Every finding on record at Nelson County Health System Care Center

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 7 sampled residents (Resident #1, #3 #5, #6, and #16) and one supplemental resident (Resident #20) observed during cares. Failure to practice infection control standards related to transmission based precautions (TBP), enhanced barrier precautions (EBP), and hand hygiene, has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled [NAME] County Health System Care Center Enhanced Barrier Precautions occurred on 06/10/26. This policy, dated April 2025, stated, . refers to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. An order for enhanced barrier precautions will be obtained for residents with . wounds and/or indwelling medical devices (. urinary catheter .) . High-contact resident care activities - . Transferring . assisting with toileting . device care or use: . urinary catheter . Review of the facility policy titled Isolation Precautions occurred on 06/10/26. This policy, dated April 2025, stated, . 'Contact precautions' are measures that are intended to prevent transmission of infectious agents . which are spread by direct or indirect contact with the patient or patient's environments . will use standard approaches, as defined by the CDC [Centers for Disease Control], for . contact . The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. Review of the facility policy titled Gloves occurred on 06/10/26. This policy, dated January 2015, stated, . change gloves between tasks on the same patients\residents. Remove promptly after use, before touching non-contaminated items and surfaces. Wash hands immediately after glove removal. Review of the facility policy titled Hand Hygiene occurred on 06/10/26. This undated policy stated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 'Hand hygiene' is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. -Review of Resident #1's medical record occurred on all days of survey and identified the presence of a feeding tube and a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) and physician's orders for contact precautions due to an active MRSA infection of the finger. Observation on 06/08/26 at 4:23 p.m. showed a Contact Precautions sign on Resident #1's door and identified gown and gloves required prior to entering the resident room. A certified nurse aide (CNA) (#7) applied a gown and gloves and entered the room. A second CNA (#8) applied an untied gown, entered the room, dropped a glove on the floor, picked it up and applied it. While providing bowel movement cares, the CNA's (#8) gown fell forward to her elbows. The CNA (#8) removed the soiled gloves, and without performing hand hygiene or glove application, tied her gown. The CNAs (#7 and #8) placed a sling under the resident and transferred him/her to a wheelchair with a mechanical lift. The CNAs failed to perform hand hygiene after completing personal cares and before touching clean items. The CNA (#8) failed to properly apply the gown and applied a soiled glove that had fallen on the floor. The CNAs (#7 and #8) failed to perform hand hygiene after glove removal and failed to wear gloves during all resident cares. -Observation 06/09/26 at 2:20 p.m. showed a nurse (#6) applied gloves and administered water into Resident #1's feeding tube. The nurse (#6) failed to apply a gown prior to administering the water bolus. -Observation on 06/10/26 at 10:32 a.m. showed a nurse (#9) provided feeding tube cares to Resident #1 at the bedside. The nurse failed to apply a gown and gloves before providing cares. The nurse (#9) then exited the room, applied a gown and gloves, re-entered the room, and continued to clean the feeding tube site. The nurse removed the soiled gloves and, without performing hand hygiene, applied new gloves, and placed a dressing on the feeding tube site. The nurse removed the gloves, and without performing hand hygiene, applied new gloves, applied ointment to the resident's right palm, and removed the gloves. Without performing hand hygiene or applying gloves, the nurse placed gauze and tape on the resident's right fingers. The nurse applied gloves, applied ointment and a bandage to the resident's coccyx, placed a gripper device in the resident's left hand and removed the soiled gloves. The nurse applied one new glove on her right hand, applied ointment to the resident's shoulder, removed the soiled glove and placed a gripper device in Resident #1's right hand. The nurse removed the gown and exited the room. The nurse (#7) failed to wear a gown and gloves while performing cares in a contact precaution room, failed to wear gloves during all cares, and failed to perform hand hygiene between glove changes and when exiting the room. -Observation on 06/09/26 at 9:28 a.m. showed Resident #3 seated in a wheelchair with a urinary drainage bag. The CNA (#3) performed hand hygiene, applied a gown and gloves, emptied the resident's urinary drainage bag, removed the soiled gloves, and without performing hand hygiene, applied new gloves and shaved Resident #3. The CNA assisted the resident from the wheelchair to the bed, removed the soiled gown and gloves, and without performing hand hygiene, offered the resident a drink of water, turned off the lights, performed hand hygiene and exited the room. The CNA (#3) failed to perform hand hygiene after removing soiled gloves and before performing other tasks. -Observation on 06/08/26 at 12:27 p.m. showed a CNA (#4) performed hand hygiene, applied gloves and transferred Resident #5 to the toilet. The CNA removed the soiled gloves, and without performing hand hygiene, applied new gloves, performed perineal care, pulled up the resident's brief and pants, and removed the gloves. The CNA transferred the resident back to the wheelchair, moved the resident out of the bathroom, then performed hand hygiene. The CNA (#4) failed to perform hand hygiene after removing soiled gloves, between glove changes and before performing other tasks. -Review of Resident #6's medical record occurred on all days of survey and identified the presence of a pressure ulcer to the sacrum and a physician's order for EBP. Observation on 06/09/26 at 9:13 a.m. showed an Enhanced Barrier Precaution sign on Resident #6's bathroom door and Resident #6 seated on the toilet. A CNA (#5) entered the room, applied clean gloves, and provided personal and perineal cares. The CNA (#5) failed to apply a gown prior to assisting Resident #6 with personal and perineal cares. -Observation 06/08/26 at 2:23 p.m. showed a CNA (#4) performed hand hygiene, applied gloves, provided incontinence cares for Resident #16, and assisted him to a wheelchair. The CNA (#4) removed the soiled gloves, and without performing hand hygiene, placed the gait belt on the back of the wheelchair, positioned Resident #16 at the sink, placed the wipes in the closet, handed the resident paper towels, moved the resident out of the bathroom and closed the bathroom door. The CNA (#4) then performed hand hygiene. The CNA (#4) failed to perform hand hygiene after removing soiled gloves and before performing other tasks. -Observation on 06/08/26 at 12:45 p.m. showed a CNA (#7) applied gloves, assisted Resident #20 to the toilet, removed the soiled brief, and removed the soiled gloves. Without performing hand hygiene, the CNA (#7) applied new gloves, assisted the resident to stand, performed perineal care, applied a new brief, and removed the soiled gloves. The CNA (#7) assisted the resident to lay down, then performed hand hygiene. The CNA (#7) failed to perform hand hygiene after removing soiled gloves, between glove changes and before performing other tasks. During an interview on 06/10/26 1:30 p.m., an administrative nurse (#2) stated she expected staff to perform hand hygiene after glove removal and before applying new gloves or touching other objects, and to wear gown and gloves when providing cares to residents in enhanced barrier or contact precautions.

Based on observation, record review, review of manufacturer's instructions, review of facility policy, and staff interview, the facility failed to provide necessary care and services for 1 of 1 supplemental resident (Resident #10) observed during administration of rapid-acting insulin. Failure to administer rapid-acting insulin according to the physician's order may result in a hypoglycemic (low blood sugar) reaction.Findings include:Review of the FIASP insulin manufacturer's instructions accessed at https://www.novomedlink.com/diabetes/patient-support/product-education/library/fiasp-instructions-for-use.html occurred on 06/10/26. This instruction, revised June 2023, stated, .administration . subcutaneous injection . FIASP starts acting fast. inject at the start of a meal or within 20 minutes after starting a meal . Review of the facility policy titled Administration of Insulin occurred on 06/10/26. This policy, dated 04/30/25, stated, . All insulins will be administered in accordance with physician's orders. Insulin administration will be coordinated with mealtimes .Review of Resident #10's medical record occurred on 06/09/26. Diagnosis included type 2 diabetes mellitus. The physician's order for FIASP insulin (rapid-acting insulin) stated, Inject 6 units subcutaneously [directly under the layer of skin] with meals .Observation on 06/09/26 at 5:00 p.m. showed a nurse (#6) administer 6 units of FIASP insulin to Resident #10. The nurse left the room and failed to offer food. At 5:22 p.m. (22 minutes after receiving insulin), the resident received a glass of milk and a dish of ice cream. Resident #10 received the evening meal at 5:55 p.m. The nurse failed to follow the manufacturer's instruction and physician's order to administer the FIASP with the meal which may result in hypoglycemia. During an interview on 06/10/26 at 2:55 p.m., an administrative nurse (#1) stated she expected food to be consumed within 20 minutes of a FIASP insulin injection.

Based on record review, review of the facility reported incident (FRI) investigations, review of facility policy, and resident interview, the facility failed to ensure residents remain free from abuse for 2 of 2 sampled residents (Resident #2 and #4) who were subjected to physical abuse by Resident #1. Failure to protect residents from physical abuse may result in injury, fear, anxiety, mental anguish, and emotional distress.Findings include:Review of the facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, occurred on 04/29/26. This policy, dated 07/07/21, stated, . all residents have the right to be free from verbal, sexual, physical . abuse . Residents must not be subject to abuse by anyone, including, . other residents .Incident between Resident #1 and #4Review of the facility's initial FRI investigation, dated 01/25/26 at 9:30 p.m. stated, . Incident happened in the west hallway where [Resident#1] grabbed another residents [Resident #4] arm and grabbed, pulled, and squeezed. The final investigation stated, . The resident [Resident #4] was interviewed on 1/25 after the incident happened. She [Resident #4] stated that the other resident [Resident #1] was strong but said her arm was okay. Resident [#4] was interviewed again on 1/28 and she stated that she was in the hall and tapped the other resident [#1] on the shoulder and commented on (sic) pretty her sweater was. Resident [#1] smiled and raised her arms in happiness. [Resident #1] then grabbed this resident arm hard, and the resident said she had to pull away.- Review of Resident 1's medical record occurred on 04/29/26. Diagnoses included Alzheimer's disease, restlessness and agitation, and anxiety disorder. The admission Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition. The care plan stated, [Resident's name] can have aggressive mood fluctuations r/t [related to] Dementia, Anxiety . HX [history] of physical contact with another resident. Distance from others when appropriate for safety.- Review of Resident 4's medical record occurred on 04/29/26. Diagnosis included non-Alzheimer's dementia, anxiety disorder, and depression. The quarterly MDS, dated [DATE], identified intact cognition.During an interview on 04/29/26 at 1: 20 p.m., when asked about the incident with Resident #1, Resident #4 stated, I didn't get hurt from it. [Resident #1's name] was a sweet gal, but she would just turn at times and get really angry and mean.Incident between Resident #1 and #2Review of the facility's initial FRI investigation, dated 02/06/26, stated, . [Resident #1's name] and [Resident #2's identification number] are both confused so cannot be interviewed. [Resident #1] has been in . Hospital since 2/3/2026 for pain/medication management.- Review of Resident #1's progress note, dated 02/03/26 at 12:22 a.m., stated, At 2040 [8:40 p.m.] on 02/02/2026 [Resident #2's identification number] was sitting next to [Resident #1's name] and talking to her. [Resident #1] started yelling and swinging at [Resident #2], hitting her in the face multiple times. [Resident #2] said, 'She just started hitting me in the face, so I moved away from her. I think she needs a shot or something.' [Resident #2] was assessed and no injuries were noted at this time and she denied any pain. [Resident #1] was moved to a quiet area and talked to by this writer, encouraged deep breathing and was reassured she was safe. Resident #1 did stop crying and calm down. Both residents are now on safety checks.- Review of Resident 2's medical record occurred on 04/29/26. Diagnoses included dementia, anxiety, behavior disturbance, and psychotic disorder. The annual Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition. During an interview with Resident #2 on 04/29/26 at 1:15 p.m., when asked if she felt safe at the facility she stated, I'm at my home right where am I. Resident could not recall the altercation on 02/02/26.The facility failed to protect Resident #2 and #4 from Resident #1's physical abuse.

Based on record review, review of the facility reported incident (FRI) investigations, review of facility policy, and resident interviews, the facility failed to investigate alleged violations of abuse for 2 of 2 sampled residents (Resident #2 and #4). Failure to investigate Resident #1's incidents of abusive behavior, ensure the protection of other residents during the investigation, implement corrective actions, and evaluate the effectiveness of the actions, placed all residents at risk for mistreatment, verbal abuse, and/or experiencing anxiety/fear. Findings include:Review of the facility policy titled Abuse, Neglect, Mistreatment, and misappropriation of Resident Property occurred on 04/29/26. This policy, dated 07/07/21, stated, . The investigation is the process used to try to determine what happened. The nurse begins the investigation immediately. A root cause investigation and analysis will be completed . The investigation will consist of at least the following . An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident. Interviews with the resident's roommate, family members, and visitors. A root cause analysis of all circumstances surrounding the incident .Review of the FRI report, dated 01/25/26 at 9:30 p.m. stated, . Incident happened in the west hallway where [Resident#1] grabbed another residents [Resident #4] arm and grabbed, pulled, and squeezed . The facility's final investigation stated, . The resident [Resident #4] was interviewed on 1/25 after the incident happened. She [Resident #4] stated that the other resident [Resident #1] was strong but said her arm was okay. Resident [#4] was interviewed again on 1/28 and she stated that she was in the hall and tapped the other resident [Resident #1] on the shoulder and commented on pretty her sweater was. Resident [#1] smiled and raised her arms in happiness. [Resident #1] then grabbed this resident arm hard, and the resident said she had to pull away.Another FRI report dated 02/02/26 at 8:40 p.m. stated, [Resident #2] was sitting next to [Resident #1] and talking to her. [Resident #1] started yelling and swinging at [Resident #2], hitting her in the face multiple times. [Resident #2] said, 'She just started hitting me in the face, so I moved away from her. I think she needs a shot or something.' [Resident #2] was assessed and no injuries were noted at this time and she denied any pain. [Resident #1] was moved to a quiet area and talked to by this writer Both residents are now on safety checks. - Review of Resident #1's medical record occurred on 04/29/26. Diagnoses included Alzheimer's disease, restlessness and agitation, and anxiety disorder. The admission MDS, dated [DATE], showed severely impaired cognition. The care plan stated, [Resident's name] can have aggressive mood fluctuations r/t [related to] Dementia, Anxiety . HX [history] of physical contact with another resident. Distance from others when appropriate for safety.- Review of Resident #4's medical record occurred on 04/29/26. Diagnosis included non-Alzheimer's dementia, anxiety disorder, and depression. The quarterly MDS, dated [DATE], identified intact cognition. - Review of Resident #2's medical record occurred on 04/29/26. Diagnoses included dementia, anxiety, behavior disturbance, and psychotic disorder. The annual Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition.During an interview on 04/29/26 at 1: 20 p.m., when asked about the incident with Resident #1, Resident #4 stated, I didn't get hurt from it. [Resident #1's name] was a sweet gal, but she would just turn at times and get really angry and mean. During an interview with Resident #2 on 04/29/26 at 1:15 p.m., when asked if she felt safe at the facility she stated, I'm at my home right where am I. Resident could not recall the altercation on 02/02/26.The facility reported the incidents that occurred on 01/25/26 and 02/02/26 to facility administration and the state agency but failed investigate the altercations, implement appropriate interventions, and evaluate the effectiveness of the interventions. An investigation into the first incident between Resident #1 and #4 may have prevented the physical abuse inflected upon Resident #2 by Resident #1 during the second incident.

Based on record review, review of the facility reported incident (FRI) and investigation, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #1) who displayed physical behaviors towards other residents. Failure to provide necessary services to protect residents from abuse resulted in physical abuse. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 06/17/25. The facility implemented and completed corrective action on 06/23/25. Review of the facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property occurred on 06/24/25. This policy, revised 07/07/21, stated, . It is the policy of the [facility] that all residents have the right to be free from . physical . abuse . PHYSICAL ABUSE includes hitting, slapping, pinching, and kicking. Review of Resident #1's medical record occurred on 06/23/25. Diagnoses included bipolar disorder, dementia, Parkinson's disease, and schizoaffective disorder. The Annual Minimum Data Set (MDS), dated [DATE], identified physical behaviors directed towards others and worsening behaviors. The current care plan stated, . [Resident #1] can have a behavior problem of wandering, refusing cares, verbal and physical aggression r/t [related to] Dementia, Parkinson's Disease. Administer medications as ordered. [Resident #1] can be physically aggressive at times. Use [a] positive approach to cares and interactions. Ask for more staff assistance as needed. Facility is pursuing placement in a special care unit d/t [due to] his elopement . A progress note, dated 06/17/25 at 2:31 p.m., stated, . This resident [#1] slapped resident [#2] on the L) [left] side of her face and pulled her hair. The FRI, dated 06/18/25, stated, . Resident [#1], was sitting in his wheelchair in the day room when Resident [#2] came up beside him in her wheelchair. Resident [#2]'s wheelchair got hung up on this resident's wheelchair. He took a swing with a closed fist and connected with her head, on the R [right] side above her temple and glasses. They were separated without incident. Again at [2:30 p.m.] Resident [#1] came past Resident [#2] . This resident slapped resident [#2] on the L) side of her face and pulled her hair. Again, they were separated by staff without difficulty. Resident [#1] is on hourly checks d/t an elopement risk. These [hourly checks] will continue for this reason as well. Resident [#2] will be monitored hourly for her safety. Staff will be informed of this, and will be told to be on the alert for any other residents that [Resident #1] may target. During interviews on 06/23/25 at 4:45 p.m. and 5:30 p.m., an administrative nurse (#1) reported Resident #2 did not have any injuries following the incident. We developed safety plans for both residents and educated staff. Staff are checking on them on an hourly basis. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions for residents who may be affected by the deficient practice as follows: * Completed an investigation into the incidents that occurred on 06/17/25 involving Resident #1 and #2, * Developed a safety plan for Resident #1 and #2, * Educated direct care staff regarding the safety plans that required hourly monitoring of Resident #1 and #2, * Implemented audits to ensure both residents were monitored hourly, * Monitored incidents involving resident-to-resident abuse, and * Arranged for Resident #1's transfer to a locked memory care unit at another facility.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 2 sampled residents (Resident #9) observed with an indwelling catheter. Failure to practice infection control standards related to enhanced barrier precautions (EBP), urinary catheters, and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 04/01/25. This policy, dated April 2024, stated, . Enhanced Barrier Precautions refers to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. Signage will be posted on the door or wall of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. High-contact resident care activities . Transferring . Providing hygiene . Device care or use: . urinary catheter . Review of the facility policy titled HANDWASHING SPECIFICS occurred on 04/01/25. This policy, dated January 2015, stated, . Handwashing decreases contamination of the hands and prevents the spread of pathogens . WHEN SHOULD YOUR HANDS BE WASHED? . Before and after handling in-use patient/resident care devices. after handling urinals, bedpans and similar contaminated items. Review of the facility policy titled Catheter Bag Draining occurred on 04/01/25. This policy, dated October 2016, stated, . Leg bag: . Dispose of urine in the toilet. Rinse out the collection container using the bedpan washer [wand sprayer]. Review of Resident #9's medical record occurred on all days of survey. The record identified an indwelling urinary catheter. Review of the care plan identified, . Urology notes that catheter will be long term. On enhanced barrier precautions (EBP) . TRANSFER: requires total assistance by 2 staff with the use of total mechanical lift for transfers. Observation on 03/30/25 at 1:43 p.m. showed Resident #9's room with signage for EBP and a supply cart located at the entrance of the room. The certified nurse aide (CNA) (#2) entered the room, applied gloves, failed to apply a gown, and emptied the urine contents from the leg bag into a collection container. The CNA then discarded the urine into the toilet, held the contaminated container under the sink faucet of a shared bathroom, obtained water, rinsed, and emptied the contents of the container into the toilet. The CNA removed her gloves, failed to complete hand hygiene, obtained the full body mechanical lift from the hallway, applied gloves, and paged for transfer assistance. The staff nurse (#3) stood at the doorway and instructed the CNA (#2) to apply a gown before the resident transfer, and both staff transferred Resident #9 into the bed. The CNA (#2) completed a brief change, cleansed an incontinent bowel movement, failed to remove her gloves, and applied skin barrier cream to the perineal area. The CNA applied a clean brief, removed her gloves and without performing hand hygiene, applied the nasal cannula/oxygen, and placed the call light for Resident #9. During an interview on 04/01/25 at 10:17 a.m., an administrative staff member (#1) reported she expected staff to change gloves after incontinence cares, perform hand hygiene after removing gloves, use the spray wand to rinse contaminated containers, and wear a gown for residents in EBP when providing high-contact care tasks.

Based on observation, record review, review of the facility reported incident, review of facility policy, and staff interviews the facility failed to ensure residents remained free from abuse from 1 of 1 sampled resident (Resident #1) who displayed verbal and physical behaviors towards residents. Failure to provide necessary services to protect residents from abuse resulted in physical and psychosocial harm. Findings include: Review of the facility policy titled Abuse Prohibition Policy occurred on 11/26/24. This policy, dated July 2021, stated, . Residents must not be subjected to abuse by anyone, including, but not limited to . other residents . Review of the facility reported incident identified on 11/02/24 at 7:30 p.m. Resident #1 kicked Resident #2 in the leg. - Review of Resident 1's medical record occurred on 11/26/24. The quarterly MDS, dated [DATE], identified severely impaired cognition. The care plan included, . [Resident #1] has a behavior problem e/b [evidenced by] verbal taunting, seeks out others, has been physically aggressive at times r/t [related to] Dementia and cognitive decline. Anticipate and meet [Resident #1's] needs. Assist [Resident #1] to develop more appropriate methods of coping and interacting. Encourage him to express feelings appropriately. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him as passing by. Follow behavior plan and interventions. See print out in nurses [sic] for reference. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for [Resident #1's] disruptive behaviors by offering tasks which divert attention such as hands on activities, 1-1s [sic] talking sports. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Praise any indication of [Resident #1's] progress/improvement in behavior. Provide a program of activities that is of interest and accommodates residents status. Review of Resident #1's progress notes included the following: * 11/02/24 at 7:30 p.m., . Resident was bickering with another resident [Resident #2] and sought her out in the day room. When she [Resident #2] tried to move away from him he kicked her several times in the lower leg. * 11/06/24 at 12:50 p.m., . [Resident #1] was seen kicking [Resident #2]. Writer removed [Resident #1] from [Resident #2]. After removing [Resident #1] was chasing [Resident #2] down the hall. [Resident #2] was taken into own room away from [Resident #1]. * 11/07/24 at 12:30 p.m., . charge nurse reported that resident kick [sic] resident [Resident #2] in the lower leg. This is the 3rd resident to resident contact made in three days. * 11/07/24 at 12:30 p.m., . Resident seen by [physician's name] for 60 day recert [recertification]. Shortly before seeing him charge nurse reported that resident kick [sic] [Resident #2] in the lower leg. This is the 3rd resident to resident contact made in three days. Order received from [physician's name] 'I recommend this resident be transferred to a facility with a locked special care unit'. Message left with [power of attorney]. Awaiting call back to inform of recommendations. * 11/09/24 at 12:29 p.m., . Resident was seeking out resident [Resident #2]. Resident was antagonizing [Resident #2]. [Resident #2] was motioning with her arms for him to go away. CNA [certified nurse aide] has separated the two residents 3 times in the last 30 minutes. * 11/09/24 at 8:09 p.m., . at 1820 [6:20 p.m.] [Resident #1] said 'I'm going to get her' and then proceeded to try and kick [Resident #2]. At 1825 [6:25 p.m.] he [Resident #1] started chasing [Resident #2] and when asked why he said 'she wants me to' this writer explained to him that she doesn't and to please go the other way. At 1840 [6:40 p.m.] he trapped [Resident #2] in the dining room and she yelled 'get out of the way' he said 'no' and was intercepted by staff and denied doing it. At 1843 [6:43 p.m.] resident was in hallway, turned his head then his chair and stopped [Resident #2] and yelled 'now who is following who?' At 1845 [6:45 p.m.] he waited for [Resident #2] to turn the corner looked around him then followed her but acted surprised when staff stopped him and said that he didn't do anything. At 1855 [6:55 p.m.] he started mocking [Resident #2] and had to be pulled away from her. * 11/10/24 at 12:30 p.m., . resident in the dinning [sic] room at [Resident #2] table. He was found shaking her wheelchair and kicking at her. * 11/10/24 at 10:21 p.m., . between 1835 [6:35 p.m.] and 1905 [7:05 p.m.] resident had to be re-directed 8 times away from [Resident #2]. Wouldn't let resident pass X3 [three times] tried to approach her X3 and followed her X3. He would wait for her and say 'there she comes again' and then follow her. 'there she goes, I should chase after her'. [Resident #2] tried to avoid him by doing a u-turn through the nurse's station and yelled 'leave me alone what's the matter with you?' Resident was told multiple times to leave her alone and he kept it up even once saying 'lets take her to the woods' . * 11/11/24 at 1:36 p.m., . CNA behavior log: intercepted 4 times in 10 mins [minutes]when he started chasing down [Resident #2] Intervention: 'tried offering snack or to go to room.' outcome: 'behavior got worse, resident became combative, resident became agitated. resident started kicking at staff when interventions were placed'. * 11/11/24 at 3:48 p.m., . Writer faxed on-call [physician] about behavior changes, blood pressure, and not sleeping at night. On-call [ordered] '3mg melatonin [an over the counter sleep aid] 30 mins before bed as needed for insomnia. Referral placed for psychiatry due to recent behavioral changes.' * 11/11/24 at 4:54 p.m., . resident was found kicking at [Resident #2]. [Resident #2] wheelchair hit the wall. * 11/15/24 at 7:27 p.m., . Within a short time he was calling [Resident #2] names and persistently chasing after her until staff intervened. He then stated 'do you want to end up on the floor?' When he was turned to be taken away from the situation, he began to swing the remote and raise his voice. * 11/16/24 at 3:54 a.m., . Resident had been picking on just one or two residents now he's starting to just yell and chase any of them around. Staff needs to keep a close eye on him when he is out of his room. * 11/19/24 at 11:00 p.m., . Management team met with [physician's name] today to discuss this resident and incidents which have been often occurring. Resident seems to be fixated on one specific resident and we met to discuss what can be done to help the situation. A resident behavior plan has been created that will be introduced to all staff to follow. Along with this, we will work with all staff and follow staff to ensure that the positive approach to care [PAC] [a specialized training specifically for taking care of patients with dementia] is being used, as we are trained and PAC certified. [Physician's name] is in agreeance with the following plan: buff up skills and alert staff as stated above, really working hard to approach resident positively; refer out to see options; Thursday, [physician's name] will see resident in regardsd [sic] to his compulsive tendancies [sic] with possible psych [psychiatry] eval [evaluation]. We will follow and document progress on situation. * 11/20/24 at 8:50 a.m., . Writer heard [Resident #2] screaming 'get away from me' this resident was behind [Resident #2] laughing. * 11/21/24 at 1:36 p.m., . Resident seen by [physician's name] for PRN [as needed] follow up visit. Reviewed behaviors. Will start Paxil [a antidepressant medication] 10mg [milligrams] daily X 1 [times 1] week then increase to 20mg daily. Call placed to [power of attorney] to inform. He appreciated the call. Also notified of team members monitoring of behaviors plans. * 11/22/24 at 10:47 p.m., . At 1830 [6:30 p.m.] resident approached and kicked the w/c of res [Resident #2], this writer removed [Resident #1] from the situation and . tried to re-direct him but he just became angry and tried to hit me and denied going near her. At 1840 [6:40 p.m.] he was removed from her again and . this writer tried to explain that she said 'stop bothering me' he denied going near her and this writer told him that I saw him do it and he said 'that's in the past I need to get her attention' this upset [another resident] who told him to 'buzz off' At 1845 [6:45 p.m.] approached [Resident #2], had to be removed . At 1846 [6:46 p.m.] he had to be removed from her again and kicked staff and raised his fist [sic] another [resident] then moved her chair between the 2 and said 'I will take care of her' At 1900 [7:00 p.m.] resident was again removed from [Resident #2], . - Review of Resident #2's medical record occurred on 11/26/24. The MDS, dated [DATE], identified severely impaired cognition. On 11/26/24 at 12:24 p.m., this surveyor heard a female voice screaming loudly outside the conference room and then heard another voice say Resident #1's name. When this surveyor exited the conference room, observation showed Resident #1 and Resident #2 in the television area with two unidentified staff members in between them. When the staff members moved away Resident #1 immediately started to move his wheelchair towards Resident #2. Review of the facilities physical abuse altercation investigation which occurred on 11/02/24 between Resident #1 and #2 included interviews with staff directly involved with the physical abuse, notification to Resident #1 and #2's physician, notification to the facilities medical director, notification to Resident #1 and #2's families, and discussion with the resident care coordinator and licensed social worker. Interventions showed the following: - A behavior plan including a behavior log for Resident #1 - A safety plan for Resident #2 - Education to all nursing staff (CNAs and nurses) regarding Resident #1's behaviors/behavior plan and a safety plan for Resident #2. During an interview on 11/26/24 at 1:08 p.m., an administrative staff member (#2) stated all current staff have been trained in PAC training which is an 8 hour class she teaches. The administrative staff member (#2) also stated any new staff are trained immediately upon hire in the PAC training. During an interview on 11/26/24 at 1:41 p.m., an administrative staff member (#1) verified the facility had contacted 4 facilities with a memory care unit regarding possible transfer for Resident #1 and stated the other facilities did not have any openings at that time. The administrative staff member (#1) also stated the facility has a meeting scheduled on 12/03/24 with Resident #1's personal representatives and physician to discuss his behaviors and other possible options. The facility failed to provide necessary services to protect residents from verbal, psychosocial and physical abuse resulted in an unsafe environment and the potential for further harm.

Based on record review and staff interview, the facility failed to ensure 1 of 1 closed record (Resident #1) remained free from a chemical restraint (morphine sulfate-an opioid pain medication). Failure to attempt non-pharmacological interventions and/or utilize the least restrictive alternative medication does not allow the resident to attain and/or maintain his/her highest level of practicable well-being. Findings include: The facility failed to provide a policy on pain management or opioid use when requested. Review of Resident #1's medical record occurred on 01/28/25. Diagnoses included Alzheimer's disease, obsessive compulsive disorder, and dementia with agitation. The current care plan stated, . [Resident #1] has behaviors e/b [evidenced by] verbal taunting, seeks out others, has been physically aggressive at times r/t [related to] Dementia and cognitive decline . Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause . Document behavior and potential causes. The care plan lacked a problem related to pain. Review of Resident #1's quarterly pain assessments, dated 08/23/24 and 11/22/24, identified the resident did not experience pain during the assessment period or display any non-verbal indicators of pain. A quarterly Minimum Data Set (MDS), dated [DATE], identified a BIMS of 5 (indicating severely impaired cognition), physical and verbal behaviors, and No for presence of pain. Resident #1's physician's orders included: * 11/18/23, acetaminophen 325 milligrams (mg). Give 2 tablets orally every 4 hours as needed for mild pain or fever. * 01/19/25 at 6:10 a.m., morphine sulfate 2.5 mg by mouth one time only for anxiety for 1 day * 01/19/25 at 1:45 p.m., morphine sulfate 2.5 mg by mouth every 2 hours as needed * 01/20/25, morphine sulfate 2.5 mg by mouth every 2 hours as needed for anxiety/pain. Review of Resident #1's progress notes and Medication Administration Record (MAR), dated January 19-21, 2025, identified the following: * 01/19/25 6:05 a.m., Late Entry: Resident up and dressed and is pacing in halls by nurses station in his w/c [wheelchair]. He is anxious as evidenced by facial scowl, repeated and troubled calling out to staff, clenched fists and repetitive negative comments. [Physician name] informed and order received for one time dose Roxanol [morphine sulfate] 2.5 mg for apparent signs of pain and anxiety. * 01/19/25 at 6:18 a.m., morphine sulfate administered for anxiety, pacing in halls, and a pain rating of 8 out of 10. * 01/19/25 at 2:21 p.m., morphine sulfate administered for a pain rating of 8 out of 10. * 01/19/25 at 8:15 p.m., morphine sulfate administered. The record lacked a pain rating. * 01/20/25 at 4:50 a.m. Behavior Note . sitting in w/c hollering 'help me.' Morphine sulfate 2.5 mg. given. The record lacked a pain rating. * 01/20/25 at 10:21 a.m., morphine sulfate administered for a pain rating of 6 out of 10. * 01/20/25 at 6:20 p.m., morphine sulfate administered for, . becoming agitated in day room now. The record lacked a pain rating. * 01/20/25 at 11:25 p.m., morphine sulfate administered for, . Sitting at bedside hollering 'help me help me' then he starts making his other vocal noises. He didn't want anything. He was given morphine sulfate and assisted to lay down. The record lacked a pain rating. * 01/21/25 at 4:45 a.m., morphine sulfate administered for . lying in bed hollering. The record lacked a pain rating. * 01/21/25 at 3:21 p.m., . monitor behaviors every day and evening shift. Resident has been go [good] this shift so far. * 01/21/25 at 6:23 p.m., morphine sulfate administered for anxiety/pain . The record lacked a pain rating. * 01/21/25 at 10:20 p.m., Behavior Note. At 6:30 [p.m.] he was lying in bed hollering 'help me' but didn't need anything. Morphine Sulfate given. He has been sleeping since then. * 01/21/25 at 10:50 p.m., morphine sulfate administered for, . needs to calm down. The record lacked a pain rating. The record showed the facility failed to administer acetaminophen in the month of January 2025. During an interview on 01/28/25 at 4:09 p.m., an administrative nurse (#1) confirmed Resident #1's medical record lacked pain documentation, use of non-pharmacological behavioral interventions, and/or use of the least restrictive medications (acetaminophen) before administering Morphine. The facility failed to complete a pain assessment related to Resident #1's new onset of pain, provide a rationale for the initiation of morphine, and attempt non-pharmacological interventions or administer the least restrictive medication (acetaminophen).

Based on record review and staff interview, the facility failed to ensure 1 of 1 closed record (Resident #1) remained free from a chemical restraint (morphine sulfate-an opioid pain medication). Failure to attempt non-pharmacological interventions and/or utilize the least restrictive alternative medication does not allow the resident to attain and/or maintain his/her highest level of practicable well-being. Findings include: The facility failed to provide a policy on pain management or opioid use when requested. Review of Resident #1's medical record occurred on 01/28/25. Diagnoses included Alzheimer's disease, obsessive compulsive disorder, and dementia with agitation. The current care plan stated, . [Resident #1] has behaviors e/b [evidenced by] verbal taunting, seeks out others, has been physically aggressive at times r/t [related to] Dementia and cognitive decline . Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause . Document behavior and potential causes. The care plan lacked a problem related to pain. Review of Resident #1's quarterly pain assessments, dated 08/23/24 and 11/22/24, identified the resident did not experience pain during the assessment period or display any non-verbal indicators of pain. A quarterly Minimum Data Set (MDS), dated [DATE], identified a BIMS of 5 (indicating severely impaired cognition), physical and verbal behaviors, and No for presence of pain. Resident #1's physician's orders included: * 11/18/23, acetaminophen 325 milligrams (mg). Give 2 tablets orally every 4 hours as needed for mild pain or fever. * 01/19/25 at 6:10 a.m., morphine sulfate 2.5 mg by mouth one time only for anxiety for 1 day * 01/19/25 at 1:45 p.m., morphine sulfate 2.5 mg by mouth every 2 hours as needed * 01/20/25, morphine sulfate 2.5 mg by mouth every 2 hours as needed for anxiety/pain. Review of Resident #1's progress notes and Medication Administration Record (MAR), dated January 19-21, 2025, identified the following: * 01/19/25 6:05 a.m., Late Entry: Resident up and dressed and is pacing in halls by nurses station in his w/c [wheelchair]. He is anxious as evidenced by facial scowl, repeated and troubled calling out to staff, clenched fists and repetitive negative comments. [Physician name] informed and order received for one time dose Roxanol [morphine sulfate] 2.5 mg for apparent signs of pain and anxiety. * 01/19/25 at 6:18 a.m., morphine sulfate administered for anxiety, pacing in halls, and a pain rating of 8 out of 10. * 01/19/25 at 2:21 p.m., morphine sulfate administered for a pain rating of 8 out of 10. * 01/19/25 at 8:15 p.m., morphine sulfate administered. The record lacked a pain rating. * 01/20/25 at 4:50 a.m. Behavior Note . sitting in w/c hollering 'help me.' Morphine sulfate 2.5 mg. given. The record lacked a pain rating. * 01/20/25 at 10:21 a.m., morphine sulfate administered for a pain rating of 6 out of 10. * 01/20/25 at 6:20 p.m., morphine sulfate administered for, . becoming agitated in day room now. The record lacked a pain rating. * 01/20/25 at 11:25 p.m., morphine sulfate administered for, . Sitting at bedside hollering 'help me help me' then he starts making his other vocal noises. He didn't want anything. He was given morphine sulfate and assisted to lay down. The record lacked a pain rating. * 01/21/25 at 4:45 a.m., morphine sulfate administered for . lying in bed hollering. The record lacked a pain rating. * 01/21/25 at 3:21 p.m., . monitor behaviors every day and evening shift. Resident has been go [good] this shift so far. * 01/21/25 at 6:23 p.m., morphine sulfate administered for anxiety/pain . The record lacked a pain rating. * 01/21/25 at 10:20 p.m., Behavior Note. At 6:30 [p.m.] he was lying in bed hollering 'help me' but didn't need anything. Morphine Sulfate given. He has been sleeping since then. * 01/21/25 at 10:50 p.m., morphine sulfate administered for, . needs to calm down. The record lacked a pain rating. The record showed the facility failed to administer acetaminophen in the month of January 2025. During an interview on 01/28/25 at 4:09 p.m., an administrative nurse (#1) confirmed Resident #1's medical record lacked pain documentation, use of non-pharmacological behavioral interventions, and/or use of the least restrictive medications (acetaminophen) before administering Morphine. The facility failed to complete a pain assessment related to Resident #1's new onset of pain, provide a rationale for the initiation of morphine, and attempt non-pharmacological interventions or administer the least restrictive medication (acetaminophen).

Based on review of the Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Long-Term Care Facility Policy Manual and staff interview the facility failed to submit direct care staffing information based on payroll data to the Electronic Staffing Data Submission PBJ for 2 of 4 reporting periods. Failure to submit direct care staffing information may result in inaccurate representation of the level of staff in the facility which can impact the quality of care delivered. Findings include: The June 2022, version 2.6 Electronic Staffing Data Submission Payroll-Based Journal (PBJ), pages 1-3, stated, . Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Facilities that do not meet these requirements will be considered noncompliant and subject to enforcement actions by CMS. Review of the PBJ Data Staff Report CASPER Report 1705D FY (fiscal year) Quarter 4 (July 1 - September 30, 2023) and Quarter 1 (October 1 - December 31, 2023) occurred on 03/18/23, stated, . Failed to Submit Data for the Quarter. Triggered. During an interview on 03/19/24 at 4:40 p.m. an administrative staff member (#2) confirmed the facility failed to submit staffing data for the reporting periods listed on the reports.

Based on observation, record review, and resident and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the resident's current status for 3 of 14 sampled residents (Resident #13, #25, and #32). Failure to revise the care plan for Residents #13 and #32 limited the staff's ability to communicate care needs and ensure continuity of care for each resident and failure to update Resident #25's transfer status placed the resident at risk for injury. Findings include: The facility failed to provide a care plan policy. - Review of Resident #13's medical record occurred on all days of survey. The care plan stated, . TOILET USE: Requires assist of 1 staff with mechanical stand lift for toileting. TRANSFER: The resident requires assist of 1 staff w/ [with] mechanical stand lift . A physician's order, dated 01/04/24, stated, Resident will transfer using mechanical stand lift with assist of 1 and gluteal [buttock] strap. Observation on 03/19/24 at 9:59 a.m. showed two certified nurse aides (CNAs) (#7 and #9) assisted Resident #13 with toileting. The CNAs applied the lift sling around the resident's waist and started to raise the lift. The resident unable to grasp the handles and the CNA (#9) stated, We better use the other strap [gluteal strap]. The CNAs then lowered the stand lift, applied the gluteal strap, and transferred the resident to the toilet. Observation on 03/20/24 at 12:24 p.m. showed a CNA (#9) transferred Resident #13 from the wheelchair to the bed using the mechanical stand lift and failed to use the gluteal strap. Resident #13's care plan lacked an intervention to use the gluteal strap when transferring the resident with the mechanical stand lift. - Review of Resident #25's medical record occurred on all days of survey. The current care plan showed, . Walking Program . Walk with 4WW [4 wheeled walker] 2x/day [twice a day] distance as tolerated assist x 1 [of 1 person] with gait belt. Initiated 07/19/23 . Physical Therapy ended Resident #25's walking program on 02/20/24. The current resident care card, used by the CNAs, dated 03/04/24, showed . Amb. [ambulate] w/ [with] FWW [front wheeled walker] short dist. [distance] . Resident #25's current care card lacked updated ambulation information to match the care plan. During an interview on 03/21/24 at 10:39 a.m., administrative staff members (#4, #5, and #6) confirmed Resident #25's care card, which the CNAs follow, lacked the resident's current ambulation status. - Review of Resident #32's medical record occurred on all days of survey. Diagnoses included atrial fibrillation (irregular heartbeat). Current physician's orders showed Rivaroxaban (a blood thinning medication) 15 mg (milligrams) one time a day related to atrial fibrillation and Mirtazapine (an antidepressant) 7.5 mg at bedtime for mood. Resident #32's current care plan lacked problems and interventions related to use of an antidepressant and anticoagulant. During an interview on 03/21/24 at 10:39 a.m., administrative staff (#4, #5, and #6) agreed Resident #32's care plan should include a problem and interventions for use of an antidepressant and anticoagulant.

Based on observation, record review, and resident and staff interview, the facility failed to provide care and services for 1 of 1 sampled residents (Resident #25) reviewed for edema (fluid retention) and 1 of 2 sampled residents (Resident #26) observed wearing a splint. Failure to apply compression stockings as ordered may result in worsening edema and failure to obtain an order for use of a splint may result in worsening pain. Findings include: - Review of Resident #25's medical record occurred on all days of survey. A physician's order, dated 08/30/23, stated, Compression stockings to be utilized for edema management. A physicians note, dated 02/20/24, stated, . bilateral lower extremity edema. Chronic. Continue with compressions [stockings] as directed. The care plan stated, . Staff to apply compression stockings to BLE [bilateral lower extremities] for edema management . Observations of Resident #25 showed the following: * On 03/19/24 at 03:26 p.m., wearing non compression stockings. The resident reported she has those socks [compression stockings] but not sure if I have them on. * On 03/20/23 at 12:30 p.m., wearing non compression stockings. * On 03/21/24 at 08:45 a.m., dressed for the day, wearing slippers without socks or compression stockings. During an interview on 03/21/24 at 10:39 a.m., administrative staff members (#4, #5, and #6) agreed they expected staff to apply compression stockings as ordered. - Review of Resident #26's medical record occurred on all days of survey. Observations on all days of survey showed Resident #26 wore a splint to the left hand/wrist. During an interview on 03/20/24 at 4:05 p.m., when asked about the splint to the left hand, Resident #26 stated, It was all swollen and very painful and the physician didn't know what was wrong with it so he told me to use this brace all the time. I'm having an MRI [magnetic resonance imaging] on Monday to see what's wrong with it. During an interview on 03/20/24 at 4:20 p.m., when asked about the left hand splint, a nurse (#10) stated, He had swelling in that hand and was using ace wraps until the last time he returned from the hospital he had the splint on. I was told he is to wear it at all times. Review of the March 2024 treatment administration record (TAR) identified an order, for a splint to left wrist for left wrist pain was discontinued on 03/11/24. The facility failed to obtain a physician's order for Resident #26 to wear the left hand splint after he returned from the hospital, monitor if the splint was in place, and failed to update the care plan to identify the splint was to be worn at all times. During an interview on 03/21/24 at 11:08 a.m., an administrative staff member (#5) stated, When the resident returned from the hospital he did not have an order for the splint, so it was discontinued on the TAR. The staff member agreed staff failed to clarify the order for the splint when Resident #26 returned from the hospital.

Based on observation, record review, review of professional reference, facility policy, and staff interviews, the facility failed to provide supervision and assistive devices necessary to prevent accidents for 2 of 14 sampled residents (Residents #13 and #19). Failure to provide supervision of certified nurse aides (CNAs) by a licensed nurse regarding resident transfer modes and failure to utilize safe/proper technique during transfers may result in unnecessary pain, falls and/or injury for residents. Findings included: Review of the North Dakota Administration Code (NDAC) online at www.ndlegis.gov/information/acdata/pdf/33-43-01.pdf stated, . 33-43-01-12. Supervision and delegation of nursing interventions. An individual on the department's nurse aide registry [CNA] may perform nursing interventions which have been delegated by a licensed nurse. An individual on the departments's nurse aide registry as delegated and supervised by a licensed nurse . Review of the facility policy titled STANDING LIFT occurred on 03/21/24. This policy, dated December 2017, stated, . The knee rest has a built-in leg strap to be used on residents without much control. it is not advised that the standing lift be used if the resident cannot assist with his/her hands and arms. - Review of Resident #13's medical record occurred on all days of survey and included diagnoses of weakness and dementia. The current care plan stated, . TRANSFER: The resident requires assist of 1 staff w/ [with] mechanical stand lift . The certified nurse aide (CNA) pocket care guide stated, . Standing lift assist of 1 with gluteal strap . A physician's order, dated 01/04/24, stated, Resident will transfer using mechanical stand lift with assist of 1 and gluteal strap. Observation on 03/19/24 at 9:59 a.m. showed two CNAs (#7 and #9) attempted to transfer Resident #13 from the wheelchair to the toilet utilizing a mechanical sit-to-stand lift without applying the gluteal strap. The CNA (#9) began to lift the resident and he/she failed to hold onto the handles. The CNA (#9) stated, We better use the other [gluteal] strap. The CNAs then utilized the gluteal strap. When asked if staff always use two assist with the sit-to-stand lift, the CNA (#9) stated, No, just with [Resident #13's name] we do because she does not always stand very good. During an interview on 03/20/24 at 11:29 a.m., when asked how she knows when to use two staff with transfers the CNA (#9) stated, It was in report a long time ago. Observation on 03/20/24 at 12:24 p.m. showed a CNA (#9) utilized the sit-to-stand mechanical lift to transfer Resident #13 from the wheelchair to the bed. The resident appeared restless and unable to follow commands. The CNA transferred the resident to the bed without using the gluteal strap, leg strap, and without the resident grasping onto the stand handles. The CNA stated, sometimes we can use one with her and the sit-to-stand. When asked how the CNA knows to use one or two staff the CNA stated, We decide based on her day and her behaviors and how she is standing. The CNAs failed to use the leg and gluteal straps while transferring Resident #13. - Review of Resident #19's medical record occurred on all days of survey. The current care plan stated, . TOILET USE: Assist of 1-2 . TRANSFER: The resident is able to transfer with extensive of 1-2 assist. The CNA pocket care guide stated, . SBA [stand by assist] of 1/FWW[front wheeled walker]/Gait belt Assist of 1 . Observation on 03/18/24 at 6:34 p.m. showed a CNA (#11) applied a gait belt and assisted Resident #19 to the bathroom. The resident ambulated slowly and grimaced the majority of the way to the bathroom. Observation on 03/20/24 at 10:02 a.m. showed a CNA (#12) assisted Resident #19 off the toilet and ambulated the resident back to his wheelchair. When asked how the CNA knows to use one or two assist the CNA stated, I only use one because that's what his care card says. It just depends upon what kind of a day he is having if we need 2 staff. When asked who makes the decision to use one or two assist the CNA stated We, the CNAs do depending upon what kind of day he is having. During an interview on 03/20/24 at 5:15 p.m., when asked how she knows whether to use one or two assist to transfer/ambulate Resident #19 the CNA (#13) stated, I usually only use one for him depends on how he is feeling. If weaker I take him with the wheelchair into the bathroom and then he can just grab the bar and get up instead of walking into the bathroom. At night we use two when getting him out of bed. When asked who makes the decision to use one or two assist the CNA stated, I do depending on how he is standing. During an interview on 03/21/24 at 11:53 a.m., an administrative staff member (#5) confirmed being unaware CNAs could not determine the number of staff needed to transfer and stated she expected staff to use the leg and gluteal straps when transferring Resident #13.

Based on observation, record review, review of a professional reference, and staff interview, the facility failed to provide appropriate toileting for 2 of 12 sampled residents (Resident #8 and #13) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed residents at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries. Findings include: The facility failed to provide a policy related to toileting of residents. Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 892, stated, Fecal and Urinary Incontinence: Moisture from incontinence promotes skin maceration [tissue softened by prolonged wetting or soaking] and makes the epidermis more easily eroded and susceptible to injury. Digestive enzymes in feces, urea in urine . also contribute to skin excoriation [area of loss of the superficial layers of the skin .]. Any accumulation of secretions . is irritating to the skin, harbors microorganisms, and makes an individual prone to skin breakdown and infection. Page 1221 stated, Managing Urinary Incontinence . Habit training, also referred to as timed or prompted voiding and scheduled toileting, attempts to keep clients dry by having them void at regular intervals, such as every 2 to 4 hours. The goal is to keep the client dry . - Review of Resident #8's medical record occurred on all days of survey. The care plan stated, . has an ADL [activities of daily living] self-care performance deficit r/t [related to] Alzheimer's disease. TOILET USE: The resident requires supervision-limited assistance by 1 staff for toileting. is at risk for falls r/t diagnoses of Alzheimer's and tremors, and has a hx [history] of falls. Bed and chair alarms . The certified nurse aide (CNA) pocket care guide stated, . Assist of 1 w/ [with] toileting q [every] 2-3 hr [hours] & prn [as needed] Pull ups-Assist to chge [change] prn . Review of Resident #8's toileting record, dated February 21 through March 20, 2024, identified 43 occasions where staff failed to assist the resident with toileting as care planned. The log showed gaps of approximately 3.5 to 14 hours between staff assistance with toileting. Progress notes stated the following: * 1/9/24 at 12:30 a.m. found [Resident #8's name] resting on buttocks in front of door . with his shoulders resting against the door. Bed alarm was not sounding. He said he had just been to the bathroom . Said after he was done on toilet he slipped. Skin tear to L) [left] elbow and 3 abrasions in a line down R) [right] elbow. He complained of pain to the ulnar [sic] side [one of the two bones in the forearm] ofhis [sic] R) hand. * 01/09/24 at 12:19 p.m. Writer informed on-call provider of fall with injury to right hand. Writer described resident's difficulty with moving 4th and 5th digits of right hand, swelling and bruising to lateral side of right hand. Provider ordered x-ray of right hand to be read stat[immediately]. * 01/09/24 at 1:45 p.m. Writer received call from on-call provider notifying that resident's x-ray revealed a broken 5th metacarpal. Provider applied splint to resident's hand and ordered orthopedics consult. During an interview on 03/19/24 at 2:17 p.m., a CNA (#7) stated, [Resident #8's name] is independent with toileting, he takes himself and does his own thing. During an interview on 03/20/24 at 11:33 a.m., a CNA (#12) stated, Most of the time [Resident #8] goes by himself once in a while he will put his call light for help but not very often. When asked if he was able to use the bathroom himself , the CNA stated, Oh yes he does all the time. - Review of Resident #13's medical record occurred on all days of survey. The care plan stated, . has an ADL self-care performance deficit r/t dementia . TOILET USE: Requires assist of 1 staff with mechanical stand lift for toileting. is at risk for skin breakdown related to incontinence, decreased mobility and cognitive decline. Open skin area to R lateral foot. is at risk for falls. Resident uses chair and bed electronic alarm. The CNA pocket care guide stated, . Toilet q 2-3 hr & PRN-Inc.[incontinent] bladder-brief . Review of Resident #13's toileting record, dated February 21 through March 20, 2024, identified 82 occasions where staff failed to assist the resident with toileting as care planned. The log showed gaps of approximately 3.5 to 13 hours between staff assistance with toileting. Observation on 03/20/24 at 9:53 a.m. showed two CNAs (#7 and #14) attempted to assist Resident #13 to the bathroom. The resident appeared restless, agitated and failed to hold onto the sit-to-stand lift. The CNA (#7) stated, We'll give her some time to calm down and try again in ten minutes. During an interview on 03/20/24 at 11:29 a.m., when asked if they had attempted to take Resident #13 to the bathroom again, the CNA (#7) stated, We tried again about 45 minutes ago, but [Resident #13] started crying so we didn't take her then either. Observation on 03/20/24 at 12:24 p.m. showed a CNA (#7) attempted to take Resident #13 to the bathroom. Using the sit-to-stand mechanical lift the CNA assisted the resident to the bed for a check and change. The resident's incontinent product appeared very wet with urine. When asked how long it had been since the CNA had toileted/checked and changed the resident, the CNA stated, Not since I got her up this morning about 7-7:30 [7 am -7:30 am]. Five hours prior to the resident being checked and changed. During an interview on 03/20/24 at 12:40 p.m., a licensed nurse (#10) stated the CNAs had not informed her Resident #13 wasn't able to stand or, hold onto the sit-to-stand mechanical lift, having behaviors, and not been toileted or changed since 7:00-7:30 this morning. During an interview on 03/21/24 at 11:53 a.m., an administrative staff member (#5) confirmed Resident #8 is not independent and expected staff to toilet/check and change residents per the care plan.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of medications in 1 of 1 medication carts. Failure to store all medications securely may result in unauthorized access to medications. Findings include: Review of the facility policy titled Medication Administration occurred on 03/20/24. This policy, revised 2016, stated, . The medication cart should be locked when left unattended . Medications should not be left on top of the medication cart . if the nurse or CMA [certified medication aide] is in a resident room and the medication cart is not locked . it has to be in an area where the nurse or CMA can see it . Observation on 03/19/24 at 11:47 a.m., showed a staff nurse (#8) left the medication cart unattended for over eight minutes with six insulin pens/vials on top of the medication cart. The medication cart remained unlocked in the hallway and out of view of the nurse. During an interview, on 03/20/24, an administrative nurse (#5) confirmed she expected staff to ensure medications are secured within the medication cart and to lock the cart when out of eyesight.

Based on observation, facility policy review, and staff interview, the facility failed to ensure staff followed standard infection control practices for 2 of 10 sampled residents (Resident #6 and #16) and 1 supplemental resident (Resident#1). Failure to follow infection control practices related to hand hygiene and glove use has the potential for transmission of communicable diseases and infections to residents and staff. Findings include: Review of the facility policy, Handwashing Specifics occurred on 3/21/24. This policy, revised January 2015, stated, . Handwashing decreases contamination of the hands and prevents spread of pathogens . personnel who perform procedures on residents . should wear gloves . even though gloves are worn, hands should still be washed . before, between and after all physical contacts with the resident . before and after performing any personal body function . - Observation on 03/18/24 at 10:18 a.m., showed a certified nurse aide (CNA) (#15) performed incontinence cares on Resident #16 while in bed. Without performing hand hygiene, the CNA (#15) donned gloves, lowered the resident's pants and brief, cleaned the resident's perineal area of bowel movement (BM), and with the same gloves on, turned the resident onto their side, removed two barrier cream tubes from the bedside drawer, applied the creams to the resident skin, and returned the tubes to the drawer. The CNA (#15) removed her gloves, and without performing hand hygiene, exited the room. - Observation on 03/19/24 at 10:20 a.m., showed a CNA (#9) provided incontinence cares for Resident #1. The CNA (#9), without performing hand hygiene, donned gloves, lowered the resident's pants, and lowered the front side of the soiled brief to perform perineal cares. The CNA (#9), without removing used gloves and performing hand hygiene, removed tubes of cleansing cream and barrier cream from the bedside drawer, put the cleansing cream on disposable wipes and cleansed the buttocks. The CNA (#9) then applied a barrier cream, placed a new brief and repositioned the resident onto their back. Resident #1 started to void and the CNA placed wipes to catch the urine. The CNA removed her gloves, and without performing hand hygiene, went to the residents closet for gloves, applied them, removed the soiled wipes, applied barrier cream under the resident's abdominal folds and fastened the brief. The CNA (#9) removed her gloves and without performing hand hygiene, touched several other surfaces/items, applied Resident #1's oxygen and gave the resident a drink of water and then performed hand hygiene. -Observation on 03/19/24 at 10:54 a.m., showed a CNA (#15) used a stand lift to provide toileting cares to Resident #6. Without performing hand hygiene, the CNA donned gloves, lowered the residents pants and brief and lowered them on the toilet. The CNA (#15) cleaned the resident's perineal area of BM, put on a clean brief and pulled up her pants, moved the lift, touched the sink, the door handle, the wheelchair, and the leg pedals, then removed her gloves and exited the room without performing hand hygiene. The staff failed to perform hand hygiene between glove changes and touched numerous items in the resident's room. During an interview on the afternoon on 03/20/24, an administrative nurse (#5) confirmed she expected staff to perform good hand hygiene with resident cares. 45873

Based on observation, record review, review of facility policy, and staff interview, the facility failed to investigate and report to the State Survey Agency (SSA) potential incidents of abuse/neglect for 2 of 2 sampled residents (Resident #13 and #29) who experienced injury. Failure to investigate and report allegations of abuse/neglect to the SSA places all residents at risk of potential abuse. Findings include: Review of the facility policy titled ABUSE, NEGLECT, MISTREATMENT, AND MISAPPROPRIATION OF RESIDENT PROPERTY occurred on 03/14/23. This policy, dated June 24, 2018, stated, . It is the facility's responsibilities to prevent not only abuse, but also those practices and omissions that if left unchecked, lead to abuse. Everyone must monitor the resident for possible signs of abuse: like suspicious or unexplained bruising . All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source . must be completed within 24 hours of the initial allegation report. Administration will provide a final written report to the North Dakota Department of Health, Division of Health Services within 5 days of the initial allegation. - Review of Resident #29's medical record occurred on all days of survey. Diagnoses included left sided muscle weakness, dementia and history of falling. Observation showed Resident #29 wearing a right wrist splint on all days of survey. The nursing progress notes identified the following: * 02/10/23 9:28 p.m. At 2050 [8:50 p.m.] one of the CNA's [certified nursing assistants] called this writer to pt [patient] room saying that he notice the pt right wrist swollen. This writer assessed pt, as the arm was red and painful to touch. This writer asked the pt what happened to his wrist? He said that he does not know what happen. Pt temp [temperature] was 98.1% [sig] This writer called at the hospital wanting to talk to the [name of provider] This nurse, [name of nurse] explained to [name of provider] about it and Dr [doctor] said that I should use cool ice pack on wrist until in the morning and try to call back if it does not resolve. This writer did that and also gave the pt Tylenol for pain. This writer later informed pt cousin, [name of cousin] about pt wrist. Will continue to monitor. * 02/11/23 6:30 a.m. Writer assessed resident's right wrist, noting that it was reddened and swollen when compared with left. Wander-guard removed from right wrist. Resident is normally stoic regarding pain, but c/o [complain of] discomfort to wrist especially when touched. Writer called hospital to speak to on-call provider. On-call provider had ordered during the night shift that resident be brought to ER if he still had pain and swelling after area iced. Rt[right] wrist had ice packs applied during the night shift with no improvement to pain or swelling. NCHS staff brought resident to hospital . * 02/11/23 11:55 a.m. Late Entry: Res. [Resident] returned from ER [emergency room ] per facility van and driver at 10:15. Res. to wear Spica splint to R) [Right] wrist at all times, except for hygiene and cold packs. Will x ray again in 4 weeks time. Res. appears to have a non-displaced ulnar fracture of the R) [Right] wrist. During an interview on 03/15/23 at 2:40 p.m. administrative staff (#1 and #3) stated at the time of the injury, Resident #29 reported to the staff nurse, he fell . Staff (#1 and #3) failed to provide documentation with details of the fall and confirmed staff failed to complete an investigation of the injury, or report the incident to the SSA. 31725 - Review of Resident #13's medical record occurred on all days of survey. Diagnoses included dementia and anxiety disorder. Review of Resident #13's nurses notes identified the following: * 04/20/22 at 5:33 a.m. resident has a bruise on her rt [right] front thigh that measures 7.5 x 7.5 cm [centimeters] the color is dark purple and red it is not warm to touch and the resident does not c/o [complain of] pain. * 04/22/22 at 12:23 p.m. CNA reported that a bruise was noted on resident's right thigh. Upon assessment, a black purple bruise measuring 10cm x 11cm was noted to resident's right thigh. Resident denies any pain to the area and was unable to report how bruising occurred. On 04/22/22 at 11:20 a.m. the SSA received an Initial Allegation of Mistreatment, Abuse, Neglect, or Theft and Facility Reported Incidents Reporting Form identifying a bruise on the front thigh measuring 7.5 cm x 7.5 cm. The facility failed to notify the SSA within 24 hours of the initial report of bruising and send a final report within 5 days. Resident #13's nursing notes identified the following: 11/08/2022 at 6:16 a.m. bruise discovered on outer part of left knee l[length]:6cm w [width]:5cm and raised approximately .1cm. Pt [Patient] denied pain in area no redness or swelling around bruise temperature is normal to touch will continue to monitor. The facility failed to investigate the cause of Resident #13's bruise to the left knee. During an interview on 03/15/23 at 2:40 p.m. administrative staff (#1 and #3) confirmed the facility failed to complete a final report for the bruise on 04/20/22 and failed to investigate the bruise on 11/08/22.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to implement policies and procedures that included additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19 for 2 of 2 unvaccinated staff (Staff A and B). Failure to implement additional precautions for staff who are not fully vaccinated may lead to increased risk of transmission and spread of COVID-19 among patients, staff, and visitors. Findings Include: Review of the policy titled Employee COVID-19 Vaccinations occurred on 03/15/23. This policy, revised 10/15/22, stated, . This policy is developed to ensure that all eligible employees are vaccinated against COVID-19 . will implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated . They will continue to wear surgical masks, check in when getting to work per recommendations. Review of employee vaccination records identified Staff A and B completed appropriate COVID-19 vaccine exemptions. Observations showed the following: * 03/14/23 8:27 a.m. Staff A walked throughout the facility, administering medications without a face mask. * 03/15/23 9:00 a.m. Staff B walked alongside a resident to the therapy room without a face mask. During an interview on 03/15/23 at 9:05 a.m., Staff B stated she is not required to wear a surgical mask and if she felt ill the recommendation is to talk to the infection preventionist or nurse. During an interview on 03/15/23 at 10:30 a.m., two administrative staff (#1 and #2) agreed the facility failed to follow the policy for mitigation strategies for unvaccinated staff.

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#9) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 10/20/21 at 12:54 p.m., a dietary manager (#9) stated she started the certified dietary manager's (CDM) course in March 2020 and has not yet completed the course. The facility failed to ensure the dietary manager (#9) completed the required education for a CDM, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control standards for 4 of 9 sampled residents (Resident #9, #16, #20, and #22) observed during cares. Failure to follow infection control practices for hand hygiene and glove use related to treatments and perineal care has the potential to spread infection from one body site to another and within the facility. Findings include: Review of the facility policy/procedure titled DRESSING CHANGE - NON-STERILE occurred on 10/20/21. This policy, dated February 2018, stated, Procedure: .*Don gloves *Remove old dressing, discard in plastic bag *Remove gloves wash hands, don clean gloves *Cleanse area with prescribed cleaning solution *Apply any prescribed medication(s) *Apply new dressing as ordered, secure with tape as needed *Remove gloves, wash hands . Review of the facility policy/procedure titled HAND WASHING SPECIFICS occurred on 10/20/21. This policy, dated January 2015, stated, . WHEN SHOULD YOUR HANDS BE WASHED? . 2. Before entering and leaving the patient/resident unit. 3. Before, between and after all physical contacts with the patient/resident. 7. After handling used dressings . - Observation on 10/18/21 at 2:54 p.m. showed a nurse (#1) provided wound treatments for Resident #16. The nurse (#1) donned gloves to remove an existing dressing, opened a new tube of medication, applied the medication to sores on the side of his foot, fifth and fourth toes (with the tube touching the resident's skin), and applied a clean dressing over the area. The nurse (#1) then moved to a wound on the heel of the same foot, opened the new dressing, applied medication from the same tube to the new dressing, removed the existing dressing, and applied the prepared dressing. The nurse (#1) failed to remove his/her gloves and perform hand hygiene between removing the old dressing/applying the new dressing. The nurse (#1) moved to another treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse changed gloves, and without performing hand hygiene, irrigated the resident's catheter using sterile supplies. - Observation on 10/18/21 at 3:54 p.m. showed two certified nursing assistants (CNAs) (#3 and #10) performed perineal cares while Resident #22 lay in bed. Without removing her gloves and performing hand hygiene, the CNA (#3) adjusted the resident's clothing, hooked the sling to a full body lift, transferred the resident to the wheelchair, placed a blanket and eye glasses on the resident, and provided the resident water. - Observation on 10/19/21 at 9:53 a.m. identified two CNAs (#3 and #7) provided perineal cares and transferred Resident #20. The CNA (#3) failed to complete hand hygiene after removing her gloves and before leaving the resident's room. - Observation on 10/19/21 at 12:50 p.m., showed two CNAs (#2 and #3) provided perineal care for Resident (#9). The CNAs failed to perform hand hygiene as they left Resident #9's room.

Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to minimize the pain for 1 of 1 sampled resident (Resident #3) who experienced pain/behaviors with perineal care. Failure to provide Resident #3 with perineal care according to the recommended plan of care resulted in pain, discomfort, and aggressive behaviors. Findings include: - Review of Resident #3's medical record occurred on January 14-16, 2013. [DIAGNOSES REDACTED]. bleed). Resident #3's most recent Minimum Data Set (MDS), dated [DATE], identified short-term and long-term memory problems; usually understands others and makes self understood; behaviors including inattention, disorganized thinking, altered level of consciousness, and rejection of care on 4 to 6 days; extensive assistance with toileting and personal hygiene. Resident #3's Treatment Administration Record (TAR), dated 11/02/12, stated, "[MEDICATION NAME] crm (cream) (a topical corticosteroid) to labia 2X (times) wkly (weekly) X 2 mo (months)." A nursing assessment on the back of the TAR, dated 01/14/13 at 8:00 p.m., stated, "Periarea (perineal area) red in color, small dark reddened area in center of vaginal opening that measures 1.5 cm (centimeters) in diameter (no) odor. Small amt (amount) of yellow drainage noted cont. (continue) to receive [MEDICATION NAME] cream 2X's wkly." Resident #3's current care plan, dated 12/23/12, stated, "Physical and verbal abuse during pericares (perineal care) . . . Do pericares (with) warm wash cloth - don't rub - pat (with) wash cloth. . . . Toilet schedule assist of 1 - q (every) 2 to 3 (hours) and prn - before and after meals. . . ." Observation on 01/14/13 at 5:00 p.m. showed a certified nursing assistant (CNA) (#10) assisted Resident #3 with toileting. When the CNA began using a disposable wipe to provide perineal care after a bowel movement, Resident #3 stated, "Ooh, Ooh, Oh my goodness hurts, Ouch, Quick, never is. Sorry, I cry all the time. It hurts, Ooh." After the CNA completed perineal care, the resident voiced no further complaints of pain. During an interview on 01/15/13 at 9:20 a.m., a CNA (#11) stated, "Resident #3's bottom is sore, so I wet toilet paper with warm water to wipe her. The resident doesn't like anything cold so she seems to do better (with warm water)." On 01/15/13 at 5:20 p.m., a CNA (#5) stated "No one had taken her." and assisted Resident #3 from the dining room to assist her with toileting. The CNA identified Resident #3 as incontinent of urine. When the CNA used a disposable wipe to provide perineal care after the resident voided, Resident #3 cried, "Oww, that's where it's sore. No, Don't, (I'm) not coming to this place anymore." After the CNA completed perineal care, the resident voiced no further complaints of pain. Observation on 01/16/13 at 9:45 a.m. showed a CNA (#11) assisted Resident #3 with toileting. The CNA identified the resident did not void, but indicated she would provide perineal care anyway. The CNA wet toilet paper with warm water to provide perineal care. When using this method, Resident #3 had no negative reaction to perineal care. The CNA stated, "I wet toilet paper with warm water because she doesn't like anything cold and her bottom is a little sore." Review of Nurses' Notes identified the following: *10/06/12, 6:00 a.m. - ". . . hollared (sic) out while CNA was washing periarea, very red . . ." *10/27/12, 6:00 a.m. - "Periarea excoriated (damaged or removed part of the skin's surface) and to vaginal area. Cleansed (with) soap and water and calmo ([MEDICATION NAME] a moisture barrier cream that temporarily relieves discomfort and itching) applied. Very tender when washing area - as tearful and stating 'stop.'" *10/27/12, 9:00 p.m. - "Periarea/vaginal area remains irritated. Cleansed (with) soap and water. Calmo applied." *10/30/12, 9:00 p.m. - "Groin red (and) cries out when pericares done - also red near rectal area." *11/02/12, no time - "Res (resident) kicked CNA stomach (with) pericares. CNA report gentle cleansing done." *11/08/12, 8:00 p.m. - "Res cont. (continues) to yell at staff when receiving pericares. Res slapped this writer in face while attempting to wash. Res allowed to calm down and then attempted to wash again." *11/10/12, 8:30 p.m. - "Resident less resistive (with) pericares when laying on bed. c/o (complained of) water being cold and reassurance given and calmed. No physical aggression." *12/14/12, 10:30 p.m. - "Requires two to assist in care - (one) to wash and one to talk to her (and) distract her when pericares done." *12/15/12, 11:00 p.m. - "CNA reports that resident hollars (sic) every morning when pericares are being done." *12/31/12, 1:00 p.m. - "Nursing Assessment . . . Res verbal and physically abusive (with) cares (pericares) . . ." During an interview on the afternoon of 01/16/13, an administrative nursing staff member (#6) confirmed staff should provide perineal care "according to the care plan."

1. Based on observation, record review, and review of facility policy, and staff interview, the facility failed to ensure safe transfers with mechanical devices for 3 of 3 sampled residents (Resident #3, #4, and #5) observed transferred with stand and/or Hoyer lifts. This resulted in an injury to Resident #3 due to falls from the stand and/or Hoyer lifts on three occasions. Findings include: Review of the facility policy titled "Mechanical Lift Operation" occurred on 02/10/11. The policy, revised 10/06, stated: "Purpose: A mechanical lift is used to transport/transfer residents who are unable to move themselves. . . . Procedure: . . . SELECTING AND APPLYING THE SLING: . . . 2. . . . Bring the sling under the arms and make sure it is centered. 3. Start with the strap loose when fastening the buckle to prevent clothing from getting caught in the buckle. 4. . . . Once the resident starts lifting, the torso will straighten out and the strap will loosen. Then re-tighten the strap to ensure the comfort and safety of the resident being transferred. ATTACHING THE SLING TO THE LIFT: . . . 5. The knee rest has a built in leg strap to be used on a resident that doesn't have much control. It will keep their knees on the knee rest. It is not necessary to use the strap on everyone. . . . 7. Place the resident's hands on the handles, if physically possible. If the resident cannot hold their hands on the handles they can let their arms hand on the side, assuming they have a little torso strengt (sic). It is not advised that the standing lift be used if the resident cannot assist with their hands and arms. 8. If the resident is totally non-ambulatory or bedridden, you would be better off using the full body lift. It is encouraged that anyone being transferred, use any upper body strength that they may have, to help maintain some of their strengt (sic). TRANSFERRING FROM CHAIR TO COMMODE: . . . 2. When the lift starts lifting and the torso starts to straighten, resnug the strap. This will make the transfer more comfortable for the resident. . . . 5. Most residents can be transferred safely with one care giver assisting with the standing lift. If a resident is unable to hold unto the handles safely, has difficulty bearing weight, or is very heavy, two caregivers should be used. Two caregivers should be used when using the full body lift." Review of the facility policy titled "FALL PROTOCOL" occurred on 02/10/11. This policy, revised January 2008, stated: "PURPOSE: to assure all residents are assessed for possible injuries. To ensure proper treatment . . . to decrease the risk for future falls. PROCEDURE: . .. . 11. Notify the health care provider if there is deterioration in the residents mental status, increase in lethargy, complaints of pain, decreased mobility, and anything else unusual. 12. Complete an incidence occurrence report. Forward this to the Director of Nursing (DON). The DON forwards the report to the Administrator and Medical Director. When the form is complete the DON gives it to the Quality Assurance director for filing and logging of trends. . . . 16. Reassess fall prevention strategies and implement as applicable. 17. Update the care plan as necessary. . . ." The facility policy titled "FALL AND INJURY PREVENTION" occurred on 02/10/11. This policy, revised September 2007, stated: "PURPOSE: Residents will be in an environment that is free from hazards over which the facility has control. Residents will be supervised and receive assistive devices to prevent avoidable accidents. AUTHORITY: The facility staff will work as a team to identify hazards, evaluate and analyze the hazards. The team will implement interventions to reduce hazards and risks. Monitoring for effectiveness and modifying interventions will be a team effort. The team consists of nursing, administration and maintenance staff. . . . 14.) Injury prevention devices and services will be implemented according to the needs of the resident. . . ." - Resident #3's medical record, reviewed February 8-10, 2011, identified [DIAGNOSES REDACTED]. The resident's quarterly MDS (Minimum Data Set), dated 01/06/11, identified total dependence on two persons for transfers. The resident's RAP (Resident Assessment Profile), dated 06/02/10, stated, ". . . COGNITIVE SUMMARY: . . . Resident has both long and short term memory difficulties. . . . FALL SUMMARY: . . . resident has had falls in past 180 days - last one 4/10/10 while in lift - no injuries. Standing lift used for all transfers. He is (T) (total assist) for cares. . . . Has impaired mobility . . ." As evidenced below, the facility staff continued to use the stand lift even though Resident #3 showed unresponsive spells, injuries and/or falls. The Nurse's Notes identified the following: * 02/27/10, "CNA (Certified Nurse Assistant) was transferring resident from BR (bathroom) to bed. When by bed resident relaxed legs (and) started to slide out of SL (stand lift). CNA went behind resident (and) lowered to floor. 0 (No) injuries noted. Used Hoyer (and) (three) staff to bed. Family (and) doctor notified. . . ." *The Incident Report for this event identified resident fatigue as a contributing factor to the fall, and indicated one staff member was present at the time of the fall. * 03/01/10, "No c/o (complaints) from incident - does have bruises to forearms." * 04/10/10, "Was being transferred in standing lift when he lifted his arms and slid thru (through) the back sling. He was lowered to the floor by the CNA - sustained a 2 cm (centimeter) x .8 skin tear on L (left) elbow . . ." *The Incident Report for this event identified the resident required "monitoring to confirm no harm." The report further stated, "Due to pacemaker site, resident needs to hang onto lift at a lower level. Do not use the gray standing lift for this resident." The report did not identify the staff member(s) who witnessed the fall. * 05/02/10, "CNA reported res. (resident) became limp (with) lift transf. (transfer) but remained alert - no (changes) to orientation . . ." * 05/06/10, "Another unresponsive spell when being transferred from w/c (wheelchair) into bed only lasting few seconds." * 05/20/10, "CNA reported res had a short spell while transf. onto toilet in lift - lasted only a few seconds." * 06/18/10, "CNA reports that resident has a bruise on top of hand (and) (at) base of thumb on inside of hand - possibly from hanging on to handle on lift." * 09/12/10, ". . . res. has a 2 x 2 cm bruise to the top of his R) (right) forearm - CNA thought from bumping it on the lift when he raises his arms to grab the handles he gets "jumpy" (at) times (and) bumps them. . . . " * 10/14/10, "CNA reported resident had 2 small circular skin tears on L) forearm from transferring on lift. Area cleansed and covered (with) bandaide (sic)." * 11/04/10, "Report from CNA that she scratched res forehead by accident when transferring him into w/c." *11/19/10, "Became dizzy during transfer to toilet - able to hold onto lift handles. . . ." * 01/01/11, "8:25 a.m., Called to res rm (room) - res laying on floor hooked up yet to body lift - in w/c. Bleeding to back of head - alt (alert) (and) oriented - res was being transf to bed (with) body lift - the lift caught on his w/c as he was being lifted (and) his w/c began to tip - the wt (weight) of his upper body (and) momentum caused him to tip backwards - the CNA attempted to grab the w/c, but was unable to hold it from falling. Res attached to lift (and) (with) assist of 4 (and) lift was raised (and) put on bed - res has a open split to the back of his head . . ." * The Incident Reports for this event identified that the resident required "monitoring to confirm no harm." The report further identified the "Res sustained a 8 cm in length split to the back of his head. He remained alert and oriented throughout. . . . No other apparent injury." The report indicated two staff members present at the time of the fall. During an interview on 02/10/11 at 10:15 a.m., the administrative nurse (#6) stated she was unable to locate incident reports for the injuries of unknown origin that occurred on 06/18/10, 09/12/10, 10/14/10, and 11/04/10. (See F225) The medical record lacked evidence of a lift transfer assessment for Resident #3. The record did contain a Physician's Telephone Order, dated 12/07/10, for an "OT (Occupational Therapy) eval (evaluation) for w/c positioning." The Occupational Therapy Plan of Treatment, dated 12/09/10, identified, ". . . Staff education on positioning via Hoyer sling . . ." Although the 12/09/10 Occupational Therapy Plan of Treatment identified ". . . Staff education on positioning via Hoyer sling . . ." and the 01/06/11 quarterly MDS identified "total dependence on two persons for transfers", the current care plan, dated 01/17/11, stated, ". . . Problem: Res needs assist (with) all ADL's. . . . Goal: Res will be free of falls that require hospitalization . . . . Approaches: . . . 2) (Stand) Lift for transfers - remind to hold on to lift (with) hands - to help prevent falls. . . . Problem: Res has hx (history) of (increased) confusion/hallucinates (at) (times). Hx of unresponsive spells - eyes become fixed (and) doesn't respond for short time . . . Approaches: . . . 6) Don't leave unattended in lift or if unresponsive . . ." During an interview on 02/10/11 at 8:15 a.m., the administrative nurse (#6) could not answer questions pertaining to 1) whether the facility assessed Resident #3 for lift transfers, 2) the type of lift (stand or Hoyer) staff currently used with the resident, 3) the number of staff required to safely transfer the resident, and/or 4) the approaches listed on his current plan of care. (See F280) Failure to ensure staff responsible for providing direct resident care had accurate information regarding the mode of transfer and the number of staff required to safely transfer the resident resulted in actual harm to Resident #3. While on site, the survey team observed two CNAs transferring Resident #3 with a Hoyer lift on three separate occasions. The team determined other residents were not at risk. - Observations of transfers with a stand lift performed by a CNA(s) for Resident #5 identified the following: * 02/08/11 at 4:55 p.m., CNA (#1) transferred Resident #5 with a stand lift from the resident's wheel chair to the toilet in her bathroom, and from the bathroom, upon completion of toileting, back to the wheel chair. The CNA failed to tighten the strap around the resident's torso upon moving the resident from the sitting to standing position during both transfers. * 02/09/11 at 9:15 a.m., two CNAs (#3 and #11) transferred Resident #5 from her bed to a shower chair with a stand lift, and failed to re-tighten the strap around the resident's torso upon moving the resident from the sitting to standing position during the transfer. Failure to re-tighten the strap across the resident's torso (abdomen) posed a potential safety hazard if the resident's ability to participate in the transfer procedure would become limited. - Review of Resident #4's record occurred on all days of survey. The record identified the resident's admission occurred in 2007, and [DIAGNOSES REDACTED]. Review of Resident #4's current care plan identified a problem with pain and history of pressure areas with approaches of repositioning every two hours and as needed during the day, and repositioning every 2-3 hours during the night. The care plan lacked any indication the facility identified a problem of the resident having a tendency to bruise easily. Resident #4's nurse's notes included a nursing assessment, dated 02/06/11 at 1:00 p.m. which stated, "Res. (resident) remains resistant to care involving moving. . . . Memory is poor, both long and short term. Speech is clear but unreliable. She is unable to make decisions involving her care. She can be combative (with) care . . . She is totally dependent for all ADL's (activities of daily living). She is repositioned frequently. Skin is free from bruises or tears. . . ." Observation on 02/09/11 at 8:55 a.m. identified Resident #4 with ecchymotic bruising to the resident's left hand and left forearm. In an interview at 9:55 a.m. on 02/09/11, a staff nurse (#4) stated Resident #4 bruises easily, and in the past, forearm protectors have been tried. Observations of transfers with a stand lift performed by a CNA(s) for Resident #4 occurred on 02/09/11 identified the following: * 8:55 a.m., two CNAs (#11 and #12) transferred Resident #4 with a stand lift from her wheel chair to a shower chair. Neither CNA re-tightened the strap around the resident's torso upon moving the resident from the sitting to standing position during the transfer. * 12:50 p.m., CNA (#11) transferred Resident #4 from the toilet in her bathroom, across the resident's room to her bed (a distance of approximately 10-20 feet) with a stand lift. The CNA failed to re-tightening the strap around the resident's torso upon moving the resident from the sitting to standing position for the transfer across the room. The observations above showed the resident cooperative with both of these transfers. Observation during these times showed the resident's bed positioned against the wall (resident's left side). Repositioning a resident in a bed pushed up against a wall would require movement of the resident's bed away from the wall (every 2 hours) or movement of the resident toward the wall, which could be a potential hazard to the resident. During an observation on the afternoon of 02/09/11, two CNAs (#3 and #11) assisted Resident #4 into bed with a stand lift, positioned the resident onto her back, and did not move the bed away from the wall for positioning. Review of Resident #4's nurse's notes included the following entries: * 02/10/11 at 4:30 a.m.: "Sustained skin tear on (left) forearm measures approx (approximately) 2 1/2 inches wide - moon shape - cleansed - edges approximated - steri strips applied - dressing applied." At 6:00 a.m.: "Day nurse notified et (and) will contact Dr (doctor) et (and) family this AM (morning)" An interview occurred with an administrative staff nurse (#6) at 11:20 on 02/10/11 to ask how the injury occurred, and the staff nurse stated she did not know the injury occurred, provided a copy of the incident report completed which identified two CNAs present when the injury occurred, and provided no causative factors. The staff member identified the problem as a "documentation issue." * The nursing assessment, dated 02/06/11, noted above, identified no bruising at that time. * 01/08/11 at 4:00 a.m.: "While turning in bed (with) assist of 2 resident received 4 cm (centimeter) skin tear to back of (right) hand area was cleaned (sic) and steri strips applied along (with) tegaderm for protection." Record review lacked evidence Resident #4 bruises easily. Record review identified the resident obtained a skin tear on the morning of 02/10/11, and did not include an identifiable cause in either the nurses notes, nor the incident report. An interview with an administrative staff member (#6) verified the incident of unknown origin was not reported. The facility failed to follow its abuse prohibition policies and procedures, including reporting, identifying and investigating resident injuries promptly. Failure to follow their abuse policies and procedures places all residents residing within the facility at risk of harm or injury. 2. Based on observation, staff interview, and review of professional literature, the facility failed to provide a safe environment for 3 of 9 sampled residents (Resident #2, #3, and #7) and 1 of 1 supplemental residents (#12) whose beds/mattresses posed an entrapment hazard. Failure of the facility to ensure residents are provided with properly fitted beds/mattresses puts residents at risk for possible accident and/or injury. Findings include: In April 1999, the Hospital Bed Safety Workgroup provided clinical guidance for the assessment and implementation of bedrails for health care facilities, including long term care facilities. Policy Considerations included, in part, inspecting, evaluating, maintaining, and upgrading equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards and appropriately match the equipment to patient needs, considering all relevant risk factors. Bed Rail Safety Guidelines included, in part, * ensuring mattresses appropriately sized for the selected bed frame, as not all beds and mattresses are interchangeable * the space between the bed rails and the mattress, and the headboard and the mattress should be filled either by an added firm inlay or a mattress that creates an interface with the bed rail that prevents an individual from falling between the mattress and bed rails * Maintenance and monitoring of the bed, mattress, and accessories such as patient/caregiver assist items should be ongoing. Failing to ensure mattresses are appropriately sized for the selected bed frame poses the risk of resident entrapment. - Resident #2's medical record, reviewed February 8-10, 2011, identified [DIAGNOSES REDACTED]. The resident's current care plan, dated 01/11/11, stated, ". . . Problem: Res has hx of wandering (at) (times) . . ." Observations of Resident #2 showed the following: * During the initial tour on 02/08/11 at 12:45 p.m., observation showed a large space between the end of Resident #2's mattress and the footboard. Resident #2 was observed laying on the foot of her bed with her head leaning down in the space between the mattress and the footboard. * On 02/08/11 at 4:20 p.m., observation showed Resident #2 asleep with her head resting on her right hand and her right elbow leaning down in the space between the mattress and the footboard. * On 02/09/11 at 8:20 a.m. and 9:22 a.m., observation showed Resident #2 again asleep with her head at the foot of her bed. A measurement taken on 02/08/11 at 4:00 p.m. showed a 4.5 inch space existed in between the end of the mattress and the footboard. The above gap existed on all three days of survey. - During the initial tour on 02/08/11 at 12:45 p.m., observation showed a large space between the end of Resident #12's (Resident #2's roommate) mattress and the footboard. A measurement taken on 02/08/11 at 4:00 p.m. showed a 7 inch space existed in between the end of the mattress and the footboard. The above gap existed on all three days of survey. - During the initial tour on 02/08/11 at 12:45 p.m., observation showed a large space between the end of Resident #3's mattress and the footboard. A measurement taken on 02/08/11 at 4:00 p.m. showed a 6 inch space between the mattress and the footboard. The above gaps existed on all three days of survey. - During the initial tour on 02/08/11 at 12:45 p.m., observation showed a large space between the end of Resident #7's mattress and the footboard. A measurement taken on 02/08/11 at 4:00 p.m. showed an 8.5 inch space existed in between the end of the mattress and the footboard. The above gap existed on all three days of survey. During an interview on 02/10/11 at 11:00 a.m., the maintenance supervisor (#9) agreed the mattresses on the beds were too short for the bed frames, which has the potential for resident entrapment and injury. Failure of the facility to ensure residents are provided with properly fitted beds/mattresses put residents at risk for possible accident and/or injury. 3. Based on observation, record review, staff interview, and review of professional literature, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 3 of 6 sampled residents (Resident #3, #7, and #9) and 1 of 1 supplemental resident (Resident #13) transported by staff in wheelchairs. Failure of the facility to ensure staff properly use assistance devices (wheelchair foot pedals) placed residents at risk for possible accident and/or injury. Findings include: Kozier & Erb's "Fundamentals of Nursing, Concepts, Process and Practice," 8th Edition, Pearson/Prentice Hall, Upper Saddle River, New Jersey, page 1141-1145, states, ". . . Practice Guidelines Wheelchair Safety: . . . Lower the footplate's after the transfer and place the client's feet on them . . ." - Observation on 02/09/11 at 8:00 a.m. showed, a CNA (#3) transported Resident #3 in his wheelchair from the dining room to the resident's room. The toes of Resident #3's shoes slid along the surface of the floor, catching and bouncing on the carpet as the CNA (#3) transported him down the hallway. Resident #3's right foot caught on the carpeting and then caught under the right front wheel of the wheelchair causing it to stop suddenly. Resident #3 inhaled sharply, stating "ah." The CNA (#3) hugged the resident, and stated "You need to lift your feet," as she proceeded to transport him down the hallway. The CNA (#3) failed to report the incident to the charge nurse. (See F225) At 10:40 a.m. (upon surveyor request), a nursing staff member (#7) assessed Resident #3's right foot for injury. As of 11:00 a.m., the nurse's notes did not identify the resident's right foot had been caught under his wheelchair during transport. The staff member failed to place foot pedals, to ensure the resident's feet/shoes cleared the floor during transport, and to remind the resident to lift his feet. Resident #3's medical record, reviewed February 8-10, 2011, identified [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified total dependence of one person for locomotion on/off unit. The resident's RAP, dated 06/02/10, stated, "COGNITIVE SUMMARY: . . . Resident has both long and short term memory difficulty. . . . FALL SUMMARY: . . . Has impaired mobility and dementia. . . ." - Observation on 02/08/11 at 5:23 p.m. showed, a CNA (#1) transported Resident #13 in her wheelchair from the resident's room to the dining room. Resident #13's shoes slid along the surface of the floor, making an audible noise whenever they made full contact with the floor. The resident did not lift her feet. The staff member failed to place foot pedals, to ensure the resident's feet/shoes cleared the floor during transport, and to remind the resident to lift her feet. Resident #13's medical record, reviewed February 10, 2011, identified [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified extensive assistance of one person required for locomotion on/off unit. The resident's RAP, dated 08/30/10, stated, "ADL SUMMARY: . . . (declined) some - - related to (increased) confusion. . . very forgetful . . . puts self in unsafe situations (and) doesn't think of her own safety. . . ." - Observation on 02/08/11 at 5:28 p.m. showed, a CNA (#2) transported Resident #7 in his wheelchair from the dining room to the resident's room. The heel of Resident #7's right shoe dragged on the carpet, catching and bouncing as staff transported him down the hallway. The resident did not lift his right foot. The CNA (#2) failed to place foot pedals, to ensure the resident's right foot/shoe cleared the floor during transport, and to remind the resident to lift his right foot. Resident #7's medical record, reviewed February 9-10, 2011, identified [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified extensive assistance of one person required for locomotion on/off unit. The resident's RAP, dated 09/10/10, further stated, "FALL SUMMARY . . . Doesn't think of own safety. Has dx (diagnosis) of AD (Alzheimer's Disease) - which is gradually worsening. . . ." - Observation on 02/09/11 at 9:12 a.m. revealed, a nursing staff member (#4) assisted Resident #9 from the dining room to his room. The heels of Resident #9's shoes dragged on the carpet, catching and bouncing as staff transported him down the hallway. The resident did not lift his feet. The staff member failed to place foot pedals, to ensure the resident's feet/shoes cleared the floor during transport, and to remind the resident to lift his feet. Resident #9's medical record, reviewed February 9-10, 2011, identified [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified extensive assistance of one person required for locomotion on/off unit. During an interview on the morning of 02/10/11, an administrative nurse (#6) agreed the staff should have ensured the residents feet/shoes cleared the floor during transport and/or should have provided reminders to lift them. Failure of the facility to ensure staff properly used assistance devices (wheelchair foot pedals) placed residents at risk for possible accident and/or injury. 4. Based on observation and staff interview, the facility failed to provide a safe environment for 2 of 9 sampled residents (Resident #2 and #9) whose rooms contained cords that posed an asphyxiation and/or tripping hazard. Failure of the facility to ensure residents are provided with a safe environment places residents at risk for possible accidents and/or injury. - During the initial tour on 02/08/11 at 12:45 p.m., observation showed Resident #2 asleep with her head at the foot of her bed. Her call light cord lay coiled (four-to-five large coiled loops) on the mattress directly behind Resident #2's head. Resident #2's medical record, reviewed February 8-10, 2011, identified [DIAGNOSES REDACTED]. The resident's current care plan, dated 01/11/11, stated, ". . . Problem: . . . Has sundowner's (at) (times). . . ." - During the initial tour on 02/08/11 at 12:45 p.m., observation of Resident #3 and Resident #9's (shared) room showed four cords (two razors cords, one fan cord, and one humidifier cord) plugged into an outlet on the wall near the restroom. One cord lay looped on the floor and posed a tripping hazard. On 02/09/2011 at 9:12 a.m., observation showed Resident #9 self propelled his wheelchair from his room to the hallway. As he propelled his wheelchair, the wheels on the left side of Resident #9's chair scraped the wall and came within two-to-three inches of the cord laying looped on the floor. During an interview on the morning of 02/10/11, an administrative nurse (#6) agreed the cords posed a hazard to the residents. Failure of the facility to ensure residents are provided with a safe environment put residents at risk for possible accidents and/or injury. .