Every finding on record at Parkview Health Care Facility

Based on observation, interview, and record review, the facility failed to provide care to all residents per standards of practice when staff failed to transcribe a physician order change in breathing treatments and failed to administer the breathing treatments as order for one resident (Resident #1). The facility census was 70. Review of facility policy, Physician Orders, reviewed November 2024, showed the following: -In most circumstances, orders should be entered electronically by the practitioner; -Verbal or telephone orders may be given to providers (for example, a nursing facility) only if there is an emergency situation when the electronic entry may delay care, or if computer access is not available to the practitioner; -Upon receipt of a written or faxed order, staff will scan the order into the resident's electronic medical records (EMR). The orders will be entered into the EMR as applicable. 1. Review of Resident #1's face sheet showed the following: -admission date of 12/02/24; -Diagnoses included high blood pressure, anxiety, heart disease, and recent history of pneumonia. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/08/24, showed the following: -Cognitively intact; -No rejection of care; -Diagnoses included asthma (A condition in which the airways narrow and swell and may produce extra mucus. This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when breathing out and shortness of breath.), chronic obstructive pulmonary disease (COPD - An ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs.), or another chronic lung problem. Review of the resident's care plan, last reviewed 12/10/24, showed the following: -Respiratory treatment as ordered; -Supplemental oxygen use as ordered. Review of the resident's December 2024 Treatment Administration Record (TAR) showed the following : -An order, dated 12/02/24, for albuterol 2.5 milligrams (mg) every 8 hours as needed (PRN); -Staff did not administer the medication on 12/02/24; -Staff did not administer the medication on 12/03/24. Review of the resident's nursing notes, dated 12/04/24, showed the resident reported to staff that he/she had breathing treatments at home twice a day. The resident told staff he/she had not had any treatments since being admitted to the facility and was starting to feel congested. The nurse requested breathing treatments twice a day (scheduled). The doctor replied for staff to go ahead and schedule the albuterol (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease (COPD - An ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs.)) breathing treatments twice a day, per resident request. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN. (Staff did not update the order to reflect the new order from the physician for treatments scheduled twice a day.); -Staff did not administer the medication on 12/04/24; -Staff did not administer the medication on 12/05/24; -Staff did not administer the medication on 12/06/24; -Staff did not administer the medication on 12/07/24; -Staff administered the medication twice on 12/08/24; -Staff administered the medication once on 12/09/24; -Staff did not administer the medication on 12/10/24; -Staff administered the medication once on 12/11/24. Review of resident's physician's note, dated 12/12/24, showed the resident reported to the doctor a recent cough, and difficulty catching breath upon exertion. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN. (Staff did not update the order to reflect the new order from the physician for treatments scheduled twice a day.); -Staff administered the medication once on 12/12/24; -Staff administered the medication once on 12/13/24; -Staff did not administer the medication on 12/14/24; -Staff administered the medication once on 12/15/24. Review of the resident's chest x-ray, completed on 12/16/24, showed findings related to pulmonary vascular congestion (PVC - an excessive accumulation of fluid in the blood vessels of the lungs, which can make breathing more difficult). Review of the resident's physician's notes showed, dated 12/16/24, showed diagnosis of PVC. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN. (Staff did not update the order to reflect the new order from the physician for treatments scheduled twice a day.); -Staff did not administer the medication on 12/16/24; -Staff did not administer the medication on 12/17/24; -Staff did not administer the medication on 12/18/24; -Staff did not administer the medication on 12/19/24; -Staff did not administer the medication on 12/20/24; -Staff did not administer the medication on 12/21/24; -Staff did not administer the medication on 12/22/24; -Staff did not administer the medication on 12/23/24; -Staff did not administer the medication on 12/24/24; -Staff did not administer the medication on 12/25/24; -Staff administered the medication once on 12/26/24; -Staff administered the medication once on 12/27/24; -Staff did not administer the medication on 12/28/24. Review of the resident's nursing note, dated 12/28/24, showed the resident requested breathing treatments to be scheduled twice a day, instead of as needed. A nurse practitioner replied on 12/29/24 that it was okay to schedule the breathing treatment twice a day for one week on a trial basis. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN; -An order, dated 12/29/24, for albuterol 2.5 mg scheduled twice a day, on a trial basis, with a stop date of 01/05/25; -Staff administered the medication twice on 12/29/24; -Staff administered the medication twice on 12/30/24; -Staff administered the medication twice on 12/30/24. Review of the resident's January 2025 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN; -An order, dated 12/29/24, for albuterol 2.5 mg scheduled twice a day, on a trial basis, with a stop date of 01/05/25; -Staff administered the medication once on 01/01/25 and did not administer any additional PRN doses; -Staff administered the medication twice on 01/02/25; -Staff administered the medication twice on 01/03/25; -Staff administered the medication twice on 01/04/25; -Staff administered the medication twice on 01/05/25. Review of the resident's January 2025 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN; -The order for scheduled albuterol was was discontinued on 01/05/25; -Staff administered the medication twice on 01/06/25; -Staff did not administer the medication on 01/07/25; -Staff administered the medication twice on 01/08/25; -Staff administered the medication once on 01/09/25; -Staff administered the medication twice on 01/10/25. Review of the resident's January 2025 TAR showed the following: -An order, dated 01/10/25, for albuterol 2.5 mg scheduled twice a day; -Staff administered the medication twice on 01/10/25; -Staff administered the medication twice on 01/11/25; -Staff administered the medication twice on 01/12/25; -Staff administered the medication twice on 01/13/25; -Staff administered the medication twice on 01/14/25; -Staff administered the medication once on 01/15/25. Observation and resident interview on 01/16/25, at 1:20 P.M., showed the following: -The resident had contracted pneumonia before being admitted to the facility and had some breathing difficulties since that time; -He/She had breathing treatments twice a day at home, immediately prior to being admitted to the facility; -The resident had an oxygen concentrator in his/her room; -The resident said if he/she goes too long between breathing treatments, he/she will start to feel congested. The breathing treatments help him/her cough up liquid, which relieves congestion and he/she feels better. During an interview on 01/16/25, at 1:03 P.M., Certified Medication Tech (CMT) A said when a resident requested a change in medication, he/she notified the nurse and the nurse notified the doctor or other provider. During an interview on 01/16/25, at 3:30 P.M., Licensed Practical Nurse (LPN) B said he/she put in the change from albuterol as needed to albuterol twice daily on 12/04/24 after the resident requested the change. However, the facility was having computer problems that day, and the change in order must not have been saved. For requests of medication changes, the usual facility process is for the charge nurse to discontinue the as needed medication, then put in the new order. To make sure orders and messages are completed, the night shift charge nurse prints off and double-checks if the new order is in the system. During an interview on 01/16/25, at 2:05 P.M., the Director of Nursing (DON) said staff sent a message to the resident's physician on 12/04/24 about changing the albuterol breathing treatments from as needed to scheduled twice daily. Although the nursing note says the task was completed, no staff updated the doctor order. She did not know why the change was accepted by the doctor, but no staff put in any new orders until the second request was made by the resident on 12/29/24 (25 days after the first request was made). During an interview on 01/16/25, at 4:00 P.M., the Administrator said doctors usually put orders into the facility records themselves. If not, then the charge nurses should put the new order in the EMR. The charge nurse or nurse manager should double check to make sure any new orders have been completed. He did not know why staff failed to completely put in the order for albuterol twice a day when first requested on 12/04/24. He said he did not know why different staff failed to double-check to assure orders were fully completed. MO00247213

Based on observation, interview, and record review, the facility failed ensure the dignity of all residents was maintained at all times when staff failed to ensure one resident's (Resident #23) catheter (a sterile tube inserted into the bladder to drain urine) bag was covered with a dignity bag when visible to others. A sample of 17 residents was reviewed in a facility with a census of 65. Review of the facility's policy titled, Resident Rights, Rules, and Regulations, updated 10/01/21, showed the following information: -Residents have the right to be treated with dignity and respect; -Residents have the right to privacy and respect regarding accommodations, personal care, medical treatment, written and telephone communications, and visits with other individuals. 1. Review of the resident's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses included acute metabolic acidosis (a condition in which too much acid accumulates in the body). Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 10/31/24, showed the following information: -Indwelling catheter use; -Diagnoses included benign prostatic hyperplasia (BPH - an age associated prostate enlargement that can cause urination difficulty) and kidney failure. Review of the resident's care plan, last reviewed on 11/24/24, showed the following information: -Monitor resident for complications of indwelling urinary catheter and report to charge nurse; -Position the drainage bag to facilitate flow of urine; -Change catheter and provide catheter care per orders; -Use leg bag when ambulating per residents choice. Observation on 11/19/24, at 9:48 A.M., showed the resident's room door open with catheter bag draining pale yellow urine hung on the right side of his/her bed visible from the hallway. Observation on 11/20/24, at 9:21 A.M., showed the resident's room door open with catheter bag draining pale yellow urine hung on the right side of his/her bed visible from the hallway. Observation on 11/20/24, at 12:09 P.M., showed the resident's room door open, catheter bag draining pale yellow urine hung on the right side of his/her bed visible from the hallway. Observation on 11/21/24, at 8:20 A.M., showed the resident's room door open, catheter bag draining pale yellow urine hung on the right side of his/her bed visible from the hallway. During an interview on 11/21/24, at 1:10 P.M., Certified Nursing Assistant/ Registered Medication Technician (CNA/RMT) A said catheter bags should be in dignity bags at all times. During an interview on 11/21/24, at 2:29 P.M., Registered Medication Technician (RMT) B said no one should be able to see urine in catheter bags from the hall. Catheter bags should be in dignity bags at all times. During an interview on 11/22/24, at 9:55 A.M., Licensed Practical Nurse (LPN) C said no one should be able to see urine in catheter bags from the hall. Catheter bags should be in dignity bags at all times, unless the staff can position the bag in a way that it is not visible from the hall. During an interview on 11/22/24, at 12:34 P.M., the Director of Nursing (DON) said she expected staff to have catheter bags covered with dignity bags at all times. During an interview on 11/22/24, at 1:19 P.M., the Administrator said he expected staff to have catheter bags covered at all times.

Based on observation, interview, and record review, the facility failed to provide pressure ulcer care consistent with standards of practice when the facility failed to consistently document regarding all wounds and failed to care plan regarding new wounds in a timely fashion for one one resident (Resident #23) withe multiple pressure wounds. A sample of 17 residents was reviewed in a home with a census of 65. Review of the facility's policy titled Pressure Ulcer/Wound Assessment and Treatment, last revised on 11/24, showed the following information: -Basic prevention includes to encourage hydration, offer moisturizing cream, provide incontinence care, reposition in bed or chart according to the individual patient needs, care goals, tissue tolerance, and response to treatment, avoid positioning on current pressure ulcer/wound. Review of the National Library of Medicines article, titled Review of Current Management of Pressure Ulcers, dated 2/1/2018, showed the following information: -Each dressing change should be accompanied by concurrent wound reassessment; -Foam dressings are ideal for stage I wounds. 1. Review of Resident #23's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included acute metabolic acidosis (too much acid in the blood). Review of the resident's nurse's note, dated 10/28/24, showed the nurse was notified of an area of concern to resident's back. Three spots of stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) nature observed along the spine. Staff notified the Nurse Practitioner (NP) in person and verbal received to cover with Optifoam (absorbent foam dressing) and change every three days. Review of the resident's physician's progress note, dated 10/28/24, showed the following information: -Pressure injury of back, stage I (intact skin with a localized area of non-blanchable erythema (redness)), apply Optifoam for cushioning and protection, and change every three days. Staff to reposition in bed often and offload pressure from back. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 10/31/24, showed the following information: -At risk for pressure ulcers; -Did not have one or more unhealed pressure ulcers at stage I or higher on admission; -Pressure reducing device for chair and bed. Review of the resident's physician's progress note, dated 11/06/24, showed the following information: -Pressure injury had worsened and was unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured) on thoracic spine. -Staff to cleanse area and cover with mepilex ag (antimicrobial foam that absorbs drainage) and apply Optifoam over it for cushioning. Review of the resident's nurse's note, dated 11/07/24, showed the nurse performed a skin assessment on resident. The resident did not have any skin discoloration on either heels. (The nurse did not document related to the resident's wound on his/her back.) Review of the resident's bath sheet, dated 11/07/24, showed staff noted an abrasion, decub (ulcer), and incision present. Staff did not indicate the location on the shower sheet. Review of the nurse's note, dated 11/11/24, showed an aide notified nurse of resident's heel. The heel assessed and showed blackened area to left heel. Staff notified the Director of Nursing (DON) and NP. Staff placed Optifoam placed on left heel. Review of the resident's physician's progress note, dated 11/11/24, showed the following information: -Pressure injury has worsened and unstageable on thoracic spine. Three circular areas of pressure, surrounded with erythema wound surface is slough (non-viable yellow, tan, gray, green or brown tissue) and kyphoscoliosis (abnormal curvature of the spine) present. -Staff to cleanse and cover with Mepilex Ag and apply Optifoam over it for cushioning. Staff to reposition frequently and offload from back. -Pressure injury to left heel unstageable has developed and right heel without redness or injury. -Staff to offload heels from bed surface, frequent repositioning in bed, and Optifoam for protection. Review of the resident's wound assessments, dated 11/12/24, showed the following information: -On 11/12/24, one acquired stage II pressure ulcer to the resident's right heel measuring 2 centimeters (cm) by 2.5 cm with a 0.1 cm depth. The appearance was dusky red and the surrounding tissue was peeling and pink, no odor. -One acquired unstageable pressure ulcer to the resident's left heel measuring 4 cm by 4.4 cm with a 0.1 cm depth. The appearance was necrotic (dead-black) the surrounding tissue was peeling. (Staff did not document an assessment of the wounds on the resident's back.) Review of the resident's care plan, revised on 11/13/24, showed the following information: -One pressure wound to left heel and one pressure wound to right heel; -Considerations included heel elevation, pressure relieving device implementation, hydration management, incontinence management, nutrition promotion, and position change; -Care included Braden scale (assessment tool to assess a patient's risk of developing pressure ulcers) as needed, float heels using pillows or offloading boots as needed, keep skin clean and dry, treatment as ordered, and weekly as needed skin monitoring by a professional nurse. (Staff did not care plan regarding the wounds on the resident's back.) Review of the resident's shower sheet, dated 11/14/24, showed staff documented abrasion, decub, and incision present. The shower sheet does not indicate location. Review of the resident's nurse's note, dated 11/15/24, showed the following information: -Per wound nurse, resident's back to remain open to air for the next few days as the area is very macerated. -Wounds cleansed, skin prep applied, and the resident repositioned on his/her right side with heel protectors on both feet and a pillow under the residents' calves to float feet. -Resident should be re-positioned as much as possible with bilateral heels always floating, and heel protectors on when up. Review of the resident's wound assessment, dated 11/15/24, showed the following information: -One acquired stage I pressure ulcer to the resident's distal (bottom) back measured 0.5 centimeters (cm) by 1 cm with a 0.1 cm depth. The appearance was reddened with no odor. -One acquired stage II pressure ulcer to the resident's medial (middle) back measured 1 cm by 1.4 cm with a 0.1 cm depth. The appearance was gray/white, surrounding tissue was red and macerated with no odor. -One acquired stage II pressure ulcer to the proximal (nearer to the center) back measured 1.5 cm by 1.8 cm with a 0.1 cm depth. The appearance was gray/white and the surrounding skin was red and macerated with no odor. (The first documented assessment for wounds staff originally identified on 10/28/24.) Review of the resident's physician progress note, dated 11/16/24, showed the following information: -Pressure injury to left heel now soft and fluid filled and continued to be black in color. -Unstageable pressure injury on thoracic lumbar spine. Staff to cleanse area and cover with Mepilex Ag, apply Optifoam over it for cushioning, and offload from back. -Right heel continued without redness or pressure. Offload heels from bed, frequent repositioning, and Optifoam to left heel. -Plans to admit resident to hospice. Review of the resident's wound assessment, dated 11/19/24, showed following information: -One acquired stage I pressure ulcer to the resident's distal back measured 0.5 centimeters (cm) by 1 cm with a 0.1 cm depth. The appearance was reddened with no odor. -One acquired stage II pressure ulcer to the resident's medial measured 1 cm by 1.2 cm with a 0.1 cm depth. The appearance was gray/white, surrounding tissue was red and macerated, with no odor. -One acquired stage II pressure ulcer to the proximal back measured 1.5 cm by 1.5 cm with a 0.1 cm depth. The appearance was gray/yellow, the surrounding skin was red and macerated with no odor. -One acquired stage II pressure ulcer to the resident's right heel measuring 3 cm by 2.4 cm with a 0.1 depth. The appearance was dusky red, and the surrounding tissue was peeling and pink, with no odor. -One acquired unstageable pressure ulcer to the residents left heel measuring 3.5 cm by 5 cm with a 0.1 depth. The appearance was necrotic the surrounding tissue was peeling. Review of the resident's physician progress note, dated 11/20/24, showed the resident on hospice services and continued with slow decline. Observation on 11/21/24, at 9:52 A.M., Licensed Practical Nurse (LPN) C, and the Wound Care/Infection Preventionist Nurse were in the resident's room performing wound care. The Wound Care/Infection Preventionist Nurse took off the resident's heel protectors and removed protective dressing to the resident's right heel. The resident had a quarter sized opening with erythema to the right heel. LPN C removed protective dressing to the resident's left heel. The resident had an area of eschar (dead or devitalized tissue), bigger than a half dollar in size. The resident rolled onto his/her left side, toward the Wound Care/Infection Preventionist nurse. At this time, a strong wound odor was present. LPN C removed the Mepilex dressing to the resident's back wounds. Two bigger than quarter size areas observed with 95 percent slough and 5 percent eschar to each wound. The tissue surrounding the wounds were dark red/purple coloring. A third wound on the back, approximately quarter size, minimally observed, with non-blanchable redness. During an interview on 11/21/24, at 1:10 P.M., Certified Nursing Assistant/ Registered Medication Technician (CNA/CMT) A said the following: -He/she noticed the resident's wounds shortly after the resident came back from the hospital; -If he/she noticed a change on the resident's skin, it was reported to the charge nurse; -Aides complete the showers and should document any skin issues on the bath sheets. Those sheets are then turned into the charge nurse, who signs and assesses any issues. After the charge nurse makes their assessment, the bath sheet is turned into the DON; -Wounds and wound care would be found on the care plan. During an interview on 11/21/24, at 2:49 P.M., Registered Mediation Technician (RMT) B said the following: -Bath sheets should be completed by the CNA completing the shower. After that's completed, it's turned into the nurse. From there, the nurse would sign it and assess any issues. After the charge nurse makes their assessment, the bath sheet is turned into the DON; -Aides should always report any new skin concerns and or worsening of skin to the charge nurse immediately; -He/she liked to follow up with the nurse after the nurse assesses the concerns to inquire about any new interventions for the resident. During an interview on 11/22/24, at 9:55 A.M., LPN C said the following: -Floor nurses are responsible for providing daily wound care; -He/she was not sure how often the Wound Care Nurse performed assessments/measurements; -If he/she noticed a wound to be deteriorating and/or not improvement, he/she would report it to the Wound Care Nurse, DON, or NP. One of them would observe the wound and maybe change the treatment; -He/she was not sure if the resident's treatment had ever been more than Mepilex Ag. He/she did not feel he/she had enough experience to say whether or not the treatment should be upgraded; -He/she was not sure if wounds and wound care should be included on the care plan. During an interview on 11/22/24, at 12:07 P.M., the Wound Care/Infection Preventionist Nurse said the following: -She was made aware of the resident's wounds the following day after discovery; -She does weekly wound rounds to include measurements and assessments for changes; -When she learned of the resident's wounds the treatment was just Optifoam dressings. It has since been changed to mepilex foam; -She feels the wounds declined quickly, but they are some better now; -If she didn't see much improvement in a wound within a week, she would let the NP know. During an interview on 11/22/24, at 12:34 P.M., the DON said the following: -The resident is also on hospice as of this date and they will get involved in the wound treatment; -She agrees that if there is no improvement in a wound within a week, the NP needs to be reached out to for a change in treatment; -The resident should be wearing heel protectors and be repositioned frequently. During an interview on 11/22/24, at 1:19 P.M., the Administrator said the following: -If a wound is not improving, there needs to be a communication with the provider to see what course of action needs to be taken next; -Pressure to the affected area needs to be limited; -Weekly wound documentation and measurements are expected.

Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff continued to transfer one resident (Resident #14) with a lift that required resident participation after to two prior falls using the same lift and after the resident showed a decline in his/her ability to bear weight. A sample of 17 residents was reviewed in a facility with a census of 65. Review of the facility's policy titled Resident Handling, revised on 04/22, showed the following information: -Mobility and transfer decision flow chart is utilized when selecting appropriate assistive equipment and devices during assessment of resident capabilities for care planning and prior to patient handling activity. When indicated on the patient care plan, the required assistive devices may be varied according to the decision flow chart. -Because resident conditions and physician or mental status may be continually changing throughout the day, staff members are encouraged and empowered to make an updated assessment with individual handling activities. -Staff members should be familiar with the resident's current status and be able to verbalize the reason(s) a particular device was selected for the activity. -Charge nurses are responsible for routinely observing resident handling activities and verifying the appropriate selection and use of safety devices. -Injury incidents, near miss incidents, or early signs and symptoms of muscle strains or other musculoskeletal injury resulting from resident handling activities are reported per policy. -Resident handling incidents are analyzed for trends or patterns and appropriate follow up, changes in policy, staff education, or equipment maintenance initiated as required. Review of the facility's Mobility and Transfer Decision Flow Chart, dated 08/05/19, showed the following information: -Team members are empowered to use the Limited Lift Flow Chart in real time when determining the proper way to lift, transfer, reposition, or ambulate a resident; -When/if there is uncertainty in answering a question on the flow chart, the next level down in the chart higher level of safety should be utilized until the next question is answered. The charge nurse or care plan team should be consulted for clarification; -One person assisting using the sit-to-stand (a mechanical device that helps people with limited mobility move from a seated position to a standing position) or full lifts (Hoyer- a mechanical device that helps move people with limited mobility by placing the resident in a sling and suspending the resident in the air with the lift, and then lowering the resident on/in the destination) are authorized unless the resident's clinical needs, risks, or behaviors indicate otherwise, such as a resident who becomes very frightened or agitated during a transfer may require additional staff to ensure safety; -Partial or non-weight bearing residents that are unable to bear weight, are dependent on staff, and/or uncooperative or resistive to care require a maximum assist and a total lift device, such as a Hoyer. 1. Review of the Resident #14's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses included fracture of the left pubis (a bone in the pelvis that protects the bladder, intestines, and internal sex organs), and subsequent encounter for fracture. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 10/26/24, showed the following information: -Severely impaired cognition with inattention and disorganized thinking; -Substantial to maximal assist from staff for all activities of daily living (basic tasks that people need to perform to live independently in a household, such as bathing, dressing, toileting, and mobility) -No falls since admission; -Diagnoses included heart disease, kidney failure, and Alzheimer's disease. Review of the resident's care plan, revised on 03/13/24, showed the following information: -Staff to assist with ADL's as needed. Staff will need to use the decision flow chart to help with transfers; -Substantial assistance from staff, sit-to-stand, and wheelchair required; -Fall risk assessments to be completed every 90 days; -Interventions for falls included call light within reach, proper use of sit-to-stand, reeducate staff in the use of the sit-to-stand, low bed, fall mat, and non-skid footwear. Review of the resident's nurses note, dated 09/06/24, showed the following information: -Will ask therapy to see resident for possible downgrade to a Hoyer lift. Resident is not able to bear weight at times for the sit-to-stand. Director of Nursing (DON), and Nurse Practitioner(NP) notified. Review of the resident's nurses notes, dated 09/07/24 to 10/06/24, showed no follow-up note regarding lift concerns. recorded. Review of the resident's nurse note, dated 10/07/24, of a fall communication form, showed the following information: -The resident was being transferred to bed via sit-to-stand when the resident unhooked his/herself. Staff member lowered the resident to the ground as resident slid out of the lift onto the floor; -Interventions included change in transfer mechanism via transfer tree protocol. Review of the resident's fall team meeting, dated 10/21/24, showed the following information: -The resident fell out of the sit-to-stand on 10/07/24; -The resident was a high fall risk; -New interventions included education on the use of a sit to stand. Review of the resident's nurses note, dated 11/07/24, of a fall communication form, showed the following information: -The certified nurses aide (CNA) was using the sit-to-stand to lift the resident from the recliner to the wheelchair. As the CNA lifted the resident, the resident slid his/her arm out of the sling and then fell on to the floor landing on his/her right side. The resident was assessed and assisted back to the wheelchair with a Hoyer lift; -New interventions include education on proper sling to use for the sit-to-stand transfer for this resident. Review of the resident's fall team meeting, dated 11/11/24, showed the following information: -The resident fell out of the sit-to-stand on 11/07/24; -No new interventions put into place; -The resident was reeducated on the use of the sit-to-stand. Review of the resident's care plan showed staff did not update the care plan regarding the need for a transfer method change to prevent future falls. During an interview on 11/20/24, at 10:32 A.M., Registered Nurse (RN) D said the following: -The resident had been a sit-to-stand transfer, but he/she is now on hospice services due to a decline; -There has been mention of switching the resident to a Hoyer lift; -He/She plans to speak with the nurse practitioner (NP) about the transfer downgrade today and get that updated in the resident's chart. Observation on 11/20/24, at 1:25 P.M., showed the following: - Registered Medication Technician (RMT) I and Certified Nurse's Aide (CNA) J prepared to transfer the resident with the sit-to-stand lift from the wheelchair to the recliner. CNA J put a sit-to-stand sling around the resident and secured the sling around the resident. -CNA J began operating the sit-to-stand lift and the sit-to-stand lift started to rise. The resident's upper body lifted and resident was unable to come to a standing position. CNA J lowered the resident back into the wheelchair. -On the second attempt, CNA J began operating the sit-to stand lift. The sit-to-stand lift started to rise and the resident's upper body lifted and resident was unable to come to a standing position. CNA J lowered the resident back into the wheelchair. -On the third attempt, CNA J began operating the sit-to stand lift and the sit-to-stand started to rise. The resident's upper body lifted and resident was unable to come to a standing position. CNA J lowered the resident back into the wheelchair. -RMT J said morning transfers are usually a struggle for the resident. Nothing was passed in report regarding a decline and/or need to transfer the resident any other way. -CNA J said the resident should probably have non-slip socks on to assist with this transfer. (CNA J did not don non-slip socks onto the resident.) -On the fourth attempt, CNA J began operating the sit-to stand lift. The sit-to-stand started to rise, the resident's upper body lifted and resident was unable to come to a standing position. CNA J lowered the resident back into the wheelchair; The resident said he/she was tired. -On the fifth attempt, CNA J began operating the sit-to stand lift, the sit-to-stand started to rise and the resident's upper body lifted. The resident was unable to come to a standing position. CNA J lowered the resident back into the wheelchair. -RMT I said it might just be better to switch the resident to a Hoyer lift. He/she will fill out a stop and watch and the nurse will take care of it. -CNA J removed the sling from around the resident, and the resident continued to sit in his/her wheelchair. During an interview on 11/21/24, at 8:16 A.M., CNA/RMT E said the following: -Staff are expected to transfer the residents with one staff; -There are several residents on the hall that are high fall risks that are either sit-to-stand or Hoyer transfers; -He/She knows from previous jobs that mechanical lifts should be done with two staff members, however this facility only lets one staff complete the task, due to staffing and cost; -Often times the transfers are not safe due to the staffing ratio and the needs of the residents. During an interview on 11/21/24, at 1:10 P.M., CNA/RMT A said the following: -If a resident is a frequent faller the aides are told to keep a closer eye on them. Other fall interventions include fall mats and low beds; -The resident is transferred with a sit-to-stand. He/she has not had any issues doing so other than with holding on at times. -He/she is aware that the resident has fallen out of the sit-to-stand before. -If a staff member doesn't feel safe, or notices that the resident is unable to bear weight, they should use the decision flow chart and downgrade the residents transfer for that occurrence. -Staff should be able to see how a resident is transferred in the care plan. During an interview on 11/21/24, at 2:49 P.M., RMT B said the following: -The resident's transfer status depends on his/her mood for the day. -Most of the time the sit-to-stand is used. Staff operate the sit-to-stand with one staff member. -He/she was aware that the resident had fallen out of the sit-to stand before. The resident chicken wings his/her arms and slides right out of it due to not being able to bear total weight; -If he/she noticed the resident was unable to bear weight, he/she would downgrade the resident's transfer status to a Hoyer lift for that occurrence; -He/she has never seen the resident attempt to unhook themselves from the lift. He/she is unsure if the resident is capable of that. During an interview on 11/22/24, at 9:55 A.M., Licensed Practical Nurse (LPN) C said the following: -The resident has been a sit-to-stand transfer; -Staff can use the sit-to-stand for transfers if the resident is able to bear weight on at least one leg and has the ability to hold on; -If a resident seemed to be having trouble coming to a standing position, he/she would expect the staff to use the decision flow chart and downgrade the residents transfer status for that occurrence; -He/She was not aware if therapy had given any input on how the resident should be transferred; -He/she has not been made aware of any changes in the residents condition lately. During an interview on 11/22/24, at 10:26 A.M., Physical Therapist (PT) K said the following: -He/she had been asked to evaluate the resident before. He/she always recommended that the staff follow the decision flow chart, which means the staff should decide how much assistance the resident needs; -Knowing the resident, he/she would say that a decline will continue due to his/her mental and physical limitations; -A nurse did come to him/her this week and asked his/her thoughts on the resident's transfer status. At that time, he/she recommended the status be downgraded and care planned to a Hoyer lift. -When a transfer status is care planned, then that is what the staff should use at all times instead of the decision flow chart. -If the resident were to fall out a sit-to-stand, an intervention of education would not be appropriate, due to the resident's mental limitations. During an interview on 11/22/24, at 12:34 P.M., The Director of Nursing (DON) said the following: -She expected the staff to use the decision flow chart for determination of transfer status. -A resident must be able to bear weight if they are going to use the sit-to-stand. -A sit-to-stand can be operated with one staff member. She does encourage two staff members as it is safer. -The resident has sustained falls out of the sit-to-stand and the Hoyer lift potential has been discussed. -Transfer status should be care planned in this case. During an interview on 11/22/24, at 1:19 P.M., The Administrator said the following: -Staff are expected to use the sit to stand with one staff member. They are able to obtain help if it is needed; -Residents should be able to bear weight if they are using a sit-to-stand; -He was not aware of any current issues with the resident's transfer status; -Transfer status as well as any fall interventions should be care planned.

Based on observation, interview, and record review, the facility failed to provide respiratory care per standard of practice when staff failed to obtain physician orders for care of a continuous positive airway pressure machine (CPAP - a treatment for sleep apnea (sleep disorder that causes people to stop breathing or breathe shallowly while they sleep)) and failed to consistently clean the CPAP canister, tubing, and face mask for one resident (Resident #53) with a CPAP. The facility census was 65. 1. Review of Resident #53's face sheet showed: -admitted [DATE]; -Diagnosis included chronic respiratory failure with hypoxia (inadequate oxygen in the body tissues). Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 10/31/24, showed the following: -Cognitively intact; -No rejection of care; -Required substantial/maximum assistance of staff with showers and toileting hygiene; -Required partial/moderate assistance of staff with dressing and personal hygiene; -On oxygen therapy and non-invasive mechanical ventilation (CPAP). Review of the resident's care plan, dated 10/25/24, showed the following: -Ineffective breathing pattern: Resident has hypoxemia and chronic respiratory failure. Resident used a CPAP at hour of sleep (HS) and have a pleural drain. Vital signs as ordered, including oxygen saturation, physical assessment, and document any teaching regarding airway; -Oxygen use: Resident to use use oxygen at all times. Oxygen as ordered, instruct resident in pursed lip breathing, elevate the head of bed if requested, and minimize activities to short periods and one at a time. Review of the resident's physician orders an order, dated 11/04/24, for CPAP every HS and remove in the morning. (The orders did not include care and cleaning of the CPAP machine, CPAP tubing, or CPAP mask.) Observation and resident interview on 11/21/24, at 8:15 A.M., showed the following: -The resident lay on his/her bed with oxygen on via nasal cannula; -The resident's CPAP mask and attached tubing lay on his/her bed connected to a CPAP machine located on his/her bedside table; -The resident said he/she had sleep apnea and used the CPAP machine every night; -Prior to admission to the facility, while at home, the resident cleaned his/her machine, the tubing, and the mask every week; -Since admission to the facility, on 10/25/24, nearly one month ago, no one had cleaned his/her CPAP machine, tubing, or mask. During an interview on 11/21/24, at 12:10 P.M., Registered Nurse (RN) F said the following: -He/she rinsed the resident's CPAP tubing with water and hung it up to dry in the resident's room; -He/she was unsure if the facility had specific physician orders to care for the resident's CPAP; -The nurse then checked the resident's electronic health record and said the resident had a physician's order for CPAP use, but no specific order to clean the CPAP machine, mask, or tubing. During an interview on 11/21/24 at 12:15 P.M., Licensed Practical Nurse (LPN) G said the following: -The nurses should obtain physician orders for care/cleaning of the resident's CPAP equipment; -Nurses generally clean the CPAP canister, mask, and tubing with a cleaning solution kept in the clean utility room and then allow to air dry; -He/she was unsure specifically what the cleaning solution consisted of. During an interview on 11/22/24, at 1:00 P.M. LPN H said the following: -The facility did not have any physician orders for care of the resident's CPAP machine; -The night shift should rinse out the CPAP canister with sterile water and change the oxygen tubing running from the oxygen machine to the CPAP every week; -He/she had not cleaned or changed out the resident's CPAP mask or tubing; -He/she had rinsed out the canister with sterile water. During an interview on 11/22/24 at 1:20 P.M., the Director of Nursing (DON) said the nurses should have orders to clean the CPAP machine canister, tubing, and mask daily.

Based on observation, interview, and record review, the facility failed to document assessment for risk for entrapment and obtain informed consent prior to bed rail use for one resident (Resident #23) out of 17 sampled residents. The facility census was 65. Review showed the facility did not provide a policy regarding bed rail use. 1. Review of Resident #23's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses included acute metabolic acidosis (too much acid in the blood). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 10/31/24, showed the resident required supervision for rolling from left to right and required substantial to maximum assistance from staff for moving from lying on the back to sitting on the side of the bed. Review of the resident's care plan, revised on 11/13/24, showed the resident used bed rails to assist in turning and repositioning. Review of the resident's medical record showed staff did not document assessment for risk of entrapment and informed consent for bed rails for the resident. Observation on 11/18/24, at 9:30 A.M., showed the resident lay in bed on his/her back with one half bed rail on each side of the bed, in the upright position. Observation on 11/19/24, at 9:48 A.M., showed the resident lay in bed on his/her back with one half bed rail on each side of the bed, in upright position. Observation on 11/20/24, at 12:11 P.M., showed the resident lay in bed on his/her back with one half bed rail on each side of the bed, in upright position. Observation on 11/21/24, at 9:52 A.M., showed the resident lay in bed on his/her back with one half bed rail on each side of the bed, in upright position. During an interview on 11/21/24, at 1:10 P.M., Certified Nursing Assistant/Registered Medication Technician (CNA/RMT) A said the following; -Residents need bed rails if they have an air mattress, so they don't roll out of bed; -There is an assessment that has to be completed by the nurses; -There has to be a physician's order; -Bed rail use should be seen in the care plan; -The Maintenance Director is who is responsible for installing and measuring the bed rails; -He/she believed the bed rails were monitored/reassessed quarterly; -The resident used side rails because he/she used to try to get out of bed a lot and would fall. The bed rails were used as a precaution to keep the resident from falling. During an interview on 11/21/24, at 2:49 P.M., RMT B said the following: -Residents use bed rails for mobility, as well as prevention for falling out of bed; -He/she was not sure if the nurses have to fill out any kind of assessment or informed consent; -He/she was not sure who measured the bed rails; -Some beds come with bed rails already on them. During an interview on 11/22/24, at 9:55 A.M., Licensed Practical Nurse (LPN) C said the following: -The nurses have to get a physician's order for a resident to use the side rails; -The Maintenance Director installs and measures them; -He/she was not sure if there was any required assessment and/or informed consent; -Residents use them for mobility, however some hospice patients are using them so they don't roll out of bed; -The resident has them for mobility. During an interview on 11/22/24, at 9:49 A.M., The Maintenance Director said the following: -He received a work order of when to add and remove bed rails; -He was responsible for installing the bed rails and doing an assessment along with measurements at the time of installation; -He checked the bed rails and re-measures quarterly; -He completed the resident's assessment and measurements on 11/21/24, after being told the rails were already installed. During an interview on 11/22/24, at 12:34 P.M., the Director of Nursing said the following: -Nursing staff will put in a request for the Maintenance Director to install the bed rails; -The nursing staff will fill out an assessment and obtain an informed consent; -Bed rails should be care planned; -The Maintenance Director will install the bed rails and measure them; -The bed rails are re-assessed and monitored quarterly by both nursing and the Maintenance Director. During an interview on 11/22/24, at 1:19 P.M., the Administrator said the following: -He expected the Maintenance Director to install and obtain bed rail measurements; -The Maintenance Director was to assess/monitor the bed rails quarterly; -Bed rails should be care planned; -An assessment and informed consent should be completed.

Based on observation, interview, and record review, the facility failed to maintain a complete and effective infection control program when staff failed to follow hand hygiene procedures and handle equipment in a manner to prevent transmission of infections agents per standards of practice for one resident (Resident #23) out of 17 sampled residents. The facility census was 65. Review of the facility's policy titled, Infection Prevention Annual Plan and Program Evaluation, dated 05/24, showed the following information: -Maintain a sanitary environment to minimize, reduce, or eliminate the risk of infection and communicable disease; -Ensure safe practices for cleaning and disinfecting environmental surfaces; -Ensure proper handling, storage, and disinfection of multi-patient use medical equipment; -Provide education to new coworkers upon hire and annually for all coworkers to prevent exposure to and transmission of infections and communicable diseases, hand hygiene, and standard precautions. Review of the facility's policy titled, Hand Hygiene, dated 11/24, showed the following information: -Perform hand hygiene on ungloved hands with approved alcohol based hand rub (ABHR) or soap and water; -Five moments for hand hygiene from the World Health Organization (WHO) are as follows: before touching a resident, before a clean or aseptic technique, after body fluid exposure risk, after touching a resident, and after touching a resident's surroundings; -Change gloves during resident care if moving from a contaminated body site to a different body site of the same resident; -Perform hand hygiene and change gloves if you suspect your gloves have been contaminated. 1. Review of Resident #23's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses included acute metabolic acidosis (too much acid in the blood). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 10/31/24, showed the following information: -At risk for pressure ulcers; -Indwelling catheter (a sterile tube inserted into the bladder to drain urine) use. Review of the resident's care plan, last revised on 11/13/24, showed the following information: -Pressure ulcers to bilateral (both) heels. Staff to keep skin clean and dry, provide treatment as ordered, and follow enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes.); -Foley catheter used. Staff to keep clean, change catheter per orders, dignity, position drainage bag to facilitate flow of urine, and follow enhanced barrier precautions. Observation on 11/19/24, at 2:55 P.M., showed the following: -Registered Medication Technician (RMT) L and Licensed Practical Nurse (LPN) M enter the resident's room without performing hand hygiene. Both staff donned gowns and gloves. -RMT L removed the resident's catheter drainage bag and placed it onto the floor near the right side of the toilet. -RMT assisted the resident to a standing position and then pivoted to the toilet. The LPN noticed the catheter drainage bag on the floor, obtained the catheter bag, and placed it back under the resident's wheelchair. Staff did not perform had hygiene or change gloves. -RMT L assisted the resident to a standing position and LPN M obtained wipes and cleansed the resident's bottom. Staff did not perform hand hygiene or glove change. -RMT L assisted the resident back into sitting position on the toilet. LPN M obtained wipes and cleansed the residents front side. RMT L assisted the resident to a standing position. LPN M obtained additional wipes and cleansed the resident's bottom once more. Staff did not complete hand hygiene or change gloves. -LPN M pulled the resident's pants up and RMT L pivoted the resident back into a seated position in his/her wheelchair. -LPN M took off gloves and without performing hand hygiene donned new gloves. -RMT L and LPN M both placed wheelchair pedals onto the resident's wheelchair. -Both staff removed gloves. LPN M sanitized his/her hands. RMT L washed his/her hands in the bathroom sink. -LPN M then obtained the resident's oxygen tubing and assisted placing it inside the resident's nostrils before exiting the room. Observation on 11/21/24, at 9:52 A.M., showed the following: -LPN C stood outside the resident's room with the treatment cart. LPN C had gloves donned and sanitized scissors with disinfectant wipes. Supplies for wound care were gathered and placed on top of the treatment cart. LPN C took off gloves, obtained a gown, and donned the gown prior to entering the resident's room. -The Wound/Infection Preventionist (IP) Nurse was in the resident's room with gown and gloves donned. -LPN C laid the wound care supplies down onto the resident's bedside table, including the previously disinfected scissors, with no clean barrier or re-sanitization. -LPN C sanitized his/her hands, donned gloves, obtained the resident's bed adjusting dial, lowered the resident's bed, removed the resident's heel protectors, and removed the resident's sock to the right foot. -Without performing hand hygiene or changing gloves. LPN C obtained gauze and wound cleanser spray. LPN C moistened the gauze with the wound cleanser and cleansed the residents wound to the right heel. -LPN C removed gloves, sanitized hands, and donned new gloves. LPN C applied the treatment to the resident's right heel wound. LPN C did not sanitize his/her hands or change gloves and moved onto removing the resident's left heel wound previous treatment. The heel protectors and sock were preciously removed by the Wound/IP Nurse. -LPN C cleansed the resident's left heel wound. LPN removed gloves, sanitized hands, donned new gloves, and performed the treatment to the resident's left heel. The Wound/IP Nurse placed the resident's sock and heel protector back on. -Without removing gloves or sanitizing hands, the LPN touched the resident's bed blankets, the bed, the bed adjustor dial, and the resident's oxygen tubing. -The resident rolled toward the Wound/IP Nurse, onto his/her left side. LPN C adjusted the bed pad underneath the resident and removed the resident's pants and brief. -Without performing hand hygiene or changing gloves, the LPN obtained the contaminated scissors and cut the dressing material and laid the scissors back down onto the resident's bedside table with no clean barrier. The LPN touched the resident's bedside table and then removed the previous treatment dressing from the resident'' bottom. The LPN obtained gauze and wound cleanser and moistened the gauze with the wound cleanser. -While cleansing the resident's wound, bowel was seen on the gauze pad. The LPN obtained wipes and cleansed the resident's bottom with the swipe and fold method. -The LPN removed gloves, sanitized hands, and donned new gloves. LPN C obtained the treatment supplies and applied the treatment to the resident's bottom, placed on the resident's brief and pants and allowed the resident to roll onto his/her back to rest. -The LPN did not change gloves or perform hand hygiene. The resident rolled back onto his/her left side toward the Wound/IP Nurse. LPN C removed the dressings to the resident's back wounds and obtained wound cleanser and gauze. LPN C cleaned the wounds with moistened gauze. LPN C removed gloves, sanitized hands, and applied treatment to the resident's back wounds. -The resident rolled back onto his/her back. LPN C covered the resident with his/her blanket, obtained the residents bed pad, along with the Wound/IP Nurse and pulled the resident up into bed. LPN C removed gloves, sanitized hands, and donned new gloves. LPN C obtained the wound cleanser, picked trash up off the floor, obtained his/her scissors from the resident's bed side table, obtained the trash, a box of opened gloves, and then touched the residents nebulizer tubing without performing hand hygiene. During an interview on 11/21/24, at 1:10 P.M., Certified Nurses Aide/ Registered Medication Technician (CNA/RMT) A said the following: -Hand hygiene should be performed before and after care and if going from a dirty surface to a clean surface; -Catheter drainage bags should not be placed on the floor. During an interview on 11/21/24, at 2:49 P.M., RMT B said the following: -Hand hygiene should be performed before and after care and if going from a dirty surface to a clean surface; -Catheter drainage bags should not be placed on the floor. During an interview on 11/22/24, at 9:55 A.M., LPN C said the following: -Hand hygiene should be performed before and after care and if going from a dirty surface to a clean surface; -Catheter drainage bags should not be placed on the floor; -Equipment should be sanitized before and after each use and should be laid on a clean barrier During an interview on 11/22/24, at 12:07 P.M., the Wound/IP Nurse said the following: -Hand hygiene should be performed before and after care and if going from a dirty surface to a clean surface; -Catheter drainage bags should not touch the floor; -She expected staff to change gloves and perform hand hygiene prior to moving onto the next wound treatment; -She expected staff to have a clean barrier laid down for supplies; -Placing supplies on a dirty surface, then using the supplies would be considered cross contamination. During an interview on 11/22/24, at 12:34 P.M., the Director of Nursing (DON) said the following: -She expected hand hygiene to be performed before and after care and if going from a dirty surface to a clean surface; -Catheter drainage bags should not touch the floor; -She expected staff to change gloves and perform hand hygiene prior to moving onto the next wound treatment; -She expected equipment to be sanitized before it enters or leaves a residents room, and to have a clean barrier laid down. During an interview on 11/22/24, at 1:19 P.M., the Administrator said the following: -Hand hygiene should be performed before any task, when hands are soiled, and before and after cares; -He expected staff to have clean equipment and clean barriers; -Catheter drainage bags should not touch the floor.

Based on observation, interview, and record review, the facility failed to provide care to all residents per standards of practice when staff failed to transcribe a physician order change in breathing treatments and failed to administer the breathing treatments as order for one resident (Resident #1). The facility census was 70. Review of facility policy, Physician Orders, reviewed November 2024, showed the following: -In most circumstances, orders should be entered electronically by the practitioner; -Verbal or telephone orders may be given to providers (for example, a nursing facility) only if there is an emergency situation when the electronic entry may delay care, or if computer access is not available to the practitioner; -Upon receipt of a written or faxed order, staff will scan the order into the resident's electronic medical records (EMR). The orders will be entered into the EMR as applicable. 1. Review of Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included high blood pressure, anxiety, heart disease, and recent history of pneumonia. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/08/24, showed the following: -Cognitively intact; -No rejection of care; -Diagnoses included asthma (A condition in which the airways narrow and swell and may produce extra mucus. This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when breathing out and shortness of breath.), chronic obstructive pulmonary disease (COPD - An ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs.), or another chronic lung problem. Review of the resident's care plan, last reviewed 12/10/24, showed the following: -Respiratory treatment as ordered; -Supplemental oxygen use as ordered. Review of the resident's December 2024 Treatment Administration Record (TAR) showed the following : -An order, dated 12/02/24, for albuterol 2.5 milligrams (mg) every 8 hours as needed (PRN); -Staff did not administer the medication on 12/02/24; -Staff did not administer the medication on 12/03/24. Review of the resident's nursing notes, dated 12/04/24, showed the resident reported to staff that he/she had breathing treatments at home twice a day. The resident told staff he/she had not had any treatments since being admitted to the facility and was starting to feel congested. The nurse requested breathing treatments twice a day (scheduled). The doctor replied for staff to go ahead and schedule the albuterol (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease (COPD - An ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs.)) breathing treatments twice a day, per resident request. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN. (Staff did not update the order to reflect the new order from the physician for treatments scheduled twice a day.); -Staff did not administer the medication on 12/04/24; -Staff did not administer the medication on 12/05/24; -Staff did not administer the medication on 12/06/24; -Staff did not administer the medication on 12/07/24; -Staff administered the medication twice on 12/08/24; -Staff administered the medication once on 12/09/24; -Staff did not administer the medication on 12/10/24; -Staff administered the medication once on 12/11/24. Review of resident's physician's note, dated 12/12/24, showed the resident reported to the doctor a recent cough, and difficulty catching breath upon exertion. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN. (Staff did not update the order to reflect the new order from the physician for treatments scheduled twice a day.); -Staff administered the medication once on 12/12/24; -Staff administered the medication once on 12/13/24; -Staff did not administer the medication on 12/14/24; -Staff administered the medication once on 12/15/24. Review of the resident's chest x-ray, completed on 12/16/24, showed findings related to pulmonary vascular congestion (PVC - an excessive accumulation of fluid in the blood vessels of the lungs, which can make breathing more difficult). Review of the resident's physician's notes showed, dated 12/16/24, showed diagnosis of PVC. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN. (Staff did not update the order to reflect the new order from the physician for treatments scheduled twice a day.); -Staff did not administer the medication on 12/16/24; -Staff did not administer the medication on 12/17/24; -Staff did not administer the medication on 12/18/24; -Staff did not administer the medication on 12/19/24; -Staff did not administer the medication on 12/20/24; -Staff did not administer the medication on 12/21/24; -Staff did not administer the medication on 12/22/24; -Staff did not administer the medication on 12/23/24; -Staff did not administer the medication on 12/24/24; -Staff did not administer the medication on 12/25/24; -Staff administered the medication once on 12/26/24; -Staff administered the medication once on 12/27/24; -Staff did not administer the medication on 12/28/24. Review of the resident's nursing note, dated 12/28/24, showed the resident requested breathing treatments to be scheduled twice a day, instead of as needed. A nurse practitioner replied on 12/29/24 that it was okay to schedule the breathing treatment twice a day for one week on a trial basis. Review of the resident's December 2024 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN; -An order, dated 12/29/24, for albuterol 2.5 mg scheduled twice a day, on a trial basis, with a stop date of 01/05/25; -Staff administered the medication twice on 12/29/24; -Staff administered the medication twice on 12/30/24; -Staff administered the medication twice on 12/30/24. Review of the resident's January 2025 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN; -An order, dated 12/29/24, for albuterol 2.5 mg scheduled twice a day, on a trial basis, with a stop date of 01/05/25; -Staff administered the medication once on 01/01/25 and did not administer any additional PRN doses; -Staff administered the medication twice on 01/02/25; -Staff administered the medication twice on 01/03/25; -Staff administered the medication twice on 01/04/25; -Staff administered the medication twice on 01/05/25. Review of the resident's January 2025 TAR showed the following: -An order, dated 12/02/24, for albuterol 2.5 mg every 8 hours PRN; -The order for scheduled albuterol was was discontinued on 01/05/25; -Staff administered the medication twice on 01/06/25; -Staff did not administer the medication on 01/07/25; -Staff administered the medication twice on 01/08/25; -Staff administered the medication once on 01/09/25; -Staff administered the medication twice on 01/10/25. Review of the resident's January 2025 TAR showed the following: -An order, dated 01/10/25, for albuterol 2.5 mg scheduled twice a day; -Staff administered the medication twice on 01/10/25; -Staff administered the medication twice on 01/11/25; -Staff administered the medication twice on 01/12/25; -Staff administered the medication twice on 01/13/25; -Staff administered the medication twice on 01/14/25; -Staff administered the medication once on 01/15/25. Observation and resident interview on 01/16/25, at 1:20 P.M., showed the following: -The resident had contracted pneumonia before being admitted to the facility and had some breathing difficulties since that time; -He/She had breathing treatments twice a day at home, immediately prior to being admitted to the facility; -The resident had an oxygen concentrator in his/her room; -The resident said if he/she goes too long between breathing treatments, he/she will start to feel congested. The breathing treatments help him/her cough up liquid, which relieves congestion and he/she feels better. During an interview on 01/16/25, at 1:03 P.M., Certified Medication Tech (CMT) A said when a resident requested a change in medication, he/she notified the nurse and the nurse notified the doctor or other provider. During an interview on 01/16/25, at 3:30 P.M., Licensed Practical Nurse (LPN) B said he/she put in the change from albuterol as needed to albuterol twice daily on 12/04/24 after the resident requested the change. However, the facility was having computer problems that day, and the change in order must not have been saved. For requests of medication changes, the usual facility process is for the charge nurse to discontinue the as needed medication, then put in the new order. To make sure orders and messages are completed, the night shift charge nurse prints off and double-checks if the new order is in the system. During an interview on 01/16/25, at 2:05 P.M., the Director of Nursing (DON) said staff sent a message to the resident's physician on 12/04/24 about changing the albuterol breathing treatments from as needed to scheduled twice daily. Although the nursing note says the task was completed, no staff updated the doctor order. She did not know why the change was accepted by the doctor, but no staff put in any new orders until the second request was made by the resident on 12/29/24 (25 days after the first request was made). During an interview on 01/16/25, at 4:00 P.M., the Administrator said doctors usually put orders into the facility records themselves. If not, then the charge nurses should put the new order in the EMR. The charge nurse or nurse manager should double check to make sure any new orders have been completed. He did not know why staff failed to completely put in the order for albuterol twice a day when first requested on 12/04/24. He said he did not know why different staff failed to double-check to assure orders were fully completed. MO00247213

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection control program when the facility failed to implement an enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities) policy timely and when staff failed to follow infection control practices, per standard of practice, when proving would care to residents (Resident #1 and Resident #2) putting the wounds at risk for contamination. The facility census was 67. Review of the facility's policy titled, Enhanced Barrier Precautions for Long Term Care, IP02-08, effective 09/2024, showed the following: -It is the policy of the facility to implement EBP for the prevention of transmission of MDROs; -The purpose of the policy was to prevent the spread of MDROs and maintain a home like environment for residents; -EBP are an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBP involve gown and glove use during high-contact resident care activities for resident known to be colonized with a MDRO, as well as those at increased risk of MDRO acquisition (e.g., residents with wound or indwelling medical devices); -High contact resident activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, or device care or use of central line, urinary catheter, feeding tube, tracheostomy/ventilator, or during wound care of any skin opening requiring a dressing; -A resident will be place on EBP with a wound even if the resident is not known to be infected or colonized with a MDRO. Review of the facility's policy titled, Hand Hygiene, IP02-07, revised July 2021, showed the following: -Hand hygiene is the single-most effective method of reducing the transmission of microorganisms in a healthcare setting. The term hand hygiene; -Perform hand hygiene on ungloved hands with approved alcohol based hand rubs (ABHR) or soap and water; -Five moments for hand hygiene from the World Health Organizations (WHO) are before touching a resident; before a clean or aseptic procedure; after body fluid exposure risk; after touching a resident; and after touching a resident's surroundings; -Examples of opportunities for hand hygiene include use ABHR before crossing the threshold/entering a resident's room; before donning sterile or non-sterile gloves; before donning any personal protective equipment (PPE - gown, mask, gloves); before inserting or handling invasive devices; before moving from a contaminated body site to a different body site during the care of the same resident; after contact with the resident's skin, body fluids, excretions, mucous membranes, or dressings; after contact with objects in the immediate vicinity of residents; after doffing of sterile or non-sterile gloves; after doffing of any PPE, and upon crossing the threshold when exiting the patient's room. -Use soap and water when hands are visibly soiled. Review of the facility's policy titled, Cleaning and Disinfecting Patient Care Equipment, IP07-01, revised January 2020, showed the following: -Purpose to provide guidelines for the recognition of clean or soiled equipment and guidelines for storage and treatment after use and to define and establish standards for assuring that non-critical items (as defined by the Centers for Disease Control (CDC)) as those that come in contact with intact skin but not mucous membranes and shared resident equipment is clean before use and that used or contaminated equipment is appropriately cleaned before reuse; -Disinfection is a thermal or chemical destruction of pathogenic and other types of microorganisms. Disinfection is less than sterilization because it destroys most recognized pathogenic microorganisms, but not necessary all microbial forms like bacterial spores. This is most often completed by use of an approved hospital disinfectant or chemical sterilant; -Resident care equipment for use for more than one resident will be disinfected with an organization approved disinfectant after each use; -Follow manufacturer's instructions for cleaning, disinfecting, and maintaining medical equipment; -Always allow for recommended contact time when using disinfectant wipes and solution. 1. Review of Resident #1's face sheet showed an admitted [DATE]. Review of the resident's diagnosis and problem list showed the resident's diagnoses included Guillain-Barre syndrome (a rapid onset muscle weakness caused by immune system damaging the peripheral nervous system) , paraplegia (chronic condition that affects the ability to move or feel the legs/feet), polyneuropathy (acute or chronic damage or disease affecting the peripheral nerves), major depressive disorder, and anxiety. Review of the resident's care plan for pressure ulcers, dated 04/02/24, showed staff care planned perineal cares as needed and wound cares as ordered. Review of the resident's quarterly Minimum Data Set (MDS - a federally-mandated comprehensive assessment tool completed by facility staff), dated 07/08/24, showed the following: -Presence of one stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and one stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer; -Presence of moisture associated skin damage; -Pressure ulcer care. Review of the resident's medial sacral (a triangular bone located at the base of the spine) pressure ulcer assessment, dated 09/02/24, showed the following: -Present on admission; -Stage III; -Wound length = 11.0 centimeters (cm); -Wound width = 9.0 cm; -Wound depth = 2.0 cm; -Presence of pain = No; -Wound appearance = Eschar (dead or devitalized tissue that is hard or soft in texture), purple reddened, slough (non-viable yellow, tan, gray, green or brown tissue), tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), unapproximated, undermining (the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface); -Wound surrounding tissue appearance: Bright red, pink; -Surrounding tissue temperature: Warm; -Wound drainage description: Creamy; -Wound drainage amount: Moderate; -Wound drainage odor: No odor. Review of the resident's current medial sacral treatment orders, dated 09/04/24, showed the following: -For tunneling and undermining wet to dry packing with Vashe (a solution used to cleanse, moisten, and aide in debridement of wounds); apply nickel layer of Santyl (an enzymatic debriding agent - used to help remove dead tissue from a wound) to necrotic area; cover with normal saline moistened gauze; then cover with vaseline gauze, ABD (absorbent gauze pad) pad, and tape; -Change two times per day and as needed if soiled/displaced. Review of the resident's left lower buttock pressure ulcer assessment, dated 09/02/24, showed the following: -Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.); -Present on admission; -Wound length = 2.9 centimeters (cm); -Wound width = 1.7 cm; -Wound depth = 1.8 cm; -Presence of pain = No; -Wound appearance = Beefy red, bone visible, muscle visible, tunneling; -Wound tunneling position = 4 o'clock; -Wound tunneling depth = 3.5 cm -Wound surrounding tissue appearance: Dark red, pink, tunneling,weeping; -Surrounding tissue temperature: Warm; -Wound drainage description: Sanguineous (containing blood); -Wound drainage amount: Moderate; -Wound drainage odor: No odor. Review of the resident's current left lower buttock treatment orders, dated 09/04/24, showed the following: -Cleanse wound and surrounding area with wound cleaner, rinse with saline, pack wound with Vashe soaked Kerlix (rolled gauze), cover with ABD pad and secure with tape; -Change the dressing two times per day and as needed. Observation on 09/09/24, at 10:30 A.M., showed the following, -Licensed Practical Nurse (LPN) A and LPN B entered the resident's room to perform wound care to the resident's two pressure ulcers; -LPN A and LPN B washed their hands and donned gloves. Neither nurse donned isolation gowns; -LPN A removed pillows from behind the resident's back, buttocks, and legs, and pulled the resident's slacks and brief down, and assisted the resident to turn more to his/her right side, exposing the resident's buttocks; -The resident had a urinary catheter; -Two dressings were present to the resident's skin, one on the left lower buttock and one to the sacrum, both dated 09/08; -The resident had a small amount of feces present near his/her rectum; -LPN A placed his/her hand on the outside of the resident's soiled brief, and used the brief to remove the feces from the resident's rectum; -Without washing or sanitizing his/her hands or changing gloves, LPN A removed the soiled dressings from the resident's left lower buttocks and coccyx (tailbone) and placed the dressings on the brief; -LPN B sprayed wound cleanser onto the existing sacral wound packing located in the resident's sacral wound and LPN A removed the packing from the wound. The gauze packing was covered in tan colored drainage; -LPN A then placed the resident's soiled brief and dressings into the trash can. A small tear (approximately 1 cm in length) to the back of LPN A's glove over one of his/her fingers was visible; -LPN B dropped the bandage scissors onto the floor, picked the scissors up off the floor with gloved hands, took the scissors to the resident's sink, and washed off the scissors with soap and water; -Wearing the same gloves and without washing his/her hands, LPN B opened a package of rolled gauze and touched the gauze with the same gloves, as he/she cut strips of the gauze using the scissors; -LPN B handed LPN A the pieces of gauze, LPN A used the gauze and wound cleanser to clean the surfaces of the wound to the resident's left buttock and wearing the same gloves. The LPN used different pieces of gauze to cleanse the resident's sacral wound. LPN A then removed his/her gloves, sanitized his/her hands, and donned clean gloves; -LPN A then removed gloves and exited room to get more Vashe from the medication cart; -LPN A reentered the room and sanitized his/her hands and donned gloves; -LPN A placed Vashe moistened gauze into the left lower buttock wound using a swab to pack the gauze into the wound tunnel. LPN A then used the scissors to cut the gauze, placed the scissors on a draw sheet on the resident's bed, covered the wound with an ABD pad, and secured the dressing with tape ; -Without washing his/her hands or changing gloves, LPN A placed Santyl on the necrotic wound edges of the sacral wound using a sterile swab and then placed Vashe soaked, cut gauze into the sacral wound with gloved hands; -LPN B then picked up the scissors off the resident's bed and cut more rolled gauze, while LPN B held onto the gauze, LPN A then placed these pieces of gauze over the packed sacral wound; -Without washing hands or changing gloves, LPN B picked up and unfolded an ABD pad and handed it to LPN A. LPN A placed the ABD pad over the resident's sacral wound and secured with tape. 2. Review of Resident #2's face sheet showed an admitted [DATE]. Review of the resident's diagnoses list showed current diagnoses included neuromuscular scoliosis (sideways curvature of the spine), Arnold Chiari Syndrome (a condition present at birth in which the brain tissue extends into the spinal canal), and depression. Review of the resident's pressure ulcer care plan, dated 08/15/19, showed the following: -Due to the resident's curved and twisted spine and his/he paralysis of the left side. He/she used a wheelchair for mobility. This puts the resident at a higher risk for skin breakdown. He/she also leans to the left while sitting up in the wheelchair. He/she had developed a pressure ulcer to the left lower back that is being monitored by the wound clinic; -Monitor skin for redness or breakdown and notify the nurse; -Dressing change and treatment to pressure ulcer as ordered. Review of the resident's current left lateral back pressure ulcer treatment orders, dated 08/01/24, showed the following: -Cleanse wound with wound cleanser, apply nickel-sized layer of Santyl to the wound for enzymatic debridement, pack moistened 4 x 4 gauze into the wound, apply ABD pad, and secure with tape, Review of the resident's quarterly MDS, dated [DATE], showed the following: -Presence of one stage III pressure ulcer; -Pressure ulcer care; -Application of ointments/medicine/dressings to skin (other than to feet). Review of the resident's left lateral back pressure ulcer assessment, dated 09/02/24, showed the following: -Stage IV; -Acquired in facility; -Wound length = 4.9 centimeters (cm); -Wound width = 2.0 cm; -Wound depth = 1.8 cm; -Presence of pain = No; -Wound appearance = Beefy red, bleeding, granulation, pink, slough, undermining; -Wound surrounding tissue appearance: Pink, purple; -Surrounding tissue temperature: Warm; -Wound drainage description: Tan; -Wound drainage amount: Moderate; -Wound drainage odor: No odor; -Comments: Resident seen by wound clinic on 08/01/24 and orders changed. Wound bed looks clean with minimal discomfort noted with dressing changes. Observations on 09/09/24, at 1:19 P.M., showed the following: -LPN B entered the resident's room to perform wound care; -The resident sat in his/her wheelchair; -The nurse did not don an isolation gown; -The nurse placed additional gloves on the resident's over bed table without cleaning the table. The resident's over bed table had smears and a white substance on the surface; -With clean gloves, the nurse removed the resident's soiled back dressing, dated 09/05. The wound did not contain any packing; -The wound dressing contained a moderate amount of tan and green drainage and had an odor; -Wearing the same gloves, the nurse cleansed the wound with gauze and wound cleanser; -The nurse removed gloves and stepped out of the resident's room to obtain more supplies; -While the nurse was out of the room, the resident rested back against his/her wheelchair back and the open wound rested against the vinyl wheelchair back; -The nurse returned and the resident leaned forward. The nurse sanitized his/her hands and picked up a pair gloves off the over bed table. The nurse donned the glove and, using a swab, applied Santyl to the wound; -The nurse then placed gauze into the wound using gloved hands and covered the wound with an ABD pad and tape to secure in place. 3. During an interview on 09/10/24, at 12:04 P.M., LPN A said the following: -Prior to resident wound care, staff should set up a clean field and place items for use on a clean surface; -The nurse would wash his/her hands and don gloves prior to removing soiled dressings; -The nurse should then remove gloves and wash or sanitize hands and don new gloves before cleaning the wound; -The nurse should then remove the gloves and wash or sanitize his/her hands and don new gloves prior to applying clean packing/dressings; -The nurse should then remove his/her gloves and wash his/her hands after completion of the wound treatment; -The nurse should treat each wound separately; -He/she did not recall have a tear in his/her gloves; -The nurse should have sanitized the scissors with a bleach wipe, washed his/her hands and changed gloves; -He/she thought Resident #1's dressings were stuck together with tape and that is why both dressings came off together; -Normally, he/she would treat each wound separately; -If a nurse had to step out of a room in the middle of wound care, the nurse should first place dry gauze over the would to decrease the risk of possible contamination. 4. During an interview on 09/09/24, at 1:45 P.M., LPN B said the following: -During wound care staff should wash hands and don gloves to remove existing dressings, then wash or sanitize hands and change gloves prior to cleansing the wound, then wash or sanitize hands and change gloves prior to placement of the clean dressing, then remove gloves and wash hands prior to exiting room; -He/she should set up a clean field for the dressing supplies and gloves. 5. During an interview on 09/10/24 at 11:33 A.M., LPN C said the following: -On Friday, 09/06/24, during the staff meeting, facility management said staff would start using EBP during wound care and any invasive procedures, and EBP would include gowns and gloves; -EBP is a new thing to the facility; -Prior to resident wound care, staff should set up a clean field and place items for use on a clean surface; -The nurse would wash his/her hands and don gloves prior to removing soiled dressings; -The nurse should then remove gloves and wash or sanitize hands and don new gloves before cleaning the wound; -The nurse should then remove the gloves and wash or sanitize his/her hands and don new gloves prior to applying clean packing/dressings; -The nurse should then remove his/her gloves and wash his/her hands after completion of the wound treatment; -The nurse should treat each wound separately. 6. During interviews on 09/09/24, at 2:00 P.M. and 2:10 P.M., the Director of Nursing (DON) said the following: -The facility had not put in place policies for staff to utilize EBP; -When the facility begins using EBP, staff will use gown and gloves during wound care; -Nurses should wash or sanitize hands and don gloves prior to removing soiled wound dressings; -After removal of soiled dressings, nurses should remove gloves and again wash or sanitize hands; -Nurse should then don a new pair of gloves and clean the wound; -After cleaning of the wound the nurse should remove gloves and wash or sanitize hands; -Nurse should don a new pair of gloves prior to dressing the wound; -Nurse should sanitize equipment, such as bandage scissors, with Sani-cloths (bleach wipes) per the manufacturer's recommendations; -Staff should not place scissors on the resident's bed, and if dropped in the floor, staff should re-sanitize the scissors and remove gloves and wash or sanitize hands; -Staff should place supplies on a clean surface in the resident's room; -If treating multiple wounds, staff should treat each wound separately without cross-contamination. 7. During an interview on 09/09/24, at 2:00 P.M., the Director of Long-Term Care Nursing Operations said the following: -The corporation is in the process of working on their EBP policies; -The policy was near completion and the corporation was also working on an online inservice for EBP; -On Friday, 09/06/24, the facility started talking to staff about EBP; -He/she was aware EBP protocols should already be in place within the facility, but was a work in progress; -Staff should use gloves and gown during wound care and face protection if irrigating wound or risk of splash; -Facility staff have not started using EBP During an interview eon 09/10/24, at 3:11 P.M., the Administrator said the following: -The corporation was working on a policy for EBP; -The facility talked about what would be implemented regarding the use of EBP at the staff meeting on 09/06/24; -Nurses should use basic hand hygiene during wound care; -Expect nurses to wash or sanitize hands and change gloves before, between, and after any procedure; -Nurses should appropriately clean any equipment used as well. MO00241562

Based on interview and record review, the facility failed to offer daily bedtime snacks to 10 residents, including two sampled residents (Resident #3 and #7) and eight randomly selected residents interviewed in a group meeting. The deficient practice had the potential to affect all residents in the facility. The facility had a census of 74 residents. 1. During the group interview on 09/23/14, at 10:00 A.M., eight of eight residents said the following: -Staff members do not pass out or offer evening snacks; -All residents said there is a small refrigerator in the sitting areas of each hall so residents who are able to can go and get a snack anytime they want; -All of the residents said they would like to be offered a snack in the evening. During an interview on 09/24/14, at 1:45 P.M., Resident #7 said snacks are available in the refrigerator and he/she can have something whenever he/she wants but staff does not offer him/her a snack in the evening. During an interview on 09/24/14, at 4:00 P.M., Resident #3 said snacks are available in the refrigerator and he/she can have something whenever he/she wants but staff does not offer him/her a snack in the evening. During an interview on 09/24/14, at 4:50 P.M., certified nursing assistant (CNA) F said snacks are available in the refrigerator in the common area on the hall. The CNA said staff offer the residents snacks depending upon their care planned risk because some residents receive special snacks. He/she said around 10:00 P.M., before bedtime, the staff does not wake the residents to offer a snack but staff ask the residents whenever they are awake if they want a snack. The CNA said otherwise they ask the residents with their rounds whenever the residents are awake. Record review of the facility's policy regarding Nourishments, last reviewed on 07/01/13, and showed the following: -Purpose is to meet the residents' nutritional needs; -Staff will restock area nourishment refrigerators daily according to resident requests, dietary orders, and general dietary manager selections; -Nursing staff will determine whether an evening snack is needed based on blood-glucose levels, meal intake, and a resident's general condition. During observations from 09/24/14 through 09/26/14, showed the following; -Each resident sitting area had a small refrigerator; -The refrigerator had little cartons of juice and milk and three to four half sandwiches covered in plastic wrap. During an interview on 09/24/14, at 4:50 P.M., CNA F said the staff store snacks in the refrigerator in the common area on the hall. He/she said the staff offer snacks to the residents depending upon their care planned risk because some residents receive special snacks. He/she said around 10:00 P.M., before bedtime, the staff offer the residents a snack whenever they are awake if they want a snack. The CNA said otherwise they ask the residents with their rounds whenever the residents are awake. During an interview on 09/26/14, at 4:05 P.M., the Director of Nursing said they do offer snacks to the diabetic residents or residents with a physician's orders [REDACTED].

Based on interview and record review the facility failed to ensure the social service worker assessed and identified the need for medically related social services to attain the highest physical, mental and psychosocial well-being for at least one resident (Resident #7). The social service worker failed to address the psychosocial needs of Resident #7 when staff notified the social worker of behavior concerns. The facility census was 74. Record review of the facility's Director of Social Services job description dated July 22, 2008, showed in part the following information: -Social Services staff should provide or arrange provisions of needed counseling; -Through the assessment and care planning process, identifying and seeking ways to support residents individual needs and preferences, customary routines, concern and choices; -Social services staff should promote actions by staff that maintain or enhance each resident's dignity in full recognition of each resident's individuality. Building relationships between residents and staff and teaching staff how to understand and support a resident's individual needs; -Social services staff should assist residents to determine how they would like to make decisions about their health care and meeting the needs of residents who may be grieving; -Social services staff should work in cooperation with other departments to assure the needs of residents are met regarding factors with a potentially negative effect on physical, mental, and psychosocial well-being; -Document in the social services section of the chart regarding resident changes in status and significant events involving the resident. 1. Record review of Resident #7's medical record showed the staff admitted the resident to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's recent annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/24/14, showed the following information: -Cognition intact; -Limited assistance with transfers, bed mobility, dressing, eating, toileting and hygiene; -Extensive assistance with bathing; -Depression; -Threatening, screaming and cursing at others; -Significantly intrudes on the privacy and activity of others; -Significantly interferes with resident participation in activities or social interactions; -Disrupts care and living environment; -Pain almost constantly; -Moderate pain. Record review of the resident's care plan, last updated on 03/31/10 and last reviewed on 07/19/14, showed resident needs as: -Assist with some Activities of Daily Living (ADLs); -Wears a CPAP (Continuous Positive Airway Pressure - breathing machine) at night; -At risk for falls; -Nutrition/hydration; -At risk for social isolation due to personal choice; -Not involved in activities due to personal choice; -Receives psychotropic medication; -Very critical of other residents, can also become suspicious of others' intentions and accuses other residents of stealing; -At risk for further skin break down; -At risk for pain. Record review of the social worker's progress notes, dated 06/18/14, a late entry for a lost note from 02/17/14, showed the social worker documented the following information: -Noted recent behaviors; -Interdisciplinary team was present; -At the meeting, staff explained to the resident that despite frequent reminders, his/her behaviors toward others was unacceptable and needed to cease; -The resident denied these events and the team explained to the resident that if he/she could not remember these events that we (the team) would need to have his/her cognition re-evaluated; -The resident was told from this point on if he/she was unkind to other residents, he/she would be asked to leave the activity/area without being given a chance, this was his/her warning; -Later that evening the resident came to my (social worker) office and asked if he/she should put a paper bag on his/her head and social services told the resident he/she "needed to mind his/her own business and needed to keep his/her comments to self." -This appeared to help for a while but it has escalated recently. During an interview on 09/24/14, at 1:45 P.M., the resident said the following: -He/she "would never attend another care plan meeting after what they did to me." -"They told me how awful I was." -"They constantly tell me to mind/tend to my own business." -"They are all against me." -"This is my home." -The resident became tearful and said "This situation makes me very sad." -The social worker "used to talk to me but she doesn't now." -He/she knows some of the residents can't help the way they are and he/she doesn't know why it gets under his/her skin the way it does; -"The staff send me back to my room if I say anything they don't like." -He/she "would like to fix things so everyone was not so mad at him/her." Record review of the June 2014 nurses' notes showed the following behavior(s): -On 06/03/14, the resident became angry and verbally aggressive towards the certified nurse's aide (CNA) while he/she provided care to the roommate; -On 06/09/14, the resident voiced concerns to the staff regarding roommate and the use of their shared bathroom. Staff noted the resident used the public bathroom and was "going up and down the halls complaining to staff about unfounded concerns"; -On 06/10/14, staff documented the resident exhibited an "aggressive verbal attack", yelled hateful remarks and showed "cattiness" directed towards the staff. Every time staff entered the residents' room to care for the roommate the resident "has continued behaviors"; -Between the 06/11/14 to 06/19/14, staff did not document any behaviors; -On 06/20/14, the staff notified the nurse and the social worker when the resident became agitated, verbally cursing and throwing items during an activity; -Between the 06/21/14 to 06/30/14, staff did not document any further behaviors. Record review of the messages reported to the physician showed the following behavior(s): -On 06/18/14, the resident was verbally aggressive towards another resident; -The resident said that he/she called the other resident a "slut and a [***] ing [***] " and he/she would break the other resident's leg." -See also nurse's note dated 06/10/14. Record review of the physician's progress notes, dated 6/24/14, showed the following; -The resident has been having trouble getting along with other people; -The resident becomes very irritable, gets mad and starts screaming at other residents; -The resident was lying in bed and said he/she didn't feel good; -The resident said he/she was feeling bad because everybody is against him/her; -The physician told the resident to just try and get along with everybody and he/she said he/she does try but it doesn't work; -Plan: Continue with care by increasing the resident's depakote to get his/her mood under control. Record review of the social worker's progress notes, dated 07/14/14, showed the following information: -The social worker documented the resident continued to be monitored for behaviors. At this time we (the facility staff) may need to look at a wellness stay or other intervention if the resident is unable to control his/her behaviors. For several years, the resident has been one to get into other residents' business, the resident also likes to complain about visitors and children, the resident was been known to go to visitors and tell them to get away from the fish tank and comments to visitors as being bad parents. The resident does not wish to talk about discharge because he/she does not have a home and would not be able to care for his/her daily needs living alone. -The social worker did not explore the psychosocial issues and contributing factors which may have added to the resident's behaviors or explore avenues/interventions to help the resident. -The social worker did not document communicating any information to other disciplines of the facility in an attempt to help alleviate or lessen the resident's behaviors or help staff deal with the resident's behaviors. There was no further documentation from the social worker. Record review of the nurses' notes showed the staff did not document any behaviors from 07/01/14 through 08/09/14. Record review of the August 2014 nurses' notes showed the following behavior(s): -On 08/10/14, after a medication pass the resident reported the nurse tried to kill him/her; -On 08/19/14, the resident came to the nurses' station and said, "Can someone put a can on that [***] es' head." The resident then said, "Last night I kicked the[***]out of the resident across the hall." The staff told the resident if he/she was voicing he/she would harm another resident, the staff would have to report that threat. The resident said he/she just shut his/her room door so he/she would not have to look at or listen to this other resident; -Between the 08/20/14 to 08/31/14, the staff did not document any further behaviors. Record review of the September 2014 nurses' notes showed the following behavior(s): -On 09/07/14, staff documented a late entry for "yesterday around 4:45 P.M." The resident was laughing very loud in a sarcastic manner and cheering to another resident's spouse; The resident became very agitated and argumentative when staff confronted him/her; -The resident denied laughing at anybody and said the staff have no right to stop him/her from any action he/she was showing; -Between 09/08/14 to 09/23/14, the staff did not document any further behaviors. Record review of social service notes from 7/15/14 through 9/25/14 showed the social worker did not explore the resident's behaviors, implement non-medical interventions to help staff deal with the resident's behaviors and/or the need for a psychological referral or any other medically-related social services the resident might require. The social worker did not document communicating any information to other disciplines of the facility in an attempt to help staff deal with the resident's behaviors. During an interview on 09/25/14, at 4:00 P.M., the facility social worker said her job responsibilities involved completion of her portion of the MDS and care plan that included resident's cognition, mood, behavior, hearing/vision and discharge planning. She does the quarterly notes and any other notes depending on what's going on with the residents. She has been the social worker at the facility for the last [AGE] years. The social worker said Resident #7 "has run off every roommate and gets into other people's business." The social worker said the resident has told visiting children to stay away from the fish tank and the water fountain outside and added that the staff have had to separate the resident from going to activities because he/she makes fun of other residents. The social worker said the resident has used some colorful language against other residents and again repeated that the resident "gets into other people's business". The social worker said Resident #7 does not like a particular resident because he/she is always rearranging the books on the book shelf. The social worker said she continues to tell the resident to "stay out of other people's business." There was a meeting earlier this year with staff, family and the resident regarding the resident's behaviors and the resident became very upset during the meeting. The social worker said she was not aware that the resident was still very upset about what happened during that meeting on 2/17/14. She said when staff report any issues or concerns to her regarding this resident she directs them to the administrator or to the Director of Nursing (DON). The social worker said she has not documented anything since the quarterly note dated 7/14/14, nor has she talked to the resident for any length of time. She said the resident has problems with the other residents in the facility but that all the other residents get along just fine. During an interview on 09/26/14, at 4:05 P.M., the administrator said the resident gets upset and intolerant with confused residents. The administrator said the social worker should be more involved and document all of her interactions with residents.

Based on observation, interview and record review the facility failed to ensure staff followed physician's orders regarding blood glucose monitoring and insulin administration for two sampled residents (Resident #10 and #11). Staff failed to follow nursing standards of practice and the facility's policy for post fall monitoring, neurological checks and vital signs for three residents (Resident #8, #1 and #2) who had falls with injury. Staff failed to monitor and treat one resident (Resident #2) for constipation. Thirteen residents were sampled with a census of 74. 1. Record review of Resident #10's annual minimum data set (MDS) a federally mandated assessment tool required to be completed by facility staff dated 6/8/12, showed the following information:-Long and short-term memory problems;-Severely impaired cognitive decision-making skills;-Total dependence on staff for transfers, mobility, toileting, personal hygiene and eating;-[DIAGNOSES REDACTED]. Record review of the care plan reviewed on 6/14/12, showed the staff did not document problems, goals and interventions to address the resident's [DIAGNOSES REDACTED]. Record review of the resident's September 2012, physician's orders showed the following information:-Blood glucose monitoring before meals and at bedtime;-Give [MEDICATION NAME] (fast-acting insulin with onset 15 minutes, peaks at 40-50 minutes and duration of 3-5 hours after administered) per sliding scale, one unit for every 20 (blood sugar reading) greater than 200. May give half dose if resident dose not eat. [DIAGNOSES REDACTED]. -Give [MEDICATION NAME] (insulin) 12 units at bedtime. During an interview on 9/26/12 at 2:36 P.M., licensed practical nurse (LPN) B said Resident #10 had orders for blood glucose monitoring before meals and at bedtime. The times were 6:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M. Staff have one hour before and one hour after the scheduled times to complete the blood glucose for it be on time. The reason the physician gave the order for the bedtime blood glucose check was to monitor the resident closely. Staff are really watching the resident's blood glucose levels because he/she is "very brittle". The resident gets the [MEDICATION NAME] at bedtime. When staff have a high blood glucose level above 350, they are supposed to re-check the level and call the physician if still high. Record review of the September 2012, treatment record showed staff documented blood glucose monitoring and insulin administered at the following times:-On 9/16/12, the electronic chart showed the nurse documented he/she administered insulin to the resident prior to obtaining blood glucose levels: -At 9:00 A.M., 6 units of [MEDICATION NAME]; -At 9:01 A.M., 199 (this reading was below 200. Orders were to administer insulin when greater than 200);-At 12:20 P.M., 6 units of [MEDICATION NAME]; -At 12:35 P.M., 508, recheck;-At 12:39 P.M., 133;-At 5:00 P.M., 6 units of [MEDICATION NAME]; -At 5:04 P.M., 381, recheck;-At 5:07 P.M., 260 (per orders the resident should have only received 3 units);-The nurse did not document he/she completed the bedtime blood glucose monitoring at 8:00 P.M.;-At 7:00 P.M., 12 units of [MEDICATION NAME];-On 9/17/12;-At 6:16 A.M., 341;-At 8:35 A.M., 7 units of [MEDICATION NAME] (per orders staff were to give 12 units or may give half if the resident did not eat, which should have been 6 units);-On 9/21/12;-At 4:14 P.M., 506, recheck;-At 4:16 P.M., 424;-At 4:17 P.M., (given prior to the evening meal) 11 units of [MEDICATION NAME] (per orders staff were to give 16 units or may give half if the resident did not eat or 8 units); -The nurse did not document he/she completed the bedtime blood glucose monitoring at 8:00 P.M.;-At 6:41 P.M., 12 units of [MEDICATION NAME]; Record review of the nurse's notes on 9/21/12, showed staff did not document they notified the physician of the resident's elevated blood glucose levels of 506 and 424. Observation and interview on 9/26/12, showed the following information:-At 11:18 A.M., the resident sat in the wheelchair in his/her room. RN A entered the room to check the resident's blood glucose level. The level was 412. RN A said he/she had to re-check the level. At 11:21 A.M., the level was 467. RN A exited the room without administering insulin to the resident;-At 11:50 A.M., the resident sat in the wheelchair at the dining room table;-At 12:15 P.M., 12:20 P.M., and 12:28 P.M., staff assisted the resident to eat lunch. RN A still had not administered the insulin or notified the physician of the elevated blood glucose level;-At 12:38 P.M., RN A called and left a message for the physician regarding the resident's elevated blood glucose levels. RN A said the resident is supposed to get 12 units but was not eating much so staff can give a half dose, which would be 6 units; -At 12:49 P.M., RN A said he/she was going to go ahead and give the resident the half dose of 6 units since the resident only ate the magic cup (high calorie supplement) and wait for the physician to return the call;-At 12:51 P.M., RN A administered 6 units of [MEDICATION NAME] to the resident; Record review of the nurse's notes on 9/26/12, showed RN A noted the following information:-At 2:54 P.M., (3 and one half hours since blood glucose level of 467, and 2 hours since the resident received 6 units of [MEDICATION NAME]) received orders to give the resident a total of 10 units of [MEDICATION NAME];-At 3:04 P.M., 6 units of [MEDICATION NAME] given post lunch per previous physician instructions. 4 units of [MEDICATION NAME] given to equal a total dose of 10 units per phone order. RN A did not note whether he/she rechecked the resident's blood glucose level prior to administering the additional 4 units. Record review of the September 2012, treatment record showed staff documented blood glucose monitoring and insulin administered at the following times: -On 9/26/12:-At 4:27 P.M., 274;-At 4:33 P.M., 3 units of [MEDICATION NAME] Record review of the physician orders dated 9/27/12, showed the staff received orders to call the physician if blood glucose greater than 400 or less than 80. 2. Record review of Resident #11's quarterly MDS dated [DATE], showed the following information:-Long and short-term memory problems;-Severely impaired cognitive decision-making skills;-Extensive staff assistance for transfers, mobility, toileting, and personal hygiene;-Set-up and supervision for eating.-[DIAGNOSES REDACTED]. Record review of the care plan reviewed on 9/11/12, showed the staff did not document problems, goals and interventions to address the resident's [DIAGNOSES REDACTED]. Record review of the resident's September 2012, physician's orders showed the following information:-Blood glucose monitoring before meals and at bedtime;-Give Humalog (fast-acting insulin with onset 15-30 minutes, peaks at 30-90 minutes and duration of 3-5 hours after administered) per sliding scale, two unit for every 50 greater than 150 (blood sugar reading). [DIAGNOSES REDACTED]. Record review of the September 2012, treatment record showed staff documented blood glucose monitoring and insulin administered at the following times:-On 9/16/12, the electronic chart showed the nurse documented he/she administered insulin to the resident prior to obtaining blood glucose levels: -At 7:50 A.M., 2 units of Humalog;-At 10:13 A.M., 102;-At 1:15 P.M., 139;-At 5:00 P.M., 2 units of Humalog;-At 5:00 P.M., (two entries made at this time) 2 units of Humalog;-At 5:18 P.M., 292;-The nurse did not document he/she completed the bedtime blood glucose monitoring at 8:00 P.M.;-On 9/24/12:-At 3:32 P.M., 228;-At 3:46 P.M., insulin not administered (per orders staff were to give 2 units of Humalog). Observation and interview on 9/26/12, showed the following information:-At 11:48 A.M., showed the resident sat in the wheelchair in his/her room. RN A entered the room to check the resident's blood glucose level. The level was 359. RN A said he/she had to re-check the level;-At 11:52 A.M., the level was 298. RN A said he/she was going to re-check it again since there was such a big difference;-At 11:54 A.M., the level was 260. RN A did not administer insulin to the resident. He/she said, "I'll wait until after you eat to give insulin" and exited the room.-At 12:01 P.M., RN A said he/she generally waited until residents were eating to administer insulin because sometimes residents do not eat. He/she knows Resident #10 had orders to give a half dose if not eating.-Between 12:20 P.M., to 12:50 P.M., the resident sat at the table and ate lunch. The resident ate at least 50% of the meal;-At 1:03 P.M., RN A asked another staff how much the resident ate. The staff said 50%;-At 1:09 P.M., RN A wheeled the resident to his/her room and administered 4 units of Humalog. (Record review showed the insulin order was for before meals. The order did not give instructions to wait until after the resident ate to administer the sliding scale). Record review of the physician's orders dated 9/26/12 at 6:22 P.M., showed staff noted new orders to give half dose of sliding scale insulin if the resident does not eat.3. During an interview on 9/26/12 at 2:30 P.M., the Director of nursing (DON) said staff should follow physician's orders. Staff should notify the physician with elevated blood glucose levels. 4. Record review of the facility fall program policy reviewed on 10/13/11, showed, in part the following information: -Policy: The facility will identify patient/resident [MEDICATION NAME] and extrinsic fall risk factors, identify and implement fall prevention/management interventions and provide patient/resident and family fall prevention/management education. -Purpose: To provide staff, patient/resident education and patient/resident specific interventions which promote a safe environment with the goal of preventing/managing falls. -Procedure of Post Fall Management: Residents who experience a fall will be re-assessed one hour post fall and monitored for 72 hours at eight-hour intervals after a fall. -Procedure following a fall: Complete a post fall assessment with vital signs with neurological checks(timed and structured assessments of neurological function that includes full vital signs, pupillary (eye pupil) response, level of consciousness, and movement, strength, and equality of the extremities). 5. Record review of Resident #8's medical record showed the following information:-Staff admitted the resident on 9/17/12;-[DIAGNOSES REDACTED]. Record review of the nurse's notes showed the following information: -On 9/25/12 at 4:22 A.M., Post fall note: staff heard a "thud". Resident found face up on the floor by the bathroom, pale and unresponsive for 1-2 minutes. Laceration to back of the resident's head approximately 2 centimeters. Normal range of motion. Pupils sluggish. Oxygen level 68, came up to 90's. New order to send to emergency room . Record review of the emergency room discharge notes dated 9/25/12, showed the following information:-The resident was walking out of the bathroom, fell and hit the back of his/her head. Unsure if resident fainted or fell and had loss of consciousness. Complained of pain to back of head. Remembers some of what happened, resident was not wearing his/her oxygen when this happened. Staff reports the resident's oxygen levels will drop quickly when off oxygen.-Impression: fall with head contusion (injury that does not break the skin but causes bruising. Forms when small blood vessels break and leak blood under the skin).-Instructions: rest, return if condition worsens, follow up with primary care physician. Record review of the notes showed on 9/25/12, staff did not document when the resident returned to the facility. (electronic charting showed the emergency room discharged the resident at 5:22 A.M.). Record review of the integrity vital signs showed staff documented the following vital signs:-On 9/25/12, at 9:49 A.M.;-Staff did not document any further vital signs. Observation and interview on 9/25/12 at 12:32 P.M., showed the resident sat in the wheelchair in his/her room. The resident had oxygen in place. The resident was alert and oriented. The resident said he/she had a "tumble" and hit his/her head. He/she went to the hospital but nothing was broken. During record review and interview on 9/26/12 at 9:53 A.M., RN C reviewed the resident's record and said:-When a resident had a fall staff should complete a Post Fall Assessment. Then staff should add interventions for post fall monitoring assessment and integrity vital signs every 15 minutes times 4, every 30 minutes times 2, every hour for 2 hours and every 8 hours times 9;-Staff should complete neurological checks (which is part of the post fall monitoring assessment);-The staff did not add the post fall intervention on 9/25/12;-The staff did not complete a note when the resident returned from the hospital. Staff should have completed a note and any orders;-The electronic charting system has guidelines/interventions for witnessed and unwitnessed fall so charting does not get missed. Record review of the care plan on 9/26/12 at 10:25 A.M., showed staff added the following interventions:-Post fall monitoring assessment (which includes the neurological checks) every 15 minutes times 4, every 30 minutes times 2, every hour for 2 hours and every 8 hours times 9;-Integrity vital signs every 15 minutes times 4, every 30 minutes times 2, every hour for 2 hours and every 8 hours times 9;-Rehab screening;-Fall risk assessment (new assessment completed with each fall). 6. Record review of Resident #1's notes showed the following information: -On 06/01/12 the staff completed a post fall communication form that showed the resident had an unwitnessed fall at 3:30 A.M., and hit his/her head; -The resident was found face down on the floor in a pool of blood surrounding his/her head; -The resident had a laceration to right eyebrow measuring 3-4 centimeters; -Staff notified the physician who gave an order for [REDACTED]. -Resident was taken to hospital by ambulance at 3:45 A.M. and returned 8:30 A.M. -The resident was alert but confused; -The resident had a splint on right wrist and was diagnosed with [REDACTED]. -Staff did not document they completed any neurological checks or vital signs to assess after returning from the hospital. Record review of the facility's electronic charting vital sign graphic sheet showed staff documented the following vital signs: -On 06/01/12:-At 2:38 P.M., (six hours after resident returned from the hospital);-At 7:16 P.M.-Staff did not document any vitals signs between 6/01/12 at 7:16 P.M., to 6/02/12 at 3:27 A.M.; -On 06/02/12, at 3:27 A.M., 12:17 P.M., and 7:48 P.M.;-On 06/03/12, at 9:49 A.M., 1:52 P.M., 3:50 P.M., and 8:07 P.M.;-On 06/04/12, at 1:34 P.M. -Staff did not complete the vital signs every 15 minutes times 4, every 30 minutes times 2, every hour for 2 hours and every 8 hours times 9 per the facility's fall management policy. Record review of the neurological checks showed staff noted the following assessments:-On 06/01/12;-At 11:08 A.M., injury follow-up: unknown at this time, resident was sent to hospital for evaluation and treatment (record showed the resident returned to the facility at 8:30 A.M.);-At 7:55 P.M.;-On 06/02/12 at 5:21 A.M., 11:12 A.M., and 8:04 P.M.;-On 06/03/12 at 4:44 A.M.-On 06/04/12 at 2:19 A.M., and 1:56 P.M.-Staff did not complete the neurological checks every 15 minutes times 4, every 30 minutes times 2, every hour for 2 hours and every 8 hours times 9 per the facility's fall management policy.Record review of the resident's quarterly MDS dated [DATE], showed the following information: -Long and short-term memory problems; -Severely impaired cognitive decision-making skills; - Limited assistance of staff for dressing and personal hygiene. -Extensive assistance of staff for bathing; -Had falls after admission; -[DIAGNOSES REDACTED]. Observations during the survey between 09/25/12 to 09/28/12, showed the following information: -The resident resided in the special care unit; -The resident was pleasantly confused; -The resident sat in a recliner in the common area or lay in bed throughout the day; -The resident would ask staff for his/her walker forgetting that he/she could not ambulate with the walker; -The resident ambulated with a wheelchair. -Staff assisted with all transfers from bed to wheelchair and wheelchair to recliner. 7. Record review of Resident #2's quarterly MDS dated [DATE], showed the following information: -Long and short-term memory problems; -Severely impaired cognitive decision-making skills; - Extensive assistance of staff for transfers, bed mobility, ambulation, dressing, toileting, personal hygiene and bathing. -Continent of bowel and frequently incontinent of bladder -Had falls after admission; -[DIAGNOSES REDACTED]. Record review of the nurses notes showed the following information: -On 06/20/12, at 9:16 A.M., staff assisted the resident to the bathroom when the resident stood up so staff could pull his/her pants down the resident lost balance and fell hitting his/her head. The resident had 6 centimeter (cm) x 6 cm x 3 cm lump on the back of his/her head. Record review of the facility's electronic charting vital sign graphic sheet showed staff documented the following vital signs: -On 06/20/12 at 11:38 A.M., 1:14 P.M., and 9:53 P.M.;-On 06/21/12 at 1:06 P.M.;-On 06/22/12 at 1:19 P.M.;-On 06/23/12 at 4:37 A.M., 10:46 A.M., and 1:28 P.M.; -Staff did not complete the vital signs every 15 minutes times 4, every 30 minutes times 2, every hour for 2 hours and every 8 hours times 9 per the facility's fall management policy. Record review of the neurological checks showed staff noted the following assessments:-On 06/20/12 at 3:01 P.M., (approximately 5 hours after the fall), and 9:28 P.M.;-On 06/21/12 at 5:41 A.M., 1:39 P.M., and 9:23 P.M.;-On 06/22/12 at 9:42 A.M., 2:45 P.M., and 9:20 P.M.;-On 06/23/12 at 5:28 A.M., and 1:07 P.M.; -Staff did not complete the neurological checks every 15 minutes times 4, every 30 minutes times 2, every hour for 2 hours and every 8 hours times 9 per the facility's fall management policy. Record review of the notes showed the following information: -On 09/03/12 the staff completed a post fall communication form that showed the resident had a witnessed fall and hit his/her head on a chair at 6:03 P.M., neurological checks completed at 6:00 P.M., -On 09/05/12 at 9:35 A.M., Post fall communication: the resident attempted to stand and lost balance, staff caught the resident before he/she hit anything. Staff completed vital signs. Record review of the facility's electronic charting vital sign graphic sheet showed staff documented the following vital signs: -Staff did not document any vital signs between 09/03 to 09/05/12;-On 09/05/12 at 1:08 P.M. (approximately 43 hours after the resident fell ). Record review of the neurological checks showed staff noted the following assessments:-On 09/03/12 at 11:37 P.M.;-On 09/04/12 at 1:15 P.M., 5:00 P.M., and 11:45 P.M.;-On 09/05/12 at 9:11 A.M., 9:53 A.M., 2:42 P.M., and 10:06 P.M.;-Staff did not complete the neurological checks every 15 minutes times 4, every 30 minutes times 2, every hour for 2 hours and every 8 hours times 9 per the facility's fall management policy. Observation during the survey between 09/24/12 to 09/28/12, showed the following information: -The resident resided in the special care unit; -The resident was pleasantly confused; -The resident sat in a recliner in the common area at times throughout the day; -The residents spouse would visit almost daily and would accompany the resident to activities in the main dining room; - Staff or spouse propelled the resident in his/her wheelchair for ambulation; 8. During an interview on 9/27/12 at 2:50 P.M., the DON said staff should continue fall interventions when a resident returned from the hospital. During an interview on 9/28/12 at 10:40 A.M., the DON said:-There is a post fall standard of care for witnessed and unwitnessed falls;-She expected the staff to follow the process and complete the vitals signs, neurological checks and assessments for 72 hours;-Every fall has to be documented; 9. Record review of Resident #2's physicians orders dated July, August and September 2012, showed the following orders information: -[MEDICATION NAME] (antianxiety) 5 milligrams (mg) one tablet two times daily. -[MEDICATION NAME] (high blood pressure) two tablet daily. -[MEDICATION NAME] (antidepressant) 60 mg one tablet daily. -an order for [REDACTED]. -an order for [REDACTED]. Record review of Mosby's Nursing Drug Reference, 2010, showed constipation to be a common side effect of [MEDICATION NAME], and [MEDICATION NAME]. Record review of resident's BM monitoring record for July 2012, showed from 07/22-07/26 (five days), the resident did not have a bowel movement. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of the July 2012 nurses notes showed staff did not document regarding the resident's lack of a bowel movement from the 07/22- 07/26, or if staff tried any interventions. Record review of resident's BM monitoring record for August 2012, showed from 08/23-08/28 (six days), the resident did not have a bowel movement. Record review of the MAR indicated [REDACTED] -Staff did administered prn MOM on 08/23/12, at 6:00 P.M., and documented follow-up on 08/24/12, at 4:24 A.M., no results noted. -Staff did not administer any prn MOM or [MEDICATION NAME] between 08/24/12-08/28/12. Record review of the August 2012 nurses notes showed staff did not document regarding the resident's lack of a bowel movement from the 08/23-08/28/12, or if staff tried any interventions. Record review of resident's BM monitoring record for September 2012, showed from 09/21-09/26 (six days), the resident did not have a bowel movement. Record review of the MAR indicated [REDACTED]. Record review of the September 2012 nurses notes showed staff did not document regarding the resident's lack of a bowel movement from the 08/23-08/28, or if staff tried any interventions. During an interview and record review on 9/28/12 at 9:00 A.M., RN D said:-Staff print a report every morning. If a resident had no bowel movement in three days, staff should administer as needed laxative or fax the physician for orders;-Resident #2 was dependent on staff for transfers and toileting;-On 7/22 to 7/26/12, the resident did have a span greater than three days, staff did not administer the as needed laxatives during that time;-On 8/23 to 8/28/12, the resident had another small span. Staff administered the MOM on 8/23/12 at 6:00 P.M., and on 8/24/12 at 4:24 A.M., noted no results. Staff should have called the physician at that point or follow-up with a repeat dose of the as needed laxative if indicated;-On 9/22 to 9/26/12, the resident should have been on the bowel report;-The resident did not have any scheduled laxatives ordered. RN D said, "probably needs something scheduled". During an interview on 9/28/12 at 10:40 A.M., the DON said staff print a report daily, if a resident had not had a bowel movement in three days staff should administer as needed laxatives or call the physician if no as needed medications ordered. Record review of the facility policy for bowel movement management (undated) showed the following information: -Routine bowel medications should be considered for all of the following residents:-Taking routine pain medications;-Decreased mobility;-Confused or have dementia;-History of recurrent constipation; -All residents will be monitored for signs/symptoms of constipation; -3 days without BM: 30 ml of MOM or other laxative; -If no response after initial intervention, review resident's orders for additional medication to be considered if no additional medication is available contact physician. If medication is available administer to resident and monitor results. If no results, contact physician.

Based on observation, interview and record review, the facility failed to use universal precautions and apply gloves during the performance of injections for two sampled residents (Resident #10 and #11) and one randomly sampled resident (Resident #16). Thirteen (13) residents were sampled out of a facility census of 74. 1. Record review of Resident #16's September 2012, physician's orders [REDACTED]. Observation on 9/26/12 at 11:32 A.M., showed registered nurse (RN) A checked the resident's blood glucose level as ordered. RN A drew up 10 units of insulin in the syringe and carried the syringe to the resident's room. RN A did not wash his/her hands or use sanitizer. RN A did not apply gloves. With his/her bare hands, RN A raised the resident's sleeve, cleansed the resident's left upper arm with an antiseptic swab and administered the insulin injection. As RN A pulled down the resident's sleeve, the nurse's thumb swept across the injection site. RN A washed his/her hands and exited the room. 2. Record review of Resident #10's September 2012, physician's orders [REDACTED]. Observation on 9/26/12 showed at 12:49 P.M., RN A drew up 6 units of insulin in the syringe and carried the syringe to the resident's room. RN A did not wash his/her hands or use sanitizer.RN A did not apply gloves. With his/her bare hands, RN A pulled down the front of the resident's pants, cleansed the resident's abdomen with an antiseptic swab and administered the insulin injection. As RN A pulled up the front of the resident's pants. RN A washed his/her hands and exited the room. 3. Record review of Resident #11's September 2012, physician's orders [REDACTED]. Observation on 9/26/12 at 1:09 P.M., showed RN A drew up 4 units of insulin in the syringe and carried the syringe to the resident's room. The resident sat in the wheelchair in his/her room. RN A did not wash his/her hands or use sanitizer. RN A did not apply gloves. With his/her bare hands, RN A pulled down the front of the resident's pants, cleansed the resident's abdomen with an antiseptic swab and administered the insulin injection. As RN A pulled up the front of the resident's pants. RN A washed his/her hands and exited the room. Record review of an educational reference from Mosby's Nursing Skills regarding medication administration: subcutaneous injections showed in part the following information: -Perform hand hygiene; -Apply clean gloves; -Cleanse site with antiseptic swab; -Administer injection; -Remove gloves and perform hand hygiene. During an interview on 9/28/12 at 9:20 A.M., licensed practical nurse (LPN) B said when administering an injection, staff should wash their hands and apply gloves, cleanse the site, inject medication, remove their gloves and wash their hands. During an interview on 9/28/12 at 10:40 A.M., the Director of nurses said staff are to wear gloves when administering injections.

Based on observation, record review and interview the facility failed: -To provide ongoing assessment and monitoring of one resident's (Resident #3) complaint of vaginal bleeding and abdominal cramps. The facility failed to obtain a pelvic ultrasound as ordered by the physician for the resident. -To provide ongoing assessment and follow up with the physician in a timely manner for one resident's (Resident #12) complaint of bladder discomfort and urinary urgency. -To appropriately document and monitor one resident (Resident #5) after he/she complained of difficulty swallowing and throat being swollen and failed to follow speech therapy instructions during eating and drinking. -To appropriately document and monitor one resident (Resident #11), who had a swollen jaw and complained of tooth pain. -To appropriately document and monitor one resident (Resident #10) who complained of pain in his/her great toe. The deficient practice involved four of 15 sampled residents. The facility had a census of 68. 1. Record review of Resident #3's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment tool required to be completed by the facility staff, dated 11/18/11, showed the following information: -Medical [DIAGNOSES REDACTED]. -Independent with cognitive skills for daily decision-making; -Limited to extensive assistance required with ADLs. Record review of a long term care history and physical (H&P), dated 11/24/11, showed the resident had a history of [REDACTED]. Record review of a nurse's note dated 11/21/11, at 8:48 P.M., showed the following information: -LPN C documented the staff assisted the resident with her shower that evening and noted the resident exhibited a scant amount of vaginal bleeding accompanied by mild abdominal cramps; -LPN C notified the physician of the resident's bleeding and abdominal cramps; -The physician provided a new order for a pelvic (lower abdomen) ultrasound test (a test that produces images of the area of the body or internal organ being scanned). Record review of a nurse's note dated 11/21/11, at 9:20 P.M., showed the following information: -LPN C notified the resident's family member of the resident's symptoms; -The family member said the symptoms had occurred in the past; -LPN C would pass the information on to the unit manager (RN/UM H); -LPN C would continue to monitor the resident. Record review of the resident's daily physical assessments completed by the nursing staff from 11/22/11 through 12/1/11, showed no further documentation of assessments or monitoring of the resident for vaginal bleeding or abdominal cramping. Record review of the nurses' notes from 11/23/11 through 11/30/11, showed no further documentation of assessments or monitoring of the resident for vaginal bleeding or abdominal cramping. Record review of nurses' notes dated 12/1/11, at 9:11 A.M., and 12/1/11, at 9:15 A.M., and of an addendum nurse's note dated 12/2/11, at 4:14 A.M., showed the following information: -RN/UM H followed up on the physician's 11/21/11, order for the resident's pelvic ultrasound test which had not been scheduled; -RN/UM H documented the resident said she had no further episodes of vaginal bleeding; -RN/UM H documented he/she notified of the physician of the resident's denial of further vaginal bleeding and asked the physician if he wanted to go ahead with the order for the resident's pelvic ultrasound; -LPN N documented the physician responded to the notification by RN/UM H with a directive to the staff to "Go ahead with the ultrasound". During an interview on 12/2/11, at 1:00 P.M., the DON said the computerized documentation system used by the facility allowed the nursing staff to type in additional comments on the physical assessment forms as needed to provide details regarding assessment items or the resident's medical status. The DON said the fact that none of the nursing staff commented on whether or not Resident #3 experienced any further vaginal bleeding or abdominal cramping was due to the facility's method of negative documentation (a method of documentation that includes documentation of only unusual or abnormal findings). The DON said since the resident denied any further episodes of vaginal bleeding or abdominal cramping she would not expect the nurses to document anything regarding the [DIAGNOSES REDACTED]l bleeding or abdominal cramping. 2. Record review of Resident #12's annual MDS, dated [DATE], showed the following information: -Good cognitive skills; -Independent with toileting; -Always continent of bladder; -History of urinary tract infection. Review of nurses' notes showed the following information: -8/9/11, The resident reported burning upon urination; -8/9/11, Addendum: showed the physician ordered a urinalysis with a culture and sensitivity test (UA and C&S); -10/22/11, The resident stated he/she had discomfort with his/her bladder at times. The resident stated the bladder discomfort comes and goes, and feels like he/she has to go urgently, but then has been unable to go; -Staff did not document between 10/22/11 and 10/25/11, regarding the resident's complaint of bladder discomfort and urinary urgency; -10/25/11, The resident stated he/she has had discomfort in the bladder that comes and goes, but had a UA done a few weeks ago that came up negative. (the medical record showed the last UA obtained was two months prior on 8/9/11). The unit manager thought [MEDICATION NAME] (a pain medication for urination discomfort) as needed might be beneficial; -10/25/11, the physician wrote an order for [REDACTED]. Record review of the medication record showed the staff administered the as needed [MEDICATION NAME] to the resident 15 times between 10/25/11 and 11/11/11. Record review of the nurses' notes showed the following information: -11/8/11, The resident complained of pain and burning when he/she first started to urinate. The resident was afebrile (had no temperature) and had no other symptoms noted. Message routed to the physician;-Staff did not document between 11/8/11 and 11/11/11, regarding the resident's complaint of pain and burning with urination. Review of the physician's progress note dated 11/11/11, showed the following: -The resident complained to the physician of frequency of urination and getting up at night to use the restroom; -The physician said the resident has taken [MEDICATION NAME] (a diuretic) and first we will try using the medication, [MEDICATION NAME], as needed only; -Make those changes and see how he/she does; -The resident refused a medication ([MEDICATION NAME]) to reduce urination due to the side effect of constipation;-The physician did not note any follow-up and/or new orders regarding the nurse's fax sent on 11/8/11, regarding the resident's complaint of pain and burning with urination. Review of the nurses' notes showed the following information: -11/12/11, The physician returned the fax with orders for a UA with C&S; -11/12/11, staff sent the UA to the laboratory; -Staff made no further entries of this issue for the resident. Record review of the UA results dated 11/12/11, showed the resident was positive for a urinary tract infection [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. Review of the resident's care plan dated 4/01/11, showed the staff added the an additional intervention of monitoring the resident's temperature on 11/14/11. Review of a vital sign record showed between 11/11/11 to 11/24/11, the staff recorded the resident's temperature one time, on 11/15/11. Review of the social service notes dated 11/16/11, showed the resident reported issues with sleeping recently. He/she had a UTI, and needed to get up several times in the night to urinate. During interview on 12/2/11, at 10:00 A.M., the Unit Manager, RN M said the resident had complained of burning during urination. The physician had prescribed [MEDICATION NAME] for bladder discomfort. Staff should watch for at least two other symptoms such as frequency of urination, confusion, and fever. Staff should monitor the resident's vital signs, and frequency of urination. Staff use a status board on the computer to track the resident's status. The resident talked to the physician on 11/11/11, about his/her need to frequently urinate. The physician changed the order on the [MEDICATION NAME] to as needed, and ordered an UA. Staff obtained the UA on 11/12/11, and the physician ordered an antibiotic. During interview on 12/2/11, at 10:05 A.M., the DON said the resident did not tell staff about getting up at night to urinate. The resident told the physician, and staff would not know. Observation and interview on 12/2/11 at 11:15 A.M., showed the resident walked independently in his/her room. The resident was alert and oriented. The resident said he/she has had UTIs in the past. A few weeks ago he/she felt uncomfortable and had pain when about to urinate and it kept him/her up at night. It felt like he/she needed to urinate but could not when he/she tried to go. The resident said the staff gave him/her a round of antibiotics and the [MEDICATION NAME]. The resident said he/she felt better now. The resident said he/she did not remember the staff checking his/her temperature over the last few weeks, maybe once or so. During interview on 12/2/11, at 1:00 P.M., the DON said the charge nurse should follow-up about any discomfort reported by the resident. The DON said the faxes sent to the physician, and returned from the physician should not have taken as long as it did. Staff should check the faxes daily. Nursing staff should be documenting on symptoms, temperatures and medication results. 3. Record review of Resident #5's quarterly MDS assessment dated [DATE], showed the following information:-Moderately impaired cognitive-decision-making skills;-Total dependence on staff for transfers, mobility, and personal hygiene;-No swallowing problems. Record review of the nurses' notes showed the following information:-On 10/7/11, the resident complained of his/her throat being swollen making it difficult to swallow. When asked if it felt like a cold/sore throat, the resident said no. The staff will continue to monitor. No white patches or swelling were visible and staff gave ice chips for the resident's report of swelling;-Between 10/7/11 and 10/25/11, staff did not document any further entries regarding the resident's complaints of his/her throat being swollen making it difficult to swallow;-On 10/25/11, the dietary manager noted the resident had no chewing or swallowing problems. The dietary manager did not indicate any follow-up regarding the resident's complaints to the nursing staff on 10/7/11;-On 10/27/11, RN M noted he/she spoke with the resident's physician. The physician gave orders for a speech consultation and talked about doing an ultrasound on the [MEDICAL CONDITION]. Staff will speak with the resident's family about the ultrasound, which would be an outpatient procedure;-Between 10/27/11 and 11/1/11, staff did not document in the notes;-On 11/1/11, (five days after staff received the orders) RN M added an addendum that the resident's family agreed with the ultrasound. RN M did not make a note regarding the speech consultation. Record review of the notes dated 11/1/11, showed speech therapist (ST) O noted the following information:-Focus: Request for modified [MEDICATION NAME] swallow (a radiological exam use to determine swallowing ability) and diet change:-Route to: Physician:-ST screened the resident with the morning meal and observed no overt signs and symptoms of aspiration or difficulty during intake of solids/liquids. No complaints from the resident during observation;-Nursing stated the resident has complained more frequently of feeling that, "food is not going down";-Nursing concerned [MEDICAL CONDITION] has enlarged and may be affecting swallowing. No apparent indicator for ST services through observations but after discussion with nursing it is recommended that a modified [MEDICATION NAME] swallow is completed to ensure no underlying issues are present with swallowing resulting in resident's complaints;-ST further discussed with nursing to begin a trial mechanical soft diet with resident to determine if this decreases his/her complaints. The resident tolerated regular consistency well during screen. ST determined the resident did not require an full ST evaluation and treatment at that time, but ST would continue to monitor the resident and screen the resident again as indicated and following the results of modified [MEDICATION NAME] swallow and ultrasound. Record review of the notes showed staff did not document between 11/1/11 to 11/8/11, regarding the ST screen and recommendation. Record review of the order history between 11/1/11 to 11/9/11, showed staff did not note any changes and/or new physician's orders [REDACTED]. The resident continued to receive a regular consistency diet. During an interview on 12/2/11 at 12:15 P.M., ST O said he/she had talked to RN/unit manager M and ST O was under the impression that nursing staff implemented a mechanical diet on 11/1/11. Record review of the notes showed the following information:-On 11/8/11, (seven days after the ST screen) ST O faxed again the order to the resident's physician for the modified [MEDICATION NAME] swallow and diet change;-Between 11/8/11 and 11/10/11, staff did not document in the notes;-On 11/10/11, the physician agreed with the ST recommendations on changing the resident's diet to mechanical soft and for the modified [MEDICATION NAME] swallow;-Between 11/10/11 to 11/17/11, staff did not document in the notes regarding the resident's swallowing. Record review of the order history showed a new physician's orders [REDACTED]. Record review of the notes showed on 11/17/11 (seven days after staff received the physician's orders [REDACTED]. During an interview on 12/2/11 at 10:30 A.M., the SSD said when staff received an order for [REDACTED]. On 11/14/11 (four days after staff received the physician's orders [REDACTED]. until 11/17/11. Record review of the notes showed the following information;-Between 11/17/11 to 11/25/11, staff did not document in the notes regarding the resident's swallowing. (The resident had the modified [MEDICATION NAME] swallow on 11/21/11);-On 11/25/11, (four days after the resident had the test) staff sent a note to the physician with the results of the modified [MEDICATION NAME] swallow. May we have orders for these recommendations? Please advise. The physician returned the fax stating agreement with the above recommendations;-Between 11/25/11 to 11/30/11, staff did not document in the notes regarding the resident's swallowing. Record review of the order history showed new physician's orders [REDACTED]. Record review of modified [MEDICATION NAME] swallow study dated 11/21/11, showed in part the following information:-Recommend diet change to: Puree with 1/2 teaspoon bites and liquids by 1 teaspoon bites;-Strategy/precautions recommended: 1. Aspiration precautions;2. Sit upright;3. Liquids from a spoon;4. Small bites and sips.-Recommend referral: ST consultation for swallowing.-ST summary for modified [MEDICATION NAME] swallow: ST referred the resident for the modified [MEDICATION NAME] swallow due to suspected swallowing deficits. According to the family, the resident has issues with choking at meals. The resident pocketed eggs under the tongue and could not clear them. The ST had to clear the resident's mouth two times because the resident could not clear it, even with pureed foods. The resident had severe penetration twice on the liquids. The resident had post-swallow choking with possible trace aspiration post-swallow;-ST conclusions: The resident would benefit from swallowing treatment. May we have orders to evaluate and treat as indicated for dysphasia (difficulty, or partial inability to swallow)? Observation and record review on 11/30/11, showed the following information:-At 8:00 A.M., the staff had handwritten "puree diet" on the resident's diet card. The staff did not list any special instructions and/or restrictions for liquids. The resident sat in the wheelchair at the dining room table. The resident had eaten more than 75% of the pureed breakfast on his/her plate. The resident had two bowls of oatmeal, two mugs of coffee and an empty juice glass. Staff members did not cue the resident during the meal. During an interview on 11/30/11 at 12:50 P.M., ST P said when therapy completed a screen and/or evaluation; they sent the recommendation to the physician and reported to the nursing staff. ST P reviewed the resident's notes; ST P saw the order for the ST evaluation dated 10/27/11. ST P said he/she was not sure why the evaluation was not completed until 11/1/11, if normally just took one to two days. When therapy sent an order request or recommendation to the physician, therapy and nursing were both responsible for checking to make sure the orders were followed up on and were to make sure the physician had responded and that any new orders were in place. ST P said the modified [MEDICATION NAME] swallow results were available on the computer on 11/21/11, a pureed diet was recommended. ST P said he/she was not sure why it took until 11/25/11, to start the puree diet order. During an interview on 11/30/11 at 12:55 P.M., CNA J said the resident had complained of having a sore throat, that he/she could not swallow and felt like his/her throat was closing. CNA J said the resident coughed repeatedly. CNA J he/she had reported the resident's complaints to the charge nurse. CNA J said the resident did have a test and had a diet consistency change to puree. CNA J said the resident still drank the same thin liquids. CNA J said he/she was not aware of any changes to the resident's liquids. Record review of the ST evaluation dated 11/30/11; (nine days after staff received the modified [MEDICATION NAME] swallow results with the recommendations for puree diet and ST evaluation) showed ST P noted in part the following information: -The resident was referred to ST for evaluation and treatment following the swallow study completed on 11/21/11. Nursing reported the resident's family was in agreement for the therapy;-ST evaluation: This ST reviewed the ST screening completed on 11/1/11 with results indicating no signs and symptoms of difficulty with regular consistency foods. A trial of mechanical soft foods was ordered (started on 11/10/11) as well as a swallow study to rule out other underlying medical issues. The swallow study completed on 11/21/11 provided recommendations for pureed diet, thin liquids by teaspoon;-ST saw the resident today following the noon meal. Nursing staff reported the resident had tolerated the pureed foods, thin liquids with no signs and symptoms of aspiration or complaints of "soreness" or trouble swallowing;-ST educated the resident on the purpose of this evaluation regarding swallowing concerns. The resident stated, "I don't have any trouble swallowing";-Results observed today, recommend thin liquids by cup, staff must encourage the resident to take small sips;-ST provided staff with a list of compensatory strategies to encourage resident to follow during oral intake (i.e.. small bites of food, small sips of liquids, alternate bites and sips, no straws...);-ST gave a complete list to nursing, ST educated nursing staff and hung the list where other nursing staff members could access. Record review of the ST swallowing instructions posted for nursing and other staff in the unit showed the following information:1. Small bites of food at a time;2. Small sips of liquid;3. Alternate foods and liquids;4. Always sit up when eating;5. Swallow twice for each bite of food or sip of liquid;6. Tuck your chin;7. Swallow hard and fast;8. No straws;9. Make sure your mouth is clear before taking another bite;10. Sit upright for 30 minutes after meals. Record review on 12/1/11, the staff had handwritten puree diet and follow ST recommendation on the resident's diet card. Observation on 12/1/11, showed the following information:-At 7:58 A.M., the resident sat in the wheelchair in the dining room. The resident had a plate with three mounds of puree food covered with pancake-type syrup, two bowls of oatmeal, any empty juice glass, glass of water, and a paper water cup (used during medication administration). The resident took multiple bites of the puree food. The resident had eaten more than 25% of the puree food on the plate. Staff did not cue and/or give instructions to the resident;-At 8:05 A.M., staff gave the resident a cup of coffee. The resident took a drink of the coffee. The staff did not give the resident any cues and/or instructions before the resident took a drink of the coffee. The resident had eaten more than 50% of the puree food on the plate. Staff did not give cues and/or instructions to the resident. -At 8:10 A.M., the resident said he/she did not like the taste of his/her coffee. Staff told the resident they would get him/her another cup. The resident started eating the oatmeal. The resident took full spoon bites of the oatmeal one after the other. CNA K sat with his/her back to Resident #5 and assisted another resident with breakfast. CNA K did not give cues and/or instructions to the resident;-At 8:14 A.M., RN/Unit Manager M gave the resident a new mug of coffee. RN M did not give cues and/or instructions to the resident and walked away from the table;-At 8:15 A.M., the resident continued to take full spoon bites of the oatmeal one after the other and drank the mug of coffee. Staff members were present at or near the tables to cue the resident at this time;-At 8:20 A.M., the resident continued to take full spoon bites of the oatmeal. During an interview on 12/1/11 at 8:25 A.M., nurse assistant (NA) L said therapy hung a list on the bulletin board about how to assist the resident with eating and drinking. CNA M said he/she had not seen the list but was told about the list by NA L. NA L and CNA M said the resident should have been cued while eating and drinking at breakfast. During an interview on 12/1/11 at 8:40 A.M., registered medication technician (RMT) E said he/she was not aware of anything new with the resident. The resident did recently have a diet change. RMT E said he/she heard there was a note about the resident but was not sure what it said and had not seen the note. RMT E said he/she did not give the resident any special instructions this morning during the medication pass when he/she gave the resident a drink. During an interview on 12/1/11 at 9:00 A.M., the DON and RN M said ST gave instructions to the staff yesterday. RN M said he/she gave the resident a cup of coffee and did not give the resident any cues and/or instructions. During an interview on 12/1/11 at 9:48 A.M., the resident's family said the resident had complained to him/her about choking and trouble swallowing and he/she reported it to the charge nurse. The family said his/her biggest concern was that it took several weeks for the staff to get the swallowing test scheduled; he/she was not sure why there was such a delay. The resident finally had the test and they found some nodules on the resident's [MEDICAL CONDITION] and esophagus. The staff members were to instruct the resident to take small bites and small sips. 4. Record review of Resident #11's quarterly MDS assessment, dated 11/13/11, showed the following information:-Independent with cognitive skills for daily decision-making;-Independent with transfers, mobility and personal hygiene. Record review of the nurse's showed on 11/26/11 at 4:51 P.M., staff called the physician on-call for the resident's physician due to the resident stating his/her right jaw was swollen and gums were red. Staff received orders for a [MEDICATION NAME] (antibiotic) pack and [MEDICATION NAME] (anti-[MEDICAL CONDITION], pain medication) every six hours as needed for pain. The nurse did not note that he/she administered the [MEDICATION NAME] for the resident's complaint of pain;-Staff did not document between 11/26/11 at 4:51 P.M., to 12/1/11 at 1:46 P.M., regarding the resident's swollen jaw and reddened gums; -Staff did not document they monitored the resident for any adverse effects of the antibiotic; -Staff documented they assessed the resident's temperature (an elevated temperature is a sign of infection) one time (on 11/28/11) before and during the antibiotic treatment. Record review of the medication record showed the following information:-On 11/26/11, at 5:03 P.M., staff administered the first antibiotic dose. Staff did not administer the as needed [MEDICATION NAME] to the resident;-On 11/27/11, 11/28/11 and 11/30/11, staff administered the as needed [MEDICATION NAME] to the resident for complaints of pain; Record review of the nurses' notes on 12/1/11 at 1:46 P.M., showed the staff sent a note to the physician to request orders for the resident to see the dentist. The note included information that the resident was having a toothache on his/her back right side of his/her jaw and that his/her tooth had a large cavity present. Record review of the care plan showed the staff did not document any problems, goals and interventions regarding the resident's swollen jaw and tooth pain between 11/26/11 to 11/30/11. On 12/1/11, staff added the following interventions: -Apply ice to the affected area; -Monitor and protect skin appropriately; -Document effectiveness. Observation and interview on 12/2/11 at 8:45 A.M., the resident sat in the wheelchair in his/her room. The resident was alert and oriented. The resident had no visible swelling to his/her right jaw. The resident palpated along his/her right cheek and said, "It is better, but still tender". The resident said his/her tooth had been hurting, it "throbbed" and felt like a "heartbeat". His/her jaw was "swollen" and he/she could hardly touch it. The nurse looked at the area and called the doctor and got antibiotics. The resident said the nurse thought that the tooth might have an abscess (a pus-filled cavity resulting from inflammation and usually caused by bacterial infection). The resident said the staff did not check his/her vital signs daily. Yesterday (12/1/11), the nurse said they were trying to get him/her a dentist visit. During an interview on 12/2/11 at 10:30 A.M., the SSD said the staff called the physician yesterday to get an order for [REDACTED]. During an interview on 12/2/11 at 1:00 P.M., the DON said she expected staff to monitor a resident's temperature every shift while on antibiotics. 5. Record review of Resident #10's quarterly MDS assessment dated [DATE], showed the following information: -Independent with cognitive decision-making;-Limited staff assistance with mobility, transfers, and personal hygiene. Record review of the nurse's notes showed the following information:-On 11/19/11 at 10:43 A.M., staff sent a note to the physician that the resident's left great toe was red and inflamed with pain. The resident said it was an ingrown toenail and needed to be cut out. He/she said he/she had always cut his/her own nails and had "dug it" out before but this time it is a lot worse. Please advise. The nurse did not document that he/she administered pain medication for the resident's complaint of pain and/or that the resident refused pain medication;-Staff did not document in the notes between 11/19/11 to 11/21/11, regarding the resident's left great toe. Record review of the medication record showed staff did not document they administered any as needed pain medication on 11/19/11 at 10:43 A.M., for the resident's complaint of toe pain. Record review of the pain assessment showed the following information: -On 11/19/11:-At 6:58 A.M. the nurse noted the resident "denies" pain. Pain level score "0". (A scale that can be used to rate the resident's pain level with 10 being severe to 0 as mild to no pain). -At 4:06 P.M., the nurse noted the resident "denies" pain. Pain level score "0";-The nurse did not document between 6:58 A.M., to 4:06 P.M., that he/she administered as needed pain medication for the resident's complaint of toe pain at 10:43 A.M., or that the resident refused the pain medication. The nurse did not indicate the resident's pain level score. -On 11/21/11, staff received a fax with orders for Keflex (antibiotic) three times a day for ten days, which staff started on 11/21/11, and a podiatry consult. Nursing staff notified the SSD and the resident's family. Staff did not document any further assessments of the resident's left great toe. Record review of the order history showed a physician's orders [REDACTED]. On 11/21/11, an order for [REDACTED]. Record review of the care plan showed the following information:-On 11/20/11, staff added an intervention for Epsom salt soaks. Soak left great ingrown toenail. Apply [MEDICATION NAME] ointment three times a day after soaks. Completed 11/23/11 (staff continued with the intervention as ordered until 11/30/11).-Staff did not document any further problems, goals, and interventions between 11/23/11 to 12/1/11, regarding the resident's left great toe. Record review of the notes showed on 11/29/11, the SSD noted the resident had an appointment for the podiatrist on 11/30/11. Record review of the nurse's notes dated 11/30/11, showed the resident returned from the podiatrist with new orders for toe wound care. Record review of the medical record between 11/19/11 to 11/30/11, showed staff did not document any further assessments of the resident's left great toe. Staff did not document they monitored the resident for any adverse effects of the antibiotic and staff not document they assessed the resident's temperature (elevated temperature is a sign of infection) before and during the antibiotic treatment. During an interview on 12/2/11 at 10:30 A.M., the SSD said on 11/22/11, (Tuesday) the resident's family told the SSD that the resident was not sure he/she wanted to leave the building to see the podiatrist. When the SSD came back to the facility on the next Tuesday (11/27/11), the resident's family had gone ahead and scheduled the podiatry appointment for 11/30/11. The SSD said he/she did not make a note regarding his/her conversation on 11/22/11, with the resident's family. The SSD said he/she was not sure if the nursing staff had been made aware that the resident did not want to leave the building to see the podiatrist. Observation and interview on 12/2/11 at 11:00 A.M. showed the resident sat in the wheelchair in his/her room. The resident had socks on both feet. The resident said he/she did not have any complaints about his/her toe at this time. He/she saw the podiatrist a couple of days ago and the podiatrist cut away part of the toe nail that had curled under. The nurses soak his/her feet and change the dressing several times a day. His/her toe hurt and was swollen at first, had been like that for a couple of weeks before he/she saw the podiatrist (complained to staff on 11/19/11, received antibiotics and saw the podiatrist on 11/30/11).

Based on observation, interview, and record review the facility staff failed to re-order and administer two of one resident's (Resident #13) medications as ordered by the physician. Staff failed to administer eight doses of one medication used to help prevent [MEDICAL CONDITION] (TIA's- mini [MEDICAL CONDITION]) and [MEDICAL CONDITION], and failed to administer seven doses of one medication used to help prevent [MEDICAL CONDITION]. The sample size of residents selected for review was 15. The facility had a census of 68 residents. 1. Review of Mosby's Nursing Drug Reference, 23rd edition, 2010, showed the following information: -[MEDICATION NAME] is a medication that dilates the vessels of the heart and also reduces the clotting ability of the blood. Indications for the use of [MEDICATION NAME] include the prevention of TIA's and [MEDICAL CONDITION]; -[MEDICATION NAME] is a medication that helps prevent the occurrence of [MEDICAL CONDITION] activity. [MEDICATION NAME] is also used to treat certain types of nerve pain and as a mood stabilizer. Record review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment tool completed by the facility staff, dated 10/23/11, showed the following information: -Medical [DIAGNOSES REDACTED]. -Independent with cognitive skills for daily decision-making; -Independent with most all activities of daily living. Review of the resident's electronic medical record (EMR) showed the physician ordered the following medications for Resident #13: -[MEDICATION NAME], one capsule twice a day (ordered 5/21/09); -[MEDICATION NAME], 100 milligrams (mg) twice a day (ordered 10/6/10). Observation and interview during medication pass on 12/1/11, at 8:00 A.M., showed Registered Medication Technician (RMT) B began the preparation of Resident #13's A.M. medications. The RMT individually scanned (electronically) each of the resident's medications into the electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued observation showed RMT B typed data into the EMAR for two medications that he/she did not place into the medication cup. RMT B said the medications, [MEDICATION NAME] and [MEDICATION NAME], were unavailable to administer to the resident. RMT B said he/she made a note in the EMAR regarding the medications unavailability and would notify the charge nurse the medications were not available. RMT B said the charge nurse would find out why the medications were not on the medication cart and would also make a note in the resident's EMAR regarding the medications unavailability. Review of the medication administration history screen in the EMAR showed the staff administered the last dose of [MEDICATION NAME] to the resident on 11/27/11, at 9:00 A.M. (eight doses missed), and the last dose of [MEDICATION NAME] on 11/27/11, at 4:41 P.M. (seven doses missed). Further record review of the resident's EMAR history showed the following information: -[MEDICATION NAME] administration history: -An entry dated 11/27/11, at 4:44 P.M., in which licensed practical nurse (LPN) A noted staff did not administer the scheduled dose because the medication was on order; -An entry dated 11/28/11, at 7:48 A.M., in which RMT B noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 11/28/11, at 5:09 P.M., in which LPN C noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 11/29/11, at 8:00 A.M., in which student practical nurse (SPN) D noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 11/29/11, at 5:32 P.M., in which SPN D noted the staff did not administer the scheduled dose of the medication because the medication was on order; -An entry dated 11/30/11, at 7:47 A.M., in which RMT E noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 11/30/11, at 5:01 P.M., in which RMT F noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 12/1/11, at 8:00 A.M., in which RMT B noted the staff did not administer the scheduled dose because the medication was on order; -[MEDICATION NAME] administration history: -An entry dated 11/28/11, at 7:45 A.M., in which RMT B noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 11/28/11, at 5:08 P.M., in which LPN C noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 11/29/11, at 8:00 A.M., in which SPN D noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 11/29/11, at 5:33 P.M., in which SPN D noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 11/30/11, at 7:48 A.M., in which RMT E noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 11/30/11, at 5:02 P.M., in which RMT F noted the staff did not administer the scheduled dose because the medication was on order; -An entry dated 12/1/11, at 8:00 A.M., in which RMT B noted the staff did not administer the scheduled dose because the medication was on order. During an interview on 12/1/11, at 9:12 A.M., registered nurse (RN)/Unit Manager (UM) G said when a medication needs refilled, the staff member is expected to scan a barcode on the medication card into a re-order screen in the EMR. Once scanned into the system, the computer automatically sends the re-order request to the pharmacy. RN/UM G said as long as the re-ordered medication is in stock, the pharmacy then provides the facility with the refilled medication by the afternoon. RN/UM G said to his/her knowledge no one had yet notified Resident #13's physician of the missed medication doses. During a telephone interview on 12/1/11, at 9:30 A.M., a staff member at the resident's pharmacy said staff at the facility notified the pharmacy that morning (12/1/11) that Resident #13's [MEDICATION NAME] and [MEDICATION NAME] needed refilled. The pharmacy staff member said both medications had been in stock without interruption in supply. During an interview on 12/2/11, at 12:40 P.M., the Director of Nurses (DON) said the staff should have re-ordered both medications when it was first noted they were not available on the medication cart. The DON said she also expected the re-ordering staff member to notify the unit manager they re-ordered a medication so the unit manager could obtain the refill when sent from the pharmacy.