a result of transmission during care. *There was no documentation if any staff had been educated on the prevention of infection including UTIs. Interview on 8/30/17 at 3:00 p.m. with the director of nursing (DON) revealed: *She had not looked at trending of infections and the relationship those infections might have had between residents. *Other than the standard infection control education staff had received during orientation and yearly she had not completed any other specific infection control training. *They discussed infection control data in the quality assurance meetings, but had not developed any project improvement plans. Review of the provider's 8/3/16 Infection Control policy revealed: *All infections would have been documented, investigated, and monitored. *Infection control data would have been analyzed and corrective actions implemented as needed on a monthly basis and/or at the quarterly quality assurance meetings. 2. Observation on 8/29/17 from 12:00 noon through 4:30 p.m. revealed approximately 98% of all the alcohol foam rub cans were either outdated or empty. They were located in all the resident rooms, dining room, medication room, restorative therapy room, whirlpool room, front activity room, and the entrance hallway. It was also observed during the above observation that the plastic holders for all the alcohol foam rub cans had various amounts of dust and a build-up of dirt on them. Interview on 8/29/17 at 4:45 p.m. with the DON revealed: *She thought housekeeping was in charge of replacing the alcohol rub cans when they were outdated or empty. *The plastic holders for the alcohol rub cans should have been cleaned on a regular basis. Observation and interview on 8/29/17 at 5:30 p.m. with the head of housekeeping revealed he: *Was in the process of changing all the alcohol rub cans that were outdated or empty. *Thought nursing was responsible for changing the alcohol rub cans. *Was not aware of how soiled the plastic holders were. *Agreed the plastic holders should have been cleaned on a regular basis. 3. Observation during the survey from 8/29/17 through 8/30/17 revealed seven random wheelchairs had cracks and tears in the armrests. Those cracks and tears exposed the foam underneath making them an uncleanable surface. Interview on 8/30/17 at 1:30 p.m. with the DON revealed she was not aware of the cracks and tears in the wheelchair armrests. She agreed they were uncleanable. 4. Observation and interview on 8/29/17 at 11:00 a.m. with LPN A during a medication pass revealed: *She dropped a pill on the top of the medication cart. *With her bare hands she picked up the pill, placed it in the medication cup, and administered it to resident 2. *She asked this surveyor if that was alright to do. *After she had administered the medication she was asked if that was the usual process when a medication had been dropped. *She stated she should have disposed of the medication and administered a new pill. 5a. Observation on 8/29/17 at 3:37 p.m. of a dressing change for resident 7 by LPN A revealed:*She retrieved a plastic tub from a cupboard at the nurses station that contained the dressing supplies for the resident. *She took the tub into the resident's room and placed it on the bed. *Put gloves on without any hand hygiene. *Pulled the garbage can closer to the resident. *Took the dressing off the resident's lower right leg. *Changed gloves without any hand hygiene. *Cleansed the wound and changed gloves without any hand hygiene. *Applied an antibiotic ointment on the wound. *Removed her gloves and without any hand hygiene put the new dressing on the resident's wound. *Took the garbage to the soiled utility room. *Washed her hands. *Returned the plastic tub to the cupboard at the nurses station. She did not sanitize the bottom of the plastic tub. b. Observation on 8/30/17 at 7:55 a.m. of a dressing change for resident 5 by LPN A revealed:*LPN A retrieved a plastic tub from a cupboard at the nurses station. That tub contained the dressing supplies for resident 5. *She took the tub into the resident's room, placed it on the overbed table, moved it to the residents bed, then moved it to the resident's desk. *Washed her hands for less than ten seconds. *Put on gloves and helped the DON position the resident on her side. *Removed her gloves and without any hand hygiene placed the plastic tub on a barrier on the bed. *Put on gloves and placed the wound care supplies on the barrier. *Removed the soiled dressing, cleansed the wound, and applied Medi-Honey to the wound. *Removed her gloves and without any hand hygiene placed a new dressing on the resident's wound. *Took the garbage to the soiled utility room and then washed her hands. c. Interview on 8/30/17 at 10:30 a.m. with LPN A confirmed the above observations. She was aware she should have performed hand hygiene in-between glove changes. Interview on 8/30/17 at 1:30 p.m. with the DON regarding LPN A and the above dressing changes revealed: *She should have performed hand hygiene between glove changes. *She should have used a barrier when bringing supplies into a resident's room. *She confirmed the lack of appropriate hand hygiene during the dressing change for resident 5. 7. Observation on 8/29/17 from 8:00 a.m. through 5:45 p.m. and again on 8/30/17 from 7:45 a.m. through 4:30 p.m. revealed all of the double-occupancy rooms had either one or two ring type towel holders near the sink. There was no designation of which towels were to have been used by which resident. Interview on 8/30/17 at 1:30 p.m. with the DON confirmed the above finding. She had not thought about those towels and wash cloths not being designated or labeled for each residents. 8. Review of the provider's 4/9/14 Hand Hygiene policy revealed: *Wash hands properly before and after wearing or changing to a new pair of gloves. *Change gloves frequently and wash hands often. *When wearing gloves work from clean surfaces to dirty surfaces. *Hand sanitizer could be used when hands were not visibly soiled or soiled with body fluids.

Based on observation, record review, interview, and policy review, the provider failed to thoroughly investigate three of three incidents reviewed for three of three sampled residents (5, 11, and 12) regarding bruising of unknown origin, a skin tear, and a fracture. Findings include: Surveyor: 1. Review of resident 5's interdisciplinary progress notes revealed: *On 7/24/17 at 11:00 p.m.: Resident was in stand lift being assisted to bathroom. Resident refused to let CNA (certified nursing assistant) tighten up straps on lift. When resident was near the edge of the bed the lift straps opened up and residents arms slid out of lift. Resident was able to sit on edge of bed and was assisted x4 up in proper position. Resident has a skin tear to the RFA (right forearm) and R (right) wrist area from the lift straps and watch that resident was wearing. Skin tears cleansed and [MEDICATION NAME] and a Band-Aid applied. Will continue to monitor. *On 7/24/17 at 11:30 p.m.: Resident very uncomfortable. Complaining of R shoulder pain all the way to her elbow. PRN (as needed) Tylenol administered, ice applied. Spoke with resident that we will have doctor look at it tomorrow as resident is having a hard time lifting arm but does normally have trouble lifting her arms prior to this incident happening. Resident verbalized understanding and stated that was her only option other than going in the ambulance to the hospital which she stated she did not want to do. Reassured resident that we would keep close eye on her and see how ice worked. *On 7/25/17 at 11:29 a.m.: Resident was seen today after slipping out of sling and landing on her bed last night. She has been complaining of severe right shoulder pain. Xrays were completed at (clinic name) and confirmed right shoulder dislocation. Resident is being transferred via ambulance to (hospital emergency room ). (Physician's names) are aware of residents transfer. Review of the provider's final facility event investigation report to the SD DOH on 8/1/17 for the above injury revealed: *(Resident) was being transferred from wheelchair to bed last night via sit to stand lift. We have been using left on (resident) for several months, she usually does well with it and bears weight well. CNA (name) reported that resident refused to allow her to tighten strap of sling. (Resident) landed on the bed in a seated position and was able to be laid into bed per 4 staff members. RN (registered nurse) was there and assessed her. She complained of extreme right shoulder pain. She had scratches down her forearms from the sling pulling her watch up her arm, these were cleaned and dressed. (Resident) was treated with pain medications. RN called on PA (physician assistant) and discussed situation, since resident was stable they opted to keep (resident) in (town) and have her seen 7/25/17. She was seen on 7/25/17 by (PA). Shoulder was assessed and xrays taken @ 1100AM. They were seen by (physician) in (town) as well. It was suspected that she had a dislocated shoulder. Xray report came back and confirmed a high-grade AC (acromioclavicular) joint separation with a glenoid fracture and a [MEDICAL CONDITION] of the acromion. She was transferred to (hospital) for further evaluation. Will investigate/interview further and finalize. Final: Staff was educated on more efficient/safe way of transferring resident. We changed type of lift with resident to a hoyer lift. She returned to us the same day she left with an immobilizer to that right arm. She is to wear it at all times. Her room has been cleaned and some stuff removed for more efficient transfers from bed to chair and chair to bed. *No abuse or neglect was suspected. *Individual was capable of providing an explanation of the event and investigation. *Actions taken included: Personnel education and changed the type of lift being used for the resident. Observation and interview on 8/29/17 at 11:20 a.m. with resident 5 revealed: *She was seated in her wheelchair in her room. *When asked about the incident with the standing lift she stated: A young aide was helping her to the bathroom. She had told her to leave her wheelchair by the bathroom, but the aide didn't do that. I fell out of the sling in the bathroom. *She had a hard time lifting her right arm when asked how her arm and shoulder were. She stated the shoulder couldn't be fixed. Interview on 8/29/17 at 4:30 p.m. with the director of nursing (DON), the ADON/SSD, and the Minimum Data Set (MDS) coordinator regarding the above incident and investigation confirmed: *RN E had not started the investigation. *There had been no individual interviews with the resident, RN E, or CNA B about the above incident. *The other staff who had assisted with moving the resident into bed had not been interviewed. *The standing lift had not been identified, taken out of service, or inspected in the investigation. They stated the facility had two standing lifts. *The sling used had not been taken out of service and inspected. *Education to the staff had not been documented. *CNA B had been re-educated on 8/8/17 on transfers. Surveyor: 2. Review of resident 11's 8/9/17 final investigation report sent to the South Dakota Department of Health (SD DOH) revealed: *It had been reported she had a bruise to the side of her right eye. *It was greenish in color and measured 0.5 centimeters (cm) by 0.5 cm. *Staff had been asked about the bruise, but no one had known where it had come from. *It had been assumed she could have hit her head on the lift when being transferred or when she was repositioned in bed. *They had concluded there had been no abuse or neglect but had provided education on safe practice with transfers and lift use. *There had been no documentation regarding the following: -Resident's cognition level. -The level of assistance required from staff for her activities of daily living. -Who had been working during the shifts when the bruise could have happened. -The names of the staff interviewed. 3. Review of resident 12's 7/13/17 final investigation report sent to the SD DOH revealed: *A skin assessment had been completed by the registered nurse on duty. *She had noted a band-aid on the resident's right middle finger. *Upon removing the band-aid she had noted a small skin tear measuring 1.0 cm in length. *She thought it looked as if it had occurred recently. *Staff had been interviewed, and all denied knowledge of what had happened. *The resident had dementia and could not state what happened. *It was assumed that due to the resident having fragile skin she bumped her hand or scratched it on something. *There had been no documentation regarding the following: -The level of assistance required from staff for her activities of daily living. -Who had put the band-aid on the resident's finger to begin with. -The names of the staff interviewed. Interview on 8/30/17 at 11:00 a.m. with the assistant director of nursing (ADON)/social services designee (SSD) revealed: *She had been responsible for the investigations into the above incidents for residents 11 and 12. *If the incident had occurred at night she would have been told the next morning. -She would have begun the investigation at that time. *The charge nurses were not responsible for starting the investigations. *She had not documented any of the interviews conducted with staff. *She had not documented who had been interviewed regarding the incidents. *There had been no documentation regarding review of the schedules for who might have been working. *There had been no other documentation of the investigation then what had been written on the SD DOH final investigation report. 4. Interview on 8/30/17 at 1:40 p.m. with licensed practical nurse (LPN) A revealed if an incident occurred she would have documented in the nursing notes. She would have informed the ADON the next morning. She would not have started an investigation into the incident. Review of the provider's 1/6/15 Abuse and Neglect policies revealed: *Investigation of any reports of misappropriate behavior by direct staff will be the initial responsibility of the charge nurse to be further investigated by the DON once notified. If the DON is unavailable the ADON will be notified and act. *Identify all possible witnesses (including non-direct staff) who may have knowledge of the incident. *Interview all witnesses, including other residents, affected resident/family, and document their accounts. *Identify any predisposing factors (belligerent resident being verbally/physically abusive, staff illness or stress) document findings.

Based on record review, interview, and policy review, the provider failed to ensure residents were free from unnecessary medications for two of two sampled residents (1 and 3). Findings include: 1. Review of resident 1's medical record revealed she: *Had been admitted on [DATE]. *Had [DIAGNOSES REDACTED]. *Her Brief Interview for Mental Status (BIMS) on 2/28/17 was a thirteen which revealed she was cognitively intact. *Had been diagnosed on [DATE] with pneumonia. *Had a urine analysis (UA) sent to the laboratory for a culture and sensitivity test on 5/16/17. The culture and sensitivity test showed she did not have a urinary tract infection [MEDICAL CONDITION]. *Had a UA sent to the laboratory on 5/26/17 for a culture and sensitivity test, and an antibiotic was started for a possible UTI. She also had an infection of a skin tear. The culture and sensitivity test showed she did not have a UTI. *Her BIMS on 5/30/17 was a three which indicated severely impaired cognition. *Had a UA completed on 6/11/17 which was treated with an antibiotic for ten days. *Had falls on 6/5/17 and on 6/19/17. *A 6/20/17 at 2:00 p.m. physician's assistant (PA) order for [MEDICATION NAME] one milligram (MG) for one dose. *A 6/21/17 at 12:05 p.m. physician's orders [REDACTED]. *Was given [MEDICATION NAME] 0.5 mg at 2:00 a.m. on 6/22/17 at 2:00 a.m. for restlessness. *Was given [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 50 mg on 6/22/17 at 6:30 a.m. for: -Wants to go to bathroom continuously. -Will not stay in dining room for breakfast insisting she needs to go to bathroom. When you assist resident to bathroom she does nothing. --Those medications had been noted to have not been effective. *An order was received on 6/22/17 at 1:22 p.m. to start [MEDICATION NAME] 25 mg every day and follow-up with her physician in one week. *Received [MEDICATION NAME] 0.5 mg on 6/29/17 at 7:00 a.m. with little effect. *An order was received on 6/30/17 at 2:37 p.m. to discontinue the [MEDICATION NAME] and increase the [MEDICATION NAME] to 25 mg twice daily. Her physician noted she had confusion and dementia. *Had a fall on 7/5/17 at midnight. *Had a new [DIAGNOSES REDACTED]. The medical director noted This has worked very well for her. I will look at decreasing her dosage in the future. *The anti-anxiety and anti-psychotic medications had been administered prior to an appropriate diagnosis. Agitation was not an appropriate [DIAGNOSES REDACTED]. *On 7/13/17 a recommendation to reduce [MEDICATION NAME] to everyday and then discontinue. *On 8/10/17 a recommendation to reduce [MEDICATION NAME] to 25 milligram every day. *Had an increase in behaviors noted from 7/12/17 through 8/21/17. *The medical director increased her [MEDICATION NAME] to 50 mg twice daily on 8/21/17. *Was treated for [REDACTED]. *Had a nine percent weight loss over the previous month on 8/22/17. *Physician decreased her [MEDICATION NAME] to 25 mg in the morning and 50 mg at night. Review of resident 1's nursing progress notes revealed: *Between 5/9/17 and 8/28/17 the resident had behaviors that included: -Removal of skin tear dressings. -Confusion regarding the day and time. -Removed clothes during some nights and would sit in her chair naked. -Threw pads, blankets, soaker pads, clothes, and whatever else came into her hands on the floor. -Required one-to-one staffing during some nights. -Refusing medications. -Swearing at staff and other residents. -Paranoid delusions that included staff doing something to her medications and being kicked out of her room. Review of resident 1's certified nursing assistant behavior documentation for: *April 2017 showed her mood was happy and had no behaviors. *May 2017 showed during the day her mood was happy and at times confused, and at night she rested and was confused at times. She had one documented behavior on 5/1/17 at night of having been socially inappropriate. *June 2017 showed her mood was happy, irritable, restless, angry, and confused. She had documented behaviors six times on the day shift, four times on the evening shift, and five times on the night shift. Those behaviors were verbally abusive, socially inappropriate, and repetitive hollering. *July 2017 her mood was the same as June. She did have increased behaviors noted during the day shift. *August 2017 her mood and behaviors remained the same for the first half of the month then increased towards the last half of the month. Review of resident 1's 5/30/17 care plan revealed no focus area, goal, or interventions related to her increased behaviors and the use of anti-anxiety and anti-psychotic medications. There was also no care plan for the effectiveness and side-effects related to the use of anti-anxiety and anti-psychotic medications. Interview on 8/30/17 at 1:30 p.m. with the director of nursing, assistant director of nursing, and the Minimum Data Set coordinator regarding resident 1 revealed: *She had experienced confusion and behaviors after her [DIAGNOSES REDACTED]. *She had been tested four times for a UTI. *They agreed only one UTI had grown bacteria with the culture. *They had not tried any other behavior modification methods. *Were not aware dementia with agitation was not an acceptable [DIAGNOSES REDACTED]. *They agreed her behaviors and mood had not improved with the use of the anti-psychotic medication. 2. Review of resident 3's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] with fixed delusions. -[DIAGNOSES REDACTED] versus a [MEDICATION NAME] dementia. -Depression. -[MEDICAL CONDITION] over the left occipital region. -History of [MEDICAL CONDITION]. -History of complex migraines. *Her BIMS score on 6/27/17 had been a fourteen indicating her cognition was intact. Review of resident 3's nursing interdisciplinary notes from 1/1/17 through 8/29/17 revealed: *On 1/1/17 she had been [MEDICATION NAME] a UTI. *On 1/2/17 she had been started on [MEDICATION NAME] for seven days. -The organism grown was [MEDICATION NAME] faecium. *On 1/15/17 she had been more confused. *On 1/18/17 she had been started on an antibiotic for a week for a UTI. *On 2/20/17 she had been started on [MEDICATION NAME] for a UTI. *On 2/21/17 she had a cathed UA done. *On 2/25/17 she continued on an antibiotic for a UTI. *On 3/4/17 she took her last dose of antibiotic. *On 3/29/17 she was started on [MEDICATION NAME] for seven days for a UTI. -Scheduled [MEDICATION NAME] 0.5 mg two times per day. *On 4/5/17 she finished that course of antibiotics. *On 4/13/17 a UA dip had been completed and was negative. *On 4/24/17 she had been started on [MEDICATION NAME] for seven days for a UTI. *On 4/28/17 she had been started on [MEDICATION NAME] for her dementia. *On 5/1/17 she finished the course of her antibiotic. *On 6/1/17 [MEDICATION NAME] was discontinued and [MEDICATION NAME] 25 mg every morning was started. *On 6/2/17 she was started on [MEDICATION NAME] for ten days for positive UTI. *On 6/7/17 the [MEDICATION NAME] had been increased to 25 mg two times per day due to behaviors. *On 6/15/17 physician's orders [REDACTED]. *On 6/16/17 resident continued to be confused. *On 7/10/17 decreased [MEDICATION NAME] to 50 mg daily. *On 7/12/17 she was very confused. *On 8/17/17 she was confused and hallucinating. A catheter UA was ordered. Review of an 8/17/17 physician's progress note regarding resident 3 revealed the [MEDICAL CONDITION] and [DIAGNOSES REDACTED] vs. frontal dementia were progressing. Interview on 8/30/17 at 8:00 a.m. with the chief operating officer regarding resident 3 revealed: *The husband was very involved. *He had taken her to see a neurologist a while back. *She had come from a behavioral health facility in a different town. *She was fixated on having to use the bathroom all the time. Interview on 8/30/17 at 10:45 a.m. with the DON, ADON, and MDS coordinator regarding resident 3 revealed: *She had been treated for [REDACTED]. *She had multiple medication adjustments while being treated for [REDACTED]. *They agreed the behaviors being demonstrated could have been related to the [DIAGNOSES REDACTED]. *She had not been sent to see a urologist. A policy had been requested on 8/30/17 at 4:45 p.m. but they did not have one.

Based on observation, record review, interview, and policy review, the provider failed to assess and implement interventions for two of four sampled residents (4 and 6) who were identified to have skin issues. Findings include: 1. Review of resident 6's skin assessment sheets revealed: *On 4/11/16 it was noted Skin CDI (clean, dry, and intact) except for little redness et peeling of skin between coccyx. *On 4/18/16 it was noted Coccyx area still gets small nickel size areas to both inner cheeks of sloughing of skin/peels away (after) bath, but no soreness when asked. *On 4/25/16 it was noted Wp (whirlpool) bath given. Skin CDI. *On 5/2/16 it was noted Dry nickel size patches noted to buttocks near coccyx (one on each buttock). Area dry and intact. *On 5/9/16 it was noted Will continue to monitor for skin breakdown. *On 5/23/16 it was noted Skin CDI. *On 5/30/16 it was noted 1 x 1 centimeter open wound to R buttock. *On 5/31/16 it was noted Wound covered with duoderm and measured. *On 6/6/16 it was noted Stg II continues to R buttock. *On 6/21/16 it was noted Stg II pressure ulcer remains to R buttock. *On 6/27/16 it was noted Stg I to L buttock, Stg II to R buttock. Dressing changed. *On 7/4/16 it was noted Stg II pressure ulcer noted to R buttock et Stg I to left buttock. *On 7/11/16 it was noted Stg I and II continues to buttock. *On 7/18/16 it was noted Stg I and II ulcers noted to buttock. *On 7/25/16 it was noted Stg I and II continues to buttock. Cleaned and dressed per orders. *On 8/1/16 it was noted Stg I and II continues to buttock. Cleaned and dressed per orders. *There were no skin assessments after 8/1/16. Review of resident 6's medical record revealed: *Her admitted was 1/3/13. *Her [DIAGNOSES REDACTED]. *She had a history of [REDACTED]. -She had a pressure ulcer to her coccyx from 7/5/13 through 11/5/13 and again starting on 2/24/14. *There had been no documentation the physician had been notified before 5/31/16. *There had been no documentation of a treatment being started prior to 5/31/16. Review of resident 6's 1/13/16 and 7/13/16 Minimum Data Set (MDS) assessments revealed she was at risk for developing pressure ulcers. The interventions had been pressure reducing device in chair, nutrition, and hydration. On the 7/13/16 MDS they had added pressure ulcer care as an intervention. There were no other interventions listed on those MDS assessments. Her brief interview of mental status score was 13 out of 15. A score of 13-15 meant her thinking ability was intact. Review of resident 6's Braden Scale for Predicting Pressure Sore Risk assessments revealed: *On 10/14/15, 1/13/16, and 4/13/16 she had scores of 23. *A score of 15-18 is at risk, 13-14 is at moderate risk, 10-12 is at high risk, and 9 or below is at very high risk. Review of resident 6's 7/13/16 care plan revealed: *A focus area that stated the resident has risk for decline in nutritional status, skin breakdown and UTI's r/t (related to) urinary incontinence (dribbling) and use of incontinence pads and resident has history of skin breakdown and constipation. *Under the goal section there was a handwritten note that stated Resident currently has stage II pressure ulcer discovered 5/31/16. -It had not indicated the location or mentioned the stage I pressure ulcer mentioned above. *Undated typed interventions included: -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -Educate resident/family/caregivers of causative factors and measures to prevent skin injury. -Encourage intake of 75% or more of foods and fluids offered at mealtimes of a house diet in order to promote healthier skin. -Encourage resident to toilet before and after meals and activities and assist PRN (as needed). -Monitor and encourage resident to report signs and symptoms of UTI and report to charge nurse/MD (medical doctor). -Fresh water at bedside. -Liquid fiber supplements PO (orally) TID (three times per day) per dietary recommendations to promote regular bowel movements. -Monitor for constipation and encourage resident to report/ask for PRN medications. -Liquid protein supplement 1 oz. daily per dietary recommendations. Started 4/3/13 d/t (due to) skin ulcer. -Monitor dental/oral status. Assist PRN and arrange dental appointments PRN. -Monitor weekly weights and vital signs and report abnormals to charge nurse/MD. -Assist MD in monitoring labs. -Provide incontinence pads and encourage appropriate peri-care and assist PRN if resident allows. Resident prefers privacy. -Whirlpool bath or shower 2 times a week with at least weekly skin assessment by charge nurse. Keep skin clean and dry. Use lotion on dry skin. *Undated handwritten interventions included: -Wound care per MD orders. -Stage and size weekly. *There was no mention of: -Pressure reducing surfaces in her wheelchair or bed. -Encouragement of repositioning. -Nutritional interventions since 4/3/13. Random observations on 8/16/16 from 8:15 a.m. through 12:10 p.m. and again from 2:15 p.m. through 4:15 p.m. of resident 6 revealed she had been sitting in her recliner in her room. At 9:35 a.m. staff had gone into her room to change the dressing to her pressure ulcer. Surveyor: Observation of and interview with registered nurse (RN) A on 8/16/16 at 9:35 a.m. during the dressing change of resident 6 confirmed the continued presence of a stage 2 pressure ulcer on her coccyx. Surveyor: Review of resident 6's interdisciplinary progress notes from October 2015 through 8/16/16 revealed: *They included: -Certified dietary manager (CDM) notes on 10/15/15, 1/14/16, 4/14/16, 6/8/16, and 7/14/16. -A Registered dietitian (RD) note on 1/20/16 and 6/16/16. -There were no further RD notes or assessments. *There was no mention of what interventions had been implemented besides the 1 oz. of liquid protein started in 2013 to prevent the pressure ulcer from developing or worsening. Review of resident 6's social services notes revealed on 7/20/16 staff had discussed with the resident about staff providing peri-care. Interview on 8/17/16 at 7:40 a.m. with the director of nursing and the assistant director of nursing regarding resident 6 revealed: *They agreed the 4/11/16 documentation revealed the beginning of a pressure ulcer. *Weekly assessments should have been started at that time. *They expected weekly assessments to have been completed by the nurse on duty that day. *The physician should have been notified and treatment started. *Her care plan had not: -Indicated when interventions and changes had occurred for her skin and pressure ulcer. -Mentioned pressure reducing devices or repositioning. -Addressed nutritional interventions to promote healing. *The RD visited monthly. -Her notes or assessments should have been documented on any resident she had reviewed. -Residents with pressure ulcers should have been assessed monthly by the RD. *They had not followed their pressure ulcer policy. Phone interview on 8/17/16 at 8:50 a.m. with the RD regarding resident 6 revealed she: *Was aware she had a pressure ulcer. *Had charted on her in June. *Responded I don't know I guess. The CDM may be giving her additional protein. I don't have it written down. when asked what interventions were in place. 2. Review of resident 4's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *Her BIMS score was 3, which indicated severe cognitive impairment. *She currently had an unstageable pressure ulcer on her coccyx. -Nursing completed a treatment to the ulcer every other day, with baths, and as needed. *She had Braden scale assessments done on 11/4/15, 2/3/16, and 5/4/16. -Her scores were 19, 19, and 17. -A score of 19 was considered not at risk of skin breakdown. -A score of 15 to 18 indicated she was at risk for skin breakdown. *Her 11/4/15 quarterly and 2/3/16 significant change Minimum Data Set (MDS) assessments indicated she: -Did not have pressure ulcers at that time. -Was at risk for developing pressure ulcers. -Did not have skin treatments such as pressure reducing devices, repositioning, or pressure ulcer care. *Her 5/4/16 signficant change MDS assessment indicated she: -Had a stage 1 or greater pressure ulcer. -Was at risk for developing pressure ulcers. -Had a pressure reducing device for her chair only. -Received pressure ulcer care. Observations of resident 4 on 8/15/16 at 5:30 p.m., and on 8/16/16 at 7:30 a.m., 8:50 a.m., 12:40 p.m., 2:20 p.m. and 3:45 p.m. revealed she: *Utilized a wheelchair for mobility. *Had a cushion in the seat of her wheelchair. *Had a personal tempurpedic memory foam mattress on her bed. *Used a stand-lift to transfer with staff assistance. *Had a 8/16/16 dated bordered foam dressing intact to her coccyx pressure ulcer. -Surveyor was unable to observe coccyx pressure ulcer due to the scheduling of dressing changes. *Required staff assistance with activities of daily living. *Sat at a table for those requiring assistance with meals. Observation and interview on 8/16/16 at 8:50 a.m. with CNA H during resident 4's personal care revealed: *The nurses took care of the dressing on the resident's coccyx pressure ulcer. *If the dressing was loose or had come off they told the nurse. *The resident had a pressure reducing cushion on her wheelchair and her own mattress on her bed. *She used a stand-lift to transfer her to the bathroom and back to her wheelchair. *The resident required assistance with the transfers, toileting, and personal hygiene. Review of resident 4's wound care measurement and assessment forms for her coccyx pressure ulcer revealed: *On 5/2/16 it had started as a stage 1. *On 6/15/16 it was a stage 2. *On 6/27/16 it was a stage 3. *On 7/13/16 it was unstageable. *Weekly assessments had not been completed for the first month after the pressure ulcer had developed on 5/2/16. Review of resident 4's undated care plan revealed: *A undated focus area of resident has a potential impairment to skin integrity r/t impaired mobility, increase pain and increased confusion. *An undated handwritten entry resident now has unstageable pressure ulcer to coccyx originally discovered as stage I (5/2/16) and has progressed. *Goals were: -The resident will maintain clean and intact skin through 8/16. -Pressure ulcer will begin to heal and be free of infection through 8/16. *Undated typed interventions included: -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -Educate resident/family/caregivers of causative factors and measures to prevent skin injury. -Encourage good nutrition and hydration in order to promote healthier skin. -Identify/document potential causative factors and eliminate/resolve where possible. -Use a draw sheet or soaker pad to move resident. -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. -Whirlpool bath once weekly with skin assessment by charge nurse at least weekly. Keep skin clean and dry. Use lotion on dry skin. *Undated handwritten interventions included: -Wound care per orders. -Stage and size weekly. -Stage 1 to coccyx. Wound care per protocol/orders 5/4/16. *An undated focus area of Resident has a potential nutritional problem (weight loss) R/T history of weight loss, poor intake at times and refusal of nutritional supplements. -There was no mention of interventions specific to her pressure ulcer. *There was no mention of: -Pressure reducing surfaces in her wheelchair or bed. -How often repositioning should have been completed. -Nutritional interventions to promote healing. Review of resident 4's interdisciplinary progress notes from October 2015 through 8/16/16 revealed: *They included: -Certified dietary manager (CDM) notes on 11/5/15, 2/4/16, 5/5/16, and 8/4/16. -A registered dietitian (RD) note on 10/28/15. -There were no further RD notes or assessments. *There was no mention of: -The stage 1 pressure ulcer starting on 5/2/16. -The pressure ulcer by the CDM on 5/5/16 or 8/4/16. -The coccyx pressure ulcer until 6/24/16. -What interventions had been implemented to prevent the pressure ulcer from developing or worsening from a stage 1 to an unstageable ulcer. Interview on 8/16/16 at 3:00 p.m. with the CDM regarding the nutritional assessments by the RD revealed: *She usually called the RD any time a resident had a new pressure ulcer or weight loss to get recommendations from her. *They talked about the residents with skin issues during the RD's monthly visits. *She thought the RD documented her assessments in the interdisciplinary progress notes for each resident she reviewed. *She confirmed assessments should have been completed more frequently on residents with pressure ulcers. Interview on 8/17/16 at 7:40 a.m. with the director of nursing and the assistant director of nursing regarding pressure ulcers and resident 4 revealed: *They confirmed her coccyx ulcer had started on 5/2/16 as a stage 1 and had currently deteriorated to an unstageable ulcer. *There were no weekly assessments completed from 5/2/16 until 6/3/16 for that ulcer. *They expected weekly assessments to have been completed by the nurse on duty that day. *Her care plan had not: -Indicated when interventions and changes had occurrred for her skin and pressure ulcer. -Mentioned pressure reducing devices or repositioning. -Addressed nutritional interventions to promote healing. *The RD visited monthly. -Her notes or assessments should have been documented on any resident she had reviewed. -Residents with pressure ulcers should have been assessed monthly by the RD. -They confirmed resident 4 had not been assessed by the RD since she had developed the pressure ulcer in May 2016. *They confirmed there were interventions they had utilized that were not documented and should have been. Those included: -The pressure reducing mattress on her bed and cushion in her wheelchair. -Repositioning every two hours. -Her sitting at an assisted table in the dining room. *They had not followed their pressure ulcer policy. Phone interview on 8/17/16 at 8:50 a.m. with the RD regarding resident 4 revealed she: *Was not aware she had a pressure ulcer. *Had not assessed the resident since 4/27/16. *Tried to complete assessments quarterly on some residents. *Was usually called by the CDM with any new pressure ulcers. *Discussed weight changes and pressure ulcers during her monthly visits. *Confirmed she had not completed assessments monthly on resident 4. *Agreed residents with pressure ulcers should have been assessed and had nutritional interventions implemented to promote healing. Interview on 8/17/16 at 12:45 p.m. with registered nurse A regarding resident 4 revealed: *She was unsure why the weekly wound assessments had not been completed from 5/2/16 to 6/3/16 by the nurses. *All pressure ulcers should have been assessed, staged, and sized weekly by the nurse on duty that day. *The assessments were scheduled weekly on the resident's medication administration record. *Interventions had been implemented for the resident and included: -Pressure reducing mattress and cushion in her wheelchair. -Repositioning every two hours. -Physician order [REDACTED]. 3. Review of the provider's 9/27/06 Prevention of Pressure Ulcer policy revealed A record of any reddened area, rash, or breaks in the skin should be: *a. reported to the Charge Nurse. *b. initiate care of the area. *c. DOCUMENT size, depth, drainage, etc, and care given in Inderdisciplinary Care Notes (Nurse Notes). *d. UPDATE CARE PLAN of resident to reflect current treatment. Review of the provider's revised 6/23/16 Pressure Ulcer Protocol policy revealed: *The objective was To monitor and treat pressure ulcers. To provide aggressive intervention. To provide prevention of pressure ulcers. *3. Treatment plan as followed: -a. Initiate repositioning every 1-2 hours depending on the sight of the ulcer. Reposition residents with pressure ulcers every 15 minutes when in wheelchair or geri-chair. -b. Place a pressure relieving air/foam layered mattress to the resident's bed (or a mattress of equal use). -c. Protecting the ulcer: --i. Buttock/coccyx ulcers: place a pressure relieving pad to wheelchair or geri-chair if immobile. Use pillows or wedges to keep ulcer free of pressure when in bed to increase blood circulation and promote healing. *4. Consult with MD/PAC for special treatment plan. *5. Report pressure ulcer to DM/RD for initiation of nutritional supplement and calculation of calorie, protein, Vitamin C and fluid requirements. *7. Monitor the healing process at least 1 time per month. An RN is to assess, stage, and size ulcer weekly. If the ulcer healing process is noted to deteriorate at any time, refer back to step 3 and follow the steps again. If progression of healing is noted after 1 month, continue treatment plan and consult the MD/PAC monthly for status updates. Review of the provider's undated Skin Assessment policy revealed interventions and prevention of skin breakdown included: *Turn immobile resident at least every 2 hours.*Reposition seated residents every 2 hours unless they can perform pressure-relief exercises/movements themselves at least every 15 minutes. *Clean and dry skin after each incontinent episode. *Wheelchairs are equipped with the appropriate cushion. Review of the provider's 9/20/06 Nutritional Assessments policy revealed Monthly charting is done on those residents who show a 5% or greater monthly weight loss, >7% quarterly weight loss or >10% semi-annual weight loss. Those residents who have pressure ulcers or on any residents that the FSS (food service supervisor) requests. Review of the provider's undated Identifying Residents at Risk for Nutritional Problems policy revealed: *Residents at risk included pressure ulcers. *4. The Dietary Manager will contact the RD consultant by phone when a resident presents with a pressure ulcer, dehydration, or significant weight loss diagnosis. The RD will evaluate the information and provide nutrition advice to the Dietary Manager for the resident(s) in question. *5. On the next visit the RD consultant will document the nutritional needs and plan of care to meet those needs for the resident in question plus any other residents she has determined to be at nutritional risk.