Every finding on record at Knife River Care Center

Based on record review, review of the facility reported incident (FRI) investigation, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring to prevent elopements from the facility for 1 of 1 sampled resident (Resident #1) Failure to provide adequate supervision and monitoring and respond to door alarms immediately resulted in Resident #1's elopement from the facility and may result in injury from prolonged exposure to cold temperatures. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the elopement. Findings include:The surveyor determined a deficient practice existed on 11/22/25. The facility implemented immediate corrective action and completed additional action/education on 11/27/25. Review of the facility's elopement policy, titled Knife River Care Center Resident Elopement and Wandering Policy, and dated 03/13/25, stated, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents . Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risk, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Resident at Risk for Elopement or unsafe wandering . b. Residents at risk of wandering and elopement will be placed in Whispering Winds or in a room at least three rooms away from exits at the end of the hall whenever possible. d. Adequate supervision will be provided to help prevent accidents or elopements. Frequent location checks may need to be implemented for high-risk wanderers. 5. Procedure for Locating Missing Resident a. Any staff member becoming aware of a missing resident will alert personnel using facility walkie talkie. b. The designated facility staff will look for the resident. Review of Resident #1's quarterly elopement assessments dated, 06/13/25 and 09/11/25, identified At risk for elopement.Resident #1's care plan stated, The resident is an elopement risk/wanderer r/t [related to] Disoriented to place, Impaired safety awareness, Resident wanders aimlessly. Wander guard present x [times] 2 [two] . The resident's safety will be maintained through the review date . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. WANDER ALERT . Review of Resident #1's nurses notes occurred on 12/10/25 and identified the following:*11/22/25 at 1:09 p.m. Nurse alerted approx. [approximately] at 10:15 [a.m.] by CMA [certified medication aide] that resident had been found outside the facility in the SW [southwest] parking lot fully dressed/wander guard in place/shoes on/sitting in WC [wheelchair] attempting to get in an employee's parked car. The employee/CNA [certified nurse aide] on [NAME] Lane recognized resident and wheeled her back into building transferring care to Harvest Lane nursing staff.*11/22/25 at 1:10 p.m. Following return of resident to facility nurse took vital signs and performed head to toe/neurological/pain/cognitive assessments. Resident found to have no pain/injuries or COC [change of condition]. Resident vital signs within baseline. Resident unable to explain why she was in parking lot. Nurse initiated facility protocol notifying MD [medical doctor]/unit manager/on call nurse/family. Resident wander guard replaced. Resident old wander guard appeared to be working. Elopement documentation initiated. Social Services to notify state health department .*11/22/25 at 1:37 p.m. This writer followed up with incident. Resident has no injuries noted. Resident currently sleeping in her chair in the day room. Resident placed on 15-minute checks. Staff education being completed on resident being placed on 15-minute checks as well as responding to the door alarm. No signs of abuse or neglect noted.Review of the facility's final FRI investigation report stated, . Facility protocol was initiated. The resident's Wander Guard was replaced; the original device appeared to be functioning appropriately. Staff replaced device during the time of investigation. Social Worker investigated the wander guard; wander guard was in good working order. Elopement documentation was initiated according to the facility protocol. [Resident #1] was placed on 15-minute checks for duration of the investigation. Cameras were reviewed; [Resident #1] was seen holding the door to disarm the locking system and [Resident #1] leaving. [Resident1] returned with staff.During an interview on 12/10/25 at 1:45 p.m., two administrative staff members (#1 and #2) stated the wander guard alarm was working when Resident #1 left the building and the alarm went to staff all walkie-talkies. During an interview on 12/11/25 at 11:57 a.m., a social service staff member (#3), who conducted the investigation of the elopement, stated the wander guard alarm on Resident #1 was working and the alarm went to staff on their walkie-talkies. The staff member stated the employee in the parking lot was alerted on his/her walkie-talkie, saw the resident outside and returned her to the building. The staff member (#3) stated when viewing the camera footage, the incident (going into the entryway and then outside to the parking lot) lasted ten minutes and the resident was outside for approximately five minutes. Based on the following information, non-compliance is considered past non-compliance. The facility implemented corrective actions for the resident and other residents who may be affected by the deficient practice as follows:* Immediately initiated 15 minute checks on Resident #1. * Immediately provided education to all staff working on 11/22/25 about the 15-minute checks, the importance of immediately responding to door alarms, and required staff to read the Elopement Policy/Procedure.* Completed investigation of Resident #1's elopement.* Added a second wander guard alarm to Resident #1's wheelchair.* Initiated wander guard checks every four hours. * Provided education to all other staff members prior to return to work about responding to door alarms and to read the Elopement Policy/Procedure.

Based on observation, review of facility cleaning logs, and family and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 2 of 11 sampled residents (Resident #32 and #65) who required a wheelchair. Failure to maintain a safe, clean, and sanitary environment may lead to injury from unsafe equipment, does not provide a homelike living area for residents, and fails to promote quality of life. Findings include: - Observation on 02/24/25 at 9:57 a.m. showed Resident #32's wheelchair in disrepair, with the vinyl of the armrest pads cracked, missing pieces, and flaking. During an interview on 02/26/25 at 11:28 a.m., a staff member (#4) confirmed the armrest pads need replacement. - During an interview on 02/24/25 at 4:50 p.m., a family member (#1) of Resident #65 stated staff do not clean his Broda chair (special type of wheelchair) or his room, noting tissues and a lollipop stick on the floor. The family member pointed to dried feces on the frame of the Broda chair. Observation showed a dried brown substance with the odor of feces on the metal frame and on the middle crossbars beneath the seat. Observation on 02/25/25 at 3:24 p.m. showed Resident #65's Broda chair contained food debris in the area between the seat and chair sides, in the pocket-like area at the top of the leg rests, and on the arm rests. The dried feces remained on the frame. A certified nurse aide (CNA) (#5) agreed the chair needed cleaning and took it to the shower to clean it. Review of the facility's Nite [sic] Shift Wheelchair/Walker & [NAME] Cleaning Schedule occurred on 02/25/25. The schedules for December 2024 - February 2025 showed Resident #65's Broda chair scheduled for weekly cleaning every Saturday night and showed staff failed to sign off on this task for seven of the 12 scheduled weeks. During an interview on 02/25/25 at 3:38 p.m., an administrative nurse (#1) stated she expected staff to clean the wheelchairs on the night shift weekly as scheduled. 46477

Based on observation, record review, review of manufacturer's instructions, and staff interview, the facility failed to provide adequate assistance for 1 of 4 sampled residents (Resident #40) observed during a ceiling lift transfer. Failure to ensure proper use of the ceiling lift, including use of the sling/straps, placed the resident at risk for a fall and injury. Findings include: Review of the manufacturer's instructions for the Maxi Sky 2 (ceiling lift) stated, . Method 1-Cross-through, legs closed with crossing straps . Review of Resident #40's medical record occurred on all days of survey. The current care plan stated, . The resident has limited physical mobility r/t [related to] contractures, weakness . requires a ceiling track for transfers . Observation on 02/24/25 at 10:28 a.m. showed a certified nurse aid (CNA) (#3) transferred Resident #40 from the wheelchair to the bed. The CNA attached the leg strap loops of the sling to the spreader bar and failed to use the cross-through method. During an interview on 02/26/25 at 9:34 a.m., a nursing supervisor (#4) confirmed staff should use the cross-through method with the sling straps, especially with Resident #40 due to his muscle weakness.

Based on review of the facility reported incident and investigation documents, record review, and review of facility policy, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who experienced physical abuse. Failure to ensure an environment free from abuse placed Resident #2 and all other residents residing in the memory care unit at risk for abuse, fear, anxiety, and/or psychosocial harm. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incident. Findings include: The surveyor determined a deficient practice existed on 11/12/24. The facility implemented and completed corrective action on 11/12/24. Review of the facility policy titled ABUSE PROHIBITION POLICY occurred on 11/26/24. This policy, dated 09/05/24, stated, . Residents must not be subject to abuse by anyone, including, but not limited to, . other residents . Abuse shall be defined as follows . 'Abuse' shall mean the willful infliction of injury . resulting in physical harm or pain or mental anguish . 'Physical abuse' shall include hitting, slapping, pinching, and kicking. Review of the facility reported incident information identified on 11/12/24 at 2:00 p.m. two staff nurses (#1 and #2) heard moaning outside an office. The nurses found Resident #2 lying on the floor on his back outside the office and observed Resident #1 seated in a wheelchair kicking Resident #2 in the lower leg. One of the nurses immediately removed Resident #1 to ensure Resident #2's safety. Review of Resident #1's medical record occurred on 11/26/24. A quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition. The care plan stated, . has a behavior problem r/t [related to] childhood trauma. LOCOMOTION . ambulates via wheelchair per self-and/or staff assistance, depending on his day . becomes aggressive towards other residents . is/has a potential to become agitated r/t dementia . has a behavior problem (physical and verbal symptoms) r/t dementia . Resident #1's progress notes stated the following: * 11/12/24 at 3:49 p.m., . At 1400 [2:00 p.m.] I found resident in wheelchair kicking another resident who was on the floor. Staff interjected. Family and provider updated. * 11/12/24 at 5:29 p.m., . Resident placed on 15 minute checks 24/7 [around the clock] for duration of investigation. Staff were educated on 15 minute checks and redirection as needed. * 11/15/24 at 10:37 a.m., . Called [Power of Attorneys name] and offered a room change to a different unit and she stated no that WW [Whispering Winds memory care unit] is now his home. - Review of Resident #2's medical record occurred on 11/26/24. A quarterly MDS, dated [DATE], identified severely impaired cognition. The care plan stated, . ambulates independently without any assistive device . is a wanderer r/t Disoriented to place, impaired safety awareness, Resident wanders aimlessly . is/has potential to be verbally aggressive r/t Dementia and hostility . has potential to be physically and verbally aggressive r/t dementia. has a communication problem r/t cognitive deficits. Has dx of early onset Alzheimer's disease and dementia. Is sometimes understood and usually understands . Resident #2's progress notes stated the following: * 11/12/24 at 3:36 p.m., . At 1400 I heard resident moaning so myself and another nurse went to see why he was moaning, he was on the floor on his back and another resident was in a wheelchair beside him kicking him. Resident kicking was removed, myself and other staff assessed resident and got him upright, no injuries noted, resident denies discomfort at this time, . Family and provider updated. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions as follows: * The interdisciplinary team met to problem solve and implement changes and interventions for resident care and safety. * Notified providers of the incident. * Notified resident representatives of the incident and actions implemented. * Education provided to all staff on the Whispering Winds unit on action plan and behavioral interventions that work best for Residents #1 and #2.

Based on record review, the facility failed to review and revise care plans to reflect residents' current status for 1 of 2 sampled residents (Resident #1). Failure to update Resident #1's care plan limited staffs ability to communicate needs and ensure continuity of care. Findings include: Review of Resident #1's medical record occurred on 11/26/24. The nursing progress notes stated the following: * 03/19/24 at 2:37 p.m., . Resident struck another resident. Resident kicking unit doors stating he is going to hell, resident told staff he was going to hang himself. * 03/25/24 at 10:26 p.m., . Resident had behaviors tonight, mentioned about committing suicide . * 04/06/24 at 3:32 p.m., . CNA [certified nurse aid] reported . res [resident] sitting in his wheelchair . began talking about his bandages on his hands to the CNA, he became increasingly verbally agitated and then stated, '. I'm just gonna commit suicide!' . Resident #1's care plan failed to include history of suicidal ideation.

Based on review of the facility reported incident and investigation documents, record review, review of facility policy, and staff interview, the facility failed to ensure residents remain free from abuse for 1 of 1 sampled resident (Resident #1) who experienced physical abuse. Failure to immediately investigate an incident of physical abuse and provide necessary services to protect residents from harm resulted in an unsafe environment and the potential for further harm. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 08/10/24. The facility implemented corrective action and completed on 08/13/24. Review of the facility policy titled Abuse Prohibition Policy occurred on 08/14/24. This policy, revised November 2023, stated, . Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. Abuse shall be defined as follows: . 'Physical abuse' shall include hitting, slapping, pinching, and kicking. Any alleged violation(s) should be recorded and reported immediately to the facility Administrator and/or designee. All alleged acts or suspected acts of abuse, neglect, or misappropriation of resident property reported shall be immediately and thoroughly investigated and reported . Any investigation may be expanded to include law enforcement officials at any phase of the investigation where there is a reasonable suspicion to indicate that a criminal act has been committed. Review of the facility reported incident information identified on 08/10/24 at 2:30 p.m. Resident #1's daughter came to the facility to visit. The activity aide observed the daughter had her hand around Resident #1's arm and described the grip as a firm grip causing the arm to be a different color. The activity aide followed Resident #1 and her daughter to the resident room. Resident #1 pulled away from the daughter and [name of daughter] simultaneously slapped Resident #1 across the face. The activity aide involved the charge nurse and removed the daughter from the situation. Review of Resident #1's medical record occurred on 08/14/24. An admission Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition. Review of the progress notes identified the following: * 08/10/24 at 2:06 p.m., Activities director, [name of staff member], reported res [resident] daughter was in res room slapping her in the face. This nurse, [name of staff member], LPN [licensed practical nurse] went to the room and asked daughter to leave facility and tell daughter abuse is not tolerated at this facility. * 08/12/24 at 11:18 am, Updated provider regarding situation on Sat [Saturday] and that resident hands are bruiesed [sic] and concern of left hand 3rd digit. Provider asked that we have her seen by her today, and son be present. Son in agreement. * 08/12/24 at 9:55 p.m., Offered ice wrapped in towel for her L [left] dislocated middle finger. Resident was doing cold compress for 20 min. Review of the physician Order Summary Report dated, 08/12/24, identified a fracture of the mid and distal portion of proximal phalanx and possible dislocation of middle joint of third finger. To ER [emergency room ] for reduction, splinting . Review of the facility's investigation document, completed by the administrative staff member (#1), identified the following notes; . On 8/12/24 . I then went to interview [Resident #1]. [Resident #1] did not remember what happened. I did observe massive dark bruises to [Resident #1] hands and her finger was bent in an abnormal way. [Resident #1] was not willing to show me her upper arms to check for bruising. The medical record lacked monitoring and/or documentation of Resident #1's skin condition such as bruising, condition of fingers/hands, and pain or discomfort following the reported incident on 08/10/24 until 08/12/24, two days later, after Resident #1 returned from the emergency room . During an interview the afternoon of 08/14/24 when asked about the lack of documentation regarding Resident #1's bruising and her finger bent in an abnormal way, an administrative staff member (#1) reported they are in the process of completing staff interviews. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions as follows: * The interdepartmental team met to problem solve, implement changes and interventions for resident care and safety. * Providers were notified, follow up care and treatment provided. * The local police department and Women's Action Resource Center (WARC) were notified and involved. * A No Trespassing order to be served to the family member. * The Resident Representative(s) and State Ombudsman was notified of the incident and actions implemented. * Education to all managers regarding the facility abuse policy, reporting time period, response to allegations of abuse, and action plan implemented. * All staff education regarding the facility abuse policy, notification to management staff, assuring resident safety/protection and the facility action plan implemented.

Based on review of the facility reported incident (FRI), record review, review of facility policy, and staff interview, the facility failed to report an incident of abuse for 1 of 1 sampled resident (Resident #1) who experienced physical abuse to the State Survey Agency (SSA) . Failure to report an event of physical abuse in the prescribed time frame does not comply with regulations established to protect residents. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 08/10/24. The facility implemented corrective action and completed on 08/13/24. Review of the facility policy titled Abuse Prohibition Policy occurred on 08/14/24. This policy, revised November 2023, stated, . Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. Abuse shall be defined as follows: . 'Physical abuse' shall include hitting, slapping, pinching, and kicking. Any alleged violation(s) should be recorded and reported immediately to the facility Administrator and/or designee. The Administrator or his/her designee will report to other officials through established procedures and in accordance with State law (including to the State survey and certification agency) as warranted. The Administrator or his designee shall report the allegation to the State survey and certification agency within a 24-hour time period unless the event resulted in serious bodily injury then it needs to be within 2 hours. Review of Resident #1's medical record occurred on 08/14/24. An admission Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition. A nurse's note, dated 08/10/24 at 2:06 p.m., stated, Activities director, [name of staff member], reported res [resident] daughter was in res room slapping her in the face. This nurse, [name of staff member], LPN [licensed practical nurse] went to the room and asked daughter to leave facility and tell daughter abuse is not tolerated at this facility. During an interview the afternoon of 08/14/24, an administrative staff member (#1) reported he/she received a phone call from the charge nurse on 08/10/24, regarding the incident, and that the charge nurse had instructed the daughter to leave the facility. The administrative staff member (#1) reported on 08/12/24, he/she began an investigation and notified the SSA. During an interview the afternoon of 08/14/24, an administrative staff member (#2) confirmed the facility did not report the incident to the SSA within the required 2 to 24-hour time period. Based on the following information, non-compliance at F609 is considered past non-compliance. The facility implemented corrective actions as follows: * The interdepartmental team met to problem solve and implement changes. * Education to all managers regarding the facility abuse policy and reporting time period to state survey agency. * All staff education regarding the facility abuse policy, assuring resident safety and protection and notification to management staff.

Based on observation, record review, and staff interview, the facility failed to ensure an environment free of accident hazards for 1 of 1 sampled resident (Resident #5) who experienced a burn related to hot coffee. Failure to ensure appropriate coffee/water temperatures resulted in Resident #5 sustaining burns and placed all residents at risk for serious burns/injuries. During the on-site facility reported incident (FRI) investigation, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 07/03/24. A nursing progress note, dated 07/03/24 at 1:03 p.m., stated, . Resident fell asleep at the table and spill [sic] hot coffee on her lap. Taken back to her room, pants removed. Large area of redness to bilateral thighs (top and inner) with blistering noted. The IJ resulted from temperature readings obtained from the coffee/hot water machine, a lack of temperature monitoring by staff, and an injury to a resident. This finding placed residents in immediate danger due to hot temperatures and potential for serious burns. *07/08/24 at 5:58 p.m. the survey team notified the administrator of the IJ situation, provided the IJ template, and requested a plan for removal of the IJ. *07/09/24 at 8:30 a.m. the survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: *Education sent to all staff members who worked on 07/08/24. A mass notice sent to all staff on 07/08/24 informing them they will be provided education before the start of their next shifts. *Education included training staff members on the correct procedure for taking temperatures of hot liquids and ensuring the beverages are less than 140 degrees Fahrenheit (F) prior to serving them to residents. *Education identified staff are not to serve hot beverages to resident that temped higher than 140 degrees Fahrenheit (F) and to hold the beverage until the temperature is less than 140 degrees (F) before serving the beverage to a resident. *07/10/24, the survey team verified the implementation of the removal plan as of 07/08/24 and the IJ removal. The deficient practice remained at a G scope and severity following the removal of the immediate jeopardy. Findings include: Review of Resident #5's medical record occurred on 07/08/24. Nursing progress notes included the following: - 07/03/24 at 1:03 p.m. Resident fell asleep at the table and spill [sic] hot coffee on her lap. Taken back to her room, pants removed. Large area of redness to bilateral thighs (top and inner) with blistering noted. Assisted to bed and placed in a gown. Call placed to [physician's name] office. Awaiting return call. [Family's name] notified. - 07/03/24 at 3:15 p.m. IDT [interdisciplinary team] met and reviewed incident regarding resident spilling her coffee. Resident to have covered mugs for all hot liquids. - 07/04/24 at 7:47 a.m. L) [left] thigh has 5 large fluid filled blister [sic]. R) [right] has 1 fluid filled blister. cleansed with gentle soap and water. Applied bacitracin [antibiotic ointment]. Telfa to cover with kerlix [a gauze strip] to hold dressing in place. Resident #5's care plan identified a focus initiated on 01/17/23, which stated, Resident is at risk for injury related to hot liquids. She has spilled tea on her hand, arm and thighs in the past . Remind staff to assure that resident has a coffee mug with a cover. RESIDENT DOES REMOVE COVERS FROM MUGS . During an interview on 07/08/24 at 1:18 p.m., an administrative nurse (#2) identified the mug lids were not on the meal ticket or the dietary care plan at the time Resident #5 spilled her coffee in the dining room. Staff interviews conducted by the facility while investigating Resident #5's coffee spill failed to identify a lid on the coffee cup or that during the meal the resident removed the lid. During an interview on 07/08/24 at 3:45 p.m., an administrative staff member (#1) confirmed the tray provided to Resident #5 at the noon meal on 07/03/24 lacked a lid on the hot beverage. Temperatures obtained by the dietary staff member (#3) with the surveyor on the afternoon of 07/08/24 showed the following: * Harvest Lane kitchenette: Coffee 170 degrees F * Whispering Winds kitchenette: Coffee 164 degrees F, hot water 186.9 degrees F* [NAME] Lane kitchenette: Coffee 161 degrees F, hot water 178.5 degrees F* Coffee/cappuccino machine: Coffee 171.1 degrees F, and cappuccino 155.7 degrees F During interviews on the afternoon of 07/08/24 with staff members from administration (#1 and #2) and dietary (#3, #4, and #5), all confirmed the facility failed to monitor the temperature of hot beverages before, on the day of, or since Resident #5 experienced burns from hot coffee.

Based on review of facility policy, review of resident council meeting minutes, and resident interviews, the facility failed to respect each resident's dignity and individuality and care for residents in a manner and an environment that promotes, maintains, or enhances the quality of life for 2 of 21 sampled residents (Residents C and E) and 2 supplemental residents (Residents A and D). Failure to provide cares in a respectful manner and respect personal property does not preserve the residents' personal dignity or enhance their quality of life. Findings include: Review of the policy titled, Promoting/Maintaining Resident Dignity occurred on 12/21/23. This policy, dated December 2022, stated, . All staff members are involved in providing care to residents to promote and maintain dignity and respect resident rights. Respect the resident's living space and personal possessions. Review of Resident Council meeting minutes occurred on 12/20/23. August 2023 Resident Council meeting minutes stated, It was mentioned by [Resident name] that CNAs should be limited to the amount of time they spend on their cell phones. September 2023 Resident Council meeting minutes stated, Cell phones- [Resident name] feels they should only be used on break. [Resident name] said she doesn't know if staff are talking to them or their phones. During confidential interviews, residents reported the following: * 12/18/23 at 12:13 p.m., Resident E stated, Staff are on their cell phones when in my room. * 12/18/23 at 12:40 p.m., in regards to call lights, Resident A stated my call light will be on and they [staff] just walk by. Resident A also stated, I feel like a second class citizen. * 12/18/23 at 1:17 p.m., Resident C stated, Last week when I had my bath the gal [CNA] grabbed onto both sides of my skin, you know my love handles to hold me up because I couldn't do it myself. The staff make fun of me and laugh at me. * 12/20/23 at 8:01 a.m., Resident C stated, I'm third class to them, they act like they are deaf when I talk to them. They holler at me like I'm a dog, I feel so mistreated. They threw a card I had got from my niece's family with a picture and when I asked her why she threw it she said it was old. That's my stuff not theirs. * 12/20/23 at 11:18 a.m. identified Resident D felt cell phone use in resident rooms and halls is still an issue. During an interview on 12/21/21 at 1:20 p.m. an administrative staff member (#13) stated he expects staff to treat all residents with respect and dignity and are not allowed to have cell phones in resident care areas. 47896 19410

Based on observation, record review, and resident and staff interviews, facility staff failed to offer fluids to 1 of 21 sampled residents (Resident #63) and 1 supplemental resident (Resident #43) during cares who required staff assistance for fluid intake and failed to provide water consistently for 4 of 21 sampled residents (Resident #6, #23, #27 and #67) and 2 supplemental residents (Resident #13, and #66). Failure to provide water to all residents consistently and provide assistance with fluid intake may result in dehydration, constipation, and urinary tract infections (UTIs). Findings include: - Review of Resident #63's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #63 required substantial/maximal assistance with eating, in which the helper does more than half the effort. A dietary note, dated 11/21/23, stated, . Staff assist resident with intake - green mug with handle is used to aid in self-feeding - staff report occasionally resident will give himself a drink. Resident #63's current care plan identified the following: The resident has dehydration or potential fluid deficit r/t [related to] Diuretic use, use/side effects of medication . Ensure the resident has access to water whenever possible. Observation of a staff member providing cares for Resident #63 occurred on 12/20/23 at 10:50 a.m. The CNA (certified nurse aide) (#7) checked Resident #63's brief and then transferred the resident from the bed to the wheelchair. The CNA (#7) failed to offer water or other fluids to the resident. - Review of Resident #43's medical record occurred on all days of survey and included a diagnosis of dementia. The care plan identified the following: . The resident requires assistance by . staff for locomotion using W/C [wheelchair] . Encourage . fluid intake . Observation of a staff member providing cares for Resident #43 occurred on 12/18/23 at 2:15 p.m. The CNA (#14) failed to offer water or other fluids to the resident. Observations during survey included the following: * 12/20/23 at 8:25 a.m. Resident #23's water pitcher was empty. * 12/20/23 at 8:01 a.m. Resident #27's water pitcher was empty. The resident stated, They didn't bring water to me all afternoon yesterday. * 12/20/23 at 8:28 a.m. Resident #66's water pitcher was empty and the resident stated, Every once in awhile they bring fresh ice water. * 12/20/23 at 8:26 a.m. Resident #67's water pitcher was empty. During an interview on 12/19/23 at 9:35 a.m., Resident #6 stated, The only time I get my water refilled is a when the water girl is here a few days a week. During an interview on 12/20/23 at 11:18 a.m. Resident #13 reported when there is not a designated staff person to fill water pitchers, the resident has to request water or the pitchers do not get refilled. Resident #13 reported the facility does not have staff to fill water pitchers in the resident's rooms on the weekends. During an interview on 12/21/23 at 4:40 p.m., an administrative nurse (#15) agreed staff providing fresh water to all residents has been an ongoing issue. 19410 47896

Based on observation, review of menus, and staff and resident interviews, the facility failed to serve food according to prepared menus for 3 of 3 units observed ([NAME] Lane, Harvest Lane, and Whispering Winds) during meals. Failure to serve food according to the portion sizes listed on the menu may result in inadequate nutrition and either weight loss or gain. Findings include: During a interview on 12/18/23 in the afternoon, (Resident B) stated, My only concern is portion sizes of meals are not enough. Observation of [NAME] Lane's breakfast tray line on 12/19/23 showed the following portion sizes served to residents and what the menu required: - Oatmeal #8 scoop, 1/2 cup (Menu: #6 scoop, 2/3 cup) - Cream of Wheat cereal #8 scoop, 1/2 cup (Menu: #6 scoop, 2/3 cup) Observation of Harvest Lane's lunch tray line on 12/19/23 showed the following portion sizes served to residents and what the menu required: - Chicken Fajita #16 scoop, 2 ounces (Menu: 3 ounces) - Pureed Chicken #12 scoop, 1/3 cup (Menu: #8 scoop, 1/2 cup) - Mechanical soft burger #16 scoop, 2 ounces (Menu: #10 scoop 3 1/3 ounces) - Pickled Beets 3-ounce ladle (Menu: #8 scoop, 1/2 cup) - Pureed Pickled Beets #12 scoop, 1/3 cup (Menu: #8 scoop, 1/2 cup) - Pureed Apple Crisp #12 scoop, 1/3 cup (Menu: #8 scoop, 1/2 cup) Observation of [NAME] Lane's lunch tray line on 12/19/23 showed the following portion sizes served to residents and what the menu required: - Chicken Fajita #16 scoop, 2 ounces (Menu: 3 ounces) - Pickled Beets served with tongs (Menu: #8 scoop, 1/2 cup) - Pureed Beef #12 scoop, 3 ounces (Menu: #8 scoop, 4 ounces) - Pureed Chicken #16 scoop, 2 ounces (Menu: #8 scoop, 4 ounces) Observation of Whispering Winds's lunch tray line on 12/20/23 showed the following portion sizes served to residents and what the menu required: - Carrots 2-ounce ladle (Menu: #8 scoop, 1/2 cup) - Pureed Carrots #16 scoop, 1/4 cup (Menu: #10 scoop, 3/8 cup) - Pureed Chicken Pot Pie #16 scoop, 1/4 cup (Menu: #8 scoop 1/2 cup) - Sauerkraut #10 scoop, 3/8 cup (Menu: 1/2 cup) Observation of Harvest Lane's lunch tray line on 12/20/23 showed the following portion sizes served to residents and what the menu required: - Sauerkraut #16 scoop, 1/4 cup (Menu: 1/2 cup) - Pureed Chicken Pot Pie #16 scoop, 1/4 cup (Menu: #8 scoop, 1/2 cup) - Pureed Carrots #12 scoop, 1/3 cup (Menu: #10 scoop, 3/8 cup) Observation of [NAME] Lane's lunch tray line on 12/20/23 showed the following portion sizes served to residents and what the menu required: - Carrots 2-ounce scoop (Menu: #8 scoop, 1/2 cup) - Mashed potatoes #12 scoop, 1/3 cup (Menu: #8 scoop, 1/2 cup) During an interview the morning of 12/21/23, an administrative dietary staff member (#8) confirmed staff should use the portion sizes listed on the menu when serving food for meals.

Based on observation, review of facility policy, and staff interview, the facility failed to serve food in a sanitary manner for 2 of 3 kitchenettes ([NAME] Lane and Harvest Lane). Failure to change gloves when the type of food being handled has changed or after touching the face and prior to handling ready-to-eat food has the potential to result in cross-contamination and/or food borne illness. Findings include: Review of the facility policy, Maintaining a Sanitary Tray Line occurred on 12/21/23. This policy, dated 08/10/23, stated, Policy: To provide an organized tray line that provides food . in a manner to prevent the spread of bacteria that may cause food borne illness. Compliance Guidelines: . 3. During tray assembly, staff should: a. Use gloves when handling food items. b. Use utensils such as tongs, serving spoons, etc. to handle food as much as possible. c. Wear gloves when direct contact with the hands and food occur. d. Wear gloves before handling ready-to-eat foods such as salads, fruits, sandwiches, breads, etc. e. Wash hands before and after wearing or changing gloves . g. Change gloves when activities are changed, or when the type of food being handled is changed, or when leaving the work station. h. Change gloves after sneezing coughing or touching your face, hands, or hair with gloved hand. - Observation of tray line in the Harvest Lane kitchenette occurred on 12/19/23 at 11:36 a.m. A dietary staff member (#10) wore gloves while using utensils to dish food onto resident plates, handling diet sheets, and retrieving items from the refrigerator. Without changing gloves, the staff member (#10) reached into a bag to place bread on several residents' plates. The staff member failed to change gloves after touching various items and prior to handling ready-to-eat food. - Observation of tray line in the [NAME] Lane kitchenette occurred on 12/19/23 at 12:00 p.m. A dietary staff member (#11) wore gloves while using utensils to dish food onto residents' plates. Observation showed the staff member handling the diet sheets and touching his/her face. Without changing gloves, the staff member (#11) reached into a bag to place bread on several residents' plates. Later in the observation, the staff member used the same gloved hands to take a lettuce salad from a container and place it onto two plates. The staff member failed to change gloves after touching utensils and his/her face and prior to handling ready-to eat food. - Observation of tray line in the Harvest Lane kitchenette occurred on 12/20/23 at 11:46 a.m. A dietary staff member (#12) wore gloves while using utensils to dish food onto resident plates. Observation showed the staff member handling the diet sheets, retrieving items from the refrigerator, and then with the same gloved hands, reached into a bag for bread, placed a chocolate bar on a plate, and handled lettuce and cheese with the gloved hands to place on top of the taco meat. (The containers with the lettuce and cheese did not have utensils in them). The staff member failed to change gloves after touching various items and prior to handling ready-to-eat food. During an interview on the morning of 12/21/23, an administrative dietary staff member (#8) confirmed staff should change gloves when changing tasks.

Based on observation and review of the facility policy, the facility failed to provide reasonable accommodation of needs regarding call lights for 3 supplemental residents (Residents #26, #45 and #50). Failure to ensure the resident can reach/access the call light may result in unmet needs and the inability to call for help. Findings include: Review of the facility policy titled Call Lights: Accessibility and Timely Response occurred on 12/21/23. This policy, revised 01/20/23, stated, .Staff will ensure the call light is within reach of the resident and secured. - Observation on 12/18/23 at 12:39 p.m. showed Resident #45 in the recliner, and the call light located on the floor under the end of the bed out of reach of the resident. - Observation on 12/20/23 at 8:45 a.m. showed Resident #26 in the recliner, and the call light attached to the bed. Observations on all days of the survey showed the call light not within the resident's reach. - Observation on 12/20/23 at 3:28 p.m. showed Resident #50 in a wheelchair, and the call light located across the bed next to the wall out of reach of the resident. During an interview on 12/21/23 at 12:55 p.m., an administrative staff member (#3) stated she expected call lights to be within the resident's reach.

Based on observation, record review, review of professional reference, and resident interview, the facility failed to honor resident choices for 1 of 19 sampled residents (Resident #10) who use incontinence products. Failure to honor Resident #10's choice to choose an incontinence product does not respect their autonomy or right to determine what is significant to their care and well-being. Findings include: A Guide to Your Rights as a Resident of a Nursing Facility In North Dakota, from the Long- Term Care Ombudsman, updated 03/21/23, page 17, stated, . You can make choices about how you want to live your life that are significant to you. This includes deciding how you want to spend your time, what you would like your daily schedule and routine to be and what your health care wishes are that are consistent with your personal beliefs, values, interests, as well as assessments and plans of care. In an interview on 12/18/23 at 1:25 p.m., Resident #10 reported that the facility staff discontinued the resident's use of a pad with a pullup due to the increased risk for infection if the pad were to stay on too long. Resident #10 reported she was independent with toileting and currently wore a pullup. Resident #10 reported she stayed wet in just a pullup for a longer amount of time because she relied on staff for assistance to remove the pullup and the wait times can be long. Resident #10 reported she was able to remove the pad on her own and would like to use a pad with a pullup to maintain her independence. Review of Resident #10's medical record occurred on all days of survey and revealed a Brief Interview for Mental Status (BIMS) score of 15 from a Minimum Data Set (MDS) dated [DATE]. The resident's care plan, updated 08/22/23, stated, TOILET USE: The resident is able to: toilet herself but sometimes needs x1 [of one] staff assistance. A Communication progress note, dated 10/27/23, stated, Resident stated to this writer that she was upset. When asked why resident stated she would like to a have a Tena [incontinence product brand] pad in her brief because she 'dribbles' and would prefer to throw away the pad opposed to the brief. This writer stated understanding and that she would note the conversation. An Alert Note, dated 12/02/23, stated, Resident stated to this writer that she would like to be allowed the addition of an incontinence pad in her brief. Resident stated that she does not want to wear more absorbent briefs . Resident is alert and oriented to person, place, time and situation. Resident stated she wanted everyone to know and except [sic] that she would like to use a pad. This writer stated understanding. A Physician Visit Note, dated 12/20/23, stated, . Booster [absorbent product without a waterproof backing] pads with pullup would help. The facility failed to acknowledge the resident's choice and preference for incontinence products.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 2 of 6 units (Golden Grain and Fruit Blossom) in the facility and one resident room on Golden Grain observed during the survey. Failure to maintain a clean, comfortable, and sanitary environment does not provide a homelike living area for residents and fails to promote quality of life. Findings include: Review of the facility policy titled HOUSEKEEPING POLICY occurred on 12/21/23. This policy, dated May 2022, stated, . Clean, sanitary, and pleasant environment, are essential to the care of the residents and staff. Resident care areas, . dining areas, . and living areas require a high quality of sanitation to be maintained. Review of the facility's Housekeeping/Laundry Daily checklist occurred on 12/21/23. This checklist showed staff complete daily housekeeping in resident rooms and lounge areas. Observations during survey showed the following: * 12/18/23 at 11:54 a.m., Fruit Blossom hallway tissues, and other unidentified items of garbage on the floor. * 12/18/23 at 12:13 p.m., resident room (Golden Grain) several broken toothpicks, pieces of food, and tissues on the floor. * 12/19/23 at 8:48 a.m., resident room (Golden Grain) several broken toothpicks, pieces of food, and tissues remained on the floor from the previous day. * 12/21/23 at 8:15 a.m., Golden Grain dayroom food on the floor. * 12/21/23 at 8:15 a.m., Golden Grain hallway food and pieces of tissue on floor. During an interview on 12/21/23 at 9:32 a.m., a housekeeping supervisor (#9) stated staff should clean resident rooms, hallways, and lounge areas daily.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 2 of 21 sampled residents (Resident #15 and #27). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy,CARE PLAN POLICY, occurred on 12/21/23. This policy, dated 12/01/23, stated, . 5. Review of care plans by individual members is expected to occur at the time of the quarterly care conference and on an ongoing basis as the resident's condition changes so that additions or deletions can be made . - Review of Resident #15's medical record occurred on all days of survey. Resident #15's care plan, reviewed on the morning of 12/19/23, identified the following: . The resident has open area of the left great toe r/t [related to] fragile skin and pressure on toe. Review of a Wound - Weekly Observation Tool, dated 11/29/23, stated, Pressure injury to tip of left great toe has heled [sic] at this time. There is [sic] no open areas noted. During an interview on the morning of 12/19/23, a supervisory nurse (#6) stated Resident #15's left toe is no longer open. - Review of Resident #27's medical record occurred on all days of survey. The Resident's care plan stated, . The resident has oral/dental health problems . She has an upper denture for her top teeth . A progress note, dated 02/14/23, stated, CNA (Certified Nurse Aide) [CNA's name] reported to the nurse the res. [resident] is missing her dentures - the CNA looked all over the res.'s [resident's] room as well. During an interview on 12/20/23 at 8:01 a.m., Resident #27 stated, My dentures have been lost for a long time now. The facility failed to review and revise Resident #27's care plan to reflect her current dental status. 40489

Based on observation and record review, the facility failed to provide care and services to aid the healing or to prevent the development of pressure ulcers for 1 of 1 supplemental resident (Resident #26) with pressure ulcers. Failure to apply the blue pressure relief boot may result in worsening and/or the development of pressure ulcers. Findings include: Review of Resident #26's medical record occurred on all days of survey. Diagnoses included pressure ulcer of right heel, stage 2. Current physician's orders included, Blue pressure relief boot at all times to R [right] foot. The December treatment administration record showed from 12/18/23 to 12/21/23 staff initialed the application of the blue pressure relieving boot. Observations on 12/18/23 to 12/21/23 showed Resident #26 without the blue pressure relieving boot to the right foot. During an interview on 12/21/23 at 12:55 p.m., an administrative staff member (#3) stated she expected staff to follow physician orders.

Based on observation, review of facility policy, record review, and staff interview, the facility failed to provide appropriate services and assistance to maintain bowel/bladder continence for 1 of 12 sampled residents (Resident #23) who required toileting assistance/incontinence care. Failure to provide toileting assistance may result in unnecessary incontinence and a loss of dignity. Findings include: Review of the facility's Incontinence Policy occurred on 12/21/23. This policy, dated 11/03/23, stated, . Policy Statement: Based on the resident's assessment, all residents that are incontinent will receive appropriate treatment and services. Review of Resident #23's medical record occurred on all days of survey and included a diagnosis of dementia. The resident's current Minimum Data Set (MDS), dated [DATE], identified frequently incontinent of bladder and continent of bowel. Resident #23's care plan stated, . TOILET USE: The resident requires supervision as he allows.The resident has urinary and bowel incontinence. INCONTINENT: Check resident as needed for incontinence. Change clothing PRN [as needed] after incontinence episodes. A bowel and bladder assessment, dated 11/01/23, stated, . Good candidate for retraining . Observations during survey showed the following: * 12/19/23 at 9:43 a.m. Resident #23 asleep in his bed, a soaker pad on the resident's recliner soiled with feces, soiled clothes on the floor by the recliner and in the bathroom. The resident's room and hallway had a strong odor. * 12/19/23 at 11:41 a.m. Resident #23 struggled and moaned as he ambulated into the bathroom by himself. The back of his pants and his bedspread were soiled with feces. * 12/19/23 at 11:51 a.m. Resident #23 seated on the side of the bed as he attempted to put his pants on. The resident's room and hallway had a strong odor. * 12/19/23 at 11:58 a.m. Resident #23 stood by the closet and naked from the waist down. When the resident saw this surveyor he pointed to the bathroom. The surveyor summoned a facility staff member to the resident's room. * 12/19/23 at 4:37 p.m. Resident #23 sat in his recliner with his pants soiled with feces. * 12/20/23 at 7:56 a.m. Resident #23 sat on the edge of the bed naked and a strong odor was noted in the room. The surveyor informed a staff member the resident needed assistance and the CNA (certified nurse aide) (#14) stated she would notify another CNA. During an interview on 12/20/23 at 8:50 a.m., when asked about Resident #23's toileting and frequent bowel incontinence observed on 12/19/23, an administrative nurse (#5) stated the resident often refuses toileting. Resident #23's toileting and behavior task record for 12/19/23 - failed to show the resident refused toileting and/or incontinence cares.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 3 sampled residents (Resident #130) receiving oxygen. Failure of maintain respiratory supplies by routinely changing and documenting the replacement of the cannula/tubing may compromise the integrity of the cannula/tubing and could result in adverse effects for the resident. Findings include: Review of the facility policy titled Oxygen Concentrator Procedure occurred on 12/21/23. This policy, dated 12/01/23, stated, . 10. Cannulas . should be changed weekly. Observation on all days of survey showed Resident #130 with continuous oxygen administered at 2 liters per nasal cannula either by an oxygen concentrator in the resident's room or a portable oxygen unit on the back of the resident's chair. The oxygen concentrator and the portable unit each had separate nasal cannula and tubing. Review of Resident #130's medical record lacked an order to change the oxygen tubing and cannula. During an interview on 12/20/23 at 5:14 p.m., a supervisory nurse (#6) stated oxygen tubing is changed every Sunday and staff document this in the Treatment Administration Record (TAR), however, review of the TAR failed to identify staff documentation of cannula/tubing changes. The nurse confirmed the record lacked documentation of staff changing the tubing weekly.

Based on observation, record review, and review of facility policy, the facility failed to ensure safe and secure storage of medicated shampoo in 1 of 5 medication carts (memory unit). Failure to store the medicated shampoo properly may result in unauthorized access and has the potential to cause resident harm. Findings include: Review of the facility policy titled Medication System Procedure occurred on 12/21/23. This policy dated December 2023 stated, . I. Medications set-up for dispensing must remain in nurse/CMA Certified[medication aide] possession or line of sight . Observations of the memory unit on 12/20/23 at 8:45 a.m., showed a bottle of medicated shampoo sitting on a bedside table in the hallway. Two residents sat near the medicated shampoo without a nurse/CMA in line of sight. During an interview on 12/21/23 at 12:55 p.m., an administrative staff member (#3) confirmed that the medicated shampoo should be stored in the medication cart until it is needed.

1. Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed infection control practices for 1 of 3 sampled residents (Resident #71) on transmission based precautions related to positive COVID-19 status. Failure to provide and properly utilize personal protective equipment (PPE) for residents on transmission based precautions has the potential to spread the COVID-19 virus to other residents, personnel, and visitors. During the on-site survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on 11/28/22 at 4:30 p.m. The IJ potential resulted from observations of improper use of PPE and lack of staff knowledge/education regarding infection control practices and procedures. These findings placed residents in immediate danger due to the potential spread of the COVID-19 virus. * 11/28/22 at 2:25 p.m.-The survey team contacted the management staff at the State Survey Agency (SSA) to report the findings and to discuss a potential IJ situation. * 11/28/22 at 4:30 p.m.- The survey team notified the facility's administrator, director of nursing (DON), of the IJ and requested they develop a plan for removal of the immediate jeopardy.The team provided the facility with the IJ template. * 11/28/22 at 4:55 p.m.- The SSA notified the regional office of the immediate jeopardy situation. * 11/29/22 at 8:25 a.m.- The facility provided a written removal plan (via verbal and e-mail) for the IJ. * 11/29/22 at 9:22 a.m.- The survey team reviewed and accepted the facility's written plan. * 11/29/22 at 10:00 a.m.- The survey team conducted staff observations and interviews. The survey team identified discrepancies in facility staff infection control practices and requested the facility administrator, DON and IP [infection preventionist] develop additional measures for removal of the immediate jeopardy. * 11/29/22 at 10:30 a.m.- The facility provided a revised written plan for the removal for the IJ. * 11/29/22 at 1:30 p.m.- The survey team reviewed and accepted the facility's revised written plan of correction for the IJ. * 11/29/22 at 1:50 p.m.- The survey team notified the facility administration and removed and reduced the IJ from a scope and severity of K to a scope and severity of E. * 11/29/22 at 1:50 p.m.- The SSA notified the CMS [Center for Medicare and Medicaid Services] location of the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Infection Prevention and Control Program occurred on 12/01/22. this policy, revised August 2022, stated, . Transmission-based precautions [TBP] and Isolation Precautions refer to the actions (precautions) implemented . that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections . facility staff will apply TBP to residents who are known or suspected to be infected with certain infectious agents requiring additional controls to prevent transmission . Review of the facility policy titled, . Personal Protective Equipment (PPE) Guidance occurred on 12/01/22. This policy, revised November 2022, stated, . PPE when caring for known/suspected COVID-19 residents . a N95 mask, eye protection, gloves, and gown must be worn at all times with every resident interaction . donning and doffing should be done in accordance with current Center for Disease Control [CDC] and Center for Medicare and Medicaid Services [CMS] and the North Dakota Department of Health [NDDOH] guidance, procedure . Review of Resident #71's medical record occurred on 11/28/22. Diagnoses included COVID19 positive on 11/22/22. The current care plan identified Resident #71 on airborne and contact precautions related to COVID 19 infection . Resident infection will be resolved without complications . Keep resident room door closed if possible to maintain resident's safety . Resident to quarantine in room . Staff to wear N95 mask when in room . Staff will donn and doff PPE appropriately when entering resident's room . Observation on 11/28/22 at 11:40 a.m. showed signage stating . Droplet precautions . Stop . everyone must clean their hands with sanitizer before entering and when leaving the room . make sure their eyes, nose and mouth are fully covered before room entry . remove face protection before room exit . Donning PPE full Garb: Gown, N95 respirator, face shield, gloves, bouffant . Doffing PPE full garb: Gown and gloves, bouffant, face shield, N95 respirator . Observation on 11/28/22 at 11:25 a.m. showed a certified nurse aide (CNA) (#5) entered Resident #71's room wearing a surgical mask and failed to donn a N95 mask, gown, face shield or gloves or perform hand hygiene. The CNA (#5) exited the room with the same surgical mask, was not wearing other PPE, failed to perform hand hygiene, and carried a meal tray with dishes (no paper products) down the hall to the kitchen. During an interview on 11/28/22 at 11:40 a.m., a CNA (#5) stated she failed to donn and doff the proper PPE (N95 mask, faceshield or goggles, gown, gloves) or hand sanitize when entering and exiting a COVID19 positive resident room. During an interview on 11/28/22 at 4:30 p.m., an administrative nurse (#1) stated she expected all staff to donn/doff appropriate PPE and perform hand hygiene when entering and exiting a COVID19 positive resident room. 31725 THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 08/23/21. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 9 sampled residents (Residents #20, #32, and #50) observed during cares. Failure to follow infection control standards has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: SANITATION Review of the facility policy/procedure titled Knife River Care Center Standard Precautions occurred on 12/01/22. This policy, dated September 2022, stated, . Body fluids considered potentially infectious include: . All body fluids, secretions, and excretions except sweat . 9. Clean up spills of blood or other infectious material in the following manner . b. disinfect the surface with a tuberculocide/germicide supplied by the facility . Observation on 11/28/22 at 4:16 p.m. showed a certified nurse assistant (CNA) (#7) donned gloves and emptied a urinary catheter bag for Resident #32, in the process of emptying the bag, the CNA (#7) spilled urine on the floor. The CNA (#7) wiped up the urine with a paper towel after finishing emptying the bag, completed hand hygiene and left the room without disinfecting the floor. Record review of facility Infection Log dated October 2022 occurred on 11/29/22. This log shows Resident #32 having a urinary infection and was on contact precautions. During an interview on the afternoon of 12/01/22, an administrative nurse (#1) confirmed the floor should have been disinfected according to facility policy. PERINEAL CARE Review of the facility policy titled Perineal Care occurred on 12/01/22. This policy, dated January 2022, stated, . It is the practice of this facility to provide perineal care to all incontinent residents . to . prevent infection . front to back . Review of Resident #20's medical record occurred on all days of survey. The care plan stated, .The resident has an ADL [activities of daily living] self-care deficit . Requires extensive assist from 1 staff to assist resident with routine toileting . provide peri cares . During an observation on 11/29/22 at 4:38 p.m., a CNA (#8) assisted Resident #20 to the bathroom. The resident was incontinent of urine and while performing perineal cares the CNA wiped, the resident's perineum from the back to the front, right groin, back to front again and left groin. The CNA failed to provide proper perineal cares to prevent risk of infection. During an interview on 12/01/22 at 8:09 a.m., an administrative staff nurse (#1) stated she expected staff to use proper infection control practices when providing perineal cares. HAND HYGIENE Review of the facility policy/procedure titled Knife River Care Center Employee Handwashing Procedure occurred on 12/01/22. This policy, dated 6/22/22, stated, . Wash Hands (at a minimum) . Before and after each resident contact . After contact with any body fluids, After handling any contaminated items (linens, soiled briefs, garbage, etc.) . Observation on 11/30/22 at 11:00 a.m. showed a CNA (#3) donned gloves and provided perineal care for Resident #50. The CNA (#3) cleansed the rectal area of stool, removed her gloves, donned clean gloves, applied a brief, and removed her gloves. Without performing hand hygiene, the CNA (#3) positioned the resident's pillows, blankets, call light and applied heel booties. During an interview on the afternoon of 12/01/22, an administrative nurse (#1) stated she expected staff to remove gloves and perform hand hygiene after perineal care before continuing other resident cares. 40489 46477

Based on observation, record review, review of information received from the facility, professional reference and resident interview, the facility failed to ensure residents remained free from accident hazards for 1 of 1 sampled resident (Resident #22) who experienced [MEDICAL CONDITION] his shower. Failure of the facility to provide a safe environment for its residents while showering resulted in avoidable [MEDICAL CONDITION] medical treatment and resulted in Resident #22 being denied the opportunity to shower independently. Findings include: Review of the medical record for Resident #22 occurred on all days of survey. Resident #22's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE] identified the resident as being independent with bathing, and having a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident is cognitively intact, receiving antianxiety medication daily, and no behaviors. The annual MDS, dated [DATE], identified the resident to have a BIMS of 15 which indicates the resident is cognitively intact,and identified the resident no longer independent with bathing and required one person physical assist with bathing. Resident #22's current care plan stated, . Problem Onset: 06/22/16 . Bathing: Independent . (updated) 05/30/18 Supervision with bathing/showers. During an interview on 09/04/18 at 10:26 a.m., Resident #22 stated, Monday, Wednesday, Friday are my shower days. Awhile ago they set the shower up the wrong way and the sanitizer was on and I [MEDICAL CONDITION] my arms and where the chemical went. I got cream. The yellow is the sanitizer. Now its labeled so that does not happen again, I went to the Emergency Department when I had my [MEDICAL CONDITION] I had some in my eyes. Review of information received from the facility, dated 05/30/18, stated, . I was walking by the Res. (resident's) room and asked how the shower went. He said good but it burned. I asked how like the water was hot. He said no like there was chemical in the water. I then asked which handle he used. He stated the gray one. That's when the bath aide at the end of the hall said they are turned around/backwards in that bathroom . The gray handle was attached to the chemical and the yellow handle was attached to the water . Interview with certified nurse assistant (CNA) bath aide on 05-31-18 . A CNA indicated the shower nozzle (gray) was broken over a month ago as the handle was dropped and needed to be replaced. She recalls this being replaced with a yellow nozzle as there was not a gray one in-house as it needed to be ordered. A CNA stated this particular shower had been worked on approximately three times in the last month. Nursing progress notes identified the following: - 05/29/18 11:33 p.m., Weekly Summary: Resident remains alert and oriented in all spheres . Remains independent of all cares and transfers. - 05/30/18 10:12 a.m., . He has taken a shower . no skin problems noted. - 05/30/18 11:27 a.m., Resident taking shower on Elm, Did not know the hoses were switched and used the chemical sanitizer to bathe in. After getting dressed resident informed staff, he was showered for 20 mins and eyes rinsed for 20 mins. Called (the physician) and he gave verbal order to send to the emergency room (ER) for Observation and treatment. Sent at 1125. - 05/30/18 12:57 p.m., Writer observed residents skin at approximately 1130 this am after he had showered and used sanitizer as soap . Writer observed (Resident #22) to have a splotchy area of redness around his neck/collarbone area, areas of redness to both armpits and redness to groin and buttock area . (Resident #22) stated that the areas were (burning a little) . Since (Resident #22's) arrival at facility, he has been independent with his showering with only set-up if needed . At this time, we will update his careplan to reflect that he have supervision with his showers from this point forward. - 05/30/18 2:42 p.m., Res (sic) returned from (name of medical center) Dx (diagnosis) Chemical burns: Apply [MEDICATION NAME] cream to burning areas on anterior scrotum and armpits BID (twice daily) x 5 days. - 05/31/18 8:58 a.m., Resident states his scrotum hurts and rates 6/10 when he walks. - 05/31/18 4:17 p.m., Scrotum is is (sic) bright red. [MEDICATION NAME] cream applied per order . Armpits and neck remain slightly reddened. - 06/04/18 12:27 p.m., Burned areas to armpits and scrotum/groin are lightly reddened . Complains of some discomfort but states it is minimal. Re-education on showering with someone available to observe and assist if necessary along with chemical education. - 06/09/18 6:24 a.m., . [MEDICAL CONDITION] resolved. - 06/13/18 6:31 a.m., . underscrotum (sic) & under arms have slight brownish discoloration from previous chemical burns. - 06/20/18 12:26 p.m., . very slight yellowish brown discoloration in bilateral arm pits. Observation on the afternoon of 09/06/18 of the Shady Lane Elm shower showed a wall mounted unit containing three handles. Above the handle on the left the word Sanitizer was written on the unit in black marker, above the handle in the middle the words Hot Cold were written on the unit in black marker and above the handle on the right the words Reg (regular) water were written on the unit in black marker. Attached to the unit were two identical hand held shower heads, one connected to a yellow hose and the other connected to a white hose. Based on an interview with administrative staff during the observation, the unit was marked with the words after the incident occurred. Review of the Material Safety Data Sheet (MSDS) for the chemical that is used to sanitize the facility shower, dated 01/15/13, stated, . PRODUCT NAME: ARJO-ALL PURPOSE DISINFECTANT CLEANER GENERIC NAME: Disinfectant . Hazardous Decomposition Products: . may product toxic fumes . Eyes: Eye contact causes painful damage and corneal irritation. Skin: Contact can cause redness, burns, pain and blistering. Inhalation (of mist): Can cause nose, throat and respiratory tract irritation, coughing and headaches. EFFECTS OF CHRONIC EXPOSURE: . material will be corrosive to the skin and eyes upon direct or prolonged contact. Solvent vapors or mists or product can produce irritation of mucous membranes. The facility failed to address how and why the incident occurred and implement effective interventions to the shower station to prevent future chemical burns, increasing the potential for another incident. Furthermore, the facility's solution resulted in Resident #22 being denied the opportunity to continue to shower independently, as no evidence was provided that indicated he could not do so, if the facility implemented effective shower safety measures.

Based on information provided by the complainants, record review, review of facility policy, and staff interview, the facility failed to respect the residents' right to have visitors at the time of their choosing for 1 of 5 sampled residents (Resident #3) and 1 closed record resident (Resident #7). Failure to allow visitation, resulted in psychosocial harm for Resident #7 and his family as they were denied his repeated requests for family visitation. Findings include: Information provided by the first complainant indicated the facility (didn't) want outsiders in due to the flu, nursing staff refused him/her access to Resident #7 for five days, knowing Resident #7 was ill, and after being told he requested his/her presence. The complainant indicated he/she offered to don a mask, gloves, gown, etc. and was still denied access to Resident #7. The complainant indicated he/she is heartbroken and can't get over the fact all (Resident #7) wanted was one last visit. Information provided by the second complainant indicated nursing staff refused family members access to Resident #7, knowing he was ill, and after being told he repeatedly requested their presence. The second complainant indicated family members continue to be haunted by the fact Resident #7 expired without family present. Information provided by the third complainant indicated nursing staff turned him away at the door of the facility and refused him/her access to Resident #3. He/she was given no prior notice that the facility was on lock-down. Review of the facility policy titled Policy for Visitor Restrictions occurred on [DATE]. This policy, revised [DATE], stated, . In the most extreme situations, no visitation will be allowed. In less severe situations, visitors will be asked to use good judgement in deciding whether or not to visit. If they are experiencing cold or flu symptoms . they are asked NOT to visit until symptoms have subsided. There may be postings of specific criteria that must be followed when visiting (especially during the influenza season), i.e.: wear a mask, use hand sanitizer upon entry and when leaving, visit only in resident rooms, etc.) . - Review of Resident #7's medical record occurred on both days of survey and identified [DIAGNOSES REDACTED]. The care plan identified, . I have a life long history of depression. Support the facilitate privacy for my family and friend visitors . Allow me opportunities to make choices regarding my schedule. The nursing progress notes identified the following: * [DATE] at 7:50 p.m., . There are [MEDICAL CONDITION] changes around the bladder. This is nonspecific and may represent infalmmation (sic) or infection. * [DATE] at 12:02 a.m., . (Physician's name) then stated that resident most likely has a bladder infection due to his white blood cell count and to start him [MEDICATION NAME](antibiotic) . At 8:20 a.m., Summoned to room at (6:45 a.m.) Respirations ceased, no BP (blood pressure), no HR (heart rate). The progress notes failed to reflect Resident #7 had repeatedly requested family visitation, that family members had contacted administrative staff in an effort to arrange visitation, that the facility continued to deny them access to Resident #7, or the rational behind their decision. During an interview [DATE] at 5:00 p.m., an administrative nurse (#5) stated, The medical director said 'I don't want any visitors.' (The facility failed to provide documentation confirming this statement.) The flu was all over in the community. The IDT team got together and decided on locking the door. She confirmed no flu in the building at the time of the lock-down. The administrative nurse (#5) reported the facility was on lock-down for four days total, and was opened on (Resident's 7's) death date. (Resident #7) didn't feel good, he went to the clinic, (and his) doctor sent him back. He ate supper in the dining room. (Facility staff) just found him gone in the morning.

Based on record review, review of the facility policy, and staff interview, the facility failed to provide physician services in a timely manner for 2 of 15 sampled residents (Resident #2 and #7) who experienced a fall with an injury. Failing to provide these services resulted in the residents' untreated pain and delay in the treatment of [REDACTED]. Findings include: Review of the facility policy titled Notification of Changes occurred on 07/01/15. This policy, dated 09/30/14, stated, . The facility . consult with the resident's physician . when there is a change requiring such notification . 1. Accidents a. resulting in injury. b. potential to require physician intervention . Review of the facility policy titled FALL MANAGEMENT, occurred on 07/01/15. This policy, dated 06/02/15, stated, . If a resident falls, the nurse will . begin the 'Falls Protocol': . Notify physician in accordance with facility guidelines . For an injured resident, call physician . -Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The progress notes identified the following: * 01/25/15 at 8:59 a.m.: . Resident was laying on her left side on the floor with only a brief on . Resident does have a large dark purple bruise behind her left ear which extends onto left side of head . Resident does state she has pain all over 'that I always have', was medicated . assisted to her bed with assist x 2 . MD (medical doctor) faxed . Resident was helped to get dressed . There was no response from the physician concerning the fax sent. The facility failed to follow up with the physician. * 01/25/15 at 3:44 p.m.: . Resident helped to the bathroom with assist x 2 and gaitbelt. Resident was able to bear weight on bilateral legs but states her buttock hurts which is a chronic complaint for her . * 01/25/15 at 5:02 p.m.: . Resident does state her left leg is more sore than her right with pain in her left buttock . *01/26/15 at 12:17 a.m.: . Resident resistive with cares . Resident could not stand for more than 5 seconds and had to sit back on bed . Resident had trouble getting her left foot/leg to move when trying to help with transfer. She c/o (complaint of) pain to right side of neck and right shoulder down right arm. She also c/o (sic) in left hip and down left leg and throughout back . She seemed confused and had a hard time with communicating but may be due in part to her hearing and lack of . Fax sent to Physician . with her c/o pain . There was no response received from the physician concerning the fax sent. The facility failed to follow up with the physician. * 01/26/15 at 11:17 a.m.: . 0800 Resident with disorientation has difficulty following cueing . Unable to bear weight due to pain in the left hip and low back. Transferred with a standing lift. Resident barely able to hold on due to pain in left hip and low back. Resident moaning with pain . speech is slightly slurred . Fax to (name of doctor) with change in mobility and continued disorientation and pain . There was no response received from the physician concerning the fax sent. * 01/26/15 at 11:35 a.m.: . Continues to complain of pain to left hip/low back. Remains disoriented . * 01/26/15 at 3:40 p.m.: . Res. (resident) is unable to bear wght (weight) at this time has had some falls. nsg. (nursing) is attempting to get her into clinic . * 01/26/15 at 10:26 p.m.: . Resident complaining of severe pain from left hip downward her legs with any slight movement . pain on the Left side hip and legs with movement or turning . * 01/27/15 at 12:12 p.m.: . 0800 Resident crying out in pain with slightest movement to left leg . * 01/27/15 at 12:16 p.m.: . pain is a 10 on the 0-10 scale . * 01/27/15 at 2:00 p.m.: 1100 (name of doctor) here to see resident. Orders Transfer to (name of hospital) ER (emergency room ). * 01/27/15 at 4:18 p.m.: Informed by (name of hospital) that resident has a fx'd (fractured) femur and was admitted to acute care for pain control and immobilization . The facility fax notices identified the following: * 01/25/15: Fall Fax Alert . Physician: (name of doctor) . nurse comment: nurse went by room and resident was laying on the floor beside her bed . * 01/25/15: Fax Alert . Physician: (name of doctor) . Resident c/o pain to right side of neck; jaw and has pain to right shoulder and down arm; she is unable to stand up straight and after 5 seconds is unable to stand at all. She is having trouble moving left foot/leg and c/o pain in left hip and down left leg. She took Tylenol but it was not effective. She c/o pain with swallowing. Would like her seen at clinic! Please advise. * 01/26/15: Fax Alert . Physician: (name of doctor) . disoriented, unable to stand, staff using standing lifts, resident complains of L (left) hip/ low back pain moans with transfers. 0 bruising to area . She was able to bear wt (weight) and walk with 2 staff assist yesterday. today her mobility status has changed from yesterday . During a telephone interview on 07/01/15 at 3:20 p.m., a staff nurse (#19) stated she called the clinic during her shift on 01/26/15 after she recognized the physician had not responded to a fax on the previous day. The staff nurse stated when she spoke with the physician's nurse, the clinic was unable to see the resident at the clinic and the physician's nurse instructed the staff nurse to fax the information and the physician would be in to see the resident the next day. The staff nurse (#19) faxed the information on 01/26/15 but did not receive a response before the end of her shift. The resident's condition worsened, but no further attempt to notify the physician was made during the next shifts. During an interview on 06/30/15 at 5:38 p.m., an administrative nurse (#13) stated the expectation after faxing a physician and not getting a response is to call the physician's office. The administrative nurse stated that when the physician's office was called with this incident, the physician's office responded with directions to fax the information to the physician's office and the physician would see the resident during rounds. The administrative nurse (#13) stated it has been an ongoing situation of not being able to reach the physician for emergency situations and that there was no other on call physician available to reach. She stated the physician's office always requests all information to be faxed to his office, and there is no other way to contact the physician for emergency situations. The facility failed to provide physician services in a timely manner for Resident #7 following her fall with injury. The resident experienced continued worsening left leg/hip pain and was unable to stand and bear weight on this leg. - Resident #2's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The progress notes identified the following: * 06/26/15 at 11:38 a.m., @ (at) 10:45 a.m. nurse summoned to resident room. CNA (certified nursing assistant) reports resident was being assisted with AM cares and lost her balance and fell l (sic) down onto resident's bottom, but resident hit her head on the left of the bedside table. Bump noted to the back R) (right) side of residents head. Cool pack applied. prn (as needed) Tylenol 325 mg (milligrams) was administered . Notified MD (medical doctor) of fall via fax. * 06/26/15 at 12:55 p.m., @ 12:40 p.m. cool pack removed. Bump continues to decrease in size. Bruising noted (to) area at this time. * 06/26/15 at 3:46 p.m., MD notified of fall via e-mail, per MD preference. Resident is now c/o (complaining of) L) (left) sided groin/hip/buttock pain. Pain is only when resident is walking/putting pressure on it. MD was notified of this information as well in the e-mail. * 06/28/15 at 12:57 a.m., . Bump continues to back of head. Bruise noted under L) eye. PCP (primary care provider) has not returned email at this time. * 06/28/15 at 10:43 a.m. with Addendum at 10:51 a.m., . Resident continues to c/o pain to L) side hip/groin area. PRN Tylenol 325 mg administered . CNA reports when resident was walking in room to the bathroom this AM resident was dragging L) leg. Bruising noted L) hip area at this time. MD e-mailed again to notify of L) groin/hip pain, and that it is not resolving. * 06/28/15 at 1:15 p.m., Resident continues to c/o pain to L) hip/groin area. Phone call made to (Physician), and unable to get through, as there has not been any response to the e-mails. E-mail sent to other e-mail address, and received response from MD. * 06/28/15 at 1:48 p.m., PO (physician's order) received: X-RAY L) hip. * 06/28/15 at 3:36 p.m., . [DIAGNOSES REDACTED]. (inferior) pubic ramus fx (fracture). The facility failed to provide physician services in a timely manner for Resident #2 and Resident #7 following falls with injury (attempts made over a 2 day period without success). Resident #2 had experienced avoidable continued left groin/hip pain reaching a level of 10 on a pain scale of 0-10 where pain at 10 is excruciating. Resident #7 was unable to stand or bear weight on her left leg. The facility staff indicated during interview that emergency physician services were not available.

Based on record review, review of facility policy, review of call light reports, and resident and staff interviews, the facility failed to provide reasonable accommodations of individual needs regarding call light response times for 1 of 1 sampled resident (Resident #5) who voiced call light concerns. Failure to answer call lights promptly resulted in avoidable psychosocial harm due to long delays in providing toileting assistance. Findings include: Review of the facility policy titled "CALL LIGHT, USE OF" occurred on 06/05/14. This policy, revised 2012, stated, ". . . Procedure: 1. All nursing personnel must be aware of call lights at all times. 2. Answer ALL call lights promptly whether or not you are assigned to the resident. . . . 5. Answer all call lights in a prompt, calm, courteous manner. . . ." Review of Resident #5's medical record occurred on June 02-05, 2014 and current [DIAGNOSES REDACTED]. During the initial tour of the facility on 06/02/14 at 10:05 a.m., Resident #5 expressed concerns with staff responding to her call light. Resident #5 stated she was incontinent of urine the morning of 06/02/14 while waiting for staff to answer her call light. Review of the call light report, dated 06/02/14, identified Resident #5 initiated her call light at 6:57 a.m. and staff responded 42 minutes later. During an interview on 06/03/14 at 7:55 a.m., Resident #5 stated she was incontinent of urine on 06/02/14 at 8:00 p.m. Resident #5 stated when a staff member responded to her call light, the staff member "did not understand (what the resident needed)" and left her room. The staff member returned after 10:00 p.m. and toileted Resident #5. Review of the call light report, dated 06/02/14, identified Resident #5 initiated her call light at 8:01 p.m. and staff responded 35 minutes later. Resident #5 initiated her call light at 9:07 p.m. and staff responded 65 minutes later. During an interview on 06/05/14 at 1:30 p.m., an administrative staff member (#4) stated call lights should be answered in a timely manner. Resident #5 brought the incontinence episodes to the surveyor's attention on two separate occasions indicating a significant impact on her mental and psychosocial well-being. Based on interviews and review of the call light report, the delay in answering Resident #5's call light resulted in avoidable psychosocial harm.

Based on observation, medical record review, review of professional reference, and staff interview, the facility failed to ensure adequate fluids to maintain an acceptable hydration status for 1 of 1 sampled resident (Resident #3) hospitalized with dehydration. Failure to ensure the availability and encourage the consumption of adequate fluid resulted in Resident #3's hospitalization for dehydration on two occasions, as well as prolonged and continued [MEDICAL CONDITION] (high sodium levels). Findings include: Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, pages 1462-1464, states, ". . . Dehydration . . . occurs when water is lost from the body, leaving the client with excess sodium. . . . Older adults are at particular risk for dehydration because of decreased thirst sensation. . . . [MEDICAL CONDITION] is excess sodium in ECF (extracellular fluid), or a serum sodium of greater than 145 mEq/L (milliequivalents per liter). . . . Clients at highest risk for [MEDICAL CONDITION] are . . . clients who are unable to request fluids such as infants or older adults with dementia . . ." Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment and extensive assistance from one person for eating. Current medications included [MEDICATION NAME] (a diuretic) 20 milligrams (mg) three times per week. The record identified hospitalization s for [MEDICAL CONDITION] from 12/18/12 to 01/01/13 and 01/29/13 to 02/08/13. Resident #3's current care plan stated, ". . . Offer fluids (encourage water) and encourage me to drink during the day. . . ." Hospital discharge notes stated the following: *01/01/13: ". . . The patient . . . had become unresponsive and feverish at the nursing home and was brought to the hospital for evaluation . . . Here he was found to be markedly hypernatremic, dehydrated, and had evidence of left lower lobe pneumonia. . . . His overall prognosis is not very good but he has survived this episode and will (sic) keep him comfortable, fed, and watered and he may survive for some time. . . ." *02/08/13: ". . . Patient . . . came in with Hypovolemic (low blood volume) [MEDICAL CONDITION] and pneumonia. . . . switched to oral intake only and with concerted (sic) effort it was demonstrated he could maintain satisfactory serum sodium with oral intake of 1500 ml/day (milliliters per day). He did not become [MEDICAL CONDITION] at this time. . . . not always simple/easy to get him to take them (medications) or take adequate oral sustenance. Serum sodium 167 at admit- 146 at discharge. . . . His chem 8 (lab test that measures electrolyte levels) will be followed weekly for the next 3 weeks. . . ." Resident #3's serum sodium levels were as follows: -01/08/13: 146 mEq/L -02/11/13: 144 mEq/L -02/18/13: 146 mEq/L -02/25/13: 151 mEq/L* -03/01/13: 146 mEq/L -03/08/13: 148 mEq/L -03/19/13: 146 mEq/L -03/26/13: 149 mEq/L, the physician wrote a response to this lab value: "Increase free water intake please." -04/02/13: 149 mEq/L -04/09/13: 152 mEq/L* -04/16/13: 152 mEq/L* -04/23/13: 152 mEq/L* * identifies critically high serum sodium levels as per clinic lab reports A physician's progress note stated the following: *04/09/13: ". . . It is a struggle to keep him hydrated enough to keep him from having pathologic elevations of his sodium. I have had to hospitalize him twice for IV (intravenous) fluids because of just the inability to get an oral intake adequate. . . . His sodium today is 152, that means that we need to work a little harder on getting some more water into him. I told him that I want him to drink a little more water and he says, 'I don't drink much water.' I asked if he would drink a little more and he said okay. . . . He is smiling today despite a 153 sodium; some patients aren't so intolerant of this that they become almost comatose at that level. . . . . We will continue to do as we are with a reminder to the staff to work extra hard on trying to get more water into him. . . ." A communication form (sent by facility staff to the physician), dated 04/12/13, stated, "Na (sodium) 152 - same as on Tuesday." The physician responded, "MORE WATER please. Repeat Chem 8 Tues." Additional physician's orders [REDACTED]. *04/09/13: "Encourage more water/juice intake" *02/27/13: "1500 cc/day (cubic centimeters per day) water - minimum" *02/21/13: ". . . supplement as needed to get 1800 cc/day (cubic centimeters per day)." Dietary assessments showed the following: *02/20/13: ". . . Na (sodium) 146 (elevated) - encourage fluids . . . Avg (average) 930 cc/d . . ." *02/27/13: ". . . Phys. (physician) ordered 1500 cc/d (water) d/t (due to) (increased) Na Level - 151 on 2/25/13. . . . Avg 1050 cc/day . . . Plan: . . . Encourage (water) acceptance. . . ." *04/03/13: ". . . 2100 cc fluids/day offered @ meals . . . Avg 855 cc/d . . . 1500 cc/d Water - needs - encouraged . . . Plan: Encourage (water)/fluid acceptance as able . . ." *05/08/13: ". . . Encourage intake- 1500 cc/d Water minimum. . . . 2280 cc/d offered @ meals. . . . Avg (average) 880 cc/d . . . Plan: continue (with) current supplements. Continue to offer/enc. (encourage)/assist (with) fluid intake throughout the day. . . ." Observations and record review of Resident #3 throughout the survey showed the following: *05/06/13 at 2:49 p.m.: A certified nursing assistant (CNA) (#22) assisted Resident #3 out of bed. Observation showed his brief was dry. The CNA asked, "You want some water?" The resident shook his head "no," and the CNA brought him to the activity area. Observations until approximately 5:30 p.m. showed staff failed to offer/encourage additional fluids. *05/07/13: a note stated, "(Resident #3) did (not) void all (night) long." *05/07/13 at 7:53 a.m.: 4 ounces (oz) cranberry juice, 4 oz water, and 4 oz Mighty Shake served on Resident #3's breakfast tray. Staff failed to offer 8 oz of juice supplement (in addition to the cranberry juice), 8 oz of water, and 8 oz of Mighty Shake as identified on the resident's tray card (a guide used by dietary staff which tells the amount of food and fluids served at each meal). CNA charting for this meal identified intakes of 6 oz juice supplement and 8 oz Mighty Shake supplement, although observation showed Resident #3 received 4 oz of cranberry juice, no additional juice supplement, and 4 oz of Mighty Shake. *05/07/13 at 8:25 a.m.: Resident #3 finished breakfast and sat in the dining room/activity area until 10:03 a.m. when a CNA (#17) assisted him to lie down. The CNA failed to offer fluids during this time. At 11:23 a.m., a CNA (#18) assisted Resident #3 to get up for lunch and failed to offer fluids with cares. *05/07/13 at 11:59 a.m.: 4 oz juice supplement and 4 oz water served on Resident #3's lunch tray. Staff failed to offer 8 oz of juice and 8 oz of water as identified on the tray card. CNA charting for this meal identified intakes of 6 oz juice supplement, although observation showed Resident #3 received 4 oz of juice. *05/07/13 at 1:30 p.m.: Resident #3 asleep in bed until 4:38 p.m. when two CNAs (#19 and #20) assisted him to the dining room. The CNAs failed to offer fluids during this time. *05/07/13 at approximately 5:20 p.m.: 4 oz water, 8 oz Mighty Shake, and 8 oz juice served on Resident #3's supper tray. Staff failed to offer 8 oz of water as identified on the resident's tray card. *The CNA flowsheet for 05/07/13 confirmed Resident #3 did not consume any fluids between meals. *05/08/13 at 7:40 a.m.: 4 oz water, 4 oz orange juice, and 8 oz Mighty Shake served on Resident #3's breakfast tray. Staff failed to offer 8 oz of juice supplement (in addition to the orange juice) and 8 oz of water as identified on the resident's tray card. *05/08/13 at 12:26 p.m.: 4 oz water, 4 oz juice, and 8 oz Mighty Shake served on Resident #3's lunch tray. Staff failed to offer 8 oz of juice and 8 oz of water as identified on the resident's tray card. Observation also showed the lid covering the Mighty Shake remained untouched. *05/08/13 at approximately 1:00 p.m.: A CNA (#17) assisted Resident #3 to lie down after lunch. The resident remained in bed until 3:56 p.m. when two CNAs (#10 and #19) assisted him to the activity area. At 5:30 p.m., staff assisted Resident #3 to the dining room for supper. Staff failed to offer fluids during this time. Although the dietician expected staff to serve 2280 ml of fluid per day, observation showed staff did not serve Resident #3 the correct fluid amounts as listed on the tray card; therefore, it is difficult to determine how much fluid Resident #3 actually consumed and does not accurately reflect the resident's hydration status. During an interview on 05/09/13 at 10:26 a.m., a supervisory nurse (#21) stated it is important for staff to offer fluids between meals and with cares, especially given Resident #3's critically high sodium levels. Failure to ensure Resident #3 (who is dependent upon staff to meet his fluid needs) received adequate fluids with meals as recommended by the dietician and failure to offer/encourage fluids frequently as recommended by the physician resulted in insufficient fluid intake, prolonged and continued [MEDICAL CONDITION], and hospitalization for dehydration on two occasions.

Based on information received from the complainant, observation, record review, review of facility policies, and staff interview, the facility failed to provide the necessary treatment and services to aid in the prevention and promote the healing of pressure ulcers for 2 of 4 sampled residents (Resident #4, and #8) with current pressures ulcers. Failure to adequately monitor and assess Resident #8 for pressure ulcers resulted in an avoidable facility aquired pressure ulcer. Failure to provide scheduled incontinence cares, reposition residents, elevate heels off the bed, utilize [MEDICATION NAME] devices such as heel boots, provide dressing changes as ordered by the physician, placed Resident #4 at risk for continued skin breakdown and worsening of existing pressure ulcers. Findings include: Review of the facility policy titled "Pressure Ulcer Policy" occurred on 05/17/12. This undated policy stated, "Knife River Care Center will provide care based on each resident's comprehensive assessment to receive the necessary treatment and services to the extent possible to prevent pressure sores from developing unless pressure sores may be expected and unavoidable due to the resident's clinical condition. . . . Residents having pressure sores will receive necessary treatment and services to promote healing and to prevent infection. Interventions may include daily monitoring, dressing changes, and medical management and interdisciplinary approach to care. The resident's care plan will be reviewed and revised as needed based on assessment and treatment. Review of the facility policy titled "Intervention for pressure ulcer risk assessment" occurred on 05/17/12. This undated policy stated, ". . . If a resident has a score of (greater than) 8 (a score greater that eight indicates the resident is at a high risk for pressure sores): Skin cleansing should occur at the time of soiling and at routine intervals . . . Proper positioning, transferring and turning technique, including a turning schedule will be implemented, if appropriate. [MEDICATION NAME] devices may be implemented, if indicated. Examples include protective dressing and padding. . . . The use of devices that relieve pressure on heels, most commonly by raising heels off the bed should be implemented as indicated. . . . A multivitamin with minerals may be requested from the physician. . . ." - Review of Resident #8's medical record occurred on May 14-17, 2012. [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified the resident as having moderately impaired cognition; required extensive assistance for transfers, bed mobility, dressing, toilet use, and personal hygiene; and a 4.0 centimeter (cm) by 6.8 cm unstageable pressure ulcer to her left heel. The prior MDS, dated [DATE], identified the resident as cognitively intact; required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene; and at a risk for pressure ulcers but no current ulcers. Review of Resident #8's interdisciplinary progress notes identified the following: * 02/03/12 - c/o (complaints of) R leg pain . . ." * 02/04/12 - "continues to c/o leg pain . . ." * 02/05/12 - "Medicated for leg pain 0800 (8:00 a.m.) . . ." * 02/06/12 at 5:30 p.m. - ". . . standing lift out of recliner. States (Resident #8) 'my legs hurt' will monitor." * 02/11/12 at 6:30 a.m. - "Resident crying out in pain . . . 1445 (2:45 p.m.) . . . crying out in pain when L (left) leg moved noted to L inner knee red swelling warm to touch . . . 1500 (3:00 p.m.) Noted pressure ulcer to L heel . . . 1515 (3:15 p.m.) Resident set to ER . . ." Review of Resident #8's transfer document to the clinic, dated 02/11/12, stated, "Reason for Appt (appointment): c/o pain to L leg, noted to L knee redness swelling, warm to touch . . . Also noted pressure area to L heel. Please address . . . Diagnosis: [REDACTED]. Dr. Orders: 1. Elevate L foot & (and) reduce pressure to L heel . . ." A dietary progress note, dated 02/15/12, stated, "Notified of pressure area to L heel. Recommend add MVI (multivitamin) (with) minerals." Review of Resident #8's medical record failed to show the initiation of a MVI with minerals. Resident #8's "Weekly Pressure Ulcer Healing Record" identified the following: * (first documentation of the resident's left heel pressure ulcer) - Date: 02/11/12 Stage: Unstageable Size: 8 cm (by) 10 cm Wound bed: black (eschar) Surrounding skin color: bright red Pain: moaning/crying Pain location: "? c/o pain to leg crying out" * (the most current assessment) Date: 05/12/12 Stage: Unstageable Size: 3.9 cm (by) 5 cm Wound bed: black (eschar) Surrounding skin color: normal Pain: no During an interview on the afternoon of 05/17/12, a licensed nurse (#18) confirmed facility staff first observed Resident #8's left heel pressure ulcer on 02/11/12 when it was identified as an 8.0 cm by 10 cm unstageable pressure ulcer. Resident #8's heel pressure ulcer progressed to the size of 8.0 cm by 10.0 cm before facility staff identified the unstageable, facility-acquired pressure ulcer. The facility failed to initiate the MVI with minerals as recommended by the dietician. These practices resulted in an avoidable, painful pressure ulcer and may have delayed healing. - Review of Resident #4's medical record occurred on May 14-17, 2012. [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident as having severely impaired cognition; requiring extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene; and a Stage 2 pressure ulcer. The "Reviews and Progress Reports", dated 04/01/12, stated, ". . . (Resident #4) currently has pressure ulcer to the outer aspect of his right ankle that was noted on 2/6/12. The skin around the right ankle has a small opening, daily care is provided to the ulcer and it is showing signs of healing in that the area is getting smaller. His heels are floated when in bed to make sure there is not pressure on the ankle bone or heel. . . ." Resident #4's current care plan stated, "Nursing: . . . I'm at risk for skin breakdown because I have diabetes, decreased sensation in my feet and poor circulation. I currently have a stage II pressure area on the outer right ankle. . . . Please make sure to float my heels when I am in bed to reduce pressure. I have a pressure relieving mattress on my bed and a Roho cushion in my wheelchair. . . ." The "Daily Care Guide" (care guide utilized by direct care staff) failed to address floating the resident's heels and/or his footwear. A summary of Resident #4's "Weekly Pressure Ulcer Healing Records" identified the following measurements for the right lateral ankle ulcer: * 02/06/12 - 1.5 cm x 1.1 cm, brown wound bed, bright red surrounding skin color, peripheral tissue [MEDICAL CONDITION], grimacing * 05/07/12 - .7 cm x .7 cm x .1 cm/questionable depth, yellow exudate, black/brown-yellow wound bed, pink surrounding skin color The Physician Orders, dated 04/03/12, stated the following: * 12/07/11- "Float heels/ankles when in bed." * 03/27/12 - "Polymen drsg (dressing) to (R) lateral malleollus (sic) wound . . ." The current "Treatments" record stated the following: * 07/01/07 - "FLOAT HEELS @ HS - MAKE SURE FEET ARE OFF BED - No pressure to (R) lateral ankle when in bed. (handwritten)." * 02/07/12 - "FLOAT HEELS/ANKLES WHEN IN BED" * 02/08/12 - " WEEKLY PRESSURE ULCER HEALING RECORD UPDATE TO (R) LATERAL ANKLE Q (every) MONDAY * 04/12/12 - POLYMEN DRSG COVERED WITH MEPORE TO (R) LATERAL MALLEOLUS - CHECK DAILY . . ." Review of Resident #4's interdisciplinary progress notes (nurses notes) and fax alerts (notes to physicians) identified the following: * 02/06/12 - "Noted 1.5 x 1.1 cm soft brown area to R) lateral ankle. (with) 5-6 cm redness surrounding. Is warm swollen (and) painful to touch. Feet floated on pillows. . . ." * 02/12/12 - "Res (resident) requires that feet be checked on often due to his rotation of Rt (right) foot To the (R) side causing the bone To press against pillow which is pushed by his feet. . . ." * 02/17/12 - "Completes coarse of [MEDICATION NAME] . . . (R) foot floated when in bed lateral malleolus protected from pressure. . . ." * 02/21/12 - ". . . Air mattress in place. (R) foot floated, (L) (left) heel also. . . ." * 04/12/12 - ". . . air mattress. float feet to keep pressure off" * 05/08/12 - ". . . Heels (up) on pillows." * 05/11/12 - "Res now has moon boots for protection of (L) heel . . ." Observations made at approximately 12:35 p.m. on 05/14/12 showed Resident #4 lying on his back in bed with his heels resting directly on a pillow. Observation at 4:45 p.m. (approximately four hours later) showed two CNAs (#6 and #28) providing Resident #4's incontinence cares. The CNA (#6) removed the resident's blanket, showing Resident #4's heels resting directly on a pillow. When she removed the pillow from below his feet, Resident #4 grimaced and stated, "Ow! Ouch, Jesus!" During an interview 05/15/12 at 8:00 a.m., a managerial nursing staff member (#10) stated, "The area to his right ankle is due to rubbing his shoes. (Resident #4) has several shoe options and prefers the pair that rubs." Observation on 05/15/12 at 1:55 p.m. showed a nursing staff member (#31) changing Resident #4's dressing. The nursing staff member (#31) measured the pressure ulcer on the resident's right ankle, and stated, "It's .4 cm times .4 cm and is 2 mm (millimeters) deep." Observation on 05/15/12 at 2:25 p.m. and 3:08 p.m., showed Resident #4 lying on his back in bed with his heels resting directly on a pillow. Observation on 05/15/12 at 5:12 p.m. (approximately two hours and 45 minutes later) showed two CNAs (#33 and #34) providing Resident #4's incontinence cares. When the CNA (#34) placed his slippers/shoes on his feet, Resident #4 grimaced and stated, "Ow! My ankle is real sore!" Observation on 05/16/12 at 1:10 p.m. and 2:05 p.m., showed Resident #4 lying on his back in bed with his heels resting directly on a pillow. Observation on 05/16/12 at 3:53 p.m. showed an unidentified nursing staff member provided care to Resident #4. She stated, "Oh, there is no dressing on his right ankle." During an interview 05/16/12 at 4:40 p.m. and 5:00 p.m., when shown the progress note regarding moon boots, a managerial nursing staff member (#10) stated, "There is no orders for moon boots. To my knowledge we put heel protectors on." Facility staff failed to identify Resident #4's pressure ulcer until it was a 1.5 cm x 1.1 cm soft brown area with a 5-6 cm surrounding reddened area. Observations during survey showed staff failed to float Resident #4's heels/ankles when in bed. In addition, facility staff continued to place a pair of shoes on his feet even though staff were aware that particular pair of shoes caused friction/pressure to his ulcer. These practices may have delayed/prevented the healing of Resident #4's right ankle ulcer.