Every finding on record at Prairie Heights Healthcare

Based on Payroll Based Journal (PBJ) CASPER (Certification and Survey Provider Enhanced Reporting) reports, interview, and record review, the provider failed to ensure the PBJ data was submitted accurately to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (January, February, and March 2025). Findings include:1. Interview on 7/29/25 at 4:20 p.m. with administrator A regarding Fiscal Year 2025 Second Quarter (Q2) PBJ data revealed that the data was submitted to the contracted submission company, and there had been an error, but she did not recall what the error was. Follow-up interview on 7/29/25 at 4:59 p.m. with administrator A regarding Fiscal Year 2025 Q2 PBJ data submission confirmed the data submission had not been accepted by CMS due to an error. She indicated that accounting clerk B would be able to provide additional information. Interview on 7/31/25 at 10:28 a.m. with accounting clerk M regarding PBJ data submission revealed she was not aware that the Q2 data for the Federal Fiscal Year 2025 submission to CMS had not been accepted by CMS. Review of the provider's undated PBJ Preparation and Submission Schedule instructions revealed:*PBJ submission due 11:59pm [p.m.] EST [Eastern Standard Time] on the 45th calendar day following the end of the reporting quarter to be considered timely.*The Q2, submission due date was May 15, and was to be submitted in the first week of May to CMS. *Validation Reports were to be provided to the provider by the contracted submission company and were to be reviewed during the second business week of the submission month (at a minimum of 72 hours) before the CMS deadline.

Based on the South Dakota Department of Health (SD DOH) complaint report, interview, record review, the provider failed to ensure services provided for four of four sampled residents (1,2,3,4,) did not meet professional standards by: *Director of nursing (DON) (B) who did not follow the rights of medication administration nor the facility policy for insulin administration when administering insulin to resident 1. *DON B who did not document a wound assessment at the time of completion or identify it as a late entry when it was documented in resident 4's medical record. *Two certified medication aides (CMA) (C and D) who did not remain within their unlicensed but certified skill set. Findings include: Surveyor 50915 1. 4. Interview on 10/23/24 at 3:30 p.m. with director of nursing (DON) B revealed: *She confirmed she made the medication error regarding resident 1's insulin on 7/6/24 at 9:00 p.m. *She confirmed resident 1 should have been administered 62 units of Lantus (long-acting insulin) insulin, he instead received 55 units of Humalog (fast-acting) insulin. 2. Review of the provider's medication error report dated 7/6/24 at 9:00 p.m. revealed: *The report confirmed that resident 1 received 55 units of Humalog insulin instead of the ordered 62 units of Lantus insulin. *The report indicated a contributing factor to the error was Both Lantus and Humalog pens were stored in the same baggie in the cart with one label. *The report indicated when DON B got a new Lantus insulin pen to prepare to administer the remaining 7 units of resident 1's Lantus insulin, she realized that the insulin pens were two different colors, and identified the medication error had occurred. *The report indicated the on-call provider was called, the Lantus insulin dose was held, and the resident was given a snack. *The report indicated that the resident was not taken to the hospital. 3. Review of resident 1's electronic medical record (EMR) revealed: *Progress note on 7/6/24 at 9:00 p.m., Dr. [name], on call, updated on insulin use and that current blood sugar is 215 with the following orders: Check blood sugars every hour for the next 4 hours, 10 p.m., 11 p.m., 12 a.m., and 1 a.m. Do not give Lantus tonight. Call on call provider again in the am with the a.m. blood sugar results to see if added Lantus should be given. Pt [patient] aware, Daughter [name] updated on orders. *On 7/6/24 at 10 p.m., resident 1's blood glucose was 143 milligrams per deciliter (mg/dl). *On 7/6/24 at 11 p.m., resident 1's blood glucose was 115 mg/dl. *On 7/7/24 at 12 a.m., resident 1's blood glucose was 123 mg/dl. *On 7/7/24 at 1 a.m., resident 1's blood glucose was 118 mg/dl. *Resident 1 was given snack as order by on-call physician. -He did not show any signs of hypoglycemia. Review of the SD DOH complaint report dated 10/4/24 revealed: *The complainant wished to remain anonymous. -Director of nursing (DON) B was at a conference but had charted that she completed a wound assessment on resident 4 when she returned from the hospital 9/24/24. -DON B was not in the building at the time that resident returned from the hospital and could not have performed that assessment she documented on. -Certified medication aides completed duties outside their scope of practice. Surveyor 49238 4. Interview on 10/23/24 at 11:19 a.m. with director of nursing (DON) B revealed: *She had gone to a conference but had come back on the 10/24/24 to see resident 2 who had returned from the hospital. -She stated she did not feel she could depend on the nurse who had been working and wanted to see the resident herself. *She had to complete a wound assessment for resident 2 who came back from the hospital with a deep tissue injury on her heel. *She agreed she completed the documentation for that wound assessment the next day remotely. *She agreed she should have charted the wound assessment as a late entry, but she did not. *She stated she would work Monday through Friday from 8:00 a.m. to 4:30 p.m. and sometimes stay until 5:30 p.m. and would chart remotely from home. 5. Review of medication administration records (MARs) revealed: *Certified medication aide (CMA) D had documented antipsychotic medication side effects on 8/8/24 and 8/20/24 for resident 3. *She had documented a pain assessment for resident 4 on 9/6/24. 6. Interview on 10/24/24 at 9:48 a.m. with CMA C revealed: *She stated she had not been trained on how to assess for psychotropic [brain altering medication that treat psychotic conditions such as delusions and hallucinations] medication side effects at this facility but had documented behavior information for the residents she was familiar with. -She charted yes or no answers for residents behaviors. *She stated she assessed residents for their pain level by resident's verbal answers or by the resident's facial expression and then documented their pain level. -She would report pain levels to the nurse that were five out of ten or higher. 7. Interview on 10/24/24 at 11:40 a.m. with DON B regarding CMAs completing pain and psychotropic medication assessments revealed: *DON B admitted that two CMAs (C and D) had documented pain and psychotropic medication assessments, and she had just heard about that from CMA C after her interview with the surveyors. -She said CMA C asked her today if she should have been charting those things and DON B told no. *DON B stated she was not aware they had been doing that and it was not in their scope of practice, but she had instructed them to stop. 8. Review of the providers's September 2014 Insulin administration policy revealed: *Preparation section, number three, The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. 9. Review of the provider's medication aide job description dated Qtr 2,2020 revealed: *Administering Medications-Specific to Unlicensed Medication Aides. -20. Medications administration tasks that may not be delegated to unlicensed assistive personnel (Unlicensed Medication Aides) are the following; -6. Exercising of nursing judgement, assessments which would require nursing intervention.

Based on South Dakota Department of Health (SD DOH) complaint online report, interviews, record review, and policy review, the provider failed to keep one of one resident (1) free from a significant medication error when administered an incorrect dose of insulon by director of nursing (B). Findings include: 1. Review of SD DOH 10/4/24 complaint report revealed: *DON B had a major medication error where she gave the incorrect insulin (large dose) to a resident but it was never reported or counted as a medication error. *The complainant identified the resident in this incident as resident 1. 2. Interview on 10/22/24 at 2:40 p.m. with resident 1 revealed: *He had a Brief Interview for Mental Status (BIMS) score 8, which indicated he had moderate cognitive impairment. *He reported that the staff did a good job providing care for him. *He confirmed he was diabetic and required insulin injections. *He was unable to recall ever having any problems getting his insulin. 3. Interview on 10/23/24 at 9:55 a.m. with certified medication aide (CMA) C revealed CMAs did not obtain blood glucose (level of sugar in blood) readings or administer insulin. 4. Interview on 10/23/24 at 3:30 p.m. with director of nursing (DON) B revealed: *She confirmed she made the medication error regardingn resident 1's insulin on 7/6/24 at 9:00 p.m. *She confirmed resident 1 should have been administered 62 units of Lantus (long-acting insulin) insulin, he instead received 55 units of Humalog (fast-acting) insulin. 5. Review of the provider's medication error report dated 7/6/24 at 9:00 p.m. revealed: *The report confirmed that resident 1 received 55 units of Humalog insulin instead of the ordered 62 units of Lantus insulin. *The report indicated a contributing factor to the error was Both Lantus and Humalog pens were stored in the same baggie in the cart with one label. *The report indicated when DON B got a new Lantus insulin pen to prepare to administer the remaining 7 units of resident 1's Lantus insulin, she realized that the insulin pens were two different colors, and identified the medication error had occurred. *The report indicated the on-call provider was called, the Lantus insulin dose was held, and the resident was given a snack. *The report indicated that the resident was not taken to the hospital. 6. Review of resident 1's electronic medical record (EMR) revealed: *Progress note on 7/6/24 at 9:00 p.m., Dr. [name], on call, updated on insulin use and that current blood sugar is 215 with the following orders: Check blood sugars every hour for the next 4 hours, 10 pm, 11 pm, 12 am, and 1 am. Do not give Lantus tonight. Call on call provider again in the am with the 7am blood sugar results to see if added Lantus should be given. Pt [patient] aware, Daughter [name] updated on orders. *On 7/6/24 at 10 p.m., resident 1's blood glucose was 143 milligrams per deciliter (mg/dl). *On 7/6/24 at 11 p.m., resident 1's blood glucose was 115 mg/dl. *On 7/7/24 at 12 a.m., resident 1's blood glucose was 123 mg/dl. *On 7/7/24 at 1 a.m., resident 1's blood glucose was 118 mg/dl. *Resident 1 was given snack as order by on-call physician. -He did not show any signs of hypoglycemia. 7. Review of the providers's September 2014 Insulin administration policy revealed: *Preparation section, number three, The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order.

Based on observation, interview, and record review, the provider failed to: *Maintain clean and sanitary conditions of appliances and utensils in one of one kitchen: -Convection oven. -Flattop griddle grease trap drawer. -Stovetop backsplash. -Oven doors. -Dishwasher. -Walk-in refrigerator. -Reach-in refrigerator. -Scoop storage in the bulk oats and brown sugar containers. *Maintain the cleanliness of the microwave and sanitary storage under the sink in one of one rehabilitation (rehab) kitchenette. Findings include: 1. Initial kitchen observation on 3/5/24 from 7:45 a.m. to 8:15 a.m. revealed: a. In the convection oven: *Baked-on grease was found inside the doors and along the inner surfaces. *Burnt food particles lined the bottom of the appliance. b. On the Vulcan brand combination gas range/flattop griddle/oven: *Thick, stuck-on grease was found lining the opening to the grease trap drawer on the flattop griddle. -Copious amounts of food particles lined the opening. *There was burnt-on black grease on the backsplash of the gas range. *There was spilled stuck-on grease and grime inside the oven door and on the bottom surface. *There was grease residue and dust buildup on the back of the oven, and on the wires and piping in between the convection oven and the Vulcan oven. c. In the dishwasher: *There was a thick layer of light brown sludge found on the inside of the doors. d. In the walk-in refrigerator: *An unknown sticky substance and food particles were found throughout the refrigerator on the shelves. e. In the reach-in refrigerator: *There was an unknown sticky red substance on the bottom surface. f. In the bulk brown sugar and oats containers: *The serving scoops were stored inside the containers. *Slices of bread were stored in the brown sugar container to prevent moisture and clumping. -There was no sign as to when those slices of bread were placed in the brown sugar container. 2. Observation on 3/5/24 at 8:19 a.m. in the rehab kitchenette revealed: a. In the microwave: *There was food splatter lining the inside of the door and inside surfaces of the appliance. b. In the cupboard beneath the sink: *Unknown particles of either food crumbs or particle board deterioration were found on the bottom surface. *A cutting board was stored in the cupboard. 3. Observation and interview on 3/5/24 at 2:39 p.m. with food services manager (FSM) D revealed: *The rehabilitation and housekeeping departments were responsible for maintaining the cleanliness of the rehab kitchenette. *She provided a cleaning log that showed how often deep cleaning in the kitchen was completed. -The log specified different appliances and areas of the kitchen. -Staff initialed the log once the deep cleaning was completed. *She was unsure how often the storage shelves were cleaned in the walk-in refrigerator. *Degreaser should have been used on grease-prone areas according to the policy. *She was unaware that the dishwasher trapped debris and sludge behind its doors. *She was unaware staff were storing slices of bread in the brown sugar container and immediately removed them. *She confirmed there was an infection prevention risk in storing serving scoops inside the brown sugar and oats containers. 4. Interview on 3/7/24 at 9:17 a.m. with cook G revealed: *Deep cleaning for the stove and ovens was completed once per week. -Spills were cleaned daily. *The griddle was cleaned after each use. *Grease traps were emptied and cleaned daily. -Deep cleaning of the grease traps was completed every other week. *All refrigerators and freezers were deep cleaned weekly. *All preparation surfaces were wiped down daily and after each use. 5. Interview on 3/7/24 at 9:25 a.m. with dietary aide (DA) I revealed: *His cleaning tasks were completed daily. -He had the same tasks each day. *He followed the cleaning log and initialed it when his tasks were completed. 6. Interview on 3/7/24 at 9:33 a.m. with DA H revealed: *Cleaning tasks were completed daily. *Deep cleaning of all hard surfaces was done weekly and as needed. *She followed the cleaning log and initialed it when her tasks were completed. 7. Review of the provider's February 2024 cleaning logs revealed all tasks were signed off as being completed. Review of the provider's 2023 Food Storage policy revealed: *Scoops should be kept covered in a protected area near the containers rather than in the containers. Scoops should be washed and sanitized on a regular basis. *All refrigerators should be kept clean and in good working condition at all times. Review of the provider's 2023 Food Safety - Director of Food and Nutrition Services' Responsibilities policy revealed: *The director of food and nutrition services will be responsible for providing safe foods to all individuals. *Regulatory requirements for food safety and sanitation will be met. *Sanitary conditions will be maintained in the food storage, preparation, and serving areas. Review of the provider's 2023 Cleaning and Sanitation of Dining and Food Service Areas policy revealed: *The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. *The methods and guidelines to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned. Review of the provider's 2023 Cleaning Instructions: Ovens policy revealed Ovens will be cleaned as needed and according to the cleaning schedule (at least once every two weeks). Spills and food particles will be removed after each use. Review of the provider's 2023 Cleaning Instructions: Microwave policy revealed The microwave oven will be kept clean, sanitized, and odor-free. The microwave oven interior should be cleaned after each use as needed, and at minimum, after each meal service. Review of the provider's 2023 Cleaning Instructions: Refrigerators policy revealed The refrigerators will be cleaned thoroughly inside and outside with a detergent followed by a sanitizer at least once every month or as needed. Spills and leaks will be cleaned as they occur. Review of the provider's 2023 Cleaning Instructions: Ranges/Griddles policy revealed The range/griddle will be cleaned after each use. Spills and food particles will be wiped up as they occur.

Based on record review, interview, and policy review, the provider failed to remove outdated code status information (emergent treatment a resident would or would not receive if the heart or breathing were to stop) for 9 of 62 resident care plans (1, 5, 6, 18, 21, 32, 35, 41, and 56). Findings include: 1. Review of resident care plans, electronic medical records (EMRs) and resident paper charts for residents 1, 5, 6, 18, 21, 35, 41, and 56 revealed: *Each resident had an active Do Not Resuscitate (DNR) code status in the EMR and paper charts, but the care plans included both Full Code and DNR code statuses. *It appeared as though the above resident's code status was Full Code upon admission to the facility and had since changed to DNR. *The resident's code status changed to DNR on the following dates: -Resident 1 on 5/19/23. -Resident 5 on 1/15/24. -Resident 6 on 3/1/24. -Resident 18 on 7/6/23. -Resident 21 on 11/8/23. -Resident 35 on 11/9/23. -Resident 41 on 6/16/23. -Resident 56 on 2/6/24. *Rather than removing the outdated code status information from the resident's care plans, the provider added the current information at the end of the associated focus area, potentially creating confusion since both code statuses were listed. 2. Review of resident 32's care plan, EMR, and paper chart revealed: *She had an active Full Code status, but her care plan listed both DNR and Full Code. *There was a focus area on her care plan that read, She does not have an advance directive, but her choice is to be a DNR . 2/2/24 [Resident 32] is now a full code. Date initiated: 9/10/23. Revised on 2/8/24. -The associated intervention read, [Resident 32] is a full code. Date initiated and revised on 2/8/24. 3. Interview on 3/6/24 at 9:13 a.m. with registered nurse (RN) F revealed: *Social services handled the beginning of the resident's advanced directives process. *A resident's code status was marked on the outside of their paper charts with a sticker. -A red sticker indicated the resident was DNR, while a blue sticker indicated Full Code. *The first page in a resident's paper chart included their code status paperwork and the physician's orders. *If a resident's code status changed, the care plan should have been updated immediately. Interview on 3/6/24 at 9:22 a.m. with social services designee (SSD) C revealed: *When a resident was admitted , she asked the resident or their representative if they already had advanced directives or a code status in place. *The code status information was included in the social services section of the resident's care plan. *She updated the social service section of the resident's care plan as needed or at least quarterly. -The care plan changes as the resident changes. *If a resident's code status changed, she added the new information to the resident's care plan and included the date which it was changed. *She confirmed she did not remove the outdated code status information from the resident's care plan. *She understood how it might have been confusing to the staff when there were two different code statuses listed. Interview on 3/6/24 at 9:39 a.m. with Minimum Data Set (MDS) coordinator E revealed: *Social services was responsible for including the resident's code status on the care plans. *The resident's care plan was updated at least quarterly. *If a resident's code status changed, the care plan should have been updated immediately. *Her expectation was to remove the old and outdated information from the resident's care plan. *She was not aware the above listed residents had both DNR and Full Code statuses listed on their respective care plans. Interview on 3/6/24 at 9:55 a.m. with director of nursing B revealed: *The resident's care plans were updated at least quarterly. Some resident's care plans were updated daily at the management team's morning meetings. *If a resident's code status changed, the charge nurses were responsible for updating the resident's EMR and paper chart. -Social services was responsible for updating the resident's care plan. *It was her expectation to resolve a care plan focus area rather than continually adding new information to the resident's care plan without removing the old information. -The resolve action would remove the item from the resident's care plan. -If needed, the staff would have been able to see the resolved items in the care plan history review. Interview on 3/7/24 at 9:34 a.m. with administrator A revealed: *She was not aware the above-mentioned resident's care plans had both DNR and Full Code status information. *She stated that having both the outdated and current code status information on the resident's care plan was completely not approved. 4. Review of the provider's undated Advance Directive Policy revealed: *There was no description on expectations for documenting a resident's advance directives or code status choice in their care plan. Review of the provider's March 2022 Care Plans, Comprehensive Person-Centered policy revealed: *Under the section titled Policy Interpretation and Implementation: -10. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. -11. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. *There was no details in the policy for keeping or removing resident's information that was no longer relevant or accurate.

Based on observation, interview, and record review, the provider failed to ensure 4 of 18 sampled residents (12, 18, 33, and 66) had received bathing per their preferences. Findings include: Surveyor 1. Interview on 8/10/21 at 3:03 p.m. with resident 18 regarding her bath preferences revealed: *They changed my bath from afternoon to evenings without a choice. *I like my bath in the morning before lunch. *Some weeks I don't get more than one a week. Surveyor Review of resident 18's bath records from 7/14/21 through 8/9/21 revealed: *The days of her scheduled baths had not been identified on the electronic medical record (EMR). *The director of nursing (DON) master paper bath schedule and the Minimum Data Set (MDS) coordinator's paper bath schedule showed she was to have received a bath on Mondays and Thursdays. *Bathing had been documented as being completed four times. -Not applicable had been documented twice. -A refusal had been documented once. -Skin assessments had been completed four times, one of which was on the same day as a bath. 2. Review of resident 12's bath records from 7/16/21 through 8/10/21 revealed: *The days of her scheduled baths had not been identified in the EMR. *The days of her bath on the DON's master paper bath schedule showed she was to have received a bath on Tuesdays and Saturdays. *The days of her bath on the MDS coordinator's paper bath schedule showed she was to have received a bath on Tuesdays and Fridays. *Bathing had been documented as being completed five times. -Two baths had been documented on Mondays, two baths on Tuesdays, and one bath on Friday. -Not applicable had been documented once. -A refusal had been documented once. -She had received five out of eight possible baths. 3. Review of resident 33's bath records from 7/13/21 through 8/10/21 revealed: *The days of his scheduled baths in the EMR, the DON's master paper bath schedule, and the MDS coordinator's paper bath schedule all showed he was to have received a bath on Tuesday's and Friday's. *Bathing had been documented as completed five times. -Two baths had been on Tuesdays and three baths had been on Fridays. -Not applicable had been documented three times. -There had been no other documentation of baths received or refused. -He had received five out of nine possible baths. 4. Review of resident 66's bath records from 7/16/21 through 8/8/21 revealed: *The days of his scheduled baths in the EMR, the DON's master paper bath schedule, and the MDS coordinator's paper bath schedule all showed he was to have received a bath on Sundays and Wednesdays. *Bathing had been documented as completed four times. -Two of the baths had been on Mondays and one of the baths had been on a Friday. -Only one of the baths had been on a Sunday (his preference). -He had received four out of seven possible baths. Surveyor 5. Interview on 8/12/21 at 8:16 a.m. with certified nursing assistant (CNA) C regarding the resident bath schedule revealed: *They followed a bath list. *The not applicable (NA) documented in the EMR indicated the bath had not been listed on the paper bath schedule. *Residents usually received a couple of baths each week. *If we don't get the baths done on the day shift then evenings will do them. *We are good about getting the showers done. Surveyor Interview on 8/12/21 at 8:59 a.m. with DON B regarding bathing of residents revealed: *All residents should have received at least two baths per week unless they wanted something different. *CNAs documented all baths given in the EMR. *No one should have been using the paper bathing schedule. *When not applicable was documented it meant they were out of the building or they had refused. -When the bath was documented as not applicable or refused, the EMR would not have shown the bath still needed to be completed. *The CNAs would verbally tell the next shift if they had not given a specific bath. *Whoever gave the bath should have documented it in the EMR. *The EMR would have 'flagged' if a bath had not been documented. -Someone would have followed up if it had been 'flagged' by the EMR system. *When a resident had been moved from one room to another the nurse would have changed the bath schedule in the EMR. *The paper bath schedule was: -A 'baseline' using the facility's room numbers as a guide for new admissions, and should not have been changed. -To be used for new residents until their preferences for bathing were identified. *Someone should have identified the EMR needed to be changed if it was not correct. *The MDS coordinator would have asked what the resident's preference had been when she completed section F of the MDS,. Interview on 8/12/21 at 9:22 a.m. with MDS coordinator F regarding residents' bathing preferences revealed: *Residents received at least two baths per week unless they requested something different. *She had updated the paper bath schedule at various times and would have put it in the CNA communication book. *Each unit had a paper bath schedule to follow. *CNAs used the paper bath schedule to know when a bath had been scheduled. *When not applicable was documented in the EMR it indicated maybe they (CNAs) were charting wrong. *When a resident refused a bath, the procedure had been to offer them a bath at a different time or on a different day. -This would have been documented in the EMR. *Physical therapists and occupational therapists had assisted residents with baths. *A CNA would have documented the bath in the EMR. *A newly admitted resident would have their first bath on the scheduled day for their room, unless, they had not had one in a while. *Skin assessments would have been completed when a resident had a bath, and could be used to identify if a resident had a bath when the EMR did not indicate one had been given. Surveyor Interview on 8/12/21 at 9:33 a.m. with activities director D regarding the MDS assessment for all residents revealed she: *Completed the MDS assessment on resident's preferences for bathing. *Would tell the CNA what the resident preferred. *Was not responsible to care plan bathing. *Did not know who updated in the EMR for bathing preferences. Surveyor Interview on 8/12/21 at 10:18 a.m. with social worker Q regarding bathing of residents revealed: *When a resident was admitted to the facility their bath had been scheduled according to their room number. *The CNAs had a book at the nurses' station that had the room number and day of the week for each resident's bath. *Residents were able to ask to have their bath day changed. *When baths were not completed as scheduled they had been moved to the next shift. *When the staff notified her a resident refused a bath she would talk to the resident and find out why they had refused. *When a resident had notified her they had not received their bath she would have talked to the nursing staff and had them give the resident a bath at that time or the next day. *She was unsure how often baths had not been completed as scheduled. *When not applicable had been documented it possibly meant the bath had been offered but refused. *Changes to the resident's bathing preferences would have been updated in the EMR every morning during the supervisors' morning meeting. 6. Review of providers 2018 Bath, Shower/Tub policy and procedure revealed documentation should have been completed including the date and time the bath was given.

Based on record review, interview, and policy review, the provider failed to ensure an advanced directive matched the residents' preference for one of eighteen sampled residents (273) who had been admitted to the facility within the past thirty days. Findings include: 1. Review of resident 273's electronic medical record revealed: *She was admitted on [DATE]. *On: -[DATE] admission and baseline care plan/summary identified her as being oriented to person, place, time, situation, and cognition intact. -[DATE] active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[DATE] there was a social services progress note stated She can express her needs and make her own decisions. She states she does have a advance directive and her choice is to be a DNR [Do Not Resuscitate]. She came with a full code order. I did fax a request to her MD [Medical Doctor] for a DNR order. Review of residents 273's paper medical chart revealed: *A red dot sticker on the exterior of the medical record. *An admission baseline care plan with a code status handwritten No Code (not to revive or sustain a resident who experienced a life-threatening event). Interview on [DATE] at 9:19 a.m. with social worker (SW) Q regarding resident 273's code status revealed: *During the admission process when completing the admission paperwork she reviewed: -Resident's preference for code status. -Whether request for full code, resuscitation or no code, no resuscitation, forwarded a fax request for an order to the physician. *Either she or a nurse would follow-up on the fax returned by the physician. *A blue dot sticker on the exterior of the medical record signified a full code. *A red dot sticker on the exterior of the medical record signified do not resuscitate. *While waiting for physician orders, the resident remained a full code. *She confirmed the electronic medical record for resident 273 had an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *On [DATE] she had faxed a request for DNR after her conversation with her and anticipated an order placed the red dot sticker. Interview on [DATE] at 9:59 a.m. with director of nursing (DON) B regarding advance directives revealed: *The facility SW was responsible for advance directives. *The charge nurse would receive the fax returned by the physician and place the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *The facility nurses looked first for the advance directive in the electronic medical record as it was readily available. *If the code status was not in the electronic medical record, the nurse would look at the resident's paper medical chart for the red or blue dot sticker. Follow-up interview regarding resident 273's advance directive on [DATE] at 10:25 a.m. with SW Q revealed she had updated the resident's advance directive in the electronic medical record to DNR/DNI [Do Not Intubate]. Review of the provider's undated Advance Directive policy revealed: *Life[-]sustaining form/advanced directives to be completed on [the] day [of] admission or next working day after admission by [the] social worker or designee. *Documentation prepared by social worker or designee based off family/resident wishes, sent to primary physician to obtain order. *Once order is obtained and processed by nursing staff, social services or designee will mark exterior of [the] chart with appropriate code status and update code status profile in point click care [electronic medical record]. *Blue will be designated for full code, red will be designated as DNR.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection control technique was maintained for: *One of one sampled resident (65) who was on transmission-based precautions by one of one certified nursing assistant (CNA) (I) and one of one licensed practical nurse (LPN) (G) during a straight catheterization procedure. *One of one unlicensed assistant personnel (UAP) (E) during the use of an oximeter for one of one sampled resident (71). *Keeping a catheter bag and tubing and oxygen tubing off of the floor for one of one sampled resident (60) by one of one CNA (I) and one of one unlicensed assistive personnel (UAP) (P). Findings include: 1. Observation on 8/10/21 at 2:13 p.m. of LPN G and CNA I performing a straight catheterization procedure for resident 65 revealed: *Unit coordinator/licensed practical nurse (LPN) H was also in the room. *CNA I was at the bed side to assist with the procedure. *LPN G had assisted resident 65 to try and void into a urinal. *Removed her gloves, did not perform hand hygiene. *She was putting on a pair of sterile gloves when unit coordinator/LPN H told her to stop and go wash her hands. *After she washed her hands she put on a new pair of sterile gloves. *After the procedure, LPN G removed her gloves, performed hand hygiene, and put on a pair of gloves from her uniform top pocket. *After CNA I performed peri care he changed his gloves without performing hand hygiene. Interview on 8/10/21 at 2:34 p.m. with LPN G and CNA I regarding the above observation of lack of hand hygiene with the removal of gloves and taking gloves from a uniform pocket revealed: *They had both agreed they should perform hand hygiene when they remove their gloves. *LPN G agreed her pocket was not clean and she should not have kept extra gloves in her pockets. Interview on 8/10/21 at 2:34 p.m. with director of nursing (DON) B revealed she had agreed: *All staff should perform hand hygiene after removing gloves. *Staff should not keep extra gloves in their pockets. Review of the provider's 2018 Handwashing/Hand Hygiene/Non-Sterile Glove Use policy revealed: *6. Hand hygiene is the final step after removing and disposing of personal protective equipment. *When applying gloves they should be removed from the dispensing box one at a time. 2. Observation on 8/11/21 at 8:06 a.m. of UAP E administering medications and taking resident 71's oxygen saturation revealed she: *Had taken an oximeter out of her pocket and taken resident 71's oxygen saturation. *Put the oximeter back into her pocket and walked back to the medication cart. *Removed the oximeter from her pocket, disinfected it, and set it on top of the medication cart. Interview on 8/11/21 at 8:20 a.m. with UAP E about the above observation revealed: *The oximeter would have been contaminated after she used it and should not have been put back in her pocket. *Her pocket was not clean. *She should not have kept the oximeter in her pocket. Review of the provider's revised July 2014 Cleaning and Disinfection of Resident-Care Items and Equipment revealed: *d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). *It did not address the storage of equipment. 3. Observation on 8/10/21 at 9:23 a.m. of resident 60 sitting in his wheelchair in his room revealed: *Part of his catheter tubing was touching the floor. *The oxygen tubing hooked to the oxygen concentrator was lying on the floor touching his catheter tubing. Observation on 8/10/21 at 9:26 a.m. with CNA I and UAP P assisting resident 60 into the bed with a Hoyer lift revealed: *CNA I picked up the oxygen tubing and attempted to set it on the bedside table where it fell to the floor and remained there until it was placed back on the resident. *CNA I removed the catheter bag from the dignity bag below the wheelchair and set it on the floor while he removed the foot pedals and prepared the resident for transfer into the bed. Interview on 8/10/21 at 9:36 a.m. with UAP P regarding the above observation revealed: *It was not common practice for oxygen tubing to be on the floor, staff tried to drape it on the table or the oxygen concentrator. *She agreed the catheter tubing and bag should also, be kept off the floor. Interview on 8/10/21 at 9:38 a.m. with CNA I revealed: *He was not aware the oxygen tubing had been on the floor. *He had not realized he had set the catheter bag on the floor while proving care to resident 60. *Agreed the oxygen tubing and catheter tubing should not have been on the floor. Review of the provider's April 2016 Catheter Care: Indwelling Catheter policy revealed: 14. Check that tubing is not looped, kinked, clamped or positioned above the level of the bladder and off of the floor - place bag in catheter bag holder if appropriate. Review of the provider's updated July 2017 Oxygen Administration policy revealed: *Completion of procedure: -When oxygen is not in use, store oxygen tubing and cannula or mask in separate, labeled plastic bag.

Based on observation, interview, record review, and admission packet review, the provider failed to ensure one of one sampled resident's (52) choices related to her therapy schedule had been followed. Findings include: 1. Review of resident 52's medical record revealed: *She had been admitted on [DATE]. *She was alert and oriented. *Her 5/14/19 admission Minimum Data Set assessment regarding her daily preferences revealed: -It was very important for her to choose her own bedtime. --There was no question to specifically address how important her wake-up time would have been. *Her 6/26/19 care plan revealed: -Involve (resident name) in IDT (interdisciplinary team) and care planning. -Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage independent activity as able and safe. Observation and interview on 6/24/19 at 4:56 p.m. with resident 52 in her room revealed: *She was sitting in her bed reading a book.*She had been admitted about five weeks ago following a fall at home when she broke her hip. *She was working with therapy services and hoping to get back home soon. *Her only complaint was having to get up so early in the morning for therapy sessions. *She was not a morning person and did not feel well at that time of the day. -She further stated she used to have low blood pressure issues early in the morning. *The white dry erase board in her room indicated she would have three therapy appointments the next day at the following times: -At 6:30 a.m. with occupational therapy (OT). -At 8:30 a.m. with physical therapy (PT). -At 12:00 noon with speech therapy (ST). *She had told more than one therapy staff person that she did not like those early morning appointments, and they still scheduled her that way at times. Observation and interview on 6/25/19 at 9:05 a.m. with resident 52 in her room revealed:*She had just returned from therapy and was sitting in her wheelchair. *She had slept well the night before, and therapy had gone okay that morning. *Her preference still would have been to not do therapy so early in the morning. Observation on 6/26/19 at 8:29 a.m. of the dry erase board in resident 52's room revealed her three therapy appointments for that day were at the following times: *At 8:00 a.m. with OT. *At 12:00 noon with PT. *At 1:35 p.m. with ST. Interview on 6/26/19 at 8:45 a.m. with the social services designee regarding resident 52's concern with her therapy schedule revealed:*She had not been aware of the resident not wanting her therapy appointments so early in the morning. *If the resident had told staff she had not wanted therapy scheduled so early in the morning her preference for that should have been followed. Interview on 6/26/19 at 8:49 a.m. with the director of rehabilitation (rehab) services regarding resident 52 revealed:*He had known her for awhile, since she had been a resident in the facility for a separate stay prior to this admission. *He was aware she did not like her therapy appointments early in the morning. *Sometimes OT was scheduled at 6:30 a.m. in order to work on specific exercises such as dressing in order to get it done before breakfast started at 7:30 a.m. *He thought the resident only had one or two times when therapy had been scheduled for 6:30 a.m. since she had been admitted . Interview on 6/26/19 at 9:34 a.m. with the director of nursing regarding resident 52's therapy schedule revealed:*She expected the resident's therapy schedule to be adjusted and meet the resident's preferences. *Therapy staff could have accommodated the resident's preferences to not be scheduled early in the morning. Further interview and record review on 6/26/19 at 10:03 a.m. with the director of rehab regarding resident 52 revealed:*He brought her 5/7/19 through 6/26/19 therapy scheduled appointments list for review. *According to that list she had been scheduled for the 6:30 a.m. time on the following dates:-On 5/10/19 with PT. -On 5/24/19 with OT. -On 5/27/19 with PT. -On 6/14/19 with PT. -On 6/17/19 with PT. -On 6/25/19 with OT. *He stated she was getting three different therapies five days a week, and it could be difficult to get them all fit in during the day. *He confirmed they could have adjusted her therapy schedule to meet her preferences. *They could have worked on dressing at the time of her shower or asked her when it worked best for her to work on those dressing exercises. Interview on 6/26/19 at 10:27 a.m. with registered nurse/unit manager A regarding the above for resident 52 revealed:*She was the unit manager for the rehab unit. *Therapy appointments were scheduled by the therapy staff. *She confirmed therapy appointments should have been scheduled to accommodate the resident's preferences. Review of the provider's revised (MONTH) (YEAR) Resident Admission packet revealed:* .The rehab gym and office hours of operation are Monday through Friday 6:40 AM to 4:30 PM and Weekends by appointment only. Our therapy sessions are conducted one on one with the resident . *The inter-disciplinary team or IDT, consists of your individual case manager, therapist(s), social services, dietary, recreation and direct care supervisor. Resident and/or family participation in our IDT meetings is extremely important and highly encouraged . *The resident had a right to choices including: -(2) Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being, and -(3) Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participated in planning care and treatment or changes in care and treatment.

Surveyor: Based on interview, record review, and policy review, the provider failed to thoroughly investigate an incident for one of one sampled resident (47) who had a fall with a head injury. Findings include: 1. Review of resident 47's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) assessment score was an eleven indicating her cognition was moderately impaired. *She required the extensive assistance of two staff members for bed mobility. *On 5/5/19 she had rolled out of bed. Review of resident 47's fall investigation from 5/5/19 revealed: *She fell out of bed. *Positioning pillows were discontinued on 12/26/19 due to limited mobility. *The staff that were present had been interviewed. -She had been provided incontinent care at 3:00 a.m. -They had been in her room at 4:00 a.m. -She was found on the floor at 4:15 a.m. --Her bed was damp, and she was wet with urine. *The investigation did not indicate the resident's position in the bed fifteen minutes prior to the fall. Interview on 6/26/19 at 8:28 a.m. with the director of nursing (DON) revealed she felt if a resident was asked immediately following an incident regardless of their BIMS score they could tell you what happened. Interview on 6/26/19 at 8:33 a.m. with registered nurse E, the director of nursing, and the administrator regarding resident 47's 5/5/19 fall revealed: *She was taken at her word for how she fell out of bed. *It was not investigated how the resident was positioned in her bed prior to the fall. -If she had been near the edge of the bed when staff were in the room fifteen minutes prior to the fall it was the expectation she would have been repositioned. -They agreed what the resident was doing prior to a fall could be added to their investigation form. *There were no other interventions evaluated prior to the implementation of the positioning pillows. *They did not know what had caused the fall. Review of the provider's (YEAR) Assessing Falls and Their Causes policy revealed: *The purposes of this procedure are to provide guidelines for evaluating/gathering data on a resident after a fall and to assist staff in identifying causes of the fall. *Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. *Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled residents (47) had individualized and meaningful activities offered and documented. Findings include: 1. Review of resident 47's 12/14/18 annual Minimum Data Set assessment revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status assessment score was an eleven, indicating her cognition was moderately impaired. *She nor her family could be interviewed regarding her preferences. *The staff assessment of preferences was completed and revealed her preferences were: -Reading books or magazines. -Listening to music. -Being around animals. -Doing things in groups. -Participating in her favorite activities. -Spending time outdoors. Interview with resident 47 on 6/24/19 at 4:13 p.m. revealed: *She laid in her bed and watched TV during the day. *She liked to go to BINGO. Observations of resident 47 on 6/24/19 from 4:10 p.m through 7:15 p.m., on 6/25/19 from 7:30 a.m. through 6:45 p.m., and on 6/26/19 from 7:30 a.m. through 3:00 p.m. revealed: *She was in her room in her bed. *She was in her room in her wheelchair. -Her TV was on at times. *She went to the dining room for meals. Review of resident 47's 6/25/19 care plan revealed: *She was receptive to: -Music. -Special events. -BINGO. -Manicures. -Visiting with staff. -Volunteers. -Pet visits. -Watching TV, specifically channel 25. Review of resident 47's activity logs revealed: *In (MONTH) 2019 she was not offered activities eleven of thirty days. -On four other days she was only offered the leisure cart and refused it. *In (MONTH) 2019 she was not offered activities on eight of thirty-one days. -On five other days she was only offered the leisure cart and refused it. *In (MONTH) 2019 she had not been offered activities twelve out of twenty-five days. -On six other days she had only been offered leisure cart and refused it. Interview on 6/26/19 at 9:14 a.m. with the activity director revealed: *The leisure cart served a dual purpose that was to promote hydration and one-to-one visits with residents. *There was no set amount of time she spent with residents. *If residents needed assistance with hydration she could spend up to ten minutes in the room. *There was no assessment for determining resident needs for activities. *There was no criteria for one-to-one visits. *Resident 47 went to music activities and stayed in her room. *She indicated resident 47 was visited weekly by a dog that came to the facility. -Documentation showed she was visited by the dog one of four weeks in April, three of four weeks in May, and zero of four weeks in June. -She agreed it should have been documented when activities were refused. Review of the provider's undated Activity Programs policy revealed: Activity programs designed to meet the needs of each resident are available on a daily basis. Review of the provider's undated Individual Activities and Room Visits Program policy revealed: *Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. *Typically a room visit is ten to fifteen minutes in length. Review of the provider's (YEAR) Charting and Documentation policy revealed: All services provided to the resident, progress towards care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of four sampled residents (69) who had dementia and behaviors had received appropriate interventions and documentation to support her psychosocial well-being. Findings include: 1. Review of resident 69's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status assessment score was a ten indicating her cognition was moderately impaired. *Her [DIAGNOSES REDACTED].>-Shortness of breath. -[MEDICAL CONDITION]. -Major [MEDICAL CONDITION] recurrent. -Anxiety disorder unspecified. -Dementia in other disease classified elsewhere with behavioral disturbance. Review of resident 69's nursing progress notes from (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019 revealed: *In (MONTH) (YEAR) she had eighteen of thirty-one days where yelling out behaviors were documented. -Of those eighteen days seven days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 eighteen of thirty-one days there were yelling behaviors documented. -Of those eighteen days two days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 she had one of twenty-five days with documentation of yelling out behaviors. -On that day a non-pharmalogical intervention was used and was successful. Review of resident 69's 6/26/19 care plan revealed: *Seven of eleven interventions for anxiety were implemented on 2/26/19. *Interventions included: -Administer medication per physician orders [REDACTED]. Try non-pharmacological interventions on her; offer the bathroom, offer something to eat and drink, monitor her health status/pain, try and redirect her to an activity in her room or in a group setting. She does like to watch TV sometimes. -Evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs PRN. -Identify and decrease environmental stressors. --Initiated 6/13/18. -Offer 1:1 conversation. -Offer snacks of her liking. -Offer talking books/headphones/MP3 player of her favorite music. -Offer to turn her air conditioner on when she states she is too warm or states she can't breath. -Psych consult and treatment. -Recruit and encourage attendance at activities. -Utilize essential oil diffuser in her room with oils when she requests. -Ensure that her hand held fan is within reach. --Initiated 2/26/19. Interview on 6/26/19 at 2:40 p.m. with certified nursing assistants C and D regarding resident 69 revealed: *She was used to having someone in her room with her. *She got lonely in her room and called out. *She typically did not know what she needed but wanted people to sit with her in her room. *She liked when staff sat with her. *She had two or three people who could come and sit with her during the day. *They would explain to her she needed to use her call light and not yell out. *Sometimes they would turn on her music or TV. Resident 69 had not received appropriate dementia care and services to meet her behavioral and psychosocial needs. Refer to F758 finding 1.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of four sampled residents (69) had appropriate documentation to support the rationale for adding and increasing [MEDICAL CONDITION] medications. Findings include: 1. Review of resident 69's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status assessment score was a ten indicating her cognition was moderately impaired. *Her [DIAGNOSES REDACTED].>-Shortness of breath. -[MEDICAL CONDITION]. -Major [MEDICAL CONDITION] recurrent. -Anxiety disorder unspecified. -Dementia in other disease classified elsewhere with behavioral disturbance. Observation and interview on 6/24/19 at 4:40 p.m. with resident 69 revealed: *She liked the facility. *The staff were nice to her. *She did not display any signs or symptoms of anxiety during the interview. Random observations of resident 69 on 6/25/19 from 7:30 a.m. through 6:45 p.m. and on 6/26/19 from 7:30 a.m. through 4:00 p.m. revealed: *She was sitting in her room in her wheelchair. *Visitors were playing cards with her at times. *Her essential oil diffuser was on at times. *No yelling out was noted. Review of all of resident 69's nursing progress notes from (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019 revealed: *In (MONTH) (YEAR) she had eighteen of thirty-one days where yelling out behaviors were documented. -Of those eighteen days seven days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 eighteen of thirty-one days there were yelling behaviors documented. -Of those eighteen days two days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 she had one of twenty-five days with documentation of yelling out behaviors. -On that day a non-pharmalogical intervention was used and was successful. Review of resident 69's medication administration records revealed: *On 12/26/19 [MEDICATION NAME] 2.5 milligrams (mg) was added at bed time for anxiety. *On 6/13/19 the [MEDICATION NAME] was increased to 2.5 mg twice daily. *She was also receiving scheduled and as needed [MEDICATION NAME]. Review of resident 69's 6/26/19 care plan revealed: *Seven of eleven interventions for anxiety were implemented on 2/26/19. -Those were two months after the [MEDICATION NAME] had been started. *Interventions included: -Administer medication per physician orders [REDACTED]. Try non-pharmacological interventions on her; offer the bathroom, offer something to eat and drink, monitor her health status/pain, try and redirect her to an activity in her room or in a group setting. She does like to watch TV sometimes. -Evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs PRN. -Identify and decrease environmental stressors. --Initiated 6/13/18. -Offer 1:1 conversation. -Offer snacks of her liking. -Offer talking books/headphones/MP3 player of her favorite music. -Offer to turn her air conditioner on when she states she is too warm or states she can't breath. -Psych consult and treatment. -Recruit and encourage attendance at activities. -Utilize essential oil diffuser in her room with oils when she requests. -Ensure that her hand held fan is within reach. --Initiated 2/26/19. Interview on 6/26/19 at 10:33 a.m. with registered nurse [NAME] and the administrator regarding resident 69 revealed: *She had anxiety. *She yelled out when people were not with her. *She was typically okay when people were with her. *Some of the interventions for her anxiety were implemented after she had started the [MEDICATION NAME]. *She had an order for [REDACTED]. *Her family knew she did better when people were with her, and they had hired two individuals to be with her in the afternoons. Interview on 6/26/19 at 2:40 p.m. with certified nursing assistants C and D regarding resident 69 revealed: *She was used to having someone in her room with her. *She got lonely in her room and called out. *She typically did not know what she needed but wanted people to sit with her in her room. *She liked when staff sat with her. *She had two or three people who could come and sit with her during the day. *They would explain to her she needed to use her call light and not yell out. *Sometimes they would turn on her music or TV. Review of the provider's (YEAR) Antipsychotic Medication Use policy revealed: Antipsychotic medications may be considered for residents with dementia but only after medial, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed.

Based on observation, interview, record review, and guideline review, the provider failed to ensure interventions were in place for two of three sampled residents (8 and 60) who developed pressure ulcers. Findings include: 1. Interview on 3/27/18 at 2:11 p.m. with licensed practical nurse (LPN) E and the administrator regarding the list of residents with pressure areas revealed: *Three out of the seven residents had suspected deep tissue injuries (SDTI). -If the area was deep purple or the blister was blood filled, it would indicate it was a deep tissue injury. *The Braden Risk Assessment tools were completed on the computer. *The Pressure Ulcer Scale for Healing (PUSH) tool was completed on paper. *The registered nurses staged the skin areas. *They had identified resident 60's left heel had a SDTI due to the blister being filled with blood. Observation and interview on 3/27/18 at 2:38 p.m. with LPN D and the director of nursing (DON) revealed: *They were completing a dressing change to resident 60's left heel. *The resident was sitting in her wheelchair. *She had a wound vac on the outer side of her left foot. -They were not to do anything with that at that time, as she had just returned from an appointment for it. *The orders were for a foam dressing and [MEDICATION NAME]. *She had a heel protector on her left foot. *The SDTI was approximately the size of a quarter. -It was unopened but dark purple and black in color. *It had developed while she had been a resident in the facility. Observation on 3/27/18 at 4:15 p.m. of resident 60 revealed she was in her room visiting with a visitor. She was sitting up in her wheelchair. Observation on 3/27/18 at 5:14 p.m. of resident 60 revealed she was propelling herself in her wheelchair going to the dining room. Observation on 3/28/18 at 8:39 a.m. of resident 60 revealed she was in therapy. Review of resident 60's medical record revealed: *Her admitted had been 1/17/18. *Her [DIAGNOSES REDACTED].>-Personal history of [MEDICAL CONDITION]. -Unspecified injury of unspecified kidney, initial encounter. -Other [MEDICAL CONDITION]. -Charcot's arthropathy. -[MEDICAL CONDITION], stage 4. -Acidosis. -[DIAGNOSES REDACTED]. -Mantle cell [MEDICAL CONDITION], unspecified site. -Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. -[MEDICAL CONDITION], unspecified. -Diabetes mellitus due to underlying condition with diabetic [MEDICAL CONDITION], unspecified. *Upon admission she had the following skin concerns: -Coccyx: opened area 3 centimeters (cm) x (by) 2.5 cm. -Groin: redness. -Left groin: pin point incision 0.1 cm x 0.1 cm. -Bottom left ulcer: 5 cm x 2 cm x 1.5 cm. -Right foot: lateral aspect, excoriated area 8 cm x 2.2 cm. Review of resident 60's 1/24/18 Braden Scale for Predicting Pressure Sore assessment revealed her score had been seventeen indicating she was at risk for developing pressure ulcers. Review of resident 60's undated care plan revealed interventions for the current left foot ulcer and for potential skin breakdown had been: *Nutrition supplements two times per day initiated on 1/24/18 and revised on 3/11/18 by the registered dietician. *Administer treatment per physician's orders. *Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify physician prn (as needed) initiated on 1/17/18. *For wound care, treat wound as needed. Currently had maggot therapy with nursing staff to reinforce dressing as needed only, initiated on 2/22/18. *Encourage to reposition as needed, use assistive devices as needed, initiated on 1/17/18 and revised on 3/13/18. *Pressure redistributing device on bed/chair per facility protocol, initiated on 3/13/18. *Provide preventative skin care routinely and prn, initiated on 3/13/18. *They had been no interventions for the left heel pressure ulcer or the use of the heel protector. Interview and record review on 3/29/18 from 8:58 a.m. through 9:35 a.m. with LPN E and the DON regarding resident 60 revealed: *The left heel pressure ulcer or SDTI had developed on 3/12/18. *They thought it had developed because her heel rested on the foot pedal. -She had to hold her foot at a different angle due to the wound vac on the side. *She had not had a heel protector on at that time. -She had worn a gripper sock on that foot. -The heel protector had been initiated after the left heel pressure ulcer had been found. *She was not one to lay down throughout the day and was very active. *A progress note indicated the physician had been notified, but there were no physician's orders in her record. *At 9:32 a.m. we went into LPN E's office for her to look as she thought she remembered writing it down. -She could not locate the physician's order for treatment. -The DON stated the process was to write the phone order, put it in the resident's chart, and send off the part to the doctor to have it signed. -They could not find that part. *The left heel pressure ulcer had not been on the care plan. -They both agreed it should have been. 2. Interview on 3/27/18 at 10:22 a.m. with resident 8 revealed: *She knew she had a bedsore on her backside. *She did not know why it had developed. *There had not been any pain. -It had caused her pain once when the adhesive from a dressing was being removed. *She was mostly numb from the waist down; not a new condition. -Staff were aware that she had limited sensation from the waist down. *She was able to readjust herself in her wheelchair, but she forgot because it did not hurt. -Staff did not remind her to readjust herself. -She was able to demonstrate how she could reposition herself but stated that if she were to lean too far forward she would lose control of her upper body and fall out of her wheelchair. Review of resident 8's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. -Early onset cerebellar ataxia. -Muscle weakness. -Need for personal care. -Unspecified dorsalgia. *A 3/23/18 cognition score of fifteen indicated she had intact cognition. *Her initial 3/25/17 Braden Scale for Predicting Pressure Sore Risk score had been nineteen indicating she had no risk of developing pressure ulcers upon admission. Review of her initial 3/25/17 care plan revealed: *A focus area: At risk for alteration in skin integrity related to: impaired mobility fracture of right wrist had the following interventions: -Observe skin conditions with activities of daily living and report abnormalities. -Use pressure redistributing device on bed/chair. -Provide preventative skin care routinely and as needed. *The above focus area had been resolved on 9/1/17 resulting in no care plan to address skin integrity. Review of her Braden Scale for Predicting Pressure Sore Risk scores for the following revealed: *For 7/18/17 and 10/2/17 had scores of sixteen indicating she had been at risk. *For 12/5/17 had a score of twelve indicating high risk. Review of her 12/5/17 Pressure Ulcer Healing Chart form revealed: *A pressure ulcer was now present. *The length times width had been 3.1 to 4. *The exudate amount had been light. *The tissue type had been [MEDICATION NAME]. Review of her 12/5/17 care plan revealed: *She had a stage two pressure ulcer to the right buttock related to decreased mobility and decreased sensation. *Interventions had included: -To assist with repositioning her in wheelchair and when in bed. -Complete a daily body audit. -To receive dietary supplements. -To encourage her to lie down during the day to reduce pressure to coccyx. --She had voiced agreement in lying down one hour per day. -Offer a whirlpool on shower days to help with circulation. -Place a pressure redistributing mattress on the bed and cushion to the wheelchair. Review of the 1/30/18 Pressure Ulcer Healing Chart form revealed the pressure ulcer had resolved. Review of the 12/5/17 care plan revealed it had been resolved on 1/30/18; there had been no care plan for skin integrity. Review of her 2/14/18 care plan revealed: *A new focus area for risk of alteration in skin integrity: related to history of pressure ulcers, impaired mobility, and incontinence had been initiated. *Interventions included: -Barrier cream to perineal area/buttocks as needed. -Encouragement to reposition as needed and use of assistive devices as needed. -Observation of skin condition with activities of daily living and report abnormalities. -Use of pressure redistributing device on bed and chair. Review of the 3/16/18 Braden Scale for Predicting Pressure Sore Risk tool revealed a score of twelve indicating high risk. Review of 3/16/18 Pressure Ulcer Healing Chart form revealed: *A pressure ulcer was now present. *The length times width had been 2.1 to 3. *The exudate amount had been none. *The tissue type had been [MEDICATION NAME]. Review of the 3/16/18 care plan revealed: *She had a stage two pressure ulcer to the right buttock related to decreased mobility and decreased sensation. *Interventions had included: -A daily body audit. -Dressing changes as ordered. -To encourage resident to lie down during the day. -Offer a whirlpool on shower days. -Use a pressure redistributing support surface-air pressure mattress on bed and ish-dish cushion to wheelchair. Interview on 3/27/18 at 3:52 p.m. with RN unit manager A regarding resident 8 revealed: *She had been admitted on [DATE] with no pressure ulcers. *She had not been at risk on her initial assessment but should have been due to decreased feeling/sensation in her lower body, and because she was often wet due to incontinence. *Some preventative measures had been put into place. *She had not been as talkative when she had first been admitted to the facility, so she might not have told her about the decreased sensation in her lower extremities. *She had then developed a stage two pressure ulcer. *A new care plan had been developed to reflect the stage two pressure ulcer to the right buttock related to decreased mobility and decreased sensation. *When the pressure ulcer had closed on 1/30/18 she had stopped the treatment on that day. -She felt she could have continued the treatment longer. *She did not know why there had not been preventative measures in place between 1/30/18, when the first pressure ulcer had been resolved, and 2/14/18 when the skin integrity care plan had been re-initiated. -She agreed there should have been a skin integrity care plan after the first pressure ulcer had healed. Surveyor: Observation on 3/28/17 at 1:45 p.m. of resident 8's pressure ulcer revealed: *She was lying on her left side, and had been in bed lying down to allow pressure relief to coccyx. *The dressing had been removed prior to observation. *The wound on the coccyx was almost healed. *Area was cleansed with wound cleanser. *[MEDICATION NAME] dressing was applied per physician order. Surveyor: Interview on 3/29/18 at 7:23 a.m. with the DON regarding resident 8 revealed: *All newly admitted residents had a skin assessment completed. *A skin care plan would have been developed for every new resident. *It was not as individualized towards her specifically as it could have been. *If a skin issue were to develop another care plan would have been created. *She agreed after the first pressure ulcer had healed they should have created an in-depth, individualized care plan to prevent further pressure ulcers. Observation and interview on 3/29/18 at 9:50 a.m. with resident 8 revealed: *She was lying on her left side in bed with a pillow propped under her back and hip area. *She was watching her television. *She stated she was laying down, because it was good for her bottom. -She had agreed to lie down more often. -She did not like to lay down. -Some days they asked her to lay down, and some days they did not. *She did like whirlpools. *If she sat in her wheelchair too long she could sometimes feel burning in her buttocks. Interview on 3/29/18 at 10:00 a.m. with certified nursing assistant (CNA) B revealed: *When residents had skin issues she was informed through verbal report. *Resident 8 was one resident they encouraged to lay down. -It was over a month ago that she was informed resident 8 needed to lay down every day. *They carried a sheet with residents' names and the type of assistance needed. -The sheets did not address if the residents had skin issues. Interview on 3/29/18 at 10:05 a.m. with CNA C revealed: *She did not usually work on the hall resident 8 resided on. *Verbal report had informed her resident 8 should have been encouraged to lay down. -No other instructions had been given to her regarding her skin interventions. --She was not aware she should have encouraged resident 8 to reposition herself in her wheelchair. 3. Interview on 3/29/18 at 10:10 a.m. with RN unit manager A revealed: *All different nurses were currently completing the Braden Scale for Predicting Pressure Sore Risk tool. *A new MDS coordinator had recently been hired, and she would be doing the quarterly assessments to promote consistency. *Communication to CNAs had been given during the daily verbal report. -There was also a communication book and an area to leave a communication note at the nurses station. Surveyor: Review of the providers (MONTH) 2013 Skin Practice Guide revealed: *The Braden assessment provides data on general pressure ulcer risk and assists clinicians to plan care accordingly. *The subscale scores provide information on specific deficient's such as moisture, activity, nutrition, and mobility. *Those areas could have been specifically addressed in the care plan. *Upon completing an evaluation, the interdisciplinary team develops a patient specific care plan to include prevention and management interventions with measurable goals.

Based on observation and interview the provider failed to ensure: *Meals were served on time for two of two observed meals in the main dining room. *Residents were aware of alternative meal options in one of two dining rooms (main dining room). Findings include: 1. Interview on 3/26/18 at 4:45 p.m. with the administrator revealed the meal times were: *In the rehabilitation (rehab) dining room breakfast was served at 7:30 a.m., lunch at 11:30 a.m., and supper at 5:30 p.m. *In the main dining room breakfast was served at 8:00 a.m., lunch at 12:00 noon, and supper at 6:00 p.m. Surveyor Observation on 3/26/18 from 5:54 p.m. through 6:30 p.m. in the main dining room revealed: *At 6:11 p.m. the serving window was closed. -No meals had been served yet. *At 6:15 p.m. the serving window opened, and the first tray was served. -An unidentified resident refused the tray and asked for soup. --She kept the bread and fruit. -Three out of four of the residents at the same table refused their tray and only took the fruit. Observation and interview on 3/27/18 from 6:13 p.m. through 6:20 p.m. in the main dining room revealed: *At 6:13 p.m. the serving window was opened. -The kitchen had not started serving. *Interview at 6:15 p.m. with licensed practical nurse D regarding resident choices for meals revealed: -They did not ask the residents prior to the meal as to what they would like to eat. -He stated We tried that once and it didn't work. -He said A resident would order fish for supper and then once supper came they would be like I don't want fish, and the server would say Yes you ordered this at breakfast today, and the resident would be like, No I don't want it, I want something else. -He thought it worked better now. --They just took the tray with the main menu meal option and if they did not want it they offered the alternative. *At 6:19 p.m. the serving window opened. *At 6:20 p.m. the first tray was served. Interview with a resident representative revealed: *Supper is routinely not served until 6:20 p.m. or 6:30 p.m. -Supper time was 6:00 p.m. *The resident would request to go back to her room before she received her meal. -He waits till 6:20 p.m. or 6:30 p.m. to take her to supper in hopes they have started serving supper. Surveyor Confidential interview on 3/28/18 at 9:30 a.m. with a group of residents revealed: *They had not gotten choices for meals. *They would be served the main meal option, and if they had not wanted it they would be told what the alternative was and could choose then. -They did not know the alternative options until they turned down the main item. *They would have liked to had choices and had the alternatives posted on the menu. *If they did not want the main dish, alternative meal option, or soup then they had to wait until the rest of the residents were served. *They were not able to recall a time the staff had asked them what they wanted prior to meal services. *The meal was never served at 6:00 p.m. -It was usually 6:20 p.m. or 6:30 p.m. before it was served. *They would like the meal to have been served at the scheduled time. Interview on 3/28/18 at 2:43 p.m. with the administrator regarding meal service revealed and confirmed: *They had complaints of beverages being served warm, so they had changed that system. *The meal was served late due to the change in the beverage system. *She knew the meals were not served on time. *Residents had not gotten a choice for their meals until they refused the main meal item. *The alternative meal option was not listed on the posted menu.

Based on observation, record review, interview, and policy review, the provider failed to update and revise care plans for 3 of 18 sampled residents (8, 28, and 60). Findings include: 1. Review of resident 60's medical record revealed she had developed a pressure ulcer to her left heel on 3/12/18. Her care plan had not been updated to reflect that information. Refer to F686, finding 1. 2. Review of resident 8's 12/5/17, 2/14/18, and 3/16/18 care plans for skin integrity and pressure ulcers revealed a gap in documentation with no preventative interventions for a resident with a history of pressure ulcers. Refer to F686, finding 2. 3. Review of resident 28's undated care plan revealed she: *Was admitted on [DATE]. *Had two hospitalization s, and her last readmitted was 1/31/18. *Had focus areas for: [MEDICAL CONDITION], anticoagulant therapy, insulin r/t (related to) diabetes, diuretic therapy r/t heart failure, and respiratory distress. *Interventions and tasks such as: -Labs as ordered. -Monitor blood sugar, lab results as ordered by physician. -Administer medication pre physician orders. --Interventions and tasks were not resident specific. --Did not have adequate information to provide interventions and methods to monitor above areas. 4. Interview on 3/29/18 at 7:50 a.m. with the minimum data set (MDS) nurse regarding care plans revealed: *The initial care plan was created from the nurses admission assessment. *The first of the year they had started a new process with the care plans where if a resident was admitted and then discharged upon return to the facility, the care plan had to be completely regenerated. -Previous to the first of the year the care plan could be used from before. *The nurses were not comparing the previous care plan to the current care plan. -Interventions and tasks had not been brought forward. -Care plans were not complete. *She stated resident 25's care plan would be corrected today. *She had been reviewing them upon quarterly review, resident 25 had been in and out of hospital, so her care plan had not been reviewed at this time. *She agreed the areas of insulin/diabetes, anticoagulant therapy, cardiac diagnoses, and respiratory distress did not have adequate information to provide interventions and methods to monitor those areas. Surveyor: Review of the provider's (MONTH) (YEAR) Interdisciplinary Care Planning policy revealed: *The patient's (residents) care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. *It also identifies the types of methods of care that the patient should receive. *The care plan should focus on: -Preventing avoidable declines in function. -Managing patient risk factors. -Preserving and building on patient's strengths. -Patient's goals and individualized preferences. -Evaluating care and progress toward goals. -Respecting the patient's right to decline treatment. -Using an interdisciplinary approach. -Involving the patient and family. -Planning to care to meet the patients needs. -Involving direct care staff. *The care plan should: -Include patient-specific measurable objectives and time frames. -Include collaboration with other agencies that provides services to the patient (i.e. hospice or [MEDICAL TREATMENT]) including who provides that service. -Describe the services that the facility is to provide. -Describe any services that the patient should have, but refuses.

Based on record review, interview, and policy review, the provider failed to ensure one of four sampled residents (4) who was an insulin dependent diabetic received her medications as ordered by the physician. Findings include: 1. Review of resident 4's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. Review of resident 4's physician's orders [REDACTED]. *[MEDICATION NAME] 3 units (u) every morning (q. a.m.). *Humalog insulin: -7 units before breakfast. -4 units before lunch. -2 units before supper. *In addition she received additional Humalog insulin on a sliding scale based on a her blood sugars: -201-250: 1 unit. -251-300: 2 units. -301-350: 3 units. -351 or greater: 4 units. *The physician was to be notified if her blood sugars were lower than 60 or higher than 450. Review of resident 4's physician's orders [REDACTED]. Review of resident 4's medical record revealed a 5/15/17 fax had been sent to her physician stating Please note that pt (patient) scheduled Humalog was missed over the weekend. Attached to that fax was a copy of her blood sugars. Interview on 5/16/17 at 10:00 a.m. with registered nurse/unit manager A regarding resident 4 revealed: *On 4/11/17 the resident's Humalog insulin for the noon meal had been changed from 3 to 4 units. *The nurse had yellowed out on the treatment record/medication record the 3 units that meant it had been discontinued. *On the next frame of the medication record she wrote the medication change increasing the noon dosage to 4 units. *She also yellowed out from 5/11/17 noon dose through 5/31/17, 5/11/17 through 5/31/17 for the supper dose, and 5/12/17 through 5/31/17 for the breakfast doses. -When a medication had been yellowed out that meant that order had been discontinued. *She never re-wrote those orders for breakfast or supper, so none of those doses were given. *The resident had missed her insulin for seven meals. *The error was found on 5/15/17 and immediately reported. *The nurse who had made the medication order change had not completed the process correctly. Review of resident 4's blood sugar records from 5/7/17 through 5/15/17 revealed her blood sugars: *Had been checked four times per day. *Her blood sugars were: -Never lower than 60, nor higher than 400. -Between 201 to 250: seven times. -251 to 300: four times. -301 to 350: four times. -350 or greater: four times. *On 5/12/17 her blood sugars ranged from 91 to 198. *On 5/13/17 her blood sugars ranged from 197 to 386. *On 5/14/17 her blood sugars ranged from 198 to 418. *On 5/15/17 her a.m. blood sugar was 145, and her noon time blood sugar was 225. Review of the provider's 8/11/06 professional standard and policy for Orders Management: Medication and Treatment Orders revealed it did not address how to change an order on the medication/treatment record. Interview on 5/17/17 at 11:00 a.m. with the director of nursing regarding resident 4 revealed: *When the above medication change occurred the nurse should not have yellowed out all of the Humalog doses without rewriting them along with the new dosage for the noon meal. -She should have put a bracket ( ) around the change and left the other medications without altering them with the yellow highlighter. *An error had been made, and the resident missed her scheduled medications.

Based on closed record review, interview, job description, and professional standards review, the provider failed to appropriately identify, intervene, and notify the physician of symptoms of [MEDICAL CONDITION] (a severe infection) in a timely manner for one of two sampled residents with an infection (14). Findings include: 1. Review of resident 14's medical record revealed she: *Was admitted from the hospital on [DATE] with a past medical history of [REDACTED].>-High blood pressure. -Sleep apnea that required the use of a C-PAP machine (special breathing machine) with oxygen to have been used only at night. -Mild [MEDICAL CONDITIONS]. -An ulcer on her buttock that had been previously infected and was currently being treated with intravenous antibiotics. *Had not shown any signs [MEDICAL CONDITION] according to her operative note when her ulcer was debrided (the removal of non-living tissue from a wound) dated 3/22/15. *Had been seen by an infectious disease specialist on 3/22/15 while in the hospital and was found to be quite stable from an infectious disease standpoint. Review of resident 14's nursing notes revealed: *On 3/27/15 she was admitted . and lung sounds were noted to be clear. She had no complaints at that time. *On 3/28/15 her oxygen level was documented as slightly low at 92 percent (%) on room air (normal is 94% to 100% and oxygen is usually given when levels fall below 90%). That would have been expected with her [DIAGNOSES REDACTED]. *On 3/29/15 her vital signs continued to remain within normal limits and her urine remained clear. *On 3/30/15 at 11:32 a.m. licensed practical nurse (LPN) A documented the drainage from her wound vac (a vacuum dressing to promote healing in a wound) was serosanguinous (clear with a slightly bloody tinge). There was no odor or other indicators of infection documented at that time. *Later that same day at 6:41 p.m. registered nurse (RN) B documented the resident had large amounts of cloudy yellow drainage (from her Foley catheter) no concerns at this time. *On 3/31/15 at 10:30 a.m. LPN A documented Resident voices she feels warm and a little hard for her to breathe. Temperature 99.6 degrees Fahrenheit (F). Encouraged resident to remove one of her blankets. There was no mention the physician had been notified by nursing staff. *Later that same day at 10:03 p.m. she had large amounts of cloudy-colored urine. On 4/1/15 at 3:30 a.m. LPN E documented the resident's oxygen levels dropped to 86% on room air. She then administered oxygen at two liters per minute (L/min) to the resident. *The primary care physician's office was not notified until 3:30 p.m., twelve hours later the resident's oxygen level had dropped to 86%. A fax was sent stating Need order for oxygen as needed. There was no mention of the increase in the resident's temperature, difficulty breathing, or the cloudy urine that had been documented by staff in the previous two days. *That fax was returned that same day at 4:06 p.m. as order ok and had been signed by physician's assistant F. On 4/1/15 at 9:30 p.m. LPN C documented the resident's oxygen saturation had dropped again while off oxygen to 84%. Oxygen was re-administered. The resident now had a productive cough with green phlegm. They were going to continue to monitor her condition. There was no mention of contacting the physician with that new information. There were no other vital signs noted in the documentation supporting further assessment was made by nursing staff at that time. On 4/2/15 at 7:30 a.m. the resident's vital signs were taken prior to her transfer to a hospital in Sioux Falls for elective surgery to close the ulcer on her buttocks. Those vital signs were as follows: *Blood pressure: 106/60 millimeter of mercury (mm/Hg) (normal range 120/80 mm/Hg). *Temperature: 101.4 degrees F (normal is 98.6 degrees F). *Pulse: 116 beats per minute (bpm)(normal is 60-100). *Breathing rate: 29 respirations per minute (normal is 10-20 breaths per minute). *Oxygen level 93% with the use of 2 L oxygen administered continuously. *She was noted to have a loose productive cough with yellow phlegm and wheezing in her lungs. *No notification to her primary physician had been documented. *On 4/2/15 at 8:10 a.m., nursing documentation showed the resident had left facility per (name) transfer service per gurney for appointment in Sioux Falls and necessary paperwork included with transfer along with C-PAP machine. Resident scheduled for surgery at 2:15 p.m. today. Per paperwork, Dr updated on elevated temperature, lung sounds, etc. Review of the provider's 4/2/15 transfer paperwork to the hospital in Sioux Falls for surgery revealed the 4/2/15 7:30 a.m. abnormal vital signs noted above were written on the transfer sheet . That was the only documented communication to the receiving facility regarding the current health of the resident. Review of the receiving hospital's 4/2/15 emergency room history of present illness report revealed: *The resident arrived for surgery by the transfer service and was taken to the surgical center for preparation. Vital signs were taken. She was given 2 L oxygen by nasal canula (tubing into her nostrils) at that time. Staff noticed large amounts of phlegm. Her oxygen level decreased to 84-85% and oxygen had to be increased to 3 L per min. *The resident's heart rate became higher than normal, she began to sweat, her cough increased, and her temperature was noted to be 101.7 degrees F. She was then suctioned for airway support, switched to an oxygen mask and the level of oxygen was increased to 4 L per minute. *The surgeon was notified, surgery was canceled and she was sent to the emergency room for evaluation. *Evaluation in the emergency room revealed her [DIAGNOSES REDACTED]. Record review and interview on 3/2/16 at 9:30 a.m. with the director of nursing (DON) regarding resident 14 revealed: *None of the nursing staff who had documented the resident's above condition were available for interview at that time. *In reviewing the nurses notes documentation she agreed: -The resident showed no fever, shortness of breath, need for continuous oxygen, or cloudy urine upon admission to the facility as documented by nursing staff from 3/27/15 until 3/30/15. -Nursing staff had not appropriately identified, intervened, or notified the primary care physician completely and in a timely manner for three days from 3/30/15 to 4/1/15. -The surgeon had not been notified of the resident's declining health status appropriately or in a timely manner. *Based on the last vital signs taken prior to departure from the facility and a shared review of the following 2012 [MEDICAL CONDITION] Campaign: International Guidelines for [MEDICAL CONDITION] and Septic Shock Diagnostic Criteria listed below she agreed the resident had displayed signs and symptoms of a [MEDICAL CONDITION] condition prior to leaving the facility. *Per the above criteria a documented or suspected infection and some of the following may include: -Temperature of 100.9 degrees F or higher or less than 96.8 degrees F. -Pulse greater than 90 bpm. -Respiration rate over 20 per minute. -Cloudy urine. -Decreased oxygen levels. *Her expectation was nursing staff should have: -Called the primary care physician in a timely manner. -Included the details of fever and cloudy urine. -Requested the resident be evaluated. Review of the provider's January 2016 RN and LPN job description revealed the nurses' job duties included: *Identifying and reporting changes in resident's condition to the supervisor, physician, and family. *Evaluate the effectiveness of care interventions, identify problems and trends, and develop alternative interventions. Review of the provider's 2014 Care Path, a algorithm document nursing staff followed as professional standard guideline revealed: *An increase in temperature of two degrees over baseline would require physician notification. *A decreased oxygen level less than 90 would require physician notification. *Signs and symptoms of urine infection (cloudy urine) would require physician notification.

Based on record review, interview, and policy review, the provider failed to thoroughly investigate falls for three of three randomly sampled residents (16, 17, and 18). Findings include: 1. Review of resident 16's 1/6/16 incident report revealed he had fallen asleep in his electric wheelchair. He had fallen forward out of his wheelchair onto the floor. The report had not stated if the fall was witnessed or unwitnessed. There had been no documentation of an investigation into that fall. Review of his 1/1/16 Minimum Data Set (MDS) assessment revealed he had a Brief Interview for Mental Status (BIMS) score of 8. A score of 8 to 12 meant there was moderate cognitive (thinking) impairment. 2. Review of resident 17's 1/21/16 incident report revealed he had been found sitting on the floor by a staff member. The resident reported he was going to stand up, and his wheelchair slipped out. He was unable to explain why he was going to stand up. He was wearing gripper socks, and the floor was free from clutter. There had been no documentation of an investigation into that fall. Review of his 2/19/16 MDS assessment revealed he had a BIMS score of 10. A score of 8 to 12 meant there was moderate cognitive impairment. 3. Review of resident 18's 1/31/16 incident report revealed she was found on the floor by a staff member. She was laying on her back on the floor with a skin tear to her right elbow and a goose egg (a swollen area) to the back of her head. There had been no documentation of an investigation into that fall. Review of her 2/3/16 MDS assessment revealed she had a BIMS score of 6. A score of 0 to 7 meant there was severe cognitive impairment. 4. Review of the above incident reports revealed there was no documentation of investigation into the following: *What had been occurring prior to the fall. *When the residents had last been assisted with activities of daily living. *If call lights had been within reach of the resident. *What staff had been working at the time of the fall. *There had been no staff interviews. *If the individual care plans and fall interventions had been followed. *Possible changes in residents' conditions. *What each environment looked like at the time of the fall. *Recent medication changes. Interview on 3/2/16 at 8:50 a.m. with the director of nursing revealed the incident reports were the investigations. There was no other documentation regarding investigations into the above mentioned residents' falls. Review of the provider's November 2011 Patient Protection Abuse, Neglect & Misappropriation Prevention policy revealed staff should have determined the who, what, when, where, why, and how for any occurrences to determine the appropriate course of action and response.

Based on record review, interview, and procedure review, the provider failed to: *Have resident specific parameters for blood glucose (sugar) results for one of five sampled residents (10) who required blood sugar monitoring for diabetes. *Notify the physician for seven of eight abnormal blood sugar levels below 60 milligrams/decilitre (mg/dL) (measure the amount of glucose on the blood) for one of five sampled residents (10) who required blood sugar monitoring. *Document interventions performed to increase eight of eight abnormal blood sugar levels for one of five sampled residents (10) who required blood sugar monitoring. *Document repeat finger sticks to indicate eight of eight abnormal blood sugar levels had improved for one of five sampled residents (10) who required blood sugar monitoring. Findings include: 1. Review of resident 10's medical record revealed: *He had been admitted on [DATE]. *He had a [DIAGNOSES REDACTED]. *His February and March 2016 blood sugar tests had indicated abnormally low blood sugars (60 or below): -2/6/16: 59. -2/10/16: 57. -2/12/16: 52. -2/13/16: 53. -2/17/16: 56. 2/23/16: 60. 2/24/16: 55. 3/1/16: 54. Review of his February and March 2016 electronic medical record progress notes revealed: *No documentation resident 10's physician had been notified of any abnormal blood sugar levels. *No documentation to indicate what interventions had been performed to increase his low blood sugar levels. *No documentation to indicate repeat blood sugar levels had been obtained to monitor the effectiveness of any interventions that might have been performed. Review of his 12/9/15 care plan revealed Review glucometer (device to measure blood sugar) readings and report abnormalities as ordered. Interview on 3/1/16 at 4:25 p.m. with licensed practical nurse (LPN) D revealed regarding resident 10: *He had faxed the resident's physician regarding the low blood sugar that morning (3/1/16) and had just received orders for insulin changes. *When asked about abnormal blood sugar protocol he stated most residents requiring blood sugar monitoring had parameters to indicate when to have notified the physician of abnormal levels. *He had been unable to locate blood sugar parameters for resident 10. *He had given him orange juice the morning of 3/1/16 to increase the blood sugar level when it was 54. *He had not documented the physician had been notified of the abnormal blood sugar. *He had not documented the effectiveness of the orange juice. Interview on 3/1/16 at 5:15 p.m. with the director of nursing revealed:*There was no policy for abnormal sugar levels. The provider used the December 2009 Nursing Procedures - H: [DIAGNOSES REDACTED] Treatment, referenced from the American Dietetic Association. *There was no policy to obtain physician's orders [REDACTED]. *If the physician wanted the resident to have blood sugar parameters he would have written the order. Review of the provider's December 2009 Nursing Procedures - H: [DIAGNOSES REDACTED] Treatment revealed:*For low blood sugars (60 or below) the provider was to Follow physician's orders [REDACTED]. -If alert the resident was to have been given milk or juice. -The provider was to repeat a blood sugar level as ordered by the physician, usually every fifteen minutes. -Documentation would have included repeat blood sugar levels, the resident's condition, vital signs, and other interventions including communication with the physician. Interview on 3/2/16 at 8:45 a.m. with the director of nursing regarding resident 10 revealed she agreed: *The physician had not been contacted for blood sugar parameters. *The physician had not been contacted for seven of eight abnormal blood sugars levels. *There had been no documentation of interventions performed, repeat blood sugar levels, or the effectiveness of the interventions. Review of Patricia A. Potter et al., Fundamentals of Nursing, 8th Ed., Elsevier, St. Louis, Mo., 2013, page 1039 revealed if the blood sugar level was below the target range the nurse was to have: *Continued to monitor the patient. *Checked the medical record to see if there was a medication order for deviations in the blood sugar level. *Contacted the physician if there were no medication orders. *Given a carbohydrate food or drink (to increase the blood sugar level). *Notified the physician of the patient's response to the intervention. *Recorded the blood sugar results and described patient's response to the interventions.

Based on observation, testing, interview, and policy review, the provider failed to maintain hot water temperatures in three of four hallways (southern east-west hallway, middle east-west hallway, and the eastern north-south hallway) containing resident rooms at a non-hazardous level. That failure created a situation of immediate jeopardy that had a potential for causing harm to the residents in those hallways. Notice: On 1/28/13 at 7:10 p.m. notice of immediate jeopardy was given verbally to the administrator of the hazardous hot water temperatures. Testing had revealed hot water temperatures up to 141.9 degrees Fahrenheit (F) in resident rooms. Plan: A plan of correction was provided by the administrator on 1/28/13 at 8:20 p.m. that revealed: *The water temperatures on the water heaters was adjusted to a safe level immediately upon notification of the immediate jeopardy situation. *All of the staff had been notified of the elevated temperatures in the residents' rooms. *The staff were further advised not to use the hot water until the temperature was in a safe range. *Any residents' sinks found with hot water in excess of 125 degrees F was to be turned off. *A list of all the sink temperatures revealed none had needed to be turned off after the water heaters had been turned down. *The water temperatures in the residents' rooms and shower rooms were to be checked every hour for twenty-four hours. *If any of those temperatures were above 125 degrees F when checked the water would be turned off to those fixtures. *After the initial twenty-four hours water temperatures would then be checked every shift in each residents' room for one week. *Training was requested for the new maintenance director. *A plumber would be contacted to install another water heater. On 1/28/13 at 8:30 p.m. the plan of correction was accepted. Observation at 8:35 p.m. revealed the temperature on the out-take thermometer on the 100 gallon water heater was at 80 degrees F. Prior to leaving the facility on 1/28/13 at 9:00 p.m. the surveyors confirmed the immediate jeopardy situation was resolved by the implementation of the written plan of correction. Findings include: 1. Observation and testing of water temperatures on 1/28/13 at 5:40 p.m. revealed the hot water temperature in resident room 100 of the north-west hallway was at 121.8 degrees F. Observation and testing of hot water temperatures on 1/28/13 revealed: *Resident room 108 in the southern east-west hallway was 141.4 degrees F at 5:55 p.m. *Resident room 153 in the middle east-west hallway was 140.1 degrees F at 5:57 p.m. *Resident room 138 in the eastern north-south hallway was 141.9 degrees F at 6:00 p.m. Interview and observation on 1/28/13 at 6:05 p.m. with the maintenance director in the boiler room confirmed: *He had started in the position as maintenance supervisor three weeks ago. *He had known the temperatures had been too hot. *He had been adjusting the temperatures for the past three weeks. *He had maintained the temperatures at a higher than 120 degree F level to provide enough hot water for the buildings needs. *The two water heaters in-use had not provided enough hot water for the provider's needs in the building. *One water heater had a capacity of 60 gallons and the other had a capacity of 100 gallons. *Both water heaters had out-take thermometers that had measured the temperature of the water as it had left the water heater. *The out-take thermometer on the 60 gallon water heater had read 120 degrees F at that time. *The out-take thermometer on the 100 gallon water heater had read 148 degrees F at that time. *The two water heaters were to have provided water for all the residents' needs to include bathing, hand washing, laundry, and dishwashing. *The mixing valve between the two water heaters had been and continued to leak. *Water was leaking onto the floor under the two water heaters causing the bottoms to visibly rust. *The parts to repair the mixing valve had been on order and had not yet arrived. *When the parts arrived and the valve was repaired the water temperatures would still have been a problem. *He believed a third water heater would be needed to meet all of the hot water demands of the facility. Surveyor : 2. Interview on 1/28/13 at 6:20 p.m. with the director of care delivery revealed she was just notified today the water was hot. She was not aware of the water being hot at any time prior to today. Interview on 1/28/13 at 6:22 p.m. with certified nursing assistant (CNA) F revealed for baths and washing at the resident's sink she always mixed hot and cold water and tested the water temperature with her hand before allowing the resident to test the water temperature. She was not aware the hot water was too hot. Interview on 1/28/13 at 6:23 p.m. with CNA G revealed she was not aware the hot water temperature was too hot. She always tested the water temperature by feeling the water before she allowed a resident to test the temperature. Sometimes the residents liked the water hotter than she had set-up and sometimes they felt like it was too warm. She always let the resident decide because everyone's preference was different. Interview on 1/28/13 at 6:25 p.m. with CNA H revealed she had not been told the hot water was too hot. She always tested the water temperature before she allowed a resident to use the water. She had not used a thermometer and tested the temperature by touch. Surveyor : Interview on 1/28/13 at 6:30 p.m. with the administrator confirmed: *She had not known about the elevated hot water temperatures until just a few minutes ago. *She had not known the maintenance director had been adjusting the water temperatures for the past three weeks. *She had not known of the need for another water heater to maintain water temperatures in a safe range and meet the demand for hot water in the facility. *The maintenance director had just notified her a few minutes ago. *The maintenance director had started three weeks ago. *He had not had orientation with the previous maintenance director. *He had been learning the job as he had worked. *None of the other staff or the residents had been alerted to the hot water temperatures prior to today (1/28/13). Interview on 1/29/13 at 5:40 p.m. with the maintenance director confirmed: *He had still been reviewing the books of procedures for maintenance. *He was to be orientated by the corporate maintenance officer. *That orientation had been scheduled for the first part of February 2013. Review of the provider's undated water temperature log directions revealed no hot water temperature limits or guidelines had been included. Review of the maintenance director's 1/9/13 signed job description revealed the maintenance director: *Was to have followed established safety policies and procedures. *Was responsible to have maintained required logs/documentation for water temperatures in accordance with the life safety documentation book. *Coordinated with other departments. *Ensured safe work practices had been used, so others were not put at risk in the workplace. *Reported any safety hazards to his supervisor. Further observation and testing on 1/30/13 at 11:00 a.m. revealed the water temperature in resident room 112 was 111.7 degrees F with this surveyor's thermometer and 111.0 degrees F with the provider's thermometer.