Every finding on record at North Dakota Veterans Home

Based on record review, review of facility policy, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #1) received the care and services necessary to attain the highest degree of safety possible during mealtime. Failure to ensure staff served Resident #1 food items consistent with his prescribed diet resulted in his choking episode/death. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Diets Available on Skilled Care Unit occurred on 03/13/25. This policy, revised 03/12/25, stated, . Consistency adjustments are determined based on swallow studies, physician orders, and speech therapy evaluations. Menu cards are used to ensure the correct diet and consistency are provided for each resident. The following Consistencies are offered in the facility . Dental Soft (Mechanical Soft) . the diet consists of food of nearly regular textures but eliminates very hard, sticky, crunchy or hard to chew foods. Foods should be moist and fork tender. Meat is ground . and should be held with a minimal amount of prepared broth, gravy, or other type of moistening agent . to keep the product moist. Hot ground meats should be topped with gravy or sauce at the point of service. Review of the facility policy titled Menu Cards occurred on 03/13/25. This policy, revised 03/12/25, stated, . Selective menu cards will be used to guide meal service, ensuring that residents receive meals that meet their prescribed diets . Each resident's menu card will include their prescribed diet, texture modifications, and any special notes related to dietary needs or restrictions. Menu cards will list foods that align with the resident's prescribed diet. Review of the facility policy titled Feeding a Resident occurred on 03/13/25. This policy, revised 03/13/25, stated, . Staff delivering meals will confirm that: The correct resident receives the correct meal. Any diet modifications are properly followed. If an error is identified, the plate will be returned to the cook for correction. Review of Resident #1's medical record occurred on all days of survey. Diagnoses included adult failure to thrive, Alzheimer's disease, dementia, dysphagia (swallow disorder), functional quadriplegia, and weakness. A Speech Therapy Evaluation and Plan of Care, dated 12/10/24, stated, . SLP [speech language pathologist] completed bedside swallowing evaluation during meal. Mechanical soft: prolonged mastication, slow AP [anterior/posterior] transit, suspected premature loss [of bolus] over tongue base. Reduced elevation, no overt s/s [signs/symptoms] of penetration [food/liquid entering the airway above the vocal folds]. Mildly thick liquids: Suspected premature loss [of bolus] over tongue base, suspected delay of onset of swallow, no overt s/s of penetration. SLP recommends diet of mechanical soft solids, ground meats, mildly thick liquids. Pt does have risk of aspiration [food/liquid entering the airway below the vocal folds], as VFSS [videofluoroscopic swallow study] did reveals [sic] deep laryngeal penetration without reaction [silent aspiration]. A physician's order, dated 12/12/24, stated, . Mechanical Soft, Nectar Thickened Liquids . Ground meat . The nutrition care plan stated, . [Resident #1's] Nutritional status is altered due to his decline. [Resident #1] needs 1:1 [one-on-one] assist with feeding . [Resident #1] was hospitalized with a diagnosis of aspiration pneumonia . Resident #1's Lunch Menu Card for 03/10/25 stated, . Ground Marinated Sirloin Steak w [with]/Gravy . The Facility Reported Incidents Reporting Form, dated 03/10/25, stated, . Resident began choking. Staff attempted the heimlich maneuver and were unsuccessful in dislodging the item. They also used [a] life vac to attempt to dislodge [the] item. Unable to remove [the] item. Resident passed away. An attached written statement indicated a dietary staff member (#2) spoke to an administrative dietary staff member (#1) after the dinner service. The dietary staff member (#2) . noted that she got the tray card and plated the food for [Resident #1]. She noted to us that she said that this needs to be chopped, then stated [certified nurse aide (CNA) (#3)] said it was fine. [CNA (#3)] left the kitchen. [Dietary staff member (#2)] did note . that she did not follow the diet, and did not grind the food and the plate left the kitchen uncompleted. During an interview on 03/12/25 at 4:00 p.m., four administrative staff members (#1, #4, #5, and #6) reported they reeducated everyone who worked on Monday, before supper was served, and reeducated everyone [nurses, CNAs, and Dietary staff] who has worked since. We have a nurses' meeting tomorrow and a Dietary staff meeting next week. We will be going over the whole process, menu cards again. They [nurses, CNAs, and Dietary staff] were also assigned a [name of company] online course. We are also going to finish tweaking our policies before the meeting. The four administrative staff members (#1, #4, #5, and #6) also confirmed monitoring the residents' tray cards/plated food items, stating, Yes. We only have one resident on a modified diet right now. The resident is on a pureed diet. As per facility policy and Resident #1's physician's orders, the facility failed to ensure Resident #1 received food items consistent with his prescribed diet. Based upon the following information, non-compliance at F684 is considered past non-compliance. The facility implemented corrective actions for other residents who may be affected by the deficient practice by: * Completing an investigation into Resident #1's choking episode/death. * Updating facility policies regarding modified diets on 03/12/25, menu cards on 03/12/25, and meal assistance on 03/13/25. * Educating staff regarding modified diets, menu cards, and meal assistance immediately and all staff that have worked since. * Completing audits on prescribed diets/meal service.

Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 15 sampled residents (Resident #34). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, page A6, stated, . Coding Instructions for A0310E, Is This Assessment the First Assessment (OBRA, Scheduled PPS, or OBRA Discharge) since the Most Recent Admission/Entry or Reentry? . Code 1, yes: if this assessment is the first of these assessments since the most recent admission/entry or reentry. Pages J-30 and J-31, stated, . J1700. Fall History on Admission/Entry or Reentry. Complete only if . A0310E = 1 . Coding Instructions for J1700A, Did the Resident Have a Fall Any Time in the Last Month Prior to Admission/Entry or Reentry? . Code 1, yes: if resident or family report or transfer records or medical records document a fall in the month preceding the resident's entry date item (A1600). Review of Resident #34's medical record occurred on all days of survey and identified the facility transferred the resident to the hospital after a fall on 05/06/24. The resident returned to the facility on [DATE]. Review of Resident #34's MDSs showed the facility completed the following: * 05/06/24, Discharge Return Anticipated (an OBRA assessment) * 05/10/24, Entry (back to the facility) * 05/17/24, Significant Change (an OBRA assessment) Review of the 05/17/24 significant change MDS identified the facility coded A0310E as 0, no rather than 1 yes as the first assessment since reentry on 05/10/24. Review of J1700A identified the facility coded 0, no falls in the last month prior to reentry. Resident #34's medical record identified a fall on 05/06/24. The facility failed to accurately code A0310E and J1700A on Resident #34's significant change MDS.

Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 1 of 1 sampled resident (Resident #32) observed during a dressing change. Failure to perform hand hygiene during and after a dressing change may result in an infection or worsening of the affected area and a delay in healing. Finding include: Review of the facility policy titled CLEAN DRESSING CHANGE occurred on 06/27/24. This policy, dated May 2023 stated, . 9. Loosen the tape and remove existing dressing. 10. Remove gloves . 11. Complete hand hygiene and put on clean gloves. 16. Discard disposable items and gloves into appropriate trash receptacle and wash hands. Observation on 06/25/24 at 9:49 a.m. showed a nurse (#2) performed hand hygiene and donned gloves. The nurse removed the old dressing from the resident's foot, cleansed the wound with saline, applied a barrier cream and rubbed lotion on the resident's legs. The nurse (#2) then removed the soiled gloves, and without performing hand hygiene donned new gloves, applied a clean dressing to the wound, and wrapped the resident's foot with a protective dressing. The nurse, removed her gloves, and without performing hand hygiene exited the resident's room. During an interview on 06/27/24 10:16 a.m., an administrative staff member (#1) stated she expected staff to follow infection control practices and perform hand hygiene after removing dirty gloves and applying new gloves and following a dressing change.

Based on observation, record review, and staff interview, the facility failed to ensure an environment free of accident hazards for 4 of 4 coffee/hot water machines located in various areas within the facility (Town Hall, and Freedom Ridge, Honor Hill, and Peace Garden households). Failure to ensure appropriate coffee/water temperatures resulted in serving temperatures above the acceptable range and resulted in one resident acquiring burns to the left thigh, forearm, and hand, and may result in serious burns to other residents. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 07/27/23 at 3:07 p.m. The IJ resulted from temperature readings obtained from coffee/hot water machines, a lack of temperature monitoring by staff, and an injury to a resident. This finding placed residents in immediate danger due to hot temperatures and the potential for serious burns. * 07/27/23 at 4:03 p.m., The survey team notified the administrator and director of nursing of the IJ and requested they develop a plan for removal of the immediate jeopardy. * 07/27/23 at 4:46 p.m., The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: * Shut off all automatic coffee machines. * Remove from households. * Cooks will brew coffee, temp it to make sure it is below 150F and place it into a carafe. * New machines will be obtained that operate at a safe temperature. * 07/27/23 at 6:25 p.m., The team notified the administrator of the IJ removal. * On 07/27/23, the survey team verified the implementation of the facility's removal plan and removed the IJ. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Review of Resident #3's medical record occurred on all days of survey. The Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairments. The current care plan stated, . [Resident #3] was deemed incompetent to make his own medical decisions. Coffee burn to left anterior mid-thigh . Encourage resident to ask for assistance when wanting fresh coffee . Resident has history of frequent spilling of drinks. Resident does have shaker cups with lids. Resident should have lids on all drinks out of dining room area . [Resident #3] has been noted to get his own coffee at nights and burn himself with the hot liquids. At this time his household (Peace Garden) will be removing coffee from the machine and turning off the machine at night or shutting off the machine, the door between the households will be closed to deter him from going to the other house to get coffee. Staff are to monitor him and make sure that coffee has ice added to help decrease the risk for burns. A progress note, date 01/15/23 at 9:30 p.m., identified, Resident sustained a coffee burn to L [left] anterior mid thigh discovered at 1925 [7:25 p.m.]. Noted full, uncovered cup of coffee he was carrying from kitchen, while propelling to living room in w/c [wheelchair]. Assisted to room, changed clothing, observed area to be 8 cm [centimeters] x 5 cm, oval shaped with medium pink coloring. No raised of [sic] blistering of skin at that time. Area is tender to touch, Some relief with cool, wet compress. Renewed cool compress, observed site at 2130 [9:30 p.m.] to be reduced to area approx [approximately] 3 cm oval. Does appear to be starting to blister, will continue to monitor, renew cool pack through night as needed. Advised to please ask for assistance for hot beverages in the future. The record showed the coffee burn resulted in a blister that resolved 18 days later. An incident report, dated 01/15/23, also identified, . large, wet coffee stain on L thigh sweat pants. 'I spilled really hot coffee on it and it hurts.' . Coffee burn to L anterior thigh. Resident is independent to obtain own drinks as wishes. Asked resident to request help and covered cup for coffee. Education provided, but with resident unable to identify his limitations continues at risk for future incidents. Staff are reminded to assist resident with his drinks . A progress note, dated 02/23/23 at 8:32 p.m., identified, Resident reported to staff that he spilled hot coffee on his leg. On assessment, left upper thigh without redness or blistering. Skin cool to touch at this time, pants are damp. Full cup of coffee on end table next to him that was cool. Resident denies pain at this time. The record showed the coffee burn resulted in a 1 cm light red area that resolved four days later. An incident report, dated 02/23/23, also identified, . Resident in living room watching tv, states it [coffee] spilled during transfer . 'I can't learn.' . Educated Resident to allow staff to help him. noted . spills occurring on PM and night shift. Discussion held with dietary with plan of unplugging coffee machine after supper meal and replug in the morning prior to breakfast. Staff and residents have access to the coffee machine on honor during time of machine being unplugged. Additional progress notes identified the following: * 03/02/23 at 1:33 a.m., . resident was attempting to clean something off of dining room floor. When this nurse offered to help, resident stated he had spilled 'hot, hot' coffee on his left forearm. Resident did have fresh cup of coffee sitting on counter near him and sleeve of shirt was wet. No redness or blistering noted to arm or hand. Resident was assisted to take his coffee to his recliner and was reminded he needed to call for help so that he didn't get burned. Resident stated 'I know. Seems like every week.' . * 04/23/23 at 10:33 p.m., This nurse noted resident cleaning coffee off of floor. Nurse assisted resident with cleaning up coffee and asked if he had spilled any on himself. Resident stated 'yes, hot, hot'. When asked, resident stated he had spilled coffee on his left hand. Hand was dry and cool to touch. No redness or blistering noted. Coffee machine locked and resident reminded to ask for staff assistance with coffee to prevent accidental burns. The record showed the coffee burn resulted in a pink area that resolved two days later. An incident report, dated 04/23/23, also identified, . resident indicated he had spilled coffee on his left hand. Resident likes to maintain as much independence as possible and does not ask for assistance. Coffee machine buttons locked at this time. Discussion held with dietary on machine being turned off at end of cooks shift and turned back on when the cook arrives in the morning. Staff will be closing the door between honor and peace households to detour resident from coming to honor to fill his coffee mug during the night. Temperature readings were obtained from various coffee/hot water machines on the afternoon of 07/27/23 and showed the following: * Town Hall: 176.7 degrees Fahrenheit (F) * Freedom: 173.2 degrees F * Honor: 174.2 degrees F * Peace Garden: 176.0 degrees F Observation showed staff posted a fact sheet on each of the coffee/hot water machines informing the residents of the coffee/hot water temperatures and warning them these temperatures could cause 3rd degree burns. During interviews on 07/27/23 at 2:15 p.m. and 2:31 p.m., an administrative nurse (#3) confirmed the facility failed to monitor the coffee/hot water temperatures resulting in injuries.

Based on record review, review of facility policy, and staff interviews, the facility failed to review and revise comprehensive care plans to reflect the current status for 4 of 20 sampled residents (Residents #12, #15, #41, and #50). Failure to review and revise the care plan limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled CARE PLAN, Baseline and Comprehensive occurred on 07/27/23. This policy, dated 04/30/18, stated, . Care plan will be updated with resident condition or per their choice. - Review of Resident #12's medical record occurred on all days of survey and identified a diagnosis of post traumatic stress disorder (PTSD). The current care plan failed to reflect the clinically appropriate and person-centered interventions used to eliminate or mitigate re-traumatization. During an interview on 07/27/23 at 10:25 a.m., an administrative nurse (#1) confirmed the current care plan failed to address Resident #12's emotional/psychosocial needs related to his identified PTSD triggers. - Review of Resident #15's medical record occurred on all days of survey and identified a diagnosis of PTSD. The current care plan failed to reflect Resident #15's identified triggers and the clinically appropriate and person-centered interventions used to eliminate or mitigate re-traumatization. During an interview on 07/25/23 at 2:49 p.m., a social services staff member (#4) confirmed the current care plan failed to identify Resident #15's triggers and/or address his emotional/psychosocial needs related to his PTSD. - Review of Resident #41's medical record occurred on all days of survey and identified a diagnosis of PTSD. The current care plan failed to reflect Resident #41's identified triggers and the clinically appropriate and person-centered interventions used to eliminate or mitigate re-traumatization. During an interview on 07/27/23 at 10:45 a.m., a social services staff member (#4) confirmed the current care plan failed to identify Resident #41's triggers and/or address his emotional/psychosocial needs related to his PTSD. - Review of Resident #50's medical record occurred on all days of survey. An emergency department note, dated 06/13/23, stated, . after having near syncopal episode . Need for IV Hydration Symptom Documentation: Dehydration . The current care plan lacked goals and interventions to monitor Resident #50's fluid intake after the emergency room (ER) visit on 06/13/23. During an interview on 07/26/23 at 5:07 p.m., an administrative nurse (#3) agreed a hydration observation should have been added to Resident #50's care plan after the ER visit. 27221 46477

Based on observation, review of manufacture instructions, review of facility policy, review of facility sanitizer logs, and staff interview, the facility failed to prepare and serve food under sanitary conditions in 1 of 1 kitchen (main kitchen) and 2 of 2 kitchenettes (Courage/Freedom and Honor/Peace). Failure to monitor the concentration of the quaternary solution may result in unsafe preparation of food and foodborne illness. Findings include: Review of the manufacturer instructions for Smart Power Sink and Surface Cleaner Sanitizer posted above the kitchen dishwasher sinks occurred on 07/27/23 at 2:03 p.m., stated, EPA-registered cleaner sanitizer for pre-cleaned use on hard, non-porous food prep surfaces and wares, kills foodborne organisms . it is a no-rinse sanitizer that is effective across a dilution range of 0.27 to 0.55 oz.[ounce] per gallon of water. Sanitization Range Testing: Testing solution should be at or above room temperature: 65F [Fahrenheit]. Withdraw a test strip from the canister. Dip test strip for 5 seconds in test solution. Shake off excess solution. Compare colors after 10 seconds with colors on the test strip canister to determine concentration (oz/gal) [ounces/gallon] . Testing solution should be between 272-700 ppm [parts per million] DDBSA [dodecylbenzene sulfonic acid] . Review of the facility policy Dietary Services Sink & Surface Sanitizer occurred on 07/27/23. This policy dated 03/01/22 stated, . Fill spray bottles with sanitizer, change out as needed per concentration level. Monitor the strength of the sanitizer and document every week. Report any problems with the machine or the strength of the chemical to the CDM [certified dietary manager] . Review of the facility high temp dishwasher and sanitizer logs stated, . Sanitizer should be 272-700 ppm . if not proper strength notify supervisor. Test Weekly. Observation of the kitchenettes occurred on 07/27/23 at 9:05 a.m. with dietary manager (#5) and showed a dietary staff member tested the concentration of the sanitizer buckets that identified the following: * Courage/Freedom kitchenette: 848 (high) * Honor/Peace kitchenette: 848 (high) Observation of the main kitchen occurred on 07/27/23 at 9:35 a.m. with dietary manager (#5) and showed a dietary staff member tested the concentration of a sanitizer bottle and identified a concentration of 848 (high). Interview with a dietary manager (#5) on 07/27/23 at 10:00 a.m. confirmed that the testing solution was not within the acceptable range.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 2 sampled residents (Resident #51) with medications observed in the resident's room. Failure to determine whether SAM is a safe practice has the potential to limit a resident's right to SAM or result in a medication error and/or harm to a resident. Findings include: Review of the facility policy titled Self-Administration of Medications occurred on 07/27/23. This policy, reviewed/revised 03/04/16, stated, . To initiate and continue self-administration, the resident must meet all of the criteria for safe administration. Brief Interview for Mental Status [BIMS] Score >=13 [greater than/equal to]. If the resident wishes to self-administer medication, the following steps will be taken for the initiation and monitoring of self-administration. Brief Interview for Mental Status will be conducted with the resident. Specific orders from the attending physician will be obtained to include: a) name of the medication/treatment b) dosages, route, frequency c) that the medication/treatment is to be self-administered. Any medication a resident should purchase on their own, needs to be reviewed by a nurse prior to use. Observation on the afternoon of 07/26/23 showed bottles of Super Silver dietary supplement and Protocel (dietary supplement) in Resident #51's bathroom. Review of Resident #51's medical record occurred on all days of survey. A Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairment. The resident's care plan stated, . Resident chooses to take several supplements, per self. These are purchased per self. The record lacked physician orders for the dietary supplements and a SAM assessment indicating Resident #51 can safely self-administer medications. During an interview on 07/26/23 at 5:18 p.m., an administrative nurse (#3) confirmed staff failed to complete the SAM assessment for Resident #51.

Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 20 sampled residents (Resident #16 and #26). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION I: ACTIVE DIAGNOSES IN THE LAST 7 DAYS The Long-Term Care Facility RAI User's Manual, revised October 2019, page I-8, stated, . Item I2300 Urinary tract infection (UTI): The UTI has a look-back period of 30 days for active disease instead of 7 days. Code only if both of the following are met in the last 30 days: It was determined that the resident had a UTI using evidence-based criteria such as McGeer, NHSN, or Loeb in the last 30 days, AND A physician documented UTI diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days. Review of Resident #16's medical record occurred on all days of survey. The annual Minimum Data Set (MDS), dated [DATE] identified under Section I: Active Diagnoses included a UTI within the last 30 days. Resident #16's medical record failed to identify a diagnosis of a UTI. During an interview on 07/26/23 at 1:15 p.m., an administrative nurse (#1) confirmed that the facility incorrectly coded Resident #16's MDS for a diagnosis of a UTI. SECTION P: PHYSICAL RESTRAINTS The Long-Term Care Facility RAI User's Manual, revised October 2019, pages P-1 and P-5, stated, . PHYSICAL RESTRAINTS: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Coding Instructions: . After determining whether or not an item . is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back or it was used but did not meet the definition. Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period. - An observation on 07/25/23 at 8:38 a.m. showed Resident #26 without a restraint. Review of Resident #26's medical record occurred on all days of survey. The quarterly MDS, dated [DATE] identified other as the type of restraint used by the resident. Resident #26's medical record failed to identify the use of a restraint. During an interview on 07/25/23 at 10:06 a.m., an administrative staff (#2) confirmed the facility incorrectly coded Resident #26's MDS for a restraint.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure 3 of 4 sampled residents (Resident #12, #15, and #41) diagnosed with post-traumatic stress disorder (PTSD) received appropriate treatment and services to meet their assessed needs. Failure to provide clinically appropriate, person-centered treatment and services may result in the residents' inability to attain their highest practicable mental and psychosocial well-being. Findings include: Review of the facility policy titled Trauma Informed Care occurred on 07/26/23. This policy, reviewed/revised 08/28/20, stated, .The facility will account for residents' experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization . care plan will be updated to reflect known trauma, potential triggers, and interventions for management. - Review of Resident #12's medical record occurred on all days of survey. The annual Minimum Data Set (MDS), dated [DATE], identified a diagnosis of PTSD. Current medications included an antidepressant. A trauma screening, dated 06/23/22, identified Resident #12 had experiences that were frightening, horrible, and/or upsetting, [he had] tried hard not to think about it [the trauma] or went out of [his] way to avoid situations that reminded [him] of it, and felt numb or detached from others, activities, [and his] surroundings. Resident #12 did not wish to talk about it [the trauma]. The screening indicated Resident #12 is triggered by loud noises . Resident #12's current care plan failed to reflect the clinically appropriate and person-centered interventions addressing his known trigger (loud noises) and interventions used to eliminate or mitigate re-traumatization. During an interview on 07/27/23 at 10:25 a.m., an administrative nurse (#1) confirmed the current care plan failed to address Resident #12's emotional/psychosocial needs related to his previously identified PTSD triggers. - Review of Resident #15's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified a diagnosis of PTSD. Current medications included an antidepressant and antipsychotics. A psychiatry provider note, dated 06/02/23, identified PTSD symptoms including nightmares, flashbacks, startle response, and intrusive thought/memories . significant panic attacks when these occur, which is disabling . The current care plan failed to address Resident #15's emotional/psychosocial needs related to his trauma/PTSD diagnosis and failed to include clinically appropriate and person-centered interventions used to avoid re-traumatization. During an interview on 07/25/23 at 2:49 p.m., an administrative nurse (#4) agreed, the current LTC [Long Term Care] trauma/PTSD assessment and care plan lacked known trauma, potential triggers, and interventions. - Review of Resident #41's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified a diagnosis of PTSD. Current medications included an antidepressant. A trauma screening, dated 06/30/22, identified Resident #41 had experiences that were frightening, horrible, and/or upsetting, and indicated he previously saw psychiatry through [a veteran's affairs facility]. He is open to this again related to high PAQ-9 [a depression scale] score. As well as referral to psychologist/therapist. The screening failed to identify Resident #41's expressions or indications of distress, identified triggers that may cause re-traumatization, and/or preferences. The current care plan failed to reflect Resident #41's identified triggers and the clinically appropriate and person-centered interventions used to eliminate or mitigate re-traumatization. During an interview on 07/27/23 at 10:45 a.m., a social services staff member (#4) confirmed the current care plan failed to identify Resident #41's triggers and/or address his emotional/psychosocial needs related to his PTSD. 27221

Based on record review, staff interview, and review of the Long-Term Care Facility Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a significant change in status assessment (SCSA) for 1 of 12 sampled residents (Resident #21). Failure to identify the need for and complete a SCSA may limit the facility's ability to accurately assess the resident's status and develop an appropriate care plan. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.15), dated October 2019, page 2-22 stated, . A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without staff intervention . 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. and page 2-25 stated, A SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement. This may include two changes within a particular domain (e.g., [for example] two areas of ADL [Activities of Daily Living] decline or improvement mobility, transfers, walking in corridor and toileting. Review of Resident #21's medical record occurred on all days of survey. The admission Minimum Data Set (MDS), dated [DATE], identified independent with bed mobility, locomotion on and off the unit, and toilet use, independent with set up assist for transfers, supervision with limited assist for walking in room, dressing, and personal hygiene, independent walking in the corridor occurred 1-2 times, and weighed 236 pounds. The quarterly MDS, dated [DATE], identified Resident #21 required extensive assist of two persons for bed mobility, transfers, and toileting, extensive assist of one person for dressing and personal hygiene, dependent on one person for locomotion on/off the unit, the resident did not walk in room or corridor, and weighed 222 pounds (a significant weight loss). The record lacked evidence the staff identified and/or completed a SCSA following Resident #21's decline in health status. During an interview on 04/06/22 at 10:55 a.m., an administrative staff (#3) was not able to show why the facility failed to complete a SCSA and agreed they should have.

Based on record review, review of the North Dakota Provider Manual Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 1 sampled residents (Resident #39) reviewed for PASARR. Failure to complete a change in status assessment with a newly diagnosed mental illness may result in the delivery of care and services that are inconsistent with the resident's needs. Findings include: The North Dakota PASARR Provider Manual states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Ascend to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability [referred to in regulatory language as related conditions or RC]) was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #39's medical record occurred on all days of survey. A Level 1 PASARR, dated 08/08/19, identified a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked evidence of an updated PASARR which included the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 04/07/22 at 10:02 a.m., a social services staff member (#1) confirmed the facility should have submitted a new Level 1 when Resident #39 was diagnosed with [CONDITION(S)] and stated, We really don't have a process in place to notify myself when a resident receives a new diagnosis.

Based on observation, review of facility policy and staff interview, the facility failed to follow infection control practices for 2 of 7 sampled residents (Resident #24 and #39) observed during toileting cares. Failure to follow infection control practices related to hand hygiene has the potential to transmit infections to other residents, staff, and visitors. Findings include: Review of the facility policy titled HAND WASHING & HAND HYGIENE occurred on 04/07/22. This policy, revised August 2006, stated, . Handwashing is the single most important means of preventing the spread of infections . The following is a list of some situations that require hand hygiene: . Before and after assisting a resident with toileting . Observation on 04/05/22 at 8:43 a.m. showed a certified nursing assistant (CNA) (#5) assisted Resident #39 to the bathroom, donned gloves, and performed perineal cares. Using the same gloves, the CNA applied a protective ointment to the resident's perineal area and removed the gloves. Without performing hand hygiene, the CNA removed the resident's hearing aid from the drawer, assisted the resident with putting in the hearing aid, opened the curtains, and made the bed. The CNA exited the room with the garbage bag in her hand, threw it away in the soiled utility room and washed her hands at the sink in the hallway. The CNA (#5) failed to perform hand hygiene after removing her gloves and before completing other tasks. Observation on 04/05/22 at 9:54 a.m. showed a CNA (#4) assisted Resident #24 to the bathroom, donned gloves, performed perineal cares after the resident had a bowel movement, and removed the gloves. Without performing hand hygiene, the CNA applied toothpaste to the resident's toothbrush, handed the toothbrush to the resident for her to brush her teeth, and combed the resident's hair. The CNA then donned new gloves, emptied the garbage, doffed her gloves, and used hand sanitizer. The CNA (#4) failed to perform hand hygiene after removing her gloves and before completing other tasks. During an interview on 04/07/22 at 9:45 a.m., an administrative nurse (#2) confirmed she expected staff to follow the facility policy regarding performing hand hygiene.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to obtain a current physician's order for a powder/barrier cream for 1 of 2 sampled residents (Resident #26) with skin breakdown. Failure to obtain a current order for the powder/barrier cream may result in adverse consequences and ineffective management of a resident's condition. Findings include: Review of the facility policy titled Physician Orders occurred on 02/18/21. This policy revised May 2014, stated, . All residents of this facility shall be accompanied by physician's orders adequate to provide immediate and essential care to the resident consistent with the resident's mental and physical status . All orders will be entered in the electronic medical record . Orders will be acknowledged and cosigned . orders will be electronically sent for signature . automatic discontinue of standing orders after 30 days if Medical Provider has not specifically renewed . each medication order must have a route, dose, frequency and related diagnosis . if any of this information is incomplete, the deficiency should be corrected by a call to the prescriber before meds [medications]/treatments administered . Review of Resident #26's medical record occurred on all days of the survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan stated, . red rash, excoriated to buttocks, denuded area to bilateral sides of rectum . stoma powder and [MEDICATION(S)] to open/red areas to buttocks . Observation on 02/17/21 at 10:47 a.m., showed two certified nursing assistants (CNA's) (#11 and #12) apply stoma powder and [MEDICATION(S)] barrier cream to Resident #26's after providing toileting cares. During an interview on 02/17/21 at 11:37 a.m., a nurse (#8) agreed Resident #26's medical record lacked physician orders for the stoma powder and [MEDICATION(S)] barrier cream, and indicated direct staff have been applying the powder and barrier cream for a few days now. The nurse (#8) acknowledged staff failed to obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 02/17/21 at 1:20 p.m., Resident #26 stated his skin broke down around last Friday [02/12/21] and reported staff applied the powder and [MEDICATION(S)] on and off throughout the weekend. During an interview on 02/18/21 at 11:15 a.m., an administrative nurse (#6) indicated staff should follow the facility's policy and stated, they are working on it. The facility failed to obtain a current physician's order for Resident #26's skin breakdown.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to ensure 2 of 2 sampled residents (Resident #1 and #12) received care and services necessary to attain the highest degree of safety possible while being fed a modified diet and drinking thickened liquids. Failure of staff to know a resident's prescribed diet, provide appropriate thickened liquids, and provide meal assistance has the potential to negatively impact residents overall swallow safety and placed Resident #1 and #12 at risk for aspiration. Findings include: Swigert's The Source for Dysphagia, 3rd ed., Pro-Ed, Inc., Texas, 2007, pages 137-138, and educational handouts, identified, . Thin liquids are the hardest thing to control in the mouth and keep together in a bolus. It is easier to aspirate thin liquids as they travel through the throat past the larynx [area of the throat involved in breathing, producing sound, and protecting the airway during a swallow] because they break apart and some of the liquid can fall into the larynx. Thickened liquids are easier to keep together as a cohesive bolus. Thickened liquids also move more slowly through the pharynx [area of the throat that carries air to the larynx and food to the stomach], giving the larynx more time to close and protect the airway. Patients with pharyngeal problems who are at risk for aspiration sometimes have more difficulty with thinned, runny purees because the disordered mechanism cannot respond in time with sufficient control to protect the airway. we make recommendations for foods to be one texture only because it's harder to manipulate something in the mouth with two textures . - Review of Resident #1's medical record occurred on all days of survey. The record identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #1 has a feeding tube and required a mechanically altered diet for all oral intake. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/17/21 at 5:00 p.m., observation showed a certified nursing assistant (CNA) (#2) squirting a liquid thickening agent into the banana dessert on Resident #1's tray. The CNA (#2) failed to look at the label to determine the correct amount of thickening agent required. After adding/mixing two squirts of the thickener, the CNA (#2) stated, I think that is good enough. When asked questions pertaining to the consistency of the dessert, the CNA (#2) squirted/mixed more thickener into the dessert until it reached a honey consistency. When asked questions pertaining to Resident #1's diet, the CNA (#2) stated, I'm not sure what his diet is. I think pureed. The CNA (#2) and an unidentified dietary staff member then located Resident #1's meal ticket which indicated a pureed diet with honey-thickened liquids. Facility staff failed to ensure they knew the resident's current diet order and thickened the foods/liquids to the appropriate consistency prior to serving them to the resident. - Review of Resident #12's medical record occurred on all days of survey. The record identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan showed, . 1:1 supervision during meal times . needs cueing and reminders often throughout meal service . mechanical soft with nectar thick liquids . encourage to alternate with fluids in between bites . A swallow study, completed 02/04/21, stated, . With thin liquids there was penetration and a tiny amount of aspiration. Solids were swallowed after a delay in initiation of the swallowing mechanism . Thin liquids are unsafe. Nectar thickness liquids were safe. Observations of Resident #12 showed the following: * 02/16/21 during the noon meal, staff sat down at the table intermittently assisting the resident during the meal. Resident #12 held fluids in her mouth for a while prior to swallowing them. * 02/17/21 at 9:31 a.m., Resident #12 asked for a drink of water. The CNA (#13) provided water from the resident's bathroom sink without thickening it. The resident held the water in her mouth for a while before swallowing it. At 9:36 a.m., Resident #12 requested another drink of water. Again, the CNA (#13) provided water from the resident's bathroom sink without thickening it. The resident held the water in her mouth for a while and swallowed after CNA (#13) prompted her to do so. * 02/17/21 at 9:54 a.m., Resident #12 sat at the breakfast table with a large glass of orange juice. The orange juice appeared thick in the middle and watery on top and on the sides (two consistencies). * 02/17/21 during the breakfast and supper meals, staff sat down at the table intermittently assisting Resident #12 during the meal. Resident #12 held fluids in her mouth for a while prior to swallowing them. During a kitchen tour on 02/18/21 at 9:55 a.m., when asked how staff know the resident's prescribed diet and the amount of assistance he/she requires during meals, a dietary supervisor (#1), stated, Diets and liquids are on the residents tray cards and amount of assistance residents need during meals is listed on the touch screen [a computer screen located on the wall for staff access] and tells them. They can also see a resident's whole care plan on the touch screen. During an interview on 02/18/21 at 10:58 a.m., when asked the definition of one-to-one (1:1) supervision during meals, the dietary supervisor (#1), stated, Staff to sit down with the resident the whole meal. The facility failed to thicken and/or appropriately thicken Resident #12's dessert/fluids as ordered and failed to provided one-to-one supervision at meals as care planned.

Based on observation, review of the facility policy, review of chemical Safety Data Sheets (SDS), and staff interview, the facility failed to ensure an environment free of accident hazards on 2 of 4 households (Freedom and Peace). Failure to store chemicals in a locked/secured area placed the residents in these households at risk for injury. Findings include: Review of the facility policy titled Chemical Use and Safety occurred on 02/18/21. This policy, revised 12/20/19, stated, . All chemicals are to be stored properly and kept in a locked area. Containers of chemical will not be left unattended. Observations on all days of survey showed, at various times, unaccompanied residents wandering in the Freedom and Peace households. A tour of the open kitchenette areas in the Freedom and Peace households occurred on the morning of 02/18/21 with a dietary supervisor (#1). Observation on the Freedom household showed an unlocked under sink cupboard with a broken lock containing a bottle of Virex (an all-purpose disinfectant cleaner) and a bottle of Ecolab 146-Quat Sanitizer, and an unlocked upper cupboard containing a bottle of liquid Dawn dish soap. Observation on the Peace household showed an unlocked upper cupboard containing an unlabeled container of what the dietary supervisor identified as Dawn dish soap. Review of the SDS sheets for the chemicals showed: * Liquid Dawn Dish Soap: Causes eye irritation * Virex: Causes serious eye irritation * Ecolab 146-Quat Sanitizer: Harmful if swallowed. Causes severe [CONDITION(S)] and eye damage. During an interview on 02/18/21, the dietary manager (#1) stated, The chemicals should be labeled and stored in a locked cupboard. I didn't know this lock was broken. Failure to store chemicals on the Freedom and Peace households in locked cupboards placed the residents at risk for injury.

Based on observation, record review, review of professional references, and staff interview, the facility failed to follow infection control standards for 2 of 2 sampled residents (Resident #90 and #91) placed on isolation precautions due to their unknown COVID-19 status. Failure of the facility to place newly admitted /readmitted residents on droplet precautions and ensure staff wear N95 masks when entering their rooms and the doors to their rooms remain closed, may result in residents and staff being exposed to COVID-19 (a [CONDITION(S)] infection) or other healthcare-associated infections. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance for PPE use, found at: https://www.cdc.gov, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/23/21, stated, . The PPE [personal protective equipment] recommended when caring for a patient with suspected or confirmed COVID-19 includes the following . Put on an N95 respirator . Put on eye protection . Put on clean, non-sterile gloves . Put on a clean isolation gown upon entry into the patient room . - Review of Resident #90's medical record occurred on all days of survey. The progress note, dated 02/02/21, identified, Resident returned following hospital stay at [Hospital] for discharged Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 02/16/21 at 5:00 p.m. showed an Enhanced Precautions sign and isolation cart outside Resident #90's door. The door to his room was wide open, and Resident #90 was observed laying on his bed. At 5:07 p.m., a certified nursing assistant (#3), wearing a surgical mask, face shield, gown, and gloves, entered Resident #90's room carrying his afternoon snack. - Review of Resident #91's medical record occurred on all days of survey. The progress note, dated 02/05/21, identified, Resident is a . gentleman admitted to [Facility] skilled unit [room] following inpatient stay at [Hospital] following [a surgical procedure] . Observation showed the following: * 02/16/21 at 1:22 p.m., An Enhanced Precautions sign and isolation cart outside Resident #91's door. The door to his room was wide open. * 02/16/21 at 4:02 p.m., An Enhanced Precautions sign and isolation cart outside Resident #91's door. The door to his room was wide open. * 02/17/21 at 5:25 p.m., An Enhanced Precautions sign and isolation cart outside Resident #91's door. The door to his room was wide open. During an interview on 02/17/21 at 10:12 a.m., when asked questions regarding Enhanced Precautions requirements, a nurse (#4) stated, Oh, the doors are usually closed. They should have been closed. During an interview on 02/18/21 at 8:15 a.m., an administrative staff member (#6) reviewed the Enhanced Precautions sign outside Resident #91's room and reported the sign failed to direct staff to close the doors. She confirmed the doors should be closed.

Based on observation, procedure review, and staff interview, the facility failed to ensure a medication error rate of less than five percent (%) for 2 of 8 residents (Resident #43 and #51) observed during medication pass. Two medication errors occurred during staff administration of 34 medications, resulting in a 5% error rate. Failure to correctly administer insulin may alter the therapeutic effect and/or result in adverse side effects. Findings include: Review of the facility procedure titled Insulin Pen Use occurred on 06/27/18. This undated procedure stated, . Put the needle straight into the skin . Using your thumb, push the end of the pen down slowly until the dose of insulin is in. Make sure the needle is all the way in the skin before pushing in the insulin. Once dose is in count to 10, do not count until AFTER dose counter is at 0. Pull the needle out. - On 06/26/18 at 4:30 p.m., observation showed a medication aide (MA) (#1) administered 18 units of [MEDICATION NAME]to Resident #43 per [MEDICATION NAME]. After pushing the end of the pen down until the dose counter reached zero (injecting the insulin), the MA lifted the pen from the resident's arm. The MA failed to hold the needle in place for a count of ten. - On 06/26/18 at 5:04 p.m., observation showed a medication aide (MA) (#1) administered 8 units of [MEDICATION NAME]to Resident #51 per a [MEDICATION NAME]. After pushing the end of the pen down until the dose counter reached zero, the MA lifted the pen from the resident's arm. The MA failed to hold the needle in place for a count of ten. During an interview on 06/27/18 at 10:40 a.m., an administrative nurse (#2) stated staff should hold an insulin pen in place for 6-10 seconds after an injection.

Based on observation, record review, policy review, and staff interview, the facility failed to maintain an infection control program to prevent the development of disease and infection for 4 of 8 sampled residents (Resident #4, #7, #10, and #11) observed receiving personal cares. Failure to practice infection control procedures for a resident in contact isolation (Resident #10), a resident with a urinary drainage bag (Resident #7), perform proper hand hygiene following incontinence cares (Resident #4), and perform hand hygiene between residents during medication pass (Resident #11), placed residents, staff, and visitors at risk of developing infections and illness. Findings include: Review of the facility policy titled Prevention and Control of Transmission of Infection occurred on 04/08/15. This policy, dated 2011, stated . Hand Hygiene: Hand hygiene is the primary means of preventing the spread of infection. The following is a list of some situations that require hand hygiene: . Before and after entering isolation precaution setting . Before and after assisting a resident with personal care . Before and after assisting a resident with toileting . after removing gloves . Contact Precautions: Prior to leaving the residents room, PPE (personal protective equipment) will be removed and hand hygiene performed. - Review of Resident #10's medical record occurred on 04/08/15. The care plan identified the problem of . occasionally incontinent of bowel and bladder. does have a history of recurrent[DIAGNOSES REDACTED] (Clostridium difficile) and has difficulty controlling loose stools at times. The progress notes identified the resident with loose stools on April 02-04, 2015. Progress notes identified on 04/03/15 the initiation of contact precautions, the identification of the history of[DIAGNOSES REDACTED], and a request for a stool culture. The resident remained in contact precautions through all days of survey. Signage on the outside of Resident #10's door stated, EVERYONE MUST: Clean hands when entering and leaving room.STAFF MUST: Glove when entering room. On 04/06/15 at 2:15 p.m., an unidentified laundry staff member entered Resident #10's room and placed washed clothing items into the resident's dresser drawers and a wardrobe cabinet. Outside of Resident #10's room sat a cart with PPE and signage for contact precautions. The staff member failed to don gloves and perform any hand washing/hygiene prior to and upon exiting the room. The staff member proceeded to enter and exit two other resident's rooms and failed to perform hand hygiene prior to and upon exiting those rooms as well. On 04/06/15 at 2:20 p.m. a supervisory staff member (#5) stated nursing staff implemented the contact precautions for a possible [DIAGNOSES REDACTED]. On 04/08/15 at 9:30 a.m., observation showed two unidentified maintenance workers dismantled the cover to the heater unit in Resident #10's room and performed repairs. One of the workers knelt down onto the floor during the maintenance. Both workers exited the room, one of them touched the door handle as he closed the resident's door, and both exited the room without performing hand washing/hygiene. The workers exited this resident unit (Honor Hill) touching the door handles and entered into the next resident unit (Peace Garden). On 04/08/15 at 1:40 p.m., a certified nursing assistant (CNA) (#6) transported Resident #10 in his wheelchair into his room. The CNA transferred the resident into his recliner and rolled up the excess oxygen tubing. Observation showed the CNA did not wear gloves, offered water to the resident, and exited the room without hand washing/hygiene. - Observation on 04/07/14 at 9:27 a.m., showed a licensed nurse (#3) assisted Resident #7 with changing his Foley catheter leg bag. As Resident #7 sat on the toilet the nurse connected the new leg bag to the suprapubic catheter tube. The nurse placed the new leg bag on the bathroom floor and left the room to obtain additional supplies. The nurse then secured the leg bag to Resident #9's lower leg. - Observation on 04/06/14 at 4:42 p.m., showed a CNA (#1) assisted Resident #4 onto and off the toilet. After the resident voided the CNA provided perineal care and removed her gloves. The CNA performed other cares which included applying a lift sling, operating a ceiling lift control, turning the call light on, adjusting the resident's clothing, transferring the resident from the lift to wheelchair, and applying the resident's leg rests to the wheelchair. The CNA failed to perform hand hygiene after completion of perineal care and before completing other tasks Observation on 04/07/14 at 10:06 a.m., showed a CNA (#2) assisted Resident #4 onto the toilet using the ceiling lift. Resident #4 voided, the CNA provided perineal care, and removed her gloves. Using the ceiling lift, the CNA assisted Resident #4 onto the bed, unhooked the sling, adjusted the resident's pants and shirt, and reapplied the lift sling. The CNA repositioned Resident #4's wheelchair, assisted the resident into the wheelchair, removed the sling, connected the chair alarm, transported the resident into the bathroom, adjusted the leg rests, brushed the resident's hair, applied oxygen per nasal cannula, put the resident's glasses on, and left the room. The CNA failed to perform hand hygiene after completion of perineal care, before completing other tasks and prior to exiting the room. - During observation of medication pass on the morning of 04/07/15, a nursing staff member (#7) provided medications for Resident #11 at the dining table. The nurse returned to the medication cart and failed to perform hand hygiene following and prior to dishing of medications for another resident. Further observation showed the staff member then entered another resident's room, assisted the resident to an upright position on the edge of bed, and administered medications. The nurse entered another resident's room, administered medications, exited the room, and walked over to another unit after opening the door and passing through. The nurse failed to perform hand hygiene after each medication administration and prior to touching other environmental surfaces. During an interview on 04/08/15 at 4:00 p.m., an administrative nurse (#4) stated she would expect staff not to place the catheter leg bag directly on the floor and perform hand hygiene after perineal care, once the resident is safe. During an interview on 04/08/15 at 4:30 p.m., an administrative staff member (#4) provided no information related to the lack of glove usage/hand hygiene of staff for a resident in contact precautions, and during medication pass.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (Version 3.0) and staff interview, the facility failed to ensure the Minimum Data Sets (MDSs) accurately reflected the residents' status for 1 of 2 sampled residents (Resident #12) identified with an active pressure ulcer during the assessment period and 1 of 1 sampled resident (Resident #9) coded as having a bowel training program. Failure to accurately complete portions of the MDS does not allow staff to develop a plan of care based on the residents' current status and needs. Findings include: - The Long-Term Care Facility RAI User's Manual, October 2012, page M-8 stated, "Definition: Stage 2 Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. . . . " Review of Resident #12's medical record occurred on 04/03/12. A quarterly MDS, dated [DATE], identified the resident had two stage 1 pressure ulcers and no stage 2 pressure ulcers during the seven day assessment period. An interdisciplinary progress note, dated 02/16/13 at 1:00 p.m. stated, ". . . Has open areas (R) (right) buttock & (and) coccyx - Allevyn (a type of dressing) used . . ." A Skin Assessment Sheet, dated 02/16/13, stated, "1. Type - open area coccyx. Description - 0.8 cm (centimeters) x (by) 1.0 cm . . . 2. Type - open area (R) coccyx. Description - 1.2 cm diameter . . . 3. Type - (R) buttock x (times) 2. Description - open area 1 cm diameter & 0.6 cm diameter . . ." An interview with an administrative nurse (#3) occurred on the afternoon of 04/04/13. The nurse agreed staff should have identified the stage 2 pressure ulcers on the 02/22/13 MDS. - The Long-Term Care Facility Resident Assessment Instrument User's Manual, October 2012, page H-11-12 states, ". . . A systematically implemented bowel toileting program may decrease or prevent bowel incontinence, minimizing or avoiding the negative consequences of incontinence. . . . Look for documentation in the medical record showing that the following three requirements have been met: implementation of an individualized, resident-specific bowel toileting program based on an assessment of the resident's unique bowel pattern; evidence that the individualized program was communicated to staff and the resident (as appropriate) verbally and through a care plan, flow records, verbal and written report; and notations of the resident's response to the toileting program and subsequent evaluations, as needed. . . ." Review of Resident #9's record occurred on 04/03/13. Quarterly MDSs, dated 12/19/12 and 03/19/13, identified the resident with an indwelling catheter and bowel continence as "Always continent." The 03/19/13 MDS also identified a bowel toileting program. Resident #9's record failed to identify staff performed an assessment of his unique bowel pattern prior to implementing the program. The resident's current care plan, dated 01/03/13, identified an undated, discontinued intervention of "Trial toileting schedule, sit on toilet at (10:00 a.m.) et (and) (2:00 p.m.)" A nursing progress note, dated 02/14/13 at 2:00 p.m., stated, "Writer visited (with) Res (resident) in regard to recent fall et toileting. Res was asked if we could better assist him (with) a certain schedule . . . Res was unable to come (with) specific times he likes to use the bathroom. Will continue to assist as needed." A progress note, dated 03/21/13 at 1:45 p.m., stated, "RLS (Resident Living Specialist) reports Res does not like to follow toileting schedule. She reports that Res will tell her when he wants to use the bathroom. . . ." During an interview on 04/03/13 at 2:10 p.m., a supervisory nurse (#3) confirmed staff did not complete an assessment of the resident's bowel pattern prior to implementing the toileting schedule. She stated staff chose the toileting times based on times Resident #9 fell in the bathroom and confirmed staff implemented the toileting schedule as a fall intervention. The above MDSs identified Resident #9 as continent of bowel. Implementation of the toileting schedule as a fall intervention failed to meet the requirements for coding a toileting schedule on the MDS.

Based on observation, policy review, and staff interview, the facility failed to ensure outdated medications/biologicals were discarded after the recommended usage period in 1 of 1 Medication (Drug) Room. Failure to dispose of expired medications allows usage beyond the recommended expiration date. Findings include: Review of the facility policy, titled "Discarding Drugs - Outdated and No Longer Used," occurred on 04/03/13. This policy, not dated, stated, "Policy: Outdated and unused drugs will not be stored with currently used drugs. . . . 3. On the date of expiration, the drug shall be removed by the medication nurse to a locked cupboard in the Drug Room - designated for old or discontinued drugs. . . . The outdated drugs will be stored until destruction during the next visit of the Pharmacist." On 04/03/13 at 9:55 a.m. observation of the Drug Room, with a staff nurse (#4), showed the following expired creams and solutions stored with currently used drugs: * A vial of sterile water, opened, not dated; * Sterile water for irrigation, expired 08/2012; * Banophen cream, expired 11/2012; and * E Cream, expired 10/2012. As the nurse (#4) removed these medications from the stock drug storage area, she stated they would be returned to the pharmacist, who checks the drug room monthly. Failure to follow facility policy allowed expired (five to seven months) solutions and creams to be available for possible use.