Every finding on record at Minot Health and Rehab, LLC

Based on observation, review of facility policy, resident and family interview, and staff interview, the facility failed to ensure a clean and homelike environment for 1of 3 sampled residents (Resident #1) dependent on staff assistance for toileting. Failure to maintain a clean and sanitary bathroom does not promote a homelike living environment or enhance the resident's quality of life.Findings include:Review of the facility policy titled Safe and Homelike Environment occurred on 06/15/26. This undated policy, stated, . the facility will provide a safe, clean, comfortable and homelike environment . services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Minimize odors . reporting lingering odors and bathrooms needing cleaning .During an interview on 06/15/26 at 9:38 a.m., Resident #1 reported she does not use the bathroom, but staff assist her with a bed pan for toileting needs. The resident's spouse, in attendance during the interview, stated, the staff do not always flush the toilet after they empty the bed pan. He also stated there are times he arrives at the room in the morning, notices an odor in the bathroom, and finds bowel movement in the toilet. Observation of the resident bathroom/toilet at 9:48 a.m. showed the bathroom door closed. When the surveyor opened the door, a urine odor was detected, and the toilet bowl contained urine colored water. Resident #1 reported staff assisted her with the bed pan prior to breakfast. During an interview on 06/15/26 at 4:30 p.m., an administrative staff member (#1) stated staff are expected to flush the toilet after emptying a bedpan and/or after resident toileting.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 4 sampled residents (Resident #1 and #11) observed during cares and storage of resident supplies. Failure to follow infection control practices while handling soiled linen, while providing cares for resident in enhanced barrier precautions (EBP), and disinfecting shared equipment has the potential to spread infection throughout the facility.Findings include: Review of the facility policy titled Infection Prevention and Control Program occurred on 04/30/26. This undated policy stated, . all reusable . equipment requiring . disinfection . shall be cleaned in accordance with our current procedures . Review of the facility policy titled Safe Resident Handling/Transfers occurred on 04/30/26. This undated policy, stated, .The lifts will be cleaned and disinfected according to manufacturer's instructions and after each resident use. Review of the facility policy titled Enhanced barrier precautions (EBP) occurred on 04/30/26. This undated policy, stated, .EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. -Observation on 04/29/26 at 1:02 p.m., a certified nurse aide (CNA) (#5) removed a full body mechanical lift from Resident #1's room and failed to disinfect it. When asked how often facility staff clean the full body mechanical lifts, The CNA (#5) stated lifts and wheelchairs are cleaned by the night shift. -Observation on 04/29/26 at 11:13 a.m. identified Resident #11 on EBP. Two CNAs (#4 and #5) entered Resident #11's room and applied gloves. The CNA (#5) placed the soiled linen from the floor into a bag. A nurse (#8) entered the resident's room and instructed the CNAs to apply personal protective equipment (PPE). The CNA (#5) applied a gown, removed Resident #11's soiled linen from the bed and placed it on the floor again. The nurse (#8) stated the soiled linens should be placed in a bag and not on the floor. During an interview on 04/30/26 at 10:15 a.m., an administrative staff member (#1) stated staff are expected to disinfect the full body mechanical lift after every use, avoid placing soiled linen on the floor, and wear gowns when entering rooms requiring EBP precautions.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 1 sampled resident (Resident #2) observed during a pivot transfer. Failure to utilize gait-belts placed residents at risk for falls and/or injury. Findings include:Review of the facility policy titled Safe Resident Handling/Transfers occurred on 04/30/26. This undated policy stated, .It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury . Resident lifting and transferring will be performed according to the resident's individual plan of care.Review of Resident #2's medical record occurred on all days of survey. Diagnoses included Parkinson's disease, muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. The current care plan stated, . Transfer: Stand pivot, 2 [staff] assist with gait belt .During an observation on 04/29/26 at 10:37 a.m., two certified nurse aides (CNAs) (#4 and #5) wheeled Resident #2 in front of the toilet. The resident utilized the grab bars to transfer from the wheelchair to the toilet with visible shakiness and an unsteady gait. The CNA (#4) assisted the resident to the toilet. After completion, the CNA (#4) cued the resident to stand and applied a clean brief and pants. The CNA (#4) placed her hands around Resident #2's ribcage and assisted to the wheelchair. The CNA (#4) failed to use a gait belt during the transfers. During an interview on 04/30/26 at 11:43 a.m., a CNA (#4) confirmed they failed to use a gait belt during toileting cares. During an interview on 04/30/26 at 10:15 a.m., three administrative staff members (#1, #2, and #3) stated they expect the facility staff to utilize a gait belt during transfers as care planned.

Based on observation, review of facility policy, and resident and staff interview, the facility failed to promote care in a manner that maintained or enhanced residents' dignity for 2 of 4 sampled residents (Resident #11 and #14) who required assistance with personal hygiene/care. Failure to assist with personal hygiene and appropriately clothe residents does not promote the resident's mental well-being or dignity.Findings include:Review of the facility policy titled Promoting/Maintaining Resident Dignity occurred on 04/30/26 at 10:25 a.m. This undated policy stated, . Groom and dress residents according to resident preference.Review of the facility policy titled Grooming a Resident's Facial Hair occurred on all days of survey. This undated policy stated, . assist resident with grooming facial hair to help maintain proper hygiene.Observation on 04/29/26 at 11:20 a.m., showed noticeable facial hair of Resident #11.During an interview on 04/29/26 at 11:20 a.m., Resident #11 identified a preference to have facial hair shaved and Preferred an electric razor but the facility only had a straight razor.During an interview on 04/29/26 at 3:02 p.m., an administrative staff member (#1) stated all residents are shaved per resident preference and shaving materials are provided.During an observation on 04/29/26 at 1:13 p.m., a nurse (#6) and a certified nurse assistant (CNA) (#7) transferred Resident #14 from the wheelchair to the bed, completed perineal cares, applied a clean brief, and without pulling up the resident's pants, covered the resident with a blanket.During an interview on 04/30/26 at 10:15 a.m., an administrative staff member (#1) stated she expected staff to pull up or take off residents' pants in bed per resident preference.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse/neglect for 1 of 1 sampled resident (Resident #4) who utilized a commode for toilet needs. Failure to place the call light within reach and check on the resident while on the commode resulted in discoloration to the resident's buttocks, a bruise to the wrist, and has the potential to cause anxiety, fear, and psychosocial harm. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following discovery of the incident.Findings include:The surveyor determined a deficient practice existed on 09/07/25. The facility implemented corrective action immediately, completed corrective action on 09/07/25, and continued with staff education and monitoring.Review of the facility policy titled Abuse, Neglect, and Exploitation occurred on 11/24/25. This policy, revised 07/15/22, stated, . Definitions . 'Neglect' means failure of the facility, its employees . to provide . services to a resident that are necessary to avoid . mental anguish, or emotional distress . C. Training will include: . 2. Identifying what constitutes . neglect . 3. Recognizing signs of . neglect . of a resident . such as . psychosocial indicators . III. Prevention of . Neglect . assure that staff assigned have knowledge of . residents' care needs . Review of Resident #4's medical record occurred on 11/24/25. Diagnoses included anxiety disorder and aphasia (inability to verbalize needs) following a stroke. The care plan stated, . Impaired communication severe expressive aphasia . Ensure resident has call light secured to bedside commode and within reach when toileting . An annual Minimum Data Set (MDS), dated [DATE], identified intact cognition and dependent on staff for toileting.A progress note dated 09/07/25, stated, Writer was informed that resident was found on bedside commode for an extended period of time last night. Writer performed skin assessment: blanchable redness noted to bilateral buttocks, blanchable light purple area noted to right buttock, bruise to left wrist. Resident denied any pain, no s/s [signs or symptoms] of pain noted. Resident's mood is at baseline, showing okay sign, requested to stay in bed as she was fatigued. During an interview on the afternoon of 11/24/25, an administrative nurse (#2) stated on the evening of 09/06/25, the certified nurse aides (CNAs) (#3 and #4) transferred Resident #4 to the bedside commode, failed to place the call light within reach, and failed to check on the resident for a period of approximately six hours. The administrative nurse (#2) indicated the resident sustained a bruise to the wrist from banging on the wall for assistance.The facility failed to ensure staff followed the care plan for toileting and failed to check on Resident #4 while on the bedside commode.Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions for all residents who may be affected by the deficient practice as follows:* Completed an investigation into the incident involving Resident #4.* Suspended both CNAs from work until completion of the investigation and provided written warnings to both CNAs.* Re-educated all staff via text message regarding following residents' care plans for toileting, rounding, and call light placement on 09/07/25.* Updated agency staff orientation to include rounding and call light placement.

Based on review of facility policy, record review, and staff interview, the facility failed to report an incident of abuse/neglect to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #4) left on the commode for toilet needs. Failure to report incidents of neglect may result in Resident #4 and other residents experiencing abuse and/or neglect and psychosocial harm.Findings include:Review of the facility policy titled Abuse, Neglect, and Exploitation occurred on 11/24/25. This policy, revised 07/15/22, stated, . Definitions . Neglect means failure of the facility, its employees . to provide . services to a resident that are necessary to avoid . mental anguish, or emotional distress . Policy and Compliance Guidelines . Reporting of all alleged violations to the . state agency . a. Immediately, but no later than 2 hours after the allegation is made, if the events that . result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not . result in serious bodily injury . Review of Resident #4's medical record occurred on 11/24/25. Diagnoses included anxiety disorder and aphasia (inability to verbalize needs) following a stroke. The care plan stated, . At risk for traumatization of . Impaired communication severe expressive aphasia . Ensure resident has call light secured to bedside commode and within reach when toileting . The Minimum Data Set (MDS), dated [DATE], identified intact cognition and dependent on staff for toileting.A progress note dated 09/07/25, stated, Writer was informed that resident was found on bedside commode for an extended period of time last night. Writer performed skin assessment: blanchable redness noted to bilateral buttocks, blanchable light purple area noted to right buttock, bruise to left wrist. Resident denied any pain, no s/s [signs or symptoms] of pain noted. Resident's mood is at baseline, showing okay sign, requested to stay in bed as she was fatigued. An administrative nurse (#2) indicated the resident's sustained the left wrist bruise from banging on the wall for assistance.During an interview on the afternoon of 11/24/25, an administrative nurse (#2) confirmed the facility failed to report this incident to the SSA.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 4 of 14 sampled residents (Resident #5, #7, #20, and #23) and one closed record (Resident #30). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the resident. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI User's Manual, revised October 2024, pages A-30 through A-32, stated, A1500: Preadmission Screening and Resident Review (PASRR) . Complete if SCSA [significant change in status assessment] . Review the PASRR report provided by the State if Level II screening was required . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . Page A-42, stated, Discharge Status. Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Code 01, Home/Community: if the resident was discharged to a private home . - Review of Resident #23's medical record occurred on all days of survey. A PASRR, dated 05/06/24 stated, . You meet PASRR inclusion criteria for Serious Mental Illness . A significant change in status assessment MDS, dated [DATE] failed to identify a serious mental illness. - Review of Resident #30's medical record occurred on 06/10/25. A progress note dated 4/10/2025 at 8:00 a.m., stated, Late Entry: Resident indicates she would like to DC [discharge] home today. Husband [name] indicates he is okay taking resident home. A Transfer Notice completed 04/10/25 and a physician's order written 04/10/25 identified discharge to home. The Admission/Discharge Return Not Anticipated MDS, dated [DATE], identified Resident #30 discharged to a nursing home. SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised October 2024, page I-1, stated, . code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments . Review of Resident #7's medical record occurred on all days of survey. A physician's order dated 01/04/25 identified, Duloxetine, an antidepressant, for depression. The quarterly MDS, dated [DATE], failed to include an active diagnosis of depression. SECTION J: HEALTH CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2024, page J-27, stated, . J1400: Prognosis . Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. Review of Resident #20's medical occurred on all days of survey. A physician's order dated 03/10/25, admission to hospice care. A progress noted dated 03/10/25, stated, [name of nurse] with [name of hospice] here to admit resident to hospice. The significant change MDS dated [DATE] failed to identify the resident's prognosis in section J1400. SECTION M: SKIN CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2024, pages M-37 and M-38, stated, . Skin and Ulcer/Injury Treatments . Review the medical record, including treatment records . for documented skin treatments during the past 7 days . Coding instructions Check all that apply in the last 7 days . M1200I, Application of dressings to feet (with or without topical medications) . Review of Resident #5's medical record occurred on all days of survey. A physician's order, dated 11/22/24, stated, Cleanse bilateral lower extremities with hibiclens [antibacterial] soap, apply calcium alginate dressing [highly absorbent wound dressings] to open areas, apply 4x4 gauze, wrap with roll gauze, and secure with tape. Review of the February 2025 treatment administration record identified facility staff changed the dressings to Resident #5's bilateral lower extremities on three of seven days during the look back period. The quarterly MDS, dated [DATE], failed to include application of a dressing. SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS The Long-Term Care Facility RAI User's Manual, revised October 2024, page O-3, stated, . Coding Instructions for Column b. While a Resident. Check all treatments, procedures, and programs that the resident received . within the last 14 days. Page O-7 stated, Hospice Care. Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. Review of Resident #20's medical record occurred on all days of survey and identified a physician's order dated 03/10/25 for admission to hospice care. A progress noted dated 03/10/25, stated, [name of nurse] with [name of hospice] here to admit resident to hospice. The significant change MDS dated [DATE] failed to identify hospice care. During an interview the afternoon of 06/10/25, an administrative nurse (#1) confirmed the facility failed to accurately code Resident #5, Resident #7, Resident #20, Resident #23, and Resident #20's MDSs.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and the State Long Term Care Ombudsman a written notice of transfer and bed-hold notice for 4 of 4 sampled residents (Resident #3, #7, #11, and #26) and 1 closed record (Resident #32) reviewed for hospital transfers. Failure to provide a written notice of transfer, a written copy of the bed-hold notice that includes the reserve bed amount, or notify the State Ombudsman of the transfer does not allow the residents and/or their representative to make informed decisions regarding their rights or inform the State Ombudsman of the transfer. Findings include: Review of the facility policy titled Transfer and Discharge (including AMA) [against medical advice] occurred on 06/10/25. This policy, dated 2022, stated, . Emergency Transfers/Discharges-initiated by the facility for medical reasons . Complete and send with the resident (or provide as soon as practicable) a Transfer Form . Social Services Director, or designee, shall provide notice of transfer to a representative of State Long-Term Care Ombudsman via monthly list. Review of the facility policy titled Bed Hold Notice occurred on 06/11/25. This policy, dated 04/23/25, stated, . the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices . at the time of, a transfer for hospitalization . the facility will provide the resident and/or the resident representative written information that specifies: . b. The reserve bed payment policy . - Review of Resident #3's medical record occurred on all days of survey and identified a hospitalization from 02/21/25 to 02/24/25. The facility failed to provide a bed hold to the resident/representative, and failed to provide the State Ombudsman a copy of the transfer notice. -Review of Resident #7's medical record occurred on all days of survey and identified a hospitalization from 03/07/25 to 03/09/25. The facility failed to provide the State Ombudsman a copy of the transfer notice. - Review of Resident #11's medical record occurred on all days of survey and identified the following: * hospitalized [DATE] to 10/20/24. The medical record lacked a written notice of bed hold or transfer notice form and lacked documentation the facility notified the State Ombudsman of the transfer. * hospitalized [DATE] to 04/08/25. The written bed hold notice lacked a reserve bed payment amount and the transfer notice form lacked evidence the facility notified the State Ombudsman of the transfer. - Review of Resident #26's medical record occurred on all days of survey and identified hospitalizations on 03/10/25 to 03/12/25 and 03/23/25 to 03/27/25. The written bed hold notices lacked a reserved bed payment amount and the transfer notices lacked evidence the facility notified the State Ombudsman of the transfers. - Review of Resident #32's closed medical record occurred on 06/10/25 and identified a hospitalization from 03/31/25 to 04/03/25. The facility failed to provide the resident and/or resident representative with a notice of transfer or bed hold. During interviews ont the afternoon of 06/09/25, an administrative nurse (#1) confirmed the above records lacked the required documentation for transfer notices, bed holds, and notification to the State Ombudsmen regarding transfers.

Based on observation, review of facility policy, review of facility housekeeping checklist, and resident and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment for 6 of 14 sampled residents (Resident #3, #7, #16, #23, #25, #133) and 2 supplemental residents (Resident #4 and #9) and 1 of 1 storage rooms. Failure to maintain equipment and maintain a safe, clean, sanitary environment may result in injuries does not provide a homelike living area for residents or promote quality of life. Findings include: Review of the facility policy, Resident/Patient Room Cleaning, occurred on 06/10/25. This policy, dated 02/02/25, stated, SCOPE: . committed to providing a safe, clean, and hygienic environment for residents, staff, and visitors . Room Cleaning: . Rooms will be regularly cleaned and disinfected . Walls . Between scheduled cleanings, walls will be spot-cleaned when they are visibly soiled. Privacy curtains should be changed whenever they are visible dirty or damaged, . and /or on a regular schedule as determined by Environmental Services management and Infection Preventionists. Review of the facility HKP [housekeeping] Daily Sheet occurred on 06/10/25. This undated checklist stated, . Steps - DEEP CLEAN . Clean ceilings, vents, . Observation on June 8-9, 2025, showed the following in resident rooms: * Resident #3: a non-functioning light in the bathroom. The resident stated the light had not been working for about two weeks and that he told a couple of staff members about it. * Resident #4: masking tape with dried paint covering the edges of the kick plate on the bottom half of the door to the resident's room. * Resident #7: visible dust/debris on the ceiling vent in the bathroom. * Resident #9: a window screen with a large hole and a broken thermostat on the wall outside of the bathroom. * Resident #16: visible dust/debris on the ceiling vent and a missing cover on the ceiling light in the bathroom. * Resident #23: soiled wallpaper, visible debris to the vent/fan, and brown spots around the vent/fan in the resident's bathroom. The privacy curtain next to the resident's bed had dark spots approximately halfway down. The resident stated, This is someone's blood. The north wall, adjacent to the door, showed a black substance the length of the wall. A window screen showed three holes the resident taped cotton over To block the bugs from coming in. * Resident #25: blue painter's tape with dried paint covering the bottom half of the outside of the door to the resident's room. * Resident #133: torn wallpaper next to the sink in the resident's room. * Storage Room: blue painter's tape with dried paint covering the edges of the kick plate on the bottom half of the door to the storage room in the north wing hallway. During an interview on 06/09/25 at 2:45 p.m., the housekeeping supervisor (#3) confirmed staff clean privacy curtains weekly and when visibly soiled and confirmed Resident #23's privacy curtain was soiled. The supervisor also confirmed staff deep clean all resident rooms monthly. During an interview on 06/10/25 at 3:38 p.m., two administrative staff members (#4 and #5) confirmed the facility failed to remove the painter's tape in a timely manner. An administrative staff member (#4) stated staff had not informed him/her of the missing cover on the bathroom light in Resident #16's room or the non-functioning light in Resident #3's bathroom. The administrative staff members stated they expected staff to report maintenance concerns/needs by completing a maintenance request form or entering the request into the TELS system (The Equipment Lifecycle System - a computer program to track maintenance).

Based on record review, review of professional reference, and staff interview, the facility failed to provide care in accordance with professional standards for 1 of 5 sampled residents (Resident #21) reviewed for unnecessary medications. Failure to transcribe physician's orders and obtain laboratory tests as ordered may result in adverse health effects. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures . ordered by the physician or primary care provider. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #21's medical record occurred on all days of survey and identified a physician's order, dated 03/26/25, for six blood tests. The medical record lacked documentation of the completion of the laboratory tests. During an interview on 06/09/25 at 11:20 a.m., two administrative staff members (#1 and #2) identified facility staff failed to transcribe the written order for the blood tests into the electronic medical record and failed to ensure collection of the blood specimens.

Based on record review, review of the hospice contract, review of facility policy, and staff interview, the facility failed to ensure residents' records contained the hospice election form for 2 of 2 sampled residents (Resident #5 and #20) receiving hospice services. Failure to obtain the hospice election form limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: The hospice contract for (hospice agency name), signed August 6, 2018, stated, . Coordination of Services: . providing Facility with a copy of each Hospice Patient's hospice election form. Review of the facility policy titled, Hospice Services Facility Agreement, occurred on 06/10/25. This policy dated 07/15/22, stated, The designated member of the facility working with hospice representative is responsible for: . Obtaining the following information from the hospice: . Hospice election form. - Review of Resident #5's medical record occurred on all days of survey. A nurse's note, dated 08/19/24 at 4:00 p.m., stated, . Resident elected to enroll with [name] Hospice for end of life cares . The medical record lacked a hospice election of benefits form. - Review of Resident #20's medical record occurred on all days of survey. A physician's order dated 03/10/25 identified an order to admit to hospice. A nurse's note, dated 03/10/25 at 10:57 a.m., stated . [name of nurse] with [name of facility] Hospice here to admit resident to hospice. Resident #20's medical record failed to contain the hospice election form. During an interview on the afternoon of 06/10/25 at 5:12 p.m., an administrative nurse (#1) confirmed Resident #5 and #20's medical records lacked a hospice election form.

Based on observation, record review, family interview, and staff interview, the facility failed to provide the necessary services to 1 of 7 sampled residents (Resident #17) dependent on staff for bathing. Failure to provide bathing as scheduled may result in poor personal hygiene and decreased self-esteem. Findings include: During an interview, on 06/09/25, at 12:28 p.m., a family member (A) stated Resident #17's fingernails have not been clean and questioned if the resident is getting his/her weekly baths. The family member stated, according to staff, the resident will refuse bathing at times. Observations of Resident #17's fingernails on 06/09/25 and 06/10/25 showed two nails on each of Resident #17's hands with dark areas under the nails. Review of Resident #17's medical record occurred on all days of survey. The care plan stated, ADL [activities of daily living] self-care deficit as evidenced by weakness . Bathing/Showering: Assist of 1, Transfer: Assist of 2 . Review of Resident #17's ADL Tasks/Intervention documentation showed bath/showers scheduled once a week on Mondays. - Review of Resident #17's March, April, and May 2025 bathing record records showed the following: * March: received two and refused two of five scheduled baths/showers. The medical record lacked documentation of refusal or completion of one scheduled bath/shower. * April: refused four of four scheduled baths/showers. The medical record lacked documentation of any completed baths/showers. * May: received one and refused one of four scheduled baths/showers. The medical record lacked documentation of refusal or completion of two scheduled baths/showers. During an interview on 06/10/25 at 5:45p.m., an administrative nurse (#1) confirmed Resident #17's bathing record lacked documentation staff provided bathing assistance as scheduled.

Based on record review, review of facility documents, Medicaid Fraud Control Unit (MFCU) investigation and interview, review of facility policy, and staff interview, the facility failed to ensure residents remained free from sexual and mental abuse for 5 of 30 residents (Resident #1, #2, #3, #4, and #5) and 1 of 1 closed record (Resident #7) identified on a staff members electronic device through the review of images/videos. Failure to protect residents from sexual abuse may result in mental and emotional distress, and physical injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. During the on-site investigation of the facility reported incident, the survey team consulted with the State Survey Agency (SSA) on 12/30/24 at 5:17 p.m. and determined an Immediate Jeopardy (IJ) situation existed. Investigation determined IJ began on 06/06/24 when the first image/video of a facility resident was sent by a staff member. On 12/13/24 law enforcement notified an administrative staff member (#1) of the arrest of a staff member (#2) who had inappropriate images/videos of possible residents on an electronic device. The survey team notified the administrator of the IJ on 12/30/24 at 6:08 p.m. The survey team confirmed by interview and record review that the IJ was removed on 12/13/24, and the deficient practice corrected on 12/19/24, prior to the start of the survey and was therefore past non-compliance. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 12/31/24. This policy, revised July 2022, stated, . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . 'Staff' includes employees . 'Willful' means the individual must have acted deliberately . 'Sexual Abuse' is non-consensual sexual contact of any type with a resident . 'Mental Abuse' . includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). The components of the facility abuse prohibition plan . 1. Screening . Potential employees will be screened for a history of abuse . I. Background, reference, and credentials' checks shall be conducted on potential employees . II. Employee Training . A. New employees will be educated on abuse . B. Existing staff will receive annual education through planned in-services and as needed. C. Training topics will include: 1. Prohibiting and preventing all forms of abuse . 2. Identifying what constitutes abuse . III. Prevention of Abuse . The facility will implement policies and procedures to prevent and prohibit all types of abuse . A. Establishing a safe environment . by establishing policies and protocols for preventing sexual abuse . B. Identifying, correcting and intervening in situations in which abuse . is more likely to occur . IV. Identification of Abuse . A. The facility will have written procedures to assist staff identifying the different types of abuse . B. Possible indicators of abuse include . 9. Evidence of photographs or videos of a resident tat are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status. Review of the facility policy titled Employee Social Media Use occurred on 12/31/24. This policy, revised June 2022, stated, . It is the policy of this company to avoid inappropriate use of social media and to protect the residents . 1. Employees are strictly prohibited from transmitting by way of any electronic media any resident-related image or information that may be reasonably anticipated to violate resident rights to confidentiality or privacy. This includes information that could degrade or embarrass the resident. 2. Photographs or recordings of a resident . without . written consent, is prohibited. Examples include taking unauthorized photographs/videos of: . d. taking unauthorized photographs or recordings of residents in any state of dress or undress . Emailed documentation received from MFCU on 12/20/24 identified the actions of a staff member which involved images and videos of residents of the facility. During an interview on 12/27/24 at 5:00 p.m., a MFCU investigator (#1) confirmed the identity of 6 residents of the facility. - Review of Residents #1's medical record occurred on 12/30/24. A quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition. - Review of Residents #2's medical record occurred on 12/30/24. A quarterly MDS, dated [DATE], identified intact cognition. - Review of Residents #3's medical record occurred on 12/30/24. A quarterly MDS, dated [DATE], identified moderately impaired cognition. - Review of Residents #4's medical record occurred on 12/30/24. A quarterly MDS, dated [DATE], identified moderately impaired cognition. - Review of Residents #5's medical record occurred on 12/30/24. A quarterly MDS, dated [DATE], identified severely impaired cognition. - Review of Resident #7's closed record occurred on 12/30/24. A discharge return not anticipated MDS, dated [DATE], identified severely impaired cognition. During an interview on 12/30/24 at 12:30 p.m., an administrative staff member (#1) confirmed law enforcement contacted the facility to report staff member (#2's) arrest, and confirmed the steps the facility completed in response. The facility completed the following steps to remove the immediacy and correct the deficient practice: * Terminated staff member (#2) on 12/13/24. * Educated all staff on-duty and all on-coming staff on facility's policy/procedure for abuse, neglect and exploitation, and social media use on 12/13/24. * Completed assessments of all residents on 12/13/24. * Notified the medical director. * Reviewed facility policies and resources and updated as necessary by 12/19/24. * Interviewed all staff to identify any allegation of misconduct to include taking of inappropriate photos/videos of residents, beginning 12/14/24 and concluding 12/19/24. * Maintained contact with law enforcement agencies to identify possible affected residents and appropriate next steps. * Implemented behavior monitoring for all residents identified.

Based on review of a facility reported incident, record review, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who experienced unwanted sexual contact from another resident. Failure to protect the resident from sexual abuse placed the resident at risk for mental and emotional distress. This citation is considered past noncompliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 12/02/24. This policy, revised 07/15/22, stated, . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . 'Sexual Abuse' is non-consensual sexual contact of any type with a resident. Review of the facility reported incident, dated 11/27/24, stated, [Staff member #2] was walking in the hall and noticed [Resident #1] had his Right [sic] hand down [Resident #2's] pants in the front. - Review of Resident #1's medical record occurred on 12/02/24. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as cognitively intact. Resident #1's nursing progress note dated 11/27/24 3:32 p.m. stated, Resident to resident incident reported by [staff member name] who witnessed incident between resident and other resident residing in [resident room number]. Incident reported to nursing staff, ED [Executive Director], and Social services. Local law enforcement notified of incident. This social worker attempted to interview resident, resident would not acknowledge or answer questions, laying in bed. Resident placed on temporary 1 to 1. This Social worker attempted to notify DPOA [durable power of attorney] no answer, unable to leave message. PCP [primary care physician] notified of incident. - Review of Resident #2's medical record occurred on 12/02/24. Diagnosis included dementia and Parkinson's disease. An admission MDS, dated [DATE], identified the resident with severely impaired cognition. Resident #2' nursing progress note dated 11/27/24 at 5:22 p.m. stated, Resident to resident incident observed by [staff title] which was reported to nursing staff, ED, and Social service. Resident was safely removed from vicinity of the other resident of [room number]. Local law enforcement was contacted by this social worker. Mood assessment completed-assessment score [number shows] s/s [signs and symptoms] of minor depression noted. Resident was able to briefly describe the incident. resident [sic] reports she does not feel in danger, and is not scarred [sic] of the other resident. Resident continues with normal routine. Daughter [name] notified of incident, PCP notified of incident. Resident to be monitored for any alterations in mood, behavior or changes in routine. During an interview on 12/02/24 at 10:30 a.m. an administrative staff member (#1) reported Resident #1 remained on 1 to 1 monitoring by staff and the resident was planning to discharge home on 12/03/24. During an interview on 12/02/24 at 12:08 p.m. staff member (#2) confirmed on 11/27/24 around 2:00 p.m. staff member (#2) was down the hall and saw Resident #1 in the hall with his wheelchair side to side with Resident #2. Resident #1's right hand was down the front of Resident #2's pants. Resident #2 looked distressed and was swatting [Resident #1] away. Resident #1 started laughing and moved away before the staff member could get there. The facility failed to protect Resident #2 from non-consensual sexual contact. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions for the resident affected by the deficient practice and put measures in place to ensure the deficient practice does not reoccur by: * Immediately implemented 1 to 1 staff supervision/monitoring for Resident #1. * Moved Resident #1's roommate to another room. * Reeducated staff regarding 1 to 1 supervision and on the abuse, neglect, and exploitation policy. * Interviewed other residents to determine if any other abuse occurred. * Reported the concern to the North Dakota Department of Health and Human Services, * Reported the concern to local Police Department. The surveyor determined a deficient practice existed on 11/27/24. The facility implemented corrective action and staff education on 11/27/24.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to prevent the development of a pressure ulcer for 1 of 1 supplemental resident (Resident #138) identified as having a stage IV pressure ulcer and exposed hardware. Failure to evaluate risk factors that may impact the development of a pressure ulcer, and implement, monitor, and modify interventions to reduce those risk factors resulted in Resident #138 developing an avoidable, facility-acquired pressure ulcer. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Pressure Injuries and Non-pressure Injuries occurred on 05/16/24. This policy, revised 07/20/22, stated, . For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. Complete a head-to-toe skin check and document findings on the Skin Review - Weekly . Assess current wounds at least every seven days, or more frequently as needed (e.g., decline in wound, presence of infection, wound healed). Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia [connective tissue that surrounds cells, nerves, joints, and organs], muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar [dark, crusty tissue that covers a wound] may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. Review of Resident #138's medical record occurred on all days of survey. The physician's orders identified, . Right lateral malleolus [ankle bone] non healing surgical wound - Using sterile technique, cleanse with NS [normal saline] and pat dry. Apply a bordered foam dressing. Change daily and PRN [as needed] when soiled more than 50% or dislodged until healed. Monitor for signs/symptoms of infection one time a day . Right lateral malleolus stage IV pressure ulcer - Using sterile technique, cleanse with NS and pat dry. Apply Calcium Alginate AG [dressing] cut to fit wound bed and secure with a bordered foam. Change every 3 days and PRN when soiled more than 50% or dislodged until healed one time a day every 3 days . CAM high tide boot [orthopedic device that limits ankle and foot movement and protects the area during recovery], rt [right] ankle. May remove at rest for ROM [range of motion]. every shift . Notify DON [Director of Nursing] immediately if resident has any of the following: 1. pain to right outer ankle, 2. elevated temp [temperature], 3. redness to wound, 4. odor to wound every shift . The most recent care plan identified, The resident has . pressure ulcer or potential for pressure ulcer development . Administer treatment as ordered and monitor for effectiveness . Monitor/document/report PRN any changes in skin status, appearance, color, wound healing, s/sx [signs/symptoms] of infection, wound size . stage . Do not massage over bony prominences . Actual surgical incision at right leg r/t [related to] ORIF [a type of surgery used to stabilize and heal a broken bone] . Administer treatment per MD [medical doctor] order . Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain . At risk for alteration in skin integrity related to immobility and weakness . Observe skin condition with ADL [activities of daily living] care daily, report abnormalities . Resident #138's progress notes identified the following: * 11/14/23 at 8:19 p.m., Resident got admitted to the building from . hospital . Resident is .here for PT [physical therapy] OT [occupational therapy] and over all strengthening. He was admitted to . hospital, because of a fall and a Brocken [sic] rt ankle . currently post-surgery to rt ankle. * 11/20/23 at 4:33 p.m., Resident had an appointment with Dr. [doctor] . for his S/p [status post] ORIF rt ankle. He was placed in CAM high tide boot, rt ankle. The weekly skin reviews, dated November 17-December 22, 2023, addressed bruising to Resident #138's bilateral upper extremities and right thigh, scabs to the right lower leg, redness to the buttocks, groin, and scrotum, and a pressure ulcer to the coccyx. Staff failed to address the surgical incision to Resident #138's right ankle. Additional progress notes identified the following: * 12/23/23 at 4:44 p.m., Dr. in to see resident at this time to look at resident's right ankle. Orders received for sterile dressing change daily and to monitor for signs/symptoms of infection. Currently no infection noted. Wound bed is pink and intact with minimal serous drainage. * 12/24/23 at 11:06 a.m., . On 12/23/23, DON was [sic] notified wound nurse that resident had hardware visible to right ankle. The current status is Res [resident] seen by provider. New orders received. Res admitted to [Hospital] for assessment of surgical repair. The weekly skin review, dated 12/23/23, identified, Pressure injury acquired . in house . Stage IV PU [pressure ulcer] to right lateral malleolus 4.5 x 6 x -.7 cm [centimeters] 80% hardware exposure and 20% granulation, 10% crust along the wound edge from approximately 11 to 3 o'clock which may be epibole. Shiney [sic] epithelial edge from 4 to 6 [o'clock]. Mild to moderate serosanguinous drainage smeared across the bedsheets. The [sic] denies pain, chills, N/V [nausea/vomiting] or feeling feverish. Was to see Dr. about weight bearing status and healing post hardware placement on 12/21 but missed the appointment. As per facility policy and the Resident 138's care plan, the facility failed to: * Assess/monitor Resident #138's right lateral malleolus non-healing surgical wound during the daily dressing changes. * Document/report any changes in wound status, appearance, color, wound healing, signs/symptoms of infection, wound size, and stage. * Identify the facility acquired pressure ulcer prior to it developing into a stage 4 ulcer with the exposed hardware. During an interview on 05/15/24 at 10:30 a.m., two administrative nurses (#1 and #4) indicated they recognized the issue and addressed it by educating their staff and initiating a performance improvement project. Based on the following information, non-compliance at F686 is considered past non-compliance. The facility implemented corrective actions for the resident affected by the deficient practice by: * Assessing the pressure ulcer to Resident #138 right ankle. * Completing an investigation into the facility acquired pressure ulcer. * Determining nursing staff failed to document wound measurements on the admission skin assessment. * Determining nursing staff failed to complete non-pressure weekly tracker assessments. * Determining nursing staff removed pressure relieving interventions from the care plan. The facility also put measures in place to ensure the deficient practice does not reoccur by: * Educating Resident #138 regarding the need for pressure relieving interventions. * Updating Resident #138's care plan. * Auditing other residents with surgical wounds and/or cam boots. * Updating other residents' care plans. * Educating staff regarding skin injuries and interventions. * Adding surgical skin areas and wounds to the wound tracker (computer program). * Completing weekly audits on skin injuries. This surveyor determined a deficient practice existed on 12/23/23. The facility implemented corrective action and completed all staff education by 12/27/23.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 2 residents (Resident #6) observed during medication administration. Failure to obtain a medication label for an insulin pen and identify and open date may result in a resident receiving an incorrect or ineffective dose of insulin. Findings include: Review of the facility policy Insulin Administration occurred on 05/15/24. This policy, revised October 2022, stated, . If a new pen is obtained from the refrigerator . document the date open on the pen body. Verify that the Medication/RX [prescription] Label matches the Medication Administration Record [MAR]. Right resident, medication, dose, dosage form, frequency, and route. Observation on 05/14/24 at 7:46 a.m., showed a nurse (#2) prepared insulin for Resident #6. The nurse removed a plastic bag labeled with Resident #6's name from the medication cart. The bag contained contained NovoLog and Tresiba insulin pens. The nurse (#2) removed the insulin pens from the bag. The NovoLog pen lacked a medication label with the resident's name and administration instructions. The Tresiba insulin pen lacked an open date. During an interview on 05/16/24 at 1:00 p.m., and administrative nurse (#4) confirmed she expected staff to follow facility policy and insure insulin pens have a label and an open date.

Based on observation and review of facility policy, the facility failed to follow professional standards of practice for 2 of 2 sampled residents (Resident #6 and #16) observed for insulin preparation and administrations. Failure to properly prepare insulin pens and administer the insulin correctly may result in residents receiving an inaccurate dose. Findings include: Review of the policy Insulin Administration occurred on 05/15/24. This policy, revised October 2022, stated . Holding pen with the needle pointing up, tap the cartridge. Press the injection button all the way in until the dose selector is back to 0. A stream or drop of insulin should appear at the tip of the needle. Insert the needle and press the injection button until the dose selector is back to 0. Continue to press the injection button until the needle has been pulled out from the skin. Keep the needle in the skin for up to 10 seconds . Observation on 05/14/24 at 7:46 a.m. showed a nurse (#2) prepared a NovoLog insulin pen for administration. The nurse inserted the needle into Resident #6's abdomen and pressed the injection button until the dose selector reached 0 and immediately removed the needle. The nurse (#2) failed to keep the needle in the skin up to 10 seconds. Observation on 05/14/24 at 11:47 a.m. showed a nurse (#3) prepared an Asepet insulin pen for Resident #16. The nurse (#3) dialed the pen to 2 and primed the pen horizontally. The nurse (#3) failed to prime the insulin pen as per facility policy.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 4 of 12 sampled residents (Resident #2, #18, and #28). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: Identification Information The Long-Term Care Facility RAI Manual, revised October 2023, pages A-30 through A-32, stated, . A1500: Preadmission Screening and Resident Review (PASRR). Coding Instructions . Code 1. yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Review of Resident #18's medical record occurred on all days of survey. A PASRR Level II Outcome, dated 06/06/23, stated, . PASRR Determination Explanation: You meet PASRR including criteria for Serious Mental Illness because you have been diagnosed with the following: Bipolar II Disorder. Resident #18's Significant Change MDS, dated [DATE], showed the facility failed to code yes for A1500. During an interview on 05/15/24 at 2:00 p.m., a social services staff member (#5) stated facility staff coded A1500 incorrectly. SECTION N: Medications The Long-Term Care Facility RAI Manual, revised October 2023, page N-2 and N-3 stated, . N0300: Injections. Record the number of days during the 7-day look-back period. that the resident received any type of medication. by injection. Insulin injections are counted in this item . Count the number of days that the resident received any type of injection while a resident of the nursing home. N0350: Insulin . Count the number of days insulin injections were received . Review of Resident #2's medical record occurred on all days of survey. Physician orders included Trulicity Subcutaneous Solution, a medicine used to control high blood sugar, once a week. Resident #2's quarterly MDS, dated [DATE], showed the facility coded N0300 for 7 days rather than one day and coded N0350 for 7 days. Trulicity is not an insulin and is not coded at N0350. During an interview the afternoon of 05/15/24, an MDS coordinator (#1) confirmed facility staff coded the MDS incorrectly. The Long-Term Care Facility RAI Manual, revised October 2023, page N-7 stated, . N0415G1. Diuretic: Check if a diuretic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) . Review of Resident #28's medical record occurred on all days of survey. Physician orders included Chlorthalidone, a diuretic, daily for high blood pressure. Resident #28's admission MDS, dated [DATE], showed the facility failed to code the use of a diuretic for N0415G. During an interview the afternoon of 05/15/24, an MDS coordinator (#1) confirmed the facility staff coded the MDS incorrectly. 39687 46964

1. Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident representative for 1 of 1 sampled resident (Resident #2) reviewed for care conferences. Failure to notify the resident representative of the care conferences does not allow the representative to be fully informed of the resident's current status. Findings include: Review of the facility policy titled, Comprehensive Care Plan occurred on 05/16/24. This policy, dated 09/23/2022, stated, Policy: . The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: . e. the resident and the resident's representative, to the extent practicable. 7. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. Review of Resident #2's medical record occurred all days of survey. The record identified resident representative (A) as the primary power of attorney for medical and financial decisions and listed as first emergency contact. The record lacked evidence the facility notified the resident representative (A) of a care conference. During an interview on the morning of 05/14/24, resident representative (A) stated, I haven't been contacted by anyone regarding the plans for my mom's care or anything since she's been in there. I just found out in March that she's been there. During an interview on 05/15/24, at 11:30 a.m., an administrative staff member (#5) confirmed that he/she failed to notify the resident's representative (A) to attend the care conferences. 2. Based on record review, review of facility policy, and staff interview, the facility failed to notify the physician of a change in condition for 1 of 1 supplemental resident (Resident #137) who experienced high blood sugars. Failure to notify the physician of blood sugar results above the ordered parameters may result in complications to the resident and prevent the physician from evaluating/prescribing an appropriate treatment plan. Findings include: Review of the facility policy titled Change in Condition of the Resident occurred on 05/16/24. This policy, revised 09/20/22, stated, . When a resident presents with a possible change of condition . Assess/evaluate the resident. The assessment/evaluation could include . blood glucose levels . Notify resident's physician . include date, time, what was conveyed, any orders received (each time notified) . - Review of Resident #137's medical record occurred on all days of survey. Diagnoses included type 2 diabetes mellitus with hyperglycemia. Medications included, . Levemir . inject . two times a day . Metformin . by mouth every morning and at bedtime . Novolog . Inject as per sliding scale . Contact MD [medical doctor] if BS is >[greater than] 300 and < [less than] 80 . The current care plan stated, . Endocrine system r/t [related to] DM II [Diabetes Mellitus Type 2] . Administer medication per MD orders . Obtain glucometer readings and report abnormalities as ordered . Report symptoms of hyperglycemia . Review of the blood sugars log, dated January 20-March 9, 2024, showed the following: * 01/27 354 milligrams per deciliter (mg/dL) * 01/28 369 mg/dL * 01/29 303 mg/dL and 329 mg/dL * 01/31 315 mg/dL * 02/02 312 mg/dL * 02/03 343 mg/dL * 02/19 343 mg/dL * 02/20 316 mg/dL * 03/03 397 mg/dL * 03/06 321 mg/dL * 03/08 381 mg/dL Review of the medical record showed the facility failed to notify Resident #137's physician of the high blood sugar readings. During an interview on 05/15/24 at 10:30 a.m., two administrative nurses (#1 and #4) confirmed facility staff failed to notify Resident #137's physician of the high blood sugar readings. The record lacked evidence the facility notified the resident representative. During an interview on the morning of 05/14/24, Resident representative (A) stated, I haven't been contacted by anyone regarding the plans for my mom's care or anything since she's been in there. I just found out in March that she's been there. I found out because my sister sent me a note attached to a bill. The note said, 'By the way, mom fell and hurt herself and is now at this place'. During an interview on 05/15/24, at 11:30 a.m., an administrative staff member (#5) confirmed that he/she failed to notify the resident's representative to attend the care conferences and regarding the significant change in Resident #2's status. Provider Notification Based on record review, review of facility policy, and staff interview, the facility failed to notify the physician of a change in condition for 1 of 1 supplemental resident (Resident #137) reviewed who experienced high blood sugars. Failure to notify the physician of blood sugar results above the ordered parameters may result in complications to the resident and prevent the physician from evaluating/prescribing an appropriate treatment plan. Findings include: Review of the facility policy titled Change in Condition of the Resident occurred on 05/16/24. This policy, revised 09/20/22, stated, . When a resident presents with a possible change of condition . Assess/evaluate the resident. The assessment/evaluation could include . blood glucose levels . Notify resident's physician . include date, time, what was conveyed, any orders received (each time notified) . - Review of Resident #137's medical record occurred on all days of survey. Diagnoses included type 2 diabetes mellitus with hyperglycemia. Medications included, . Levemir . inject . two times a day . Metformin . by mouth every morning and at bedtime . Novolog . Inject as per sliding scale . Contact MD [medical doctor] if BS is >[greater than] 300 and < [less than] 80 . The current care plan also stated, . Endocrine system r/t [related to] DM II [Diabetes Mellitus Type 2] . Administer medication per MD orders . Obtain glucometer readings and report abnormalities as ordered . Report symptoms of hyperglycemia . Review of the Blood Sugars Log, dated January 20-March 9, 2024, showed the following: * 01/27 354 milligrams per deciliter (mg/dL) * 01/28 369 mg/dL * 01/29 303 mg/dL and 329 mg/dL * 01/31 315 mg/dL * 02/02 312 mg/dL * 02/03 343 mg/dL * 02/19 343 mg/dL * 02/20 316 mg/dL * 03/03 397 mg/dL * 03/06 321 mg/dL * 03/08 381 mg/dL Review of the medical record showed the facility failed to notify Resident #137's physician of the high blood sugar readings. During an interview on 05/15/24 at 10:30 a.m., two administrative nurses (#1 and #4) confirmed facility staff failed to notify Resident #137's physician of the high blood sugar readings. 27221

Based on observation, review of facility policy, and resident and staff interview, the facility failed to provide dignity for 1 of 1 sampled resident (Resident #21). Failure to address the resident with the name of the resident's choice does not preserve the resident's personal dignity or enhance the quality of life and places the resident at risk for anger, anxiety, lack of self-esteem, and other forms of emotional distress. Findings include: Review of the facility policy titled Resident Rights occurred on 05/08/23. This policy, revised in September 2022, stated, .Do not use nicknames when addressing or referring to a resident, unless the resident asks that you do. other such names . shows disrespect for the resident. During an observation of cares on 05/07/23 at 2:11 p.m., a registered nurse (#3) referred to and called Resident #21 Bud multiple times. During an interview on 05/07/23 at 4:41 p.m., Resident #21 stated he did not like to be called Bud because that is not his name. During an interview on 05/09/23 at 10:45 a.m., when asked questions pertaining to dignity, two administrative staff members (#1 and #2) stated they expected staff to follow policy and resident's rights, and address residents as they wish to be addressed.

Based on observation, review of facility reported incident (FRI) reports, review of medical records and facility policies, and resident and staff interviews, the facility failed to provide appropriate supervision and/or assistance to prevent an accident for 1 of 1 resident (Resident #3) who fell during van transport. Failure to utilize chest and lap seatbelts to restrain a resident in the facility van resulted in Resident #3's fall from his tilt-in-space wheelchair, serious injury, and placed all residents transported via the facility van at risk for falls and/or injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: A Initial Allegation of Mistreatment, Abuse, Neglect or Theft and Facility Reported Incidents Reporting Form, dated 08/24/22, stated, . [Resident #3] was being transported by [staff member #2] in the facility vehicle. At a stop sign [Resident #3] slid out of the wheelchair and fell on to the floor. Resident was helped by two EMS [emergency medical services] personnel and [staff member #2] back into his wheelchair. Resident was found to have bilateral broken femurs. Review of the facility policy titled Facility Van occurred on 09/07/22. This policy, revised 02/02/18, stated, . Training to include vehicle specific operations, lift use and safety . Residents . must be restrained with seatbelts and tie downs prior to driving. One of the most important safety tips when operating a vehicle is to make sure every passenger is buckled up at all times. Random observations September 6-7, 2022 showed Resident #3 lying in bed with both legs in immobilizers. During an interview on 09/06/22 at 2:56 p.m., Resident #3 stated, I think my care has been pretty [profanity] poor. I have two broken legs. It was [staff member #2]. As soon as he [staff member #2] slammed on the brakes, I went flying. He didn't strap me in at all. Yep, I had pain, between an 8 & a 10 [on a 1-10 point pain scale, with 10 being severe]. Review of Resident #3's medical record occurred on September 6-7, 2022. Diagnoses included fractures to bilateral femur bones. The quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition and extensive assistance of two or more staff members required for transfers. The current physician's orders identified, . Immobilizer on at all times to BLE [bilateral lower extremities] except for routine wash ups and skin checks. The current care plan identified, . Alteration in musculoskeletal r/t [related to] to [sic] bilateral broken femurs 8/24/22. Non ambulatory. Assess CMS [circulatory, motor, sensory] and skin every shift to bilateral legs . Assess for pain every shift . Bilateral leg immobilizers on at all times except with skin checks and bathing. ADL [activities of daily living] self care deficit . [tilt-in-space wheel]chair . Transfer with [full body lift] x [times] 2 [two staff members] . The progress notes, dated 08/24/22, identified the following: * At 2:30 p.m., identified, Resident had a fall in the transportation vehicle while going to [medical center] for a lab draw. Resident was sitting in his [tilt-in-space wheel]chair and slid forward onto the foot rests and touched the floor. Driver called dispatch for assistance and resident was assisted by two staff to get back into his [tilt-in-space wheel]chair. Resident was brought to his appointment and back to the [nursing home] facility. Resident stated that he did not have injuries. Guardian and physician aware of the incident. * At 3:30 p.m., At 1530 [3:30 p.m.] 08-24-2022, resident came back from his appointment, was reported he fell from the facility van on the way going to his lab appointment but an ambulance helped him getting back to his wheelchair and he went to his lab appointment. Nurse assessment done per protocol. Resident stated he did not hit his head. ROM [range of motion] on his BUE [bilateral upper extremities] and BLE was [at] his baseline. He was then transferred to his bed x 2, using a mechanical lift. When asked about his pain, he stated it was 5/10. This is his baseline. He had abrasions on the inner aspect of the left leg and 3rd digit left toe about less than 1 cm [centimeter] in diameter. 1730 [5:30 p.m.] Reassessed post fall. Noticed swelling with deformity and crepitus [a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone] on his knees. Placed a [sic] pillows on the side while stabilizing legs. Asked him about the pain and he stated 5/10 again. This nurse explained pain scale and he said 7/10. Tylenol 500 mg [milligrams] was given PRN [as needed] for pain per MAR [medication administration record]. On call MD [medical doctor] [physician's name] called orders to send resident to ED [emergency department] obtained. * At 6:44 p.m., Spoke to residents guardian, [guardian's name], updated her on the incident. Ok to send to ER [emergency room ] for evaluation and treatment . A ETC [early total care] Physician's Note, dated 08/24/22 at 9:51 p.m., identified, . Patient presents following fall . Was not adequately secured and so fell out of his wheelchair inside the transportation van. after his lab tests he went back to the nursing home where they decided to send him to the emergency room for evaluation of possible left knee injury. Radiology results: . Bilateral distal femur fractures. During an interview on 09/07/22 at 10:00 a.m., an administrative staff member (#1) reported, [Staff member #2] signed off on the [facility van] education. [Staff member #2] said he wanted more training after [Resident #3] fell . He didn't ask for addition training prior to the fall. The resident [should have been] strapped to the wheelchair with two seatbelts, one running across his waist and another across his left shoulder to right waist. [Staff member #2] submitted a handwritten note, dated 08/24/22, which stated, Backed up and parked facility vehicle at main entrance. [Resident #3] was secured in van with all hooks on [tild-in-space wheelchair] at 1:15 p.m. I failed to put shoulder and lap seat belt on. At first stop sign [Resident #3] slid forward out of chair to the floor of the van. Called dispatch at 1:21 p.m. for assistance getting [Resident #3] back in his chair and properly secured. A Facility Van Training form, signed by [staff member #2] on 06/02/22, identified, . I have read and understand the attached . Facility Van Training and have been oriented on specific manufacturer guidelines for wheelchair lift systems, wheelchair restraint systems . and other safety features systems of the facility van. An administrative staff member co-signed the form, indicating I have observed this employee demonstrating the functions on specific manufacturer guidelines for wheelchair lift systems, wheelchair restraint systems . and other safety features systems of the facility van. The [Nursing Home] Incident Investigation, dated 08/30/22, identified, . Interviewed . staff . [and] residents . [staff member #2] was placed on suspension prior to the start of his shift on 8/25/22 and removed from his position on 8/30/22. Van taken out of use on 8/24/22, staff reeducation of proper van use policy titled, 'Facility Van Policy' started 8/26/22, and an automotive shop reviewed the vehicle on 08/29/22 for safety needs of the van. Quality Assurance review of event occurred on 08/25/22 with an action and audit plan created. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for the resident affected by the deficient practice by: * Completing an investigation on 08/30/22, including an interview with [staff member #2] who transported Resident #3 via the facility van, * Determining [staff member #2] failed to adequately secure Resident #3 in his [tilt-in-space] wheelchair in the facility van during transport resulting in a fall with serious injury. The facility also put measures in place to ensure the deficient practice does not recur by: * Suspending [staff member #2] on 08/25/22 and removing him from his position on 08/30/22, * Having an automotive shop review the facility van for safety issues, * Providing education to all staff members who transport residents with the facility van on 08/26/22, ensuring a return demonstration to ensure proper placement of the chest and lap seatbelts, and * Completing quality assurance audits to ensure resident safety during facility van transport. The survey team determined a deficient practice existed on 08/24/22. The facility implemented various corrective actions on August 24-30, 2022, immediately suspending and later removing [staff member #2] from his position, assessing the facility van for safety issues, re-educating all staff members who transport residents in the facility van, and completing quality assurance audits.

Based on information provided by the complainant, record review, and staff interview, the facility failed to ensure professional standards of practice 1 of 1 closed record (Resident #1) with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: Information provided by the complainant indicated the facility failed to complete hemoglobin blood testing weekly as ordered by the physician Review of Resident #1's medical record occurred on 02/01/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record identified the following completed laboratory results: * 10/20/21 Hemoglobin of 7.3 * 11/05/21 Hemoglobin of 5.6 Resident #1's progress notes identified the following: * 10/25/2021 at 6:49 p.m., Resident c/o [complained of] nausea and vomited once during the day shift. Physician ordered 4mg [milligrams] of [MEDICATION(S)] (anti-nausea medication) q [every] 6 hours prn [as needed], which was administered with good effect. * 10/25/2021 at 3:16 p.m., Resident refused lunch today. Had one episode of emesis this afternoon. MD [medical doctor] notified and order obtained for PRN [MEDICATION(S)]. VS [vital signs] WNL [within normal limits]. Resident is now sleeping. * 10/28/2021 at 4:13 p.m., Resident had episode of N/V [nausea and vomiting] this afternoon. PRN [MEDICATION(S)] given and found effective. Reported no ABD [abdominal] pain at the moment. Bowel sounds present and active x 4. No fever present. Will continue to monitor. * 11/04/2021 at 1:29 p.m., Physical therapy and staff CNA [certified nurse assistant] reported that resident has blood in stool when was toileted. This nurse did not observed [sic] this episode. Resident did not have another BM [bowel movement] on this shift. This nurse faxed physician with updated status and current vitals. No other concerns. * 11/05/21 at 4:02 p.m., Late Entry: Resident grand daughter called to report resident has seemed more fatigued. Resident Hgb [hemoglobin] results not received from lab 11/03/21. [Hospital name] lab called and they report they don't see any lab results at this time. Hgb drawn and transported to [hospital] lab . * 11/05/2021 at 9:24 p.m., [physician] phoned and stated resident has a critical hgb of 5.6, provider stated he would like to send resident to the ER [emergency room ], he also stated he spoke with the family, resident is agreeable to be admitted for a blood transfusion. * 11/05/2021 at 9:47 p.m., Resident left with ambulance crew to the ER at this time. The facility failed to complete a hemoglobin laboratory draw on 10/27/21 and 11/03/21. During an interview on 02/01/22 at 5:30 p.m., an administrative nurse (#1) confirmed the hemoglobin laboratory test was not completed weekly as ordered.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 05/24/21 Based on observation, record review, and review of facility policy, the facility failed to ensure acceptable parameters of nutritional status for 1 of 2 sampled residents (Resident #11) with weight loss. Failure to adequately monitor and evaluate weights, assess the effectiveness of interventions and consistently implement existing interventions, and re-evaluate the need for updated or additional interventions resulted in severe weight loss for Resident #11. Findings include: Review of facility policy titled WEIGHT ASSESSMENT AND INTERVENTION occurred on 11/04/21. This policy, revised 10/14/20, stated, . Any weight change of five (5) or more pounds since the last weight assessment will be retaken for confirmation. The Dietician will review the monthly weights . Weight trends will be evaluated by the interdisciplinary team . The threshold for significant weight change will be based on the following criteria . 1 month - 5% weight change is significant; greater than 5% is severe . 3 months - 7.5% weight change is significant; greater than 7.5% is severe . 6 months - 10% weight change is significant; greater than 10% is severe . The nursing staff will notify the responsible party . of any individual with an unintended significant weight change . Observation on 11/02/21 at 11:47 a.m. showed Resident #11 in the community living area eating candy. The resident chewed on the candy with the wrapper still on and staff failed to assist her to remove the wrapper. Review of Resident #11's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . At risk for nutritional status change r/t [related to] H/O [history of] Dementia/Alzheimer's Disease . Follow RD [Registered Dietician] recommendation and MD [Medical Doctor] orders . Review weights and notify RD, MD, and responsible party of significant weight change . Provide additional calories/protein at meals . Provide supplements as ordered . Resident #11's current provider orders showed the following: * 05/07/21: WEIGHT . one time a day for 3 Days, one time a day every Sunday for 3 weeks, one time a day every 1 month. * 08/15/21: one time a day nutritional juice 6 oz (180 mL) as mid-morning 10:00 AM snack. * 08/15/21: one time a day fortified hot cereal at breakfast AND in the afternoon fortified pudding afternoon snack. Resident #11's dietary progress notes occurred on all days of survey and included the following: * 05/23/21: . Weekly weight until stable . Fortified breakfast cereal . Fortified pudding 3 p.m. * 08/14/21: . Significant weight change present . -3.9% x2 month, -11.7% x3 month . follow a regular diet to promote improved PO [by mouth] intake . * 09/12/21: . appears to have preference for sweets, recommend to add supplemental nutritional juice . follow resident weight weekly . If resident continues further weight loss trend may try adding more sweets and desserts to resident meals. Review of Resident #11's provider notes showed an office visit note dated 06/23/21 stated, . Nursing staff mentioned that the patient has been losing weight . [resident] states appetite is good and [resident] does not want to eat more . The note failed to show additional interventions to address resident's weight loss. Meal intake records, dated 10/12/21 to 11/01/21, showed Resident #11 consumed 50% or less at 24 of 60 meals and refused 4 of 60 meals. The record lacked evidence of staff documentation/monitoring of Resident #11's intakes of supplements (nutritional juice, fortified pudding). Resident #11's weights included the following: * 05/10/21 147.0 pounds (Lbs) * 05/23/21 138.7 Lbs (>5 lb weight loss without evidence of a re-weigh) * 05/31/21 134.0 Lbs * 06/1/21 135.0 Lbs * 06/28/21 128.4 Lbs * 06/29/21 126.6 Lbs * 07/1/21 126.6 Lbs * 07/2/21 131.4 Lbs * 08/1/21 129.8 Lbs * 09/1/21 122.0 Lbs (>5 lb weight loss without evidence of a re-weigh) * 09/9/21 119.0 Lbs * 09/16/21 118.8 Lbs * 10/6/21 119.0 Lbs * 11/3/21 117.0 Lbs The above weights identified a 30 pound (over a 20%) weight loss in approximately a six months period, indicating a severe weight loss. The record lacked evidence of consistent weekly weights as suggested by the dietician. Failure to consistently obtain weekly weights, ensure implementation of current interventions, evaluate interventions for effectiveness, monitor intakes of supplements, and promptly communicate weight changes to the doctor and dietician resulted in continued, severe weight loss for Resident #11.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY CONDUCTED ON 10/21/19 Based on observation, record review, review of professional references, review of the facility's policy, and resident and staff interviews, the facility failed to ensure residents remained free from significant medication errors for 1 of 3 sampled residents (Resident #5) receiving [MEDICATION(S)] (an anticoagulant medication) who experienced a significant medication error. Failure of facility staff to clarify and obtain a signed physician order ergarding [MEDICATION(S)] dose change resulted in a critically high INR value (international normalized ratio, a test to ensure blood clots normally), a hematoma, and excessive bruising. Findings include: Berman, Snyder, and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., [NAME] Education, Inc., Massachusetts, page 68, stated, . Carrying Out a Physician's Orders . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Question and record verbal orders to avoid miscommunications . In addition to recording the time, the date, the primary care provider's name, and the orders, the nurse documents the circumstances that occasioned the call to the primary provider, reads the orders back to the primary care provider confirmed the orders as the nurse read them back . pg. 752, stated, . nurses should question any order that appears unreasonable and refuse to give medication until the order is clarified . Wolters Kluwer Nursing 2017 Drug Handbook, 37th Edition, page 1512, stated, . [MEDICATION(S)] . Usual maintenance dosage is 2 to 10 mg [milligrams] P.O. [by mouth] daily . Recommended INR range is usually 2 to 3 for most patients . Review of the facility policy titled RECEIVING AND RECORDING MEDICATION ORDERS occurred on 05/19/21. This policy, dated 06/01/17, stated, . Supervision by a Physician . Orders will be written/signed and placed in chronological order in the medical record . Telephone or verbal orders must be countersigned by the physician within forty-eight (48) hours of receiving the order . During an interview on 05/16/21 at 2:30 p.m. Resident #5 stated she was receiving double the amount of [MEDICATION(S)] she normally received and developed a hematoma (collection of blood) on her right side. Resident #5 showed this surveyor her hematoma on right lower abdomen which had a light purplish color. The resident also described the area as hard when touched. Review of the medical record for Resident #5 occurred on all days of survey and included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's nurses' notes (NN) and physician orders (PO) identified the following: * (NN) 03/23/21 at 5:24 p.m. - INR 2.2 . Received orders from [doctor's name]/INR Clinic to change [MEDICATION(S)] to 5 mg 5mg [sic] today then 7.5 mg daily. Recheck INR 3/29/2021. * An unsigned verbal (PO) 03/29/21 - [MEDICATION(S)] Tablet ([MEDICATION(S)] Sodium) Give 7.5 mg by mouth in the evening for INR 2.3 . * An unsigned verbal (PO) 04/05/21 - [MEDICATION(S)] Tablet ([MEDICATION(S)] Sodium) Give 17 mg by mouth one time a day for anticoagulant therapy. INR today 2.6 . * (NN) 04/15/21 at 1:52 p.m. - Resident has some reddened area to her lower abdomen, site is used for insulin injections. Currently resident hematoma is intact with no drainage . Per protocol we need to informed [sic] her primary care physician. Will continue to monitor. * (NN) 04/19/21 at 11:20 a.m. - Resident continues to have hematoma on R) [right] lower abdomen . Resident is on long term [MEDICATION(S)] . Resident has large, hard area to R)abdomen warm to touch. This area is noted to have began on 4/15/22 [sic] after insulin injection. Provider was contacted. Resident INR 8.0 [critical level] per INR machine and venous INR will be drawn at this time . Phone call to MD [medical doctor], awaiting response . The venous INR collected on 04/19/21 at 11:28 a.m. showed a prothrombin time (PT) 162.6 seconds (high level) (reference range 9.4 - 12.5) and an INR 14.1 (critical level) (suggested therapeutic range 2.0 - 4.0). A fax received from the physician, dated 04/19/21 at 2:06 p.m., stated, Hold [MEDICATION(S)] till INR below 3 . Vitamin K 2.5 mg PO today . Daily INR x [times] 3 days & [and] fax results to Anticoagulant clinic daily . An assessment form from the Anticoagulation Clinic, dated 04/23/21, stated, . I spoke with [doctor name] today and she confirmed that patient not have [sic] any medication changes from her appt [appointment]. [Doctor] noticed the MAR [medication administration record] read [MEDICATION(S)] 17 mg daily and that the patient received that dose x2 weeks . During an interview on the afternoon of 05/18/21, an administrative nurse (#2) confirmed staff failed to transcribe the [MEDICATION(S)] order correctly, administered 17 mg of [MEDICATION(S)] for two weeks instead of 7.5 mg, and failed to complete an investigation related to the significant medication error.

1. Based on record review, review of professional references, review of the facility's policy, observation, resident and staff interviews, the facility failed to ensure residents received treatment and services to maintain the highest practicable physical well-being for 1 of 3 sampled residents (Resident #5) on [MEDICATION(S)] (an anticoagulant medication). Failure to accurately transcribe a physician's order and monitor Resident #5 for side effects of anticoagulant use resulted in a critically high INR value (international normalized ratio, a test to ensure blood clots normally) which required Vitamin K treatment to reverse, as well as a hematoma and excessive bruising. Findings include: Berman, Snyder, and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., [NAME] Education, Inc., Massachusetts, page 68, stated, . Carrying Out a Physician's Orders . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Question and record verbal orders to avoid miscommunications . In addition to recording the time, the date, the primary care provider's name, and the orders, the nurse documents the circumstances that occasioned the call to the primary provider, reads the orders back to the primary care provider confirmed the orders as the nurse read them back . pg. 752, stated, . nurses should question any order that appears unreasonable and refuse to give medication until the order is clarified . Wolters Kluwer Nursing 2017 Drug Handbook, 37th Edition, page 1512, stated, . [MEDICATION(S)] . Usual maintenance dosage is 2 to 10 mg [milligrams] P.O. [by mouth] daily . Recommended INR range is usually 2 to 3 for most patients . Review of the facility policy titled RECEIVING AND RECORDING MEDICATION ORDERS occurred on 05/19/21. This policy, dated 06/01/17, stated, . Supervision by a Physician . Orders will be written/signed and placed in chronological order in the medical record . Telephone or verbal orders must be countersigned by the physician within forty-eight (48) hours of receiving the order . During an interview on 05/16/21 at 2:30 p.m. Resident #5 stated she was receiving double the amount of [MEDICATION(S)] she normally received and developed a hematoma (collection of blood) on her right side. Resident #5 showed this surveyor her hematoma on right lower abdomen which had a light purplish color. The resident described the area as hard when touched. Review of the medical record for Resident #5 occurred on all days of surveyand included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's nurses' notes (NN) and physician orders (PO) identified the following: * (NN) 03/23/21 at 5:24 p.m. - INR 2.2 . Received orders from [doctor's name]/INR Clinic to change [MEDICATION(S)] to 5 mg 5mg [sic] today then 7.5 mg daily. Recheck INR 3/29/2021. * An unsigned verbal (PO) 03/29/21 - [MEDICATION(S)] Tablet ([MEDICATION(S)] Sodium) Give 7.5 mg by mouth in the evening for INR 2.3 . * An unsigned verbal (PO) 04/05/21 - [MEDICATION(S)] Tablet ([MEDICATION(S)] Sodium) Give 17 mg by mouth one time a day for anticoagulant therapy. INR today 2.6 . * (NN) 04/15/21 at 1:52 p.m. - Resident has some reddened area to her lower abdomen, site is used for insulin injections. Currently resident hematoma is intact with no drainage . Per protocol we need to informed [sic] her primary care physician. Will continue to monitor. * (NN) 04/19/21 at 11:20 a.m. - Resident continues to have hematoma on R) [right] lower abdomen . Resident is on long term [MEDICATION(S)] . Resident has large, hard area to R)abdomen warm to touch. This area is noted to have began on 4/15/22 [sic] after insulin injection. Provider was contacted. Resident INR 8.0 [critical level] per INR machine and venous INR will be drawn at this time . Phone call to MD [medical doctor], awaiting response . The venous INR collected on 04/19/21 at 11:28 a.m. showed a prothrombin time (PT) 162.6 seconds (high level) (reference range 9.4 - 12.5) and an INR 14.1 (critical level) (suggested therapeutic range 2.0 - 4.0). A fax received from the physician, dated 04/19/21 at 2:06 p.m., stated, Hold [MEDICATION(S)] till INR below 3 . Vitamin K 2.5 mg PO today . Daily INR x [times] 3 days & [and] fax results to Anticoagulant clinic daily . An assessment form from the Anticoagulation Clinic, dated 04/23/21, stated, . I spoke with [doctor name] today and she confirmed that patient not have [sic] any medication changes from her appt [appointment]. [Doctor] noticed the MAR [medication administration record] read [MEDICATION(S)] 17 mg daily and that the patient received that dose x2 weeks . During an interview on the afternoon of 05/18/21, an administrative nurse (#2) confirmed staff failed to transcribe order correctly and gave 17 mg of [MEDICATION(S)] for two weeks instead of 7.5 mg. The facility failed to complete an investigation related to this medication error. 2. Based on observation, information received from a complainant, record review, and staff interview, the facility failed to provide care and services in a manner to maintain the highest practicable well-being for 2 of 19 sampled residents (Resident #27 and #36) observed. Failure to provide positioning devices in a Broda chair for Resident #36 and apply ACE wraps for Resident #27 placed the residents at risk for discomfort/pain, increased skin concerns, and infections. Findings include: Information received from the complainant indicated the facility staff failed to follow physician's orders for wound care. - Review of Resident #27's medical record occurred on all days of survey. A physician order, dated 04/01/21, stated, [CONDITION(S)] to BLE [bilateral lower extremities] management: Cleanse BLE with wound cleanser, apply vasoline impregnated gauze to any open areas, wrap with [MEDICATION(S)] [gauze] and wrap with ACE [a proprietary elastic bandage] wraps once daily and as needed. Random observations on days of survey showed Resident #27 without ACE wraps to both lower legs per physician's order. Review of the May 2021 Treatment Administration Record (TAR) showed staff failed to document the application of ACE wraps on 7 of 19 days. The facility failed to ensure staff applied ACE wraps per physician's orders for Resident #27 to ensure healing and decrease risk of infection. - Review of Resident #36's medical record occurred on all days of survey and included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Assist with daily hygiene, grooming, . An annual Minimum Data Set (MDS), dated [DATE], identified extensive assistance with transfers and bed mobility with 2 or more staff. Observations of Resident #36 showed the following: * 05/16/21 at 3:21 p.m., in Broda chair hunched over, head resting on knees. * 05/17/21 at 9:27 a.m., in Broda chair hunched over, head in lap. * 05/17/21 at 1:07 p.m., in Broda chair hunched over, head rested on left arm rest. * 05/17/21 at 4:53 p.m., in Broda chair hunched over, appeared close to falling out of the chair. During an interview on 05/19/21 at 2:11 p.m., a therapist (#22) stated the facility switched Resident #36 from a regular wheelchair to the Broda chair about six months ago. The therapist agreed the resident was not properly positioned in the Broda chair, no facility chair reevaluation completed, and no positioning devices attempted.

Based on information received from the complainants, observation, record review, and staff interview, the facility failed to provide the necessary care and services to prevent the development and promote healing of pressure ulcers for 2 of 2 sampled residents (Resident #3 and #14) and 1 discharged resident (Resident #17) at risk of developing and/or with known ulcers. Failure to implement, monitor, and modify interventions to reduce risk factors and consistently provide treatment to prevent the development of new pressure ulcers and/or heal current pressure ulcers resulted in Resident #14 and #17 developing avoidable facility-acquired pressure ulcers and had the potential to result in other residents (Resident #3) developing skin breakdown. Findings include: Information provided by the complainants indicated nursing staff failed to consistently utilize physician ordered interventions in a timely manner to prevent and/or heal ulcers. Review of the facility policy titled Skin Management System occurred on 06/10/19. This undated policy stated, . Pressure Ulcers, Venous Ulcers, and Arterial Ulcers, and surgical sites will be documented on . form or EMR (electronic medical record). Use one form per wound. Wound progress is to be documented each week with measurement and wound descriptions. Daily treatments are also documented on the same form. Skin issues such as skin tears, bruises, rashes, abrasions,[MEDICAL CONDITION]. will be documented . - Review of Resident #14's medical record occurred on all days of survey. The Significant Change Minimum Data Set (MDS), dated [DATE], identified extensive assistance from two or more people for bed mobility, one Stage II pressure ulcer, and one venous and arterial ulcer. Right Lower Leg Resident #14's current physician order stated, .Wound to right lower extremity: Apply santyl ointment to dark eschar tissue. Apply hydrogel gauze over santyl (not on good tissue). Cover with non-adherent dressing. Wrap with gauze and with tape. Apply protective ointment to peri-wound area. Change daily. Wound nurse to follow (started 05/17/19) . Resident #14's progress notes showed the following: * 03/06/19 at 7:44 a.m. - Resident has a wound on lower right calf. cleansed with NS. Patted dry. TAO (triple antibiotic ointment) applied and covered . MD (physician) notified. * 03/06/19 at 12:43 p.m. - New orders for wound to lower right leg. Apply steri strips to wound, apply gauze and [MEDICATION NAME]. Change gauze and [MEDICATION NAME] BID (twice per day). * 03/08/19 skin assessments shows open area to right lower leg (RLL) 11 centimeters (cm) x 4 cm No further documentation regarding right lower leg until 05/04/19 *05/04/19 at 11:41 a.m. - Writer was dressing RLL and noted open areas that were weeping and swelling from ankle to mid-leg. Area is red, no warmth noted. MD notified via phone, ordered [MEDICATION NAME] over open areas, change MWF (Monday, Wednesday, Friday). Ace wraps to be put on from foot to mid leg and taken off at HS (night) . * 05/06/19 at 10:05 a.m. - Resident RLL (right lower extremity) continues to be weeping and writer noted bleeding. CNA (certified nursing assistant) reported foul odor when removing dressing for shower. Area is red, warm and tender to touch, no swelling noted . MD has been updated via fax. * 05/07/19 at 6:13 p.m. - . Dressing change to right lower lateral leg. Area is red, cool to touch et draining clear fluid . * 05/08/19 at 3:32 a.m. - Resident has a treatment to RLE (right lower extremity) for swelling and weeping . some redness present which may be related to dressing changes and ACE wrap. at (sic) this time RLE is not wrapped with bandage. Will continue to monitor and notify md of any changes or worsening. * 05/09/19 at 5:47 a.m. - . discoloration to area scattered. some redness and purplish skin present which may be related to dressing changes and ACE wrap. at (sic) this time RLE is not wrapped with bandage . Will continue to monitor and notify md of any changes or worsening. Review of record showed the doctor responded to fax on 05/09/19. The physician stated he/she would see the resident tomorrow (4 days after symptoms reported). * 05/10/19 at 12:37 p.m. - . Ulcer on right leg is red, with darken area small amount of clear fluids was seen draining at left lateral aspect of wound . * 05/10/19 at 7:21 p.m. - . rt lower leg wound- dakens wet to dry BID until healed . wound nurse to follow, [MEDICATION NAME] 100mg (milligrams) po (oral intakes) BID X 7 days. * 05/11/19 at 2:29 p.m. - Resident's ulcer on right leg is blackish in color . minimal serosanguineous drainage . * 05/12/19 at 11:07 a.m. - . Eschar/scabbing is resolving. Yellow purulent drainage . * 05/13/19 at 9:50 p.m. - . area has some debrided areas and some dark colored tissue . * 05/15/19 at 10:49 p.m. - Continues on an antibiotic for RLE wound. wound (sic) area is around lower ankle, dark tissue, with some small areas of debridement . * 05/16/19 at 2:43 p.m. - Order received from (doctor name) . apply santyl to dark eschar tissue, apply hydrogel gauze over eschar, cover with non-adherent [MEDICATION NAME] dressing, wrap with gauze and secure with tape . Wound nurse to follow. * 05/19/19 at 1:01 p.m. - . Wound on her right lower extremity drains has a serosanguinuous drainage, black skin tissue softens and easily removed. * 05/20/19 at 2:47 p.m. - . (doctor name) recommended resident be seen in the emergency department due to [MEDICAL CONDITION] . * 05/20/19 at 6:17 p.m. - Resident admitted to . Trinity Health hospital . * 05/24/19 at 11:28 a.m. - Resident returned to facility . New orders for [MEDICATION NAME] 250mg PO every other day x3 days . Right lower leg has minimal eschar and slough present, wound bed is pink . Review of Resident #14's Admission/Readmission Evaluation on 05/24/19 identified a Stage III vascular ulcer to right lower leg (front). The record showed no further documentation after 05/24/19 regarding the progress of the wound. Review of progress notes and skin/wound assessments identified the facility failed to document weekly measurements. Coccyx Resident #14's current physician order stated, . [MEDICATION NAME] to open areas on bottom. Change every MWF until healed (started 05/01/19) . Resident #14's progress notes showed the following: * 04/27/19 at 1:50 p.m. - Writer noted three open areas to resident's bottom. the (sic) first one measures 0.8cm x 1cm on the left buttock and the second one measures 0.5cm x 0.8cm on the left buttock, and the third one measures 0.4 cm x 0.5cm on the right buttock. Foam dressings applied. Writer also noted redness around anal area, calmo applied. Will update MD at this time and continue to monitor. * 04/29/19 at 9:31 a.m. - MD would like areas on bottom to be treated with [MEDICATION NAME], change every MWF . Physician's order to start [MEDICATION NAME] on 04/29/19 to the open area on bottom. Review of (MONTH) 2019 Treatment Administration Record (TAR) showed Resident #14's treatment failed to be started until 05/01/19. Review of progress notes and skin/wound assessments showed the facility failed to document weekly on the progress of the wounds including measurements and descriptions. Right Toe The current physician order stated, . Paint wound on RT 1st MTPJ (metatarsophalangeal joint) wound, with [MEDICATION NAME] and cover with a [MEDICATION NAME] type bandage change daily (started 02/28/19) . Resident #14's progress notes showed the following: * 02/19/19 9:17 p.m. - (Doctor name) here to round on resident, order rec'd (received) to continue [MEDICATION NAME] dressing to rt MTP joint ulcer until healed. Change every 3 days and prn. Appt with podiatry for evaluation. * 02/27/19 7:33 p.m. - Resident went out to a podiatry appt. (appointment) today, recommends paint wound with [MEDICATION NAME] and cover with [MEDICATION NAME] type dressing daily. No soaking. * 05/11/19 6:39 p.m. - .Ulcer on right phalangeal region . * 05/28/19 3:01 p.m. - Has vascular wound on her toe. Review of progress notes and skin/wound assessments identified the facility failed to document weekly on the progress of the wound including measurements and descriptions. - Review of Resident #17's medical record occurred on all days of survey and identified [DIAGNOSES REDACTED]. Right Second Toe The progress notes identified the following: * 12/06/18 at 7:00 a.m. and 12/07/18 at 10:13 a.m., Will update MD Resident rt (right) great toe (nail) came off during showers . her second rt toe has a 2 cm (centimeter) wt (width) by 1.2 cm Lt (left) pressure area. Skin is intact and without drainage. Site is red, resident denies sensation or pain . * 12/11/18 at 3:26 p.m., This nurse paged (physician) regarding resident sore toe. He ordered Keflex 500 mg (milligram) PO (by mouth) TID (three times per day) for 10 days. First dose given by this nurse. The facility notified Resident #17's physician five days after discovering the pressure area on her right second toe. The facility failed to notify Resident #17's physician in a timely manner, paging him five days after they discovered the ulcer on her toe. * 12/12/18 at 10:39 a.m., . Pharmacy called and reported a different dosage, Author contacted (Physician), and confirmed dosage with (Physician) and pharmacy . and at 8:48 p.m., Resident continues with Keflex abt (antibiotic) 250 mg po Tid x 10 days for infection [MEDICATION NAME] to right great toe nail bed where toenail came off . Right great toe nail bed is dark pink (and) without any drainage. Right 2nd toe distal joint has a 2 cm (W) (width) x 1/2 cm (L) (length) red area that blanches. Resident denies any pain to the toes . * 12/13/18 at 3:58 a.m., Resident great toe and distal middle toe assessed. No drainage, swelling or signs of infection observed. Resident denied pain. * 12/14/18 at 9:33 p.m., Resident continues with alert charting for infection to right second toe distal joint. Right 2nd toe is red with a small yellow hardened area to anterior aspect. No drainage. Site blanches. Resident denies having any pain. Right great toe nail bed . has no redness or drainage. * 12/17/18 at 9:18 p.m., . continues on Keflex . 2nd toe right foot distal joint has a red area with a firm yellow center that has a scab forming. No drainage. Area left OTA (open to air). Resident denies any pain or discomfort to the right foot (and) toes. * 12/18/18 at 9:07 p.m., . remains on Keflex . Right 2nd toe distal joint is slightly red (and) blanches with palpation. Center of red area has a small circular hard white area with scab forming. No drainage (and) OTA. Resident denies any pain or discomfort to her toes. * 12/19/18 at 9:00 p.m., . continues with Keflex . Right second toe distal joint has a slightly red area with small circular yellow center with scab formed. No drainage. The care plan identified, . Date Initiated: 12/17/2018 . Infection of wound/skin (Right great toe) . Administer meds as ordered, Diagnostic tests as ordered, Maintain precautions as indicated, Obtain labs as ordered and notify MD of results, Record temperature as clinically indicated. Date Initiated: 12/19/2018 . Scab at right 2nd toe r/t (related to) friction, impaired mobility, diabetes . Administer treatment per MD orders, Diet and supplements per MD orders, Encourage and assist as needed to turn and reposition, use assistive devices as needed, Float heels as able, Follow up care with MD as ordered, Report evidence of infection such as purulent drainage, swelling. Localized heat, increased pain, etc. Notify MD PRN (as needed). Progress notes also identified the following: * 12/20/18 at 8:00 p.m., . continues with Keflex . Right 2nd toe is slightly red with small white center forming a scab. No drainage. no c/o pain to toe. * 12/21/18 at 4:16 p.m., Wound nurse assessed the open area to resident's right foot 2nd toe. The wound measures 1.1 cm x 0.9 cm. The wound bed contains 100% hard slough. No drainage. No odor. No c/o pain. The wound nurse recommends that the area be cleansed with normal saline. Apply Antisept, and wrap in gauze. Change daily. The facility failed to measure the wound for nine days. * 12/22/18 at 1:06 p.m., . continues with Keflex . Right 2nd toe is slightly red with small white center forming a scab. No drainage. * 12/25/18 at 8:00 p.m., . completed . Keflex . right 2nd toe distal joint has a small scab dry (and) intact (and) base of toe is slightly red (and) warm to touch. This note faxed to Dr. * 12/26/18 at 10:05 p.m., . Right 2nd toe distal joint has a small brown scab dry (and) intact. Base of right 2nd toe is slightly red (and) warm to touch. denies any pain or discomfort. The chart lacked evidence that the ulcer resolved, as staff failed to document further observations of the toe. The quarterly MDS, dated [DATE], identified the resident was at risk of developing pressure ulcers and had moisture associated skin damage. The physician's orders identified, Start Date 03/07/19 . Skin evaluation every Thursday AM, every day shift every Thu (Thursday) . The next set of progress notes addressing Resident #17's toe identified the following: * 03/10/19 at 9:49 p.m., Resident's daughter approached this recorder and stated, my Mom's toe is infected . On exam 2nd toe on rt foot is light red, no swelling noted, has a dry callous type lesion of DP (sic) joint area, no drainage noted, residents (sic) states it does not hurt . Callous is dry measures 0.9 cm x 1 cm. The facility failed to identify the observable changes to Resident #17's toe prior to family voicing their observations/concerns. * 03/11/19 at 2:54 p.m., . Resident has Dx (diagnosis) of [MEDICAL CONDITION] to right 2nd toe. New orders for . [MEDICATION NAME] 100 mg tab po Bid x 7 days . Apply [MEDICATION NAME] daily to right 2nd toe. The significant change MDS, dated [DATE], identified the resident was at risk of developing pressure ulcers and infection of the foot (e.g., [MEDICAL CONDITION], purulent drainage). A progress noted, dated 03/12/19 at 4:41 a.m., identified, . received first dose of [MEDICATION NAME] . Toe is [DIAGNOSES REDACTED] and slightly warm to touch. Skin is intact. No drainage noted. She stated only has pain when blanket is laying on the foot. Blanket was pulled back and she stated she had relief. and at 9:11 p.m., . Right 2nd toe is red (and) swollen. Anterior distal tip of toe has a small circular open area with no drainage. Resident denies any pain or discomfort to toe. The facility failed to measure the open area on the tip of Resident #17's toe. The care plan identified, . Date Initiated: 03/12/2019 . Infection of wound/skin (right 2nd toe) . Administer meds as ordered, Maintain precautions as indicated, Record temperature as clinically indicated. The care plan failed to address removing pressure from the top of Resident #17's feet. Progress notes also identified the following: * 03/17/19 at 2:52 a.m., . continues taking [MEDICATION NAME] . No drainage. Denies of (sic) any pain. Foot elevated while in bed. * 03/18/19 at 9:05 p.m., . took last dose of Doxycycine . Right 2nd toe is dark pink with small circular scab to the anterior tip of toe. No drainage. Resident denies any pain or discomfort. * 03/29/19 at 1:27 p.m., Received new order from podiatry . Continue [MEDICATION NAME] treatment to right second toe for 7 days then discontinue. * 04/03/19 at 11:19 a.m., Note received from (Physician) with addendum made to specify painful calluses and ulceration to right 2nd toe, left foot hammer toe deformity and callus the left big toe. * 04/09/19 at 6:03 p.m., Resident's daughter . concerned that resident's right 2nd toe diabetic vascular ulcer is not improving. I note that right 2nd toe has a very thick necrotic black 0.8 cm circular scab dry (and) intact. No drainage. Surrounding toe is slightly red. Right foot is slightly cool to touch with pedal pulses palpable. Resident denies any pain or discomfort to the right foot. ROM (range of motion) (and) sensation is intact to right foot (and) toes when palpated (sic). Daughter . requests that a f/u (follow up) appointment be made ASAP (as soon as possible) with podiatrist . Staff failed to identify the observable necrosis to Resident #17's toe prior to family voicing their observations/concerns. The facility failed to measure/assess the ulcer since it was first identified on 03/12/19. * 04/17/19 at 2:25 p.m., Made an appointment with . podiatry to see if resident scabbed to her right second toe can be debride (sic). Staff failed to schedule an appointment with Resident #17's podiatrist in a timely manner, contacting his office eight days after the family made their request. * 04/22/19 at 2:00 p.m., Resident returned from appointment with podiatrist . No new orders. Dr. report states improving [MEDICAL CONDITION] right 2nd toe. Continue observation . The only weekly skin review provided by the facility, dated 05/02/19, identified, Skin intact, dry. Four days later, a progress note, dated 05/06/19 at 1:41 a.m., identified, Medial right great toe is not blanchable, black in color, redness present at ankle to black area at base of the toe. redness measures 22 cm in length from above the ankle to base of toe. blackened area on toe is 5 cm x 2 cm. Areas between the toes are flesh colored. 2nd toe has 1 cm x 1 cm area previously noted to be discolored and is in notes from podiatry. 3rd toe has reddened area 1 cm x 1 cm right lowere extremity is warm and dry, no [MEDICAL CONDITION] present, dorsal part of foot is cool to touch as are the toes, reflexes in expremity and foot present. telephone order OK to transfer resident to ER and treat per family request. Family in facility requesting resident be transferred to hospital for eval and treatment related to recent [DIAGNOSES REDACTED] and discolored toe. On 04/09/19, staff described a very thick necrotic black 0.8 cm circular scab. The chart lacked documentation regarding the toe until 05/06/19, at which time staff described a blackened area on toe, is 5 cm x 2 cm. During an interview on 06/06/19 at 8:00 a.m., when asked questions pertaining to Resident #17's ulcer, a managerial nurse (#5) stated, Originally, it was due to pressure, then they decided it was a diabetic ulcer, and then it became necrotic. She was put on antibiotics when she went to the hospital. When asked questions pertaining to the facility's care expectations, the managerial nurse (#5) stated, What they were supposed to do was complete a weekly wound tracker. Every week the Nurse Manager measures pressure sores. I would assume they started a wound tracker as soon as they found the sore. They would document the size, color, drainage, and stuff. I couldn't find a weekly skin assessment either. The weekly skin assessment would catch any other type of skin issue, non-pressure sore. so we know it's there. The facility failed to: * Notify physician in a timely manner after discovering the ulcer on Resident #17's toe, * Accurately identify/document observations of the infected area, * Measure Resident #17's toe ulcer in a timely manner/weekly per facility policy, * Document if/when Resident #17's ulcer resolved, * Assess/identify observable color changes/necrosis on Resident #17's toe, * Care plan the need to remove pressure from the top of Resident #17's feet, and * Schedule an appointment with the podiatrist in a timely manner after discovering the necrosis on Resident #17's toe. - Review of Resident #3's medical record occurred on all days of survey. A Significant Change MDS, dated [DATE], identified a risk for pressure ulcer, no pressure ulcer present, pressure reducing device for chair, and pressure reducing device for bed. The current care plan, dated 04/10/19, stated, . resident has suspected deep tissue injury to buttock, coccyx area r/t (related to) immobility during recent hospital stay . The resident requires an APM (air pressure mattress)for her bed . Observation on 06/05/19, at 9:55 a.m., showed two CNAs (#3 and #4) assisted Resident #3 from the wheelchair to the bed, performed ADL's (activities of daily living) and exited Resident #3's room. Resident #3's air mattress pump was unplugged from the electrical outlet. The CNAs failed to assure the air mattress was on and fully inflated. During an interview on 06/06/19 at 9:05 a.m., an administrative nurse stated he/she would expect staff to make sure the air mattress was on and lying on the bed frame would create a problem because there is nothing soft to prevent the resident from lying on the steel frame.

1. Based on record review, review of facility policy, staff interview, and information provided by the complainant, the facility failed to provide the necessary assistance to prevent falls with injury for 1 of 1 sampled resident (Resident #4) and 1 of 1 record of a resident discharged from the facility (Resident #10) who experienced falls with injury which resulted in hospitalization . Failure of the facility to reassess Resident #10 and implement fall safety interventions for Residents #4 and #10 resulted in unwitnessed falls resulting in injury requiring emergency care. Findings include: Information provided by the complainant indicated facility staff failed to provide care in a manner that ensured the safety of residents. The complainant indicated facility staff failed to initiate fall prevention interventions in a timely manner. Review of a facility document, titled "Fall Practice Guide Flowchart," occurred on 11/20/13. The document, dated 2011, stated, "Assess: . . . Complete MDS (Minimum Data Set) . . . Plan: Develop Initial . . . Care Plan . . . Task List . . . Implement: Ongoing Fall Prevention Strategies . . . Evaluate: Change in Condition or Fall Occurrence . . . Eagle Room Review (Interdisciplinary Staff Meeting) . . . Complete Fall Evaluation . . . Revise Initial . . . Care Plan . . . Task List . . ." Resident #10's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The (Hospital) Transfer Record, dated 11/07/12 (upon admission to the nursing home), identified, ". . . Diagnoses: [REDACTED]. . . Mental Status: occasionally confused . . . Ambulation Status: assist, walker . . . Nurse's Report: . . . Follows most commands, Doesn't always answer . . . (increased) confusion at x's (times) . . ." The quarterly MDS, dated [DATE], identified the resident as moderately cognitively impaired, required extensive assistance of one person for dressing, transfers, walking in room/corridor, locomotion on/off unit, and toilet use, required staff assistance to stabilize when moving from a seated to standing position, walking, turning around, moving on/off toilet and from surface to surface, was frequently incontinent of bowel and bladder, and experienced falls since admit to the facility. The MDS further showed Occupational/Physical therapy (OT/PT) and Restorative Nursing services (RT) were not being provided at the time of the assessment. The current care plan identified, "Focus ADL (Activities of Daily Living) Self care deficit as evidenced by weakness, limited ROM related to recent fall with fractures . . . Interventions . . . Transfer with 1 assist with gait belt, Uses walker and assist of 1 for ambulation. . . . Focus At risk for falls due to unsteady gait, history of falls . . . Interventions . . . Provide assist to transfer and ambulate as needed (Initiated 11/07/12), Staff education regarding wheelchair/resident safety and awareness. (Initiated 11/28/12) . . . Encourage resident to wear nonskid slippers when shoes are removed (Initiated 03/18/13) . . . perimeter mattress (Initiated 04/11/13) . . . Self locking brakes on wheelchair (Initiated 05/03/13) . . . Shoes placed on floor beside bed for easier patient access (Initiated 07/25/13) . . . Resident not to be left unattended in wheelchair in room. To be laid down after meals (Initiated 10/17/13) . . ." The assignment sheet/task sheet utilized by direct care staff, printed 11/20/13, identified, ". . . Usually independent with ambulkation (sic) with cad. (sic) walker . . . FALL RISK perimeter mattress . . . Gait belt for transfer with 1 staff assist . . . Mobility Device: Uses w/c to move about, Non-slip slippers when shoes are removed . . ." Resident #10's progress notes identified the following: * 03/14/13 at 12:28 p.m., "Floor nurse reports that she was alerted by CNA (Certified Nursing Assistant) that resident lying on floor. Entered room to find resident lying on R (right) side with head resting on nightstand. States he landed on his R side. Stated discomfort to R shoulder and R wrist. Noted dark reddened area to R wrist measuring 3.4 x 4.4 cm (centimeters). Skin intact. No redness noted to R shoulder. Physical assessment completed. ROM (Range of Motion) intact to bilateral lower and upper extredmitied (sic). Able to move R wrist and hand. Assisted up with 2 staff and gaitbelt. Resident rates pain at 1/10 . . . Neurochecks initiated per unwitnessed fall. Neuros intact. . . ." * 03/14/13 at 8:40 p.m. and 03/15/13 at 5:51 p.m., ". . . resident still continue (sic) to get out of bed and wheelchair without asking for assistance. . . ." The fall event form, dated 03/14/13 at 12:37 p.m., stated, "States was trying to get up per self. Call light not on. Declined need to void. Staff to ensure up for meals 15 minutes prior to meal time." The facility failed to add this intervention to Resident #10's care plan. The progress notes identified the following: * 03/16/13 at 10:10 p.m., identified, "pt (Patient) was noted on floor beside bed laying on back, no shoes or socks on, wc (wheelchair) bedside (sic) bed, call light noted attach (sic) to pillow. pt states that he was getting out of w/c when he got dizziness (sic) and fell . noted a skin tear to LFA (left forearm), 3 cm x 2.5 cm in size. no other injuries noted. . . . pt c/o (complained of) of pain to neck and back, neuro checks normal. . . ." The facility initiated the following fall intervention on 03/18/13: "Encourage resident to wear nonskid slippers when shoes are removed." * 03/24/13 at 4:39 p.m., "Resident . . . Has been instructed to use call light so staff can assist to bath room is forgetful lacks safety awareness and lacks understanding of his limitations." * 03/25/13 at 9:49 a.m., "Noted to have recent increase in falls. . . . requesting . . . PT (Physical Therapy) to evaluate and treat for strengthening. . . ." * 03/26/13 at 3:46 p.m., "PT attempted evaluation today to address multiple falls. Pt refused at this time, will attempt tomorrow." * 03/27/13 at 2:16 a.m., "pt transfer (sic) self to commode twice during shift. pt did not use call light for assistance. pt instruct (sic) to call for assistance with transfer and toileting to prevent falling." The rehabilitation progress note, dated 03/29/13, identified, "PT eval (evaluation) (with) Tx (Therapy) order completed on this date. . . . skilled PT appropriate due to high frequency of falls. . . ." The progress notes identified the following: * 03/31/13 at 2:21 a.m., "(Resident #10) was found laying on the floor next to his bed. Stated, 'I rolled out of bed.' A skin tear to left elbow 1.0 cm x 1.0 cm reddened area to the lower left back approx (approximately) 10.0 x 12.0 cm, with skin abrasion in the middle, approx 6.0 cm x 5.0 cm A purple bruise to left forearm approx 14.0 cm x 7.0 cm. (Resident #10) denies hitting his head . . . Neuro checks started . . ." * 03/31/13 at 9:06 a.m., ". . . A small abrasion noted to right mid back, and and (sic) abrasion to left elbow. . . ." The fall event form, dated 03/31/13, stated, "Fall mat in place while in bed." The facility failed to add this intervention to Resident #10's care plan. The progress notes identified the following: * 04/03/13 at 12:39 p.m., ". . . pt continues to transfer self from w/c to bed, w/c to commode. pt instructed to call for assistance with transfers to prevent falling." The facility initiated the following fall intervention on 04/11/13 (11 days after he fell from his bed): "Perimeter mattress." * 05/15/13 at 3:19 p.m., ". . . He also has a history of falls. Physical therapy reports that they are currently working (sic) strengthening and walking with resident. . . ." * 06/07/13 at 2:51 a.m., ". . . (Resident #10) was caught transferring self from the bed to w/c or from toilet to w/c. . . . Staff educated (Resident #10) to wait for help and that he could fall during his transfer. (Resident #10) had no response to staff." A rehabilitation progress note, dated 06/21/13, stated, "D/C (Discontinue) skilled PT . . . Pt able to amb (ambulate) to/from meals with 4ww (4 wheeled walker) (SBA-CGA) (standby assist-contact guard assist) up to 200 feet, in addition, he needs CGA-SBA for transfers. w/c for longer distance. . . ." A progress notes dated 07/24/13 at 2:29 p.m. stated, "Staff responded to patient yelling and found him on the floor in his room lying on his right side in front of the couch. Patient had been in bed and was going to take himself to the bathroom using the w/c and chair rolled away from him. Denies injury . . . Neurochecks started . . ." The incident report, dated 07/24/13, stated, "Resident was attempting to take himself to the bathroom, stated that his shoes were in his chair so he was going to put his shoes on the couch, when he went to do so, he stated that he fell , he denies hitting his head, denies pain et (sic) states that he was not injured. The w/cf (sic) was at his side as he was pushing the wheelchair." The progress notes identified the following: The facility initiated the following fall intervention on 07/25/13: "Shoes placed on floor beside bed for easier patient access (even though Resident #10 required extensive assistance for both dressing and transfers)." * 07/27/13 at 4:50 p.m., ". . . needs much assistance e (sic) by staff to go to bath room and transfer but this is the norm for resident." * 08/04/13 at 2:48 p.m., ". . . is frequently reminded to use assistance for transfers . . ." * 09/25/13 at 10:49 p.m., ". . . Neuro checks WNL (within normal limits) Res. (Resident) has a cut to bridge of nose with dressing intact. No drainage noted. Res. has 6 cm by 1 cm ped (sic) purple area down length of nose. Res. has reddened areas under both eyes. Res. has deep pudple (sic) bruise to right ear approximately 4 cm by 1 cm. . . ." Facility staff failed to document Resident #10's 09/25/13 fall in the progress notes. The incident report, dated 09/25/13, stated, "resident was transferring from wheelchair to bed, and apparently mis-judged distance and hit head/glasses on headboard." A physician order, dated 09/25/13 (and written following the Resident #10's second fall from his wheelchair), stated, "Cold compress to L forehead - prn (as needed), paper tape to skin tear to nose, monitor daily, follow fall protocol (per facility)." The progress notes identified the following: * 09/26/13 at 2:44 a.m., "Resident had facial discomfort . . . Right ear has dark bruise to area and below eyes with bruise to nose area and paper tape to nose abrasion from bumping face. . . . Would not open right (sic) due to fall. Refused to open right eye for staff. . . ." * 09/26/13 at 11:29 a.m., ". . . all neuro's intact . . . does have skin tear to bridge of nose, papertape intact, bruise noted today to right ear also." The facility failed to complete a fall evaluation, revise the interdisciplinary care plan, or update the task list as per physician's orders [REDACTED]. * 10/16/13 at 6:40 p.m., "At 6:40 p.m., pt. was found on the floor of his room next to his wheelchair. Pt was assessed. . . . Pt had a large gash in his forehead that was bleeding continuously. L (left) hand was swollen and purple. Had a (sic) gashes on L side of nose and bridge of nose. L knee purple and swollen. . . . (On-call Physician) was notified at 7 p.m. Order for pt to go to to (sic) the ER (emergency room ) for evaluation. Pt left facility at 7:20 p.m. via ambulance." * 10/16/13 at 11:21 p.m., "Resident arrived back in the facility via ambulance/stretcher." * 10/17/13 at 2:16 a.m., ". . . (Physician) ordered to take out the sutures after 10 days . . . Change dressing daily, apply Bacitracin ointment, and non-adherent dressing until resolved. . . . (Resident #10) requested pain med (medication) . . . at 11:30 p.m. and again at 1:30 a.m. C/O pain to right wrist, fingers, and headache. (Resident #10) has bruising to both eyes, bridge of nose, knuckles to both hands and right wrist. Sutures to forehead above nose . . . Swelling noted to fingers, and knuckles bilateral. Swelling noted to right eye. ER nurse reported (Resident #10) broke his nose from the fall. . . ." * 10/17/13 at 10:20 p.m., "Resident is on neuro checks for recent fall. . . ." The facility initiated the following fall intervention on 10/17/13 (after Resident #10 experienced his third fall from the wheelchair): "Resident not to be left unattended in wheelchair in room. To be laid down after meals." * 10/18/13 at 5:52 a.m. and 2:02 p.m., "Continues on neuro checks per policy. Eyes purple and swollen bilaterally. C/o headache . . . Stitches intact to laceration mid forehead . . . Swelling and bruising to hands bilaterally. Transferred self into bed x 1 today. Reminded that he needed to wait for staff to assist with transfers." * 10/18/13 at 8:47 p.m. and 10/19/13 at 1:48 p.m., ". . . Sutures to for head (sic) in tact (sic) and covered . . . Has bruises to face and eyes purple wine color and to back of hands. . . . Remains on Neuro checks." * 10/19/13 at 2:52 p.m., ". . . reminded to use call light for assistancea (sic) . . . neurochecks within normal limits . . ." * 10/21/13 at 1:28 p.m., "Resident is complaining of not feeling well today, cannot specify what it actually is. . . ." * 10/22/13 at 1:15 p.m., "Resident was yelling 'On the floor. On the floor.' Patient was found lying on the floor in front of wheelchair in hallway. Patient's sutures from fall on 10/16/13 had opened up on patient's forehead. Pressure was applied to area to stop the bleeding. Neurochecks started. . . . Paged (Physician) and received order to send to ER for sutures to forehead. . . . Notified ambulance of need for transfer to ER." * 10/22/13 at 1:33 p.m., "Ambulance here to transfer patient to ER." * 10/22/13 at 9:05 p.m., ". . . (Family) stated Resident is being admitted into hospital for possible CVA (cerebrovascular accident/stroke) . . . ." The physician's discharge summary, dated 10/22/13, identified, "Resident admit to (Facility) after hospitalization for falling . . . Resident completed PT (and) OT program for strength, endurance, balance, pain tx and safety awareness. Resident reached his highest level goals that was able to obtain. Resident had numerous falls and started declining in health. . . ." During interviews on 11/20/13 at 11:00 a.m. and 1:30 p.m., an administrative nurse (#1) reported the facility is alarm/restraint free. She described Resident #10 as "impatient" and "not wanting to ask for help." When asked why the facility failed to request a Physical Therapy reassessment for Resident #10, she stated, "PT was offered in the past. He refused sometimes. That's probably why they didn't do it (refer to Physical Therapy)." During an interview on 11/20/13 at 2:00 p.m., when asked who was responsible for assessing a resident's safety, a physical therapist (#13) stated, "Physical Therapy, if it has to do with weakness. We determine if therapy is appropriate, and make safety recommendations." When asked when she would consider it appropriate/expect facility staff to refer a resident to her department, she stated, "It depends on the resident, and what the investigation showed . . . the circumstances of the fall." When the question was rephrased specific to Resident #10, she stated, "With repetitive falls. Maybe after the second fall from the same surface." When asked for examples of the safety recommendations she referred to above, the physical therapist (#13) reported the facility is restraint free. She indicated some interventions (dicem, seatbelts, pummel cushions, even certain types of chairs) would be considered a restraint, and even if determined to be in the resident's best interest (following an assessment), would not be allowed in the facility. When asked what the therapists do if presented with a cognitively impaired resident who has a history of falls, she stated, "It makes it difficult. We could recommend 1:1 care. If we can't care for the resident, maybe they should be referred to another location (facility) who can meet their needs." The facility failed to: * Follow the physician's orders [REDACTED]." * Refer to Physical Therapy/reassess Resident #10's strength, endurance, balance, and safety awareness as per the facility's fall protocol. * Recognize Resident #10's cognitive deficits/poor safety awareness limited his ability to use his call light functionally to request assistance and placed him at risk for further falls. * Update the fall care plan/task list (based on the results of the reassessment) as per the facility's fall protocol, and ensure both documents reflect the same information. * Consider all possible safety interventions (dicem, seatbelt, pummel cushion, a different type of wheelchair, transfer to another facility, etc), if it were determined to be in Resident #10's best interest, following his repeated falls and based upon the results of his reassessment. * Monitor the effectiveness and modify Resident #10's fall interventions when necessary. - Resident #4's medical record, reviewed on all days of survey, indicated [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident as having severe cognitive impairments, required physical assistance of one person for transfers and toilet use, unsteady, required staff assistance for transitions and walking, and frequently incontinent of bowel and bladder. Resident #4's care plan, dated 04/25/13, stated, "Problem: ADL's (Activities of Daily Living): Self care deficit as evidenced by weakness related to physical limitations. . . Interventions: . . . Ambulation: On walk to dine program. Ambulate with assist of one and a gait belt. Often transfers self in room. . . ." Review of Resident #4's progress notes idicated the following: * 07/27/13 at 10:51 p.m., "Resident about to transfer self and to go to bath room and lost grasp of w/c as it was facing toward the head of the bed and he slipped and was found on the floor laying on his left side. Possibly struck a metal part on the side of the w/c and caused considerable skin tear to his left arm. To upper shoulder area 1.24x1 cm, open area not able to approximate the skin with surrounding this sight (sic) a 6x6 redness slight bruise like appearance. To above elbow area left arm 8x4 cm skin tear that was able to approximate the skin and use steri strips with bruising to the area. Above wrist area 4x2.5 cm skin tear approximated and steri strips applied. To inner left arm area bruising and skin tear 13.4x2 cm which as well (sic) it was approximated and steri strips applied. Stockinette was placed on arm to secure area and to prevent steri strips from coming off for protection. . . Resident was instructed to use call light and staff would be in to help him with toileting. . ." * 10/08/13 at 6:15 p.m., "Pt (patient) was found on the floor of his bathroom, still holding onto his chair. Pt. was assessed. . . Denies pain or discomfort. Pupils unequal (L (left) larger than R (right), reactive to light and accommodation. . ." * 11/01/13 at 9:13 p.m., "Resident was found sitting on the floor with his back to the side of the bed. Resident stated he had called out for help and no one came so he self transfers (sic). When examined by staff only notice (sic) left hand/wrist swollen tender to touch no discoloration. Could move fingers and thumb and wrist with pain only to palpation. No discoloration noted. W/c was away from door. Resident assistance (sic) three to mechanical lift to transfer to bed. . . Trinity ER (emergency room ) was called . . . Ambulance was called . . . They placed resident on straight board and cervical collar due to it being a no witnessed fall. . . Resident was alert to name and what occurred but not to date time and place. . ." * 11/01/13 at 11:23 p.m., "ER called and stated resident has a fracture to his hand and that they splinted it and ace wrapped hand and arm. . ." The "Incident Report - Patient Involved" report, dated 11/01/13 at 8:00 p.m., stated, ". . . Description of Incident: Resident found sitting on the floor with his back to the bed had self transferred himself from the bath room. Examined by staff and has left wrist pain and swollen to area able to move fingers, thumb, and wrist. . ." During an interview on 11/20/13 at 1:35 p.m., an administrative nurse (#1) identified the facility interventions following each of the above-mentioned falls. After the 07/27 fall, the interventions included minimizing environmental clutter and reminding the resident to use his call light. Following the 10/08 fall, staff added the intervention of self-locking brakes to the resident's wheelchair. Following the 11/01 fall, staff added the intervention for the resident to receive occupational therapy when he is healed enough. The administrative nurse (#1) stated the facility is restraint free so alarms or positioning devices are not considered as an intervention for fall prevention. The facility failed to provide a copy of the restraint free policy upon requested. The facility failed to ensure Resident #4 received the care and services necessary to attain the highest degree of safety possible when he began falling during self-transfers. THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED ON 04/11/12 and 03/07/13. 2. Based on observation, record review, and staff interview, the facility failed to provide assistive devices necessary to prevent accidents for 1 of 9 sampled residents (Resident #2), 4 of 4 supplemental residents (Resident # 12, #13, #14, and #15), and 2 unknown residents observed without wheelchair foot pedals in place. Failure to apply foot pedals to wheelchairs during staff-assisted transport may result in falls and/or injuries to the residents. Findings include: When requested the facility failed to submit a policy on transferring residents. - Resident #12's medical record, reviewed on 11/20/13, identified [DIAGNOSES REDACTED]. Observation during the initial tour on 11/18/13, showed an unidentified Certified Nurse Assistant (CNA) transported Resident #12 down the hallway to the dining room in a wheelchair without footpedals. During transport, Resident #2's feet brushed the floor. The CNA failed to cue the resident to lift her feet and failed to place footpedals on her wheelchair. - Observation on 11/18/13 at 6:10 p.m. showed an unidentified CNA transported an unknown resident from the dining room down the north hallway in a wheelchair without foot pedals. During transport, the resident's feet brushed the tiled floor. The CNA failed to cue the resident to lift her feet and failed to place footpedals on her wheelchair. - Resident #13's medical record, reviewed on 11/20/13, identified [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident as moderately cognitively impaired and required extensive assistance for locomotion on/off the unit. Observation on 11/19/13 at 9:32 a.m., showed a CNA (#9) transported Resident #13 down the hallway towards her room in a wheelchair without footpedals. During transport, Resident #13's feet brushed the floor. The CNA failed to cue the resident to lift her feet and failed to place footpedals on her wheelchair. - Resident #14's medical record, reviewed on 11/20/13, identified [DIAGNOSES REDACTED]. Observation on 11/19/13 at 9:34 a.m., showed a CNA (#9) transported Resident #14 down the hallway towards her room in a wheelchair without footpedals. During transport, Resident #14's feet brushed the floor. The CNA failed to cue the resident to lift her feet and failed to place footpedals on her wheelchair. - Resident #15's medical record, reviewed on 11/20/13, identified [DIAGNOSES REDACTED]. Observation on 11/19/13 at 11:00 a.m., showed a CNA (#9) transported Resident #15, whose left leg was in a brace, down the hallway towards his room in a wheelchair without footpedals. During transport, Resident #15's feet brushed the floor. The CNA failed to cue the resident to lift his feet and failed to place footpedals on his wheelchair. - Resident #2's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The significant change MDS, dated [DATE], identified the resident as moderately cognitively impaired and required extensive assistance for locomotion on/off the unit. Observation on 11/19/13 at 2:00 p.m., showed an unidentified CNA transported Resident #2 in a wheelchair without footpedals. During transport, Resident #2's feet brushed the floor. The CNA failed to cue the resident to lift his feet and failed to place footpedals on his wheelchair. - Observation on 11/20/13 at 11:26 a.m. showed an unidentified CNA transported an unknown resident without foot pedals. During transport, the resident's feet brushed the carpeted floor. The CNA failed to cue the resident to lift her feet and failed to place footpedals on her wheelchair. During an interview on 11/20/13 at 10:25 a.m., when asked if/when staff should place footpedals on the residents' wheelchairs, two managerial nurses (#10 and #11) stated, "If they (the residents) can't lift their legs, we'd expect them to have pedals. If the resident has a cast or splint (brace), we'd expect their feet to be on pedals. If they aren't on, they (the CNAs) have to go get them and put the pedals on then. If the resident can lift their legs, they should cue the resident to put them up." During an interview on 11/20/13 at 1:30 p.m., an administrative nurse (#1) confirmed staff should place foot pedals on the resident's wheelchair or cue the residents to lift their feet during transport.

Based on observation, record review, professional reference, and family/staff interviews, the facility failed to provide the necessary treatment and services to prevent the occurrence and promote the healing of pressure ulcers for 1 of 1 sampled resident (Resident #5) identified with pressure ulcers. Failure to provide timely and appropriate interventions and ensure staff consistently implemented existing interventions resulted in the development of new pressure ulcers and the deterioration of existing facility-acquired pressure ulcers for Resident #5. Findings include: The facility failed to provide a policy and procedure specific to pressure ulcers when requested. The Clinical Practice Guidelines from the Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov <http://www.ahrq.gov> (Guideline No 15: treatment of [REDACTED]. 3: Pressure Ulcers in Adults: Prediction and Prevention) defined a pressure ulcer as any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged as follows: * Stage I: Nonblanchable [DIAGNOSES REDACTED] (diffuse redness of the skin) of intact skin. * Stage II: Partial thickness skin loss involving the epidermis/dermis (outermost layer of the skin). The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. * Stage III: Full thickness skin loss involving damage or necrosis (death of tissue or bone surrounded by healthy parts) of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. * Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures. At risk individuals include those that are bed-/chair-bound or those with impaired ability to reposition, those with incontinence, and those with inadequate dietary intake. Prompt and effective treatment can minimize the deleterious effects of an ulcer and speed recovery. Offer support with eating, and plan/implement a nutritional support/supplementation program. Establish a written repositioning schedule based on the patient's risk for additional ulcers and on the response of the tissue to pressure. The bed-/chair-bound individual should be repositioned at least every two hours. Patients at risk should be turned more frequently. If a patient has a large Stage III or Stage IV pressure ulcer, a low-air-loss bed or air-fluidized bed may be indicated. Limited sitting may be allowed for a patient who has a pressure ulcer on a sitting surface. Reposition the sitting individual so the points under pressure are shifted at least every hour. - Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition, extensive assistance for activities of daily living (ADLs), has one or more unhealed pressure ulcers, one unstageable pressure ulcer due to slough (light colored tissue) and/or eschar (brown/ black necrotic tissue), one unstageable pressure ulcer with suspected deep tissue injury in evolution, longest length from head to toe: 6.0 centimeters (cm), widest width side-to-side perpendicular to length: 3.0 cm, necrotic tissue, and receiving skin treatments including: pressure reducing device for chair and bed, turning/repositioning program, nutrition/hydration intervention to manage skin problems, ulcer care, application of nonsurgical dressings, and application of ointments/medications. Resident #5's current care plan stated, ". . . Focus ADL (Activities of Daily Living) Self care deficit . . . Interventions . . . Extensive assist with daily hygiene, grooming . . . and eating as needed . . . Focus Altered nutrition r/t (related to) . . . Incr (increased) need with wound . . . Intervention . . . Diet/snacks as ordered, assist as needed to consume foods, fluids . . . Focus Potential for pain related to . . . decreased mobility . . . Interventions Encourage/assist to reposition frequently to position of comfort . . . Focus At risk for alteration in skin integrity related to MS, decreased mobility . . . Interventions Encourage and assist as needed to reposition frequently . . . Pressure reduction mattress and WC (wheelchair). . . Focus . . . Open area at right inner buttock related to: incontinence of bowels, pressure . . . Open area to right calf related to friction . . . Interventions Administer treatment per physician orders, Encourage and assist as needed to turn and reposition; use assistive devices as needed . . . Use pillows and/or positioning devices as needed . . ." The physician orders, dated 02/20/13 identified the following: * Protein powder TID (three times daily) * Holister barrier cream as needed * [MEDICATION NAME] ointment * Monitor reddened area to right lower leg * Pressure reduction mattress The progress notes identified the following: The resident was hospitalized from [DATE] to 10/05/12 for urosepsis (infection). * 10/06/12 at 3:36 a.m., ". . . Resident is requesting an air mattress, states this bed is ' uncomfortable ' . . ." The resident was hospitalized from [DATE] to 10/24/12 for pseudo (false)-obstruction of the intestines. * 11/06/12 at 3:04 p.m., ". . . Noted open area to right buttock and tailbone area. MD (physician) faxed. [MEDICATION NAME] applied to area. . . ." * 11/07/12 at 3:38 a.m., "new order recieved (sic)/fax for replicare (a [MEDICATION NAME] dressing for wounds) to open areas on bottom, * 11/10/12 at 4:51 a.m., "Noted 0.5 cm by 0.5 cm reddened area to right outer heel, heel protectors applied. . . ." * 11/13/12 at 2:26 p.m., "Pt. (Patient) with reddened coccyx area with a 2 cm x 2 cm spot that is a hole and is blackened. . . ." * 11/13/12 at 8:36 p.m., (Five weeks after Resident #5 first requested an air mattress and one week after a pressure ulcer was identified to her right buttock/tailbone area and reddened area to her right outer heel) "new order recieved (sic)/fax for pressure reduction mattress" * 11/15/12 at 8:01 a.m., ". . . Diet meets est (estimated) need for calories and pro (protein). Has red area on bottom r/t (related/to) freq (frequent) BM (bowel movement) when has loose stools. . . . Continue to monitor and adjust meals as needed to meet her needs." * 11/26/12, ". . . The patient is having loose stools 3 times per shift with associated skin breakdown on her buttocks. . . . [DIAGNOSES REDACTED] with 1.5 cm area of necrosis on the buttock crease . . . necrotic areas on the right side, loose stool is present. . . . Cut back on laxatives . . . Will use [MEDICATION NAME] and Vaseline gauze to the buttocks. . . ." * 11/28/12 at 1:06 p.m., "Wound rounds completed. (Resident #5) has a boomerang shaped 5.5 x 5.5 cm area to right buttock. 100% slough with [DIAGNOSES REDACTED] around wound. This area started when she (was) frequently incontinent of diarrhea. 2 x 2.4 x .5 cm area to sacrum that is 100% black eschar. Surrounding area [DIAGNOSES REDACTED]tous. (Resident #5) reports increased discomfort when up in wheelchair for long periods of time. Instructed CNA's that she should only be up for meals and therapy. . . ." (Three weeks after Resident #5 developed the pressure ulcer to her right buttock/tailbone area) Resident #5's care plan was not revised to include this intervention, * 11/30/12 at 9:54 a.m., "(Resident #5) has an open area on her bottom. . . . Cont (continue) to monitor healing. If no improvement will recommend pro pwd (protein powder)." * 12/02/12 at 2:26 p.m., ". . . Pt (Patient) is up for all meals and then laid down and change (sic) from side to side every two hours to relieve pressure to coccyx area. . . ." * 12/04/12 at 4:50 a.m., ". . . Antibiotic ointment and gauze dressing applied with every BM . . ." * 12/05/12 at 9:56 a.m., "(Resident #5's) wound is not improving faxded (sic) MD (physician) for Pro powder," and at 8:42 p.m., "Orders received for Pro powder TID (three times daily) from (Physician)." (One month after Resident #5 developed the pressure ulcer to her right buttock/tailbone area) * 12/09/12, ". . . The patient has persistent diarrhea in spite of cutting back on laxatives. . . . Stage III ulcers on the bilateral anal crease. Probable stage IV ulcer measuring 2 x 3 cm up her anal crease which is black in color with most likely a very deep area of necrosis . . ." Failure of facility staff to provide timely perineal care after incontinent episodes resulted in continued skin breakdown for Resident #5. * 12/12/12 at 3:00 p.m., "Wound rounds completed. Open area to sacrum measuring 3 x 2.7 x 0.7. Stage 4 with eschar to outer edges of wound and slough to the center of wound. Previous boomerang shaped ulcer has improved and is now one Coccyx 4 x 2.4 cm stage three with pink tissue surrounding open area. Second are (sic) is to right buttock measuring 0.7 x 3.4 cm stage 3. Currently using ABX (antibiotic) ointment and vaseling (sic) gauze to open area. . . ." * 12/15/12 at 11:49 a.m., ". . . Pt. has sore to coccyx that is red and has a quarter sized necrotic area. Pt anal area is also red. . . ." * 12/17/12 at 10:37 a.m., ". . . has blackened area with slough present rest of wound dark red in color . . ." * 12/19/12 at 5:22 p.m., "Wound rounds completed. Sacral/Coccyx wound has combined into one. 7 x 4.5 x 1 cm. Upper portion (sacral) is stage 4. Lower part is stage 3. Right buttock is healed. . . ." 12/20/12 at 8:38 a.m., ". . . Has increased need for healing open area. . . . Continue to monitor as wound heals. MD (physician) did started (sic) pro pwd for increased protien (sic). Diet meet (sic) est need for calories. Very limited movement." 12/21/12 at 7:01 p.m., ". . . Wound to coccyx is light green in color with surrounding skin red in color, drainage is dark yellow in color, odor noted. New wound to rt (right) calf that is pink in color with surrounding skin red in color. no drainage. . . ." 12/22/12 at 3:11 a.m., "(Question) Friction rub noted to RT posterior calf. Site is open to air without drainage. . . ." * 12/22/12 at 2:42 p.m., "Pt seen by (Physician) with new orders for open area on rt calf: clean with ns (normal saline), pat dry, apply TAO (triple antibiotic ointment), cover with nonadhesive dressing, cover with #4 net stocking daily. . . ." * 12/23/12 at 1:46 p.m., ". . . Wound bed is green and yellow in color, drainage is green and red in color, surrounding skin is red in color. . . . rt calf . . . Wound bed is pink in color with light yellow drainage, surrounding skin light red in color. . . ." * 12/31/12, ". . . Buttock - - [DIAGNOSES REDACTED] around the gluteal area, anal crease ulcer which is butterfly shaped and has evolving necrosis. The size is about 4 x 5 cm. The central area is necrotic and sloughing skin. . . . Prognosis is guarded as she will develop a very deep progressive ulcer, most likely. . . ." * 01/03/13 at 5:48 p.m., "Spoke with (family member) last evening . . . He feels like he has to wait to (sic) long for staff to put her to bed after supper and in fact puts her to bed himself using the Hoyer lift. I encouraged him not to transfer him and the risks involved. He reported . . . I'm going to do what I need to do for her. Also asked if we could put her in a Broda chair so that she could recline after eating supper to offload her bottom until staff could transfer her to bed. . . ." Resident #5's current care plan states, "Transfer with 2 assist with Hoyer lift." * 01/13/13 at 10:58 a.m., "Wt (weight) review (Resident #5) continues to have small wt loss. Meal intakes 50-75% or (sic) most meals. Diet meets est need. Given yogurt instead of bread for added protein. Small wt loss is beneficial but has healing wound so it is not our goal at this time. Wound is improving." * 01/16/13 at 4:08 a.m., "Rt posterior calf wound healed. . . . Decubitus ulcer appears deeper with small amt (amount) of serosanquinous drainage. No odor noted. Vaseline gauze with antibiotic ointment applied to crease. . . ." * 01/17/13 at 3:50 p.m., "Wound note (Resident #5) has improved her intakes at meals. . . . Offered yogurt at meals in place of bread. . . . Diet meets est need for healing. Added protein from Pro pwd TID. . . . Wound increased in size this week. Continue to monitor. . . ." * 01/18/13 at 5:06 p.m., "Stage 4 to coccyx and right buttock. Wound to coccyx measures 6 cm x 3 cm beefy red in color with a scant amount of drainage no odor noted at this time. . . . Wound to rt buttock measures 1 cm x 1 cm beefy red in color with no drainage or odor noted. . . . Interventions: APM (air pressure relieving mattress) mattress, change and reposition every 2 hours. . . ." * 01/22/13 at 4:13 p.m., ". . . received order from (physician) to apply a wet to dry dressing to open area on left lower leg bid till healed. . . ." * 01/25/13 at 10:27 a.m., "Stage 3 to coccyx and right buttock. Wound to coccyx measures 4.5 cm x 2.1 cm beefy red in color with a scant amount of drainage, edges well approximated with no odor noted at this time. . . . Wound to rt buttocks resolved. . . ." * 01/31/13 at 4:44 p.m., "Wound rounds completed . . . Area to right buttocks is healed and completely covered with epithelium tissue (outermost layer of skin). Wound to sacrum measures 4.1 x 1.4 cm pink red moist granular appearance (pink-red moist tissue that fills an open wound) no odor present. . . . Continue wound treatment per Provider. . . ." * 02/05/13 at 1:32 p.m., ". . . He (family member) does express concern of patient not receiving snacks between meals . . ." * 02/08/13 at 4:00 p.m., ". . . Wound to sacrum measures 2.3 x 2.1 x 0.1 cm pink shiny tissue, well approximated with no odor. . . ." * 02/14/13 at 4:09 p.m., ". . . Wound to sacrum measures 1 x 0.3 x 0 cm shiney (sic) moist granular appearance no odor present at this time. . . ." * 02/22/13 at 4:39 p.m., ". . . Sacral ulcer now divided in two. Upper wound measures 2 x 1 x 0.1 cm granulation tissue with light exudates. Lower sacral ulcer measures 2.1 x 0.6 cm granulation tissue with light exudates. Dressing continues to be antibiotic ointment with Vaseline guaze (sic). . . ." * 02/28/13 at 1:07 p.m., "Wound rounds completed . . . Pt has one pressure wound to the Sacral that measures 4.1 x 1.3 x 0 cm shiney (sic) moist granulation tissue with light exudates. Dressing continues to be double antibiotic ointment with Vaseline guaze (sic). . . ." During an interview on 03/07/13 at 8:45 a.m. and 10:40 a.m., when asked for information regarding pressure ulcer interventions, an administrative nurse (#1) and a managerial nurse (#21) stated the facility provided Resident #5 with a pressure reducing mattress prior to ordering an alternating pressure mattress on 11/13/12. They further stated Resident #5 is "repositioned every two hours per physician order [REDACTED]." Resident #5's care plan stated, "Encourage and assist as needed to reposition frequently." During an interview on 03/07/13 at 3:25 p.m., when asked for information regarding pressure ulcer interventions, a managerial dietary staff member (#36) stated she would "give (the resident) a chance to heal first. If (the resident had) a Stage III or IV (ulcer) that was not healing" she would "make sure they were eating well and getting enough protein" by adding "supplements, protein powder, and multivitamins." She further stated, "There is not support in the literature for (products like) [MEDICATION NAME] (supplements used to assist wound healing)." During an interview on 03/05/13 at 5:45 p.m., when asked for comments/concerns, Resident #5's family member stated, "Sometimes, the CNAs drop her snack on the bedside table. She's unable to pick it up to feed herself." He further stated, "There are not enough CNAs. Things get done, but you wait for over an hour. I watch the clock, and stand in the hall trying to get someone's attention (to transfer Resident #5 from her wheelchair to her bed) . . . from supper to 10:00 p.m. there are two CNAs running from room to room." Observation showed the following: * 03/05/13 at 7:50 a.m. 8:08 a.m., 9:45 a.m., 11:40 a.m., 2:40 p.m., 3:30 p.m., and 5:15 p.m., Resident #5 lying on her back in bed. * On 03/06/13 at 9:17 a.m., two certified nursing assistants (CNAs) (#31 and #32) transferred Resident #5 to her bed, checked her brief, and placed a pillow behind her back and heel protectors on her feet. * 03/06/13 at 10:25 a.m., 10:49 a.m., 11:30 a.m., 3:00 p.m., 3:50 p.m., 4:28 p.m., 4:50 p.m., and 5:00 p.m., Resident #5 lying on her back in bed. One observation (in a two day time span) showed facility staff placed a positioning pillow behind the resident's back and placed heel protectors on her feet. The facility failed to promptly treat Resident #5's pressure ulcer; minimizing the effects of the ulcer, promoting healing, and resulting in the development of a Stage IV pressure ulcer. * Five weeks after Resident #5 first requested an air mattress and one week after she developed a pressure ulcer to her right buttock/tailbone area and reddened area to her right outer heel the facility ordered an alternating pressure mattress. * One month after Resident #5 developed the pressure ulcer to her right buttock/tailbone area, dietary staff requested an order for [REDACTED]. * Family interview revealed the facility failed to ensure Resident #5 consistently received her protein snack and/or feeding assistance. * Three weeks after Resident #5 developed the pressure ulcer to her right buttock/tailbone area and she expressed discomfort, facility staff were instructed to lay the resident down following meals/therapy, however the resident's current care plan only stated, to "Encourage and assist as needed to reposition frequently." Observation showed and family interview confirmed the facility failed to ensure Resident #5 was repositioned every two hours.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 04/11/12. Based on observation, record review, resident interview, and staff interview, the facility failed to provide assistive devices and supervision necessary to prevent accidents for 2 of 4 sampled residents (Resident #2 and #10) with a fall and fracture. Failure to provide Resident #10 with prompt assistance and supervision in the bathroom resulted in multiple falls and a left fibula fracture. Failure to provide Resident #2 with adequate supervision and fall prevention measures may result in avoidable falls and/or injuries. Findings include: - Review of Resident #10's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified intact cognition, makes self understood and understands others, and extensive assistance from two or more people for transfers and toilet use. Resident #10's current care plan stated, ". . . At risk for falls due to new environment, hx (history) of falls, unsteady gait, weakness, use of antipsychotic, use of cardiac meds (medications), anemia, psychiatric d.o. (disorder) . . . Interventions . . . Assist to toilet resident before and after each meal (initiated 01/09/13) . . . Do not leave unattended in bathroom (initiated 01/07/13) . . . ADL (activities of daily living) Self care deficit as evidenced by weakness, related to disease process . . . Interventions . . . Transfer and ambulate with gaitbelt, walker and 2 staff (initiated 01/24/13) . . ." Nurses' notes showed the following: *01/08/13 at 6:56 p.m.: ". . . Staff answered B/R (bathroom) call light and had found (Resident #10) holding onto the railing and wedged in between his foot pedals on the w/c (wheelchair). . . . States "I could'nt (sic) wait for staff." Incontinent of both B&B (bowel and bladder). . . . Two reddened areas noted to both sides of lower back. No other injuries noted at this time. . . ." *01/09/13 at 1:46 p.m.: ". . . To appt (appointment) with (physician name) . . . 'I'm going tell (sic) (physician name) I was in an awkward position yesterday & I think I injured by (sic) ankle.' (Resident #10) points to left leg. No redness, bruising or swelling noted to leg/ankle. Able to move leg & foot. Does say 'ouch' when left ankle palpated. Update sent with (Resident #10) paperwork re: (regarding) (Resident #10) report of pain to left ankle. . . ." *01/09/13 at 6:45 p.m.: ". . . (Resident #10) and (one) CNA (certified nursing assistant) returned from F/U (follow up) appointment with (physician's name). While there (Resident #10) c/o (complained of) L) (left) ankle/leg pain. X-rays done in office and findings noted on consultation report. . . . given tramadol 50 mg (milligrams) PO (by mouth) for c/o pain to LLE (left lower extremity) . . ." A physician's consultation report, dated 01/09/13, identified a left fibula fracture. *01/10/13 at 2:00 p.m.: ". . . Up with assist from two staff & gait belt. . . . Medicated for pain to left leg upon request. 'You know I have a broken leg.' Staff propelled (Resident #10) once in w/c. . . ." *01/11/13 at 11:04 a.m.: ". . . C/O pain to left ankle and medicated with tramadol with some relief. . . ." *01/20/13 at 10:13 a.m.: ". . . Bathroom call light on, (Resident #10) sitting on the floor in bathroom between toilet and wheelchair and leaning on the wall for support. . . . Was re-instructed not to attempt to stand or transfer self; (Resident #10) was told 'You need to call us for assist with all transfers and toileting!'. States that he stood up and grabbed ahold of the toilet paper holder instead of the grab bar and the paper holder fell out and was on the floor. . . ." *03/04/13 at 9:14 p.m.: ". . . Resident on floor by toilet. resident trying to get up without assistance. slipped of (sic) edge of toilet. . . ." An interview occurred with Resident #10 on 03/06/13 at 10:05 a.m. During the interview, the resident stated the following: *He has fallen twice waiting for someone to answer his call light. *He "waits and waits" for someone to help him on the toilet, and for someone to help him off. *He fell "a couple days ago" in the bathroom. He was alone and put his call light on, but no one came, so "I decided to do something about it." He attempted to transfer himself and fell . The resident stated he did not hit his head, but hurt his left ankle during the fall. *He broke his left leg in January. He went into the bathroom after supper, "about 6:15" and put on his call light, but "they (staff) can't come, they're in the dining room." He "got tired of waiting" and attempted to transfer himself. The resident fell and x-rays later showed a left fibula fracture. Review of facility incident reports occurred on 03/06/13 at 4:54 p.m. with a supervisory nurse (#2). The report identified a fall without injury on 03/04/13 at 7:00 p.m. The nurse (#2) stated staff left Resident #10 alone in the bathroom, and the report did not identify if Resident #10 used his call light or not. She stated the report identified "did not ask for assistance," and stated Resident #10 does not always remember to use his call light. She confirmed that staff are not supposed to leave Resident #10 alone in the bathroom. A second incident report identified a fall on 01/08/13 at 7:00 p.m. The nurse (#2) identified that staff reported to Resident #10's bathroom call light and found him "wedged" between his wheelchair foot pedals while holding the bathroom railing. The nurse stated she implemented the intervention of "assist to toilet before and after each meal" after this fall. Resident #10 experienced two falls in the bathroom after supper time (around 7:00 p.m.); one on 01/08/13 (which resulted in a fractured fibula), and one on 03/04/13. During an interview, Resident #10 identified that he activated his call light in both instances. Because staff failed to respond promptly, Resident #10 identified that he attempted to transfer himself and fell . In addition, the fall on 03/04/13 occurred as a result of inadequate supervision by staff. Failure to provide prompt assistance and supervision in the bathroom resulted in Resident #10 experiencing avoidable falls and a fractured fibula. Refer to F246. - Review of Resident #2's medical record occurred on March 05-07, 2013. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident with highly impaired vision; severely impaired cognition; extensive assistance for bed mobility, transfers, locomotion, and personal hygiene; and two falls without injury. The current care plan stated, ". . . Focus: At risk for falls due to unsteady gait . . . Interventions: Covered mug in room for liquids (initiated 09/27/12), Dycem to wheelchair . . . Fall Matt(s) . . . Low bed . . . monitor resident more frequently (initiated on 11/23/12) . . . Place fall matts under bed when resident NOT in bed (initiated on 01/10/13), Provide assist to transfer and ambulate as needed . . ." The nurse's notes identified the following falls: * 07/21/12 at 2:00 p.m. - staff witnessed fall as the resident slid out of her wheelchair onto the floor - assessment negative, denied pain, however, on 07/25/13 resident complained of pain to left leg, x-ray revealed fractures to the left hip and right pelvis, hospitalized [DATE]-28, 2012 * 11/23/12 at 9:00 p.m. - "fall occurred in residents room by bathroom door. resident transferring self from w/c by bed to the bathroom door. no shoes on just skid slippers. roommate witnessed fall . . . nsg (nursing) found resident on floor on buttocks. resident stated she felt real dizzy and lost balance . . . no bleeding or injuries noted . . ." * 11/27/12 at 6:15 p.m. - "(Resident #2) w/c noticed in hallway next to small D/R (dining room); Staff found (Resident #2) sitting in upright position next to d/r doorway . . . Denies hitting her head or any injury . . ." * 01/31/13 at 8:07 p.m. - resident witnessed walking from her wheelchair without assistance, staff unable to get to her in time, landed on her left side on the lounge (TV area) carpet, no injury * 01/09/13 at 4:30 p.m. - "(Resident #2) was found on the floor on a falls mat next to her bed. The wheelchair was setting in front of the drawers next to the closet. (Resident #2) could not recall when she fell or why she fell . She was not able to say where she was sitting prior to the fall. (Resident #2) stated she hit her head and that she had a little headache . . . Bed was at lowest position. Neuro checks started . . ." * 02/16/13 at 3:15 p.m. - "resident found by another resident on floor in residents room by bed . . . one small 1 cm (centimeter) rd (round) bruise to left eye brown w/no (with no) other injuries noted at this time . . . resident trying to transfer self from chair to bed . . ." A report for the fall on 02/16/13 at 3:15 p.m. stated, "resident to be place (sic) in view of staff." The care plan failed to identify this intervention. (Refer to F280) Observations of Resident #2 during the week of survey identified the following: * 03/05/13 9:02 a.m. until approximately 11:45 a.m. - sitting in her wheelchair in her room alone until taken to the dining room (except for when staff entered her room to toilet the resident and again to do a treatment to her toes) * 03/05/13 at 2:40 p.m. - sitting in her wheelchair in her bathroom, a CNA (#10) entered the room and found the resident in her wheelchair with stool all over the resident, her wheelchair, the toilet, the bathroom floor, and a large amount of stool in the toilet (it appeared the resident transferred herself onto and off the toilet) * 03/06/13 at 3:50 p.m. - sitting in her wheelchair in her room alone * 03/06/13 at 4:45 p.m. - sitting in her wheelchair in the doorway of her room * 03/07/13 at 9:10 a.m. - sitting in her wheelchair in the corridor next to the small dining room * 03/07/13 at 9:45 a.m. until approximately 11:40 a.m. - sitting in her wheelchair in her room alone until taken to the dining room, fall mat remained flat on the floor next to her bed Observations on March 05-07, 2013 showed staff failed to place Resident #2's between meal liquids in a covered mug as care planned. Observation on 03/06/13 at 3:50 p.m. showed the resident sitting in her wheelchair in her room and her juice supplement spilled on the floor. (Refer to F312) During an interview on 03/06/13 at 3:45 p.m., an administrative nurse (#2) stated she expected staff to place Resident #2 in main areas within view of staff due to her history of falls and self-transfers. The staff failed to place Resident #2 in areas visible by staff, to place her fall mat under the bed when the resident was out of bed, to frequently monitor the resident, and to utilize covered mugs for liquids in the resident's room, increasing Resident #2's risk for additional falls and injury.