Every finding on record at Prince of Peace Care Center

Based on record review, review of the facility reported incident (FRI), and staff interview, the facility failed to ensure adequate supervision for 1 of 1 closed record (Resident #54) reviewed with a choking incident. Failure to prevent a resident from accessing and ingesting food inconsistent with their diet resulted in a choking incident and death. This citation is considered past non-compliance based on the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 01/06/26. The facility implemented and completed corrective action on 01/12/26. Review of Resident #54's medical record occurred on April 15-16, 2026. Diagnoses included adjustment disorder with mixed disturbance of emotions and conduct, Alzheimer's disease and dysphagia. Physician's orders included IDDSI (International Dysphagia Diet Standardization Initiative) level 4, pureed. An annual Minimum Data Set (MDS), dated [DATE], identified coughing or choking during meals or when swallowing and a mechanically altered diet. Review of the FRI, dated 01/06/26, stated, On 1/6/2026 at approximately 1543, the resident [Resident #54] was observed on the unit while independently mobilizing in his wheelchair, which is his baseline, and engaged in a phone call. Staff noticed he was getting increasingly agitated. He had been agitated throughout the day. At the time of the incident, [Resident #54] took a brownie from the snack cart and placed a piece of the brownie in his mouth. Staff immediately attempted to intervene as he was grabbing the brownie. He started hitting the staff to get them away from him when he took a piece of the brownie into his mouth. The staff member attempted to get the brownie out of his mouth and as she was attempting, and he was striking out, he shoved the entire piece of brownie into his mouth and gulped it down. The Heimlich maneuver was initiated promptly, and staff were directed to call 911. Suctioning was performed . Emergency Medical Services [EMS] arrived approximately 10 minutes after the 911 call. Despite continued life-saving measures, the resident was pronounced deceased by EMS at the scene. During an interview on 04/16/26 at 8:30 a.m., an administrative nurse (#1) confirmed Resident #54 had access to a snack cart and ingested a food item not consistent with the resident's prescribed diet and choked. The administrative nurse (#1) reported food items were arranged openly on the top of the snack cart without protective coverings, allowing residents access to items. The administrative nurse (#1) reported, at the time of the incident, a certified nurse aide (CNA) (#3), an activity staff member, and an administrative staff member were present on the unit. During an interview on 04/16/26 at 9:25 a.m., the CNA (#3) reported leaving the snack cart unattended to converse with another resident. While conversing, Resident #54 appeared visually agitated, self-propelled to the snack cart, and obtained a brownie. The CNA reported responding immediately, but Resident #54 had placed the brownie fully into their mouth and began choking. The CNA (#3) responded immediately and called for assistance. An administrative staff member and the administrative nurse (#3) responded. The CNA (#3) confirmed awareness of Resident #54's prescribed pureed diet, and the brownie was not consistent with the resident's diet order. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for residents who may be affected by the deficient practice as follows: * The facility completed an investigation identifying the problem, factors, root causes, corrective action, identification of other residents at risk, systemic changes, and monitoring. * Provided education to nursing and dietary staff regarding supervision of snack carts and not to leave unattended in resident-accessible areas and must be secured when not in use. * Identified residents with dysphagia, altered diets, and/or behaviors related to food. Residents were reviewed and care plans were updated. * Reviewed facility policy and procedure for snack cart delivery and supervision with nursing and dietary staff. * Implemented covered containers for units with locking mechanisms to prevent or slow residents from obtaining food items not consistent with prescribed diet. * On 01/12/26, all staff educated on choking risks, diet compliance, and the cardiopulmonary resuscitation (CPR)/choking policy/procedure. * Quarterly audits conducted by a Registered Dietitian for residents with dysphagia and behavioral risk factors.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to complete a Significant Change in Status Assessment (SCSA) for 1 of 15 sampled residents (Resident #22) who experienced a significant change in status. Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facilities ability to identify and implement appropriate care approaches. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.20.1), dated October 2025, page 2-24 stated, . A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention . 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. Page 2-27 stated, An SCSA is also appropriate if there is a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement. Any decline in an ADL [activities of daily living] physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individuals functioning. Review of Resident #22's medical record occurred on all days of survey. A Minimum Data Set (MDS) SCSA, dated 11/06/25, identified set-up or clean-up assistance with upper and lower body dressing and personal hygiene. A quarterly MDS, dated [DATE], identified substantial/maximum assistance with upper and lower body dressing and personal hygiene. The facility failed to complete a SCSA related to Resident #22's decline in ADLs. During an interview on 04/15/26 at 2:43 p.m., an administrative nurse (#2) confirmed the facility should have completed a SCSA.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 13 sampled residents (Resident #22 and #23) observed during cares. Failure to practice infection control standards related to hand hygiene and glove usage has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 04/15/26. This policy, dated September 2023, stated, . Times to perform Hand Hygiene are, but not limited to: . Before and after direct resident contact . Before and after entering isolation precaution setting . Before and after assisting a resident with personal cares . Before and after assisting a resident with toileting - wash hands with soap and water . Review of Resident #22's medical record occurred on all days of survey. The current care plan stated, . Enhanced Barrier Precautions r/t [related to] diagnosis of MRSA [Methicillin-resistant Staphylococcus aureus] . Staff are to . sanitize hands after PPE [Personal Protective Equipment] removal. - Observation on 04/13/26 at 12:49 p.m. showed a certified nurse aide (CNA) (#3) entered Resident #22's room, performed hand hygiene, applied a gown and gloves, and assisted the resident to the bathroom. After providing perineal cares, the CNA (#3) removed the gown and gloves and assisted Resident #22 into a recliner. The CNA then proceeded to care for another resident without performing hand hygiene. The CNA (#3) failed to perform hand hygiene after assisting Resident #22 with cares and before assisting another resident. -Observation on 04/14/26 at 9:29 a.m. showed a CNA (#4) entered Resident #23's room to assist with toileting. The CNA performed hand hygiene, applied gloves, removed Resident #23's soiled brief, placed it in the trash and removed the soiled gloves. Without performing hand hygiene, the CNA (#4) applied new gloves, assisted Resident #23 to stand and performed perineal care. The CNA (#4) removed the soiled gloves, applied a new brief and pulled up Resident #23's pants. Without performing hand hygiene, the CNA (#4) applied new gloves and transferred Resident #23 into a wheelchair. The CNA then used wipes to clean stool from the toilet seat and removed the soiled gloves. The CNA failed to perform hand hygiene between glove changes. During an interview on the afternoon of 04/15/26, an administrative nurse (#1) confirmed staff should perform hand hygiene between residents and after removing soiled gloves and applying clean gloves.

Based on review of the facility reported incident (FRI) investigation and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell from a mechanical lift. Failure to ensure proper connection of the sling safety loops to the lift resulted in a fall with injury to Resident #1 and has the potential for falls/injuries for all residents who utilize a mechanical lift. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.Findings include: The surveyor determined a deficient practice existed on 12/15/25. The facility immediately implemented corrective action, completed corrective action on 12/16/25, and continued with staff education and monitoring.Review of Resident #1's medical record occurred on 12/22/25. The care plan stated, receives hospice services . Utilize the Hoyer lift with A2 [assist of 2 staff] for transfers. The FRI investigation, dated 12/17/25, stated, . On 12-15-25, [Resident #1's initials] was transferred using a full-body mechanical lift in accordance with her care plan. Two CNAs [certified nurse aides] and an LPN [licensed practical nurse] were present in her room. The two CAN's (sic) were assisting with the transfer.While elevated in the sling, [Resident #1's initials] shifted her weight. At that time, a loud pop was heard, and a sling loop disengaged from the lift bar. The lift bar shifted to a perpendicular position, and the resident fell from the sling to the floor. [Resident #1's initials] sustained a laceration to the forehead requiring staple closure. [Resident #1's initials] was transferred via [by] ambulance to [hospital name] for evaluation and treatment, where the forehead laceration was closed with staples. Following a thorough investigation, including reenactments of the transfer, interviews with involved staff, and review of the incident, it was determined that the resident's leaning during the transfer caused the right upper sling strap to slide along the moveable strap attachment bar. This movement resulted in the attachment bar rotating perpendicular to the main crossbar. This configuration along with poor bodily control caused the upper sling strap to slide on the moveable strap attachment bar causing it to become perpendicular to the main crossbar. As a result, the sling strap disengaged from the bar, causing the resident to began moving toward the floor, hitting her head. Upon entry to the room for post-incident assessment, the resident was observed on the floor and sling pad attached to the lift with the upper right loop of the lift pad unattached to the bar.A physician's progress note, dated 12/15/25, stated, . presents [to] the emergency room with EMS (emergency medical services) for evaluation of sustaining a laceration to her left forehead after falling from a Hoyer lift at a skilled nursing facility. Laceration was closed with 7 staples.Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for all residents who may be affected by the deficient practice as follows:* Completed an investigation into Resident #1's fall.* Education provided to all CNAs and nurses working on 12/15/25 regarding the policy/procedure for mechanical lifts.* All other CNAs and nurses will be educated prior to the start of their next shift.* The lift and sling used during transfer were immediately taken out of use until full inspections could deem the equipment in working order. The inspection found the lift and sling to be in good working order. * Mechanical full-body lift transfer audits were initiated and will continue for a minimum of six weeks. * The resident was assessed by physical therapy for appropriate sling selection and mechanical lift procedures. No changes or additional recommendations were identified. * The safe lift Stop for Safety Process was implemented and incorporated into ongoing audits for all staff completing resident transfers utilizing any lift. * The interdisciplinary team has begun a review of all residents who utilize mechanical lifts to assess safety and appropriateness of current interventions. Additional care plan interventions were added as necessary based on individual resident needs. * All mechanical lift sling sizes were reviewed and reassessed for accuracy and appropriate resident fit.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 1 of 8 residents observed during medication administration (Resident #13). Three medication errors occurred during staff administration of 30 medications, resulting in a 10% error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions. Findings include: Review of policy titled Insulin Administration- PEN occurred on 11/22/22. This policy, revised January 2018, stated, . H. remove the cap from the pen and wipe the rubber stopper with an alcohol wipe. I. Attach a needle to the insulin pen following manufacturer's guidelines. J. Perform an air shot [prime]. K. Turn dose selector to 2 units. L. Holding pen with the needle point up, tap the cartridge. 1) This moves any collected air to the top of the cartridge. M. Press the injection button all the way in until the dose selector is back to 0. 1) A stream or drop of insulin should appear at the tip of the needle. 2) If no drop appears, follow specific pen guidelines for additional testing. Review of Resident #13's medical record occurred on 11/22/22. Orders included: * 8/24/2022, [MEDICATION(S)] [MEDICATION(S)] U-100 Insulin (insulin [MEDICATION(S)]) 100 unit/milliliter (ml), subcutaneous, 5 units, once a day. * 09/14/2022, [MEDICATION(S)] KwikPen U-100 Insulin (insulin [MEDICATION(S)]) 100 unit/ml, subcutaneous, 76 units, once a morning. Observation of medication administration on 11/22/22 at 8:55 a.m. for Resident #13, showed a nurse (#2) prepared a [MEDICATION(S)] insulin pen. The nurse (#2) wiped the tip of the insulin pen with an alcohol swab, applied a needle, and without removing the needle cap dialed the pen to two units and held the pen horizontally to prime the pen. The nurse (#2) dialed the pen to 17 units which was the amount left in the pen. The nurse (#2) obtained a new [MEDICATION(S)] insulin pen, wiped the tip of the insulin pen, applied a needle, and without removing the needle cap dialed the pen to two units, held the pen horizontally, primed the pen and dialed the syringe to the remaining units to equal 76 units as ordered. The nurse (#2) obtained a [MEDICATION(S)] insulin pen, wiped the tip of the insulin pen, applied a needle, and without removing the needle cap dialed the pen to two units, and held the pen horizontally to prime the pen before she dialed the pen to five units as ordered. The nurse failed to follow the facility policy by priming insulin pens held horizontally versus vertically. During an interview on 11/23/22 at 11:45 a.m., an administrative staff member (#1) stated the nurse should follow the manufacturer's instructions and facility policy for priming of insulin pens.

1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 1 supplemental resident (Resident #12) observed receiving eye drops. Failure to wait five minutes between administering eye drops per physician's orders may cause a decreased efficacy of the eye medication. Findings include: Review of the facility policy titled Eye Drop Administration occurred on 8/31/21. This policy, revised January 2018, stated, . When two or more eye drops must be administered into the same eye, allow three minutes between each drop. This wait time is required whether it is the same medication or a different medication. Review of Resident #12's medical record occurred on 8/30/21. The physician's order stated: * [MEDICATION(S)] (non-steroidal anti-[CONDITION(S)] eye drop) special instructions: one drop to left eye, make sure that eye drops are given at least 5 minutes apart * Dorzolamide-[MEDICATION(S)] (eye drops to reduce pressure in the eye) one drop to both eyes special instructions: Give eye drops at least 5 minutes apart from each other Observation on 8/31/21 at 10:13 a.m. showed a licensed nurse (#2) administered Resident #12's eye drops. The nurse administered the [MEDICATION(S)] eye drop to the left eye, looked at her watch, and stated I will wait two minutes. The nurse (#2) waited approximately 90 seconds and administered the Dorzolamide-[MEDICATION(S)] to both eyes. The nurse failed to wait five minutes between administering the eye drops. During an interview on the afternoon of 8/31/21 an administrative nurse (#1) stated she expected staff to follow physician's orders and wait five minutes between administering eye drops. 2. Based on record review, review of facility policy, and staff interview, the facility failed to complete safety checks as indicated for 1 of 1 sampled residents (Resident #30) requiring 15-minute safety checks. Failure of facility staff to complete 15-minute safety checks puts the residents at risk for self injury, hospitalization , or death. Findings include: Review of the facility policy titled Interventions for Those at Risk of Suicide occurred on 08/30/21. This undated policy stated, . If a resident's statements or actions reflect SI [suicidal ideation] at any time, immediate actions are taken to maintain safety . Attachment C: . The resident is 1) ambivalent regarding their intent to engage in suicidal behavior, OR, 2) has expresses a vague plan, or one that is not imminent . OR, 3) has describes a plan that the resident is clearly incapable of implementing . Implement individualized safety checks. Review of Resident #30's medical record occurred all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS, dated [DATE], identified no cognitive impairment and antidepressant use. Review of nursing notes identified the following: * 06/07/21 at 11:31 a.m., . Suicide precautions implemented, resident on 15 minute checks. Call light will be removed from the room, staff exploring best options for resident to notify staff . * 06/09/21 at 10:47 a.m., . Resident mood has improved, resident reports feeling better and that she has no plan for self harm. Resident will be removed from 15 minute check. * 06/18/21 3:35 p.m., 15 MINUTE CHECKS: Documentation done entire shift. The medical record lacked documentation of completed 15-minute checks as stated in the nursing notes. During an interview on 08/31/21 at 5:00 p.m., an administrative nurse (#1) agreed the medical record lacked documentation of the completed 15-minute checks.

Based on observation and staff interview, the facility failed to ensure timely posting of nursing staff data in a prominent place accessible to residents, families, and visitors for 2 of 3 days of survey (August 30-31, 2021). Failure to post staffing data in a timely manner and in a prominent place does not allow residents, families, and visitors knowledge of the number of licensed and unlicensed staff directly responsible for resident care on each shift. Findings include: Observation of the daily staffing report occurred on all days of survey. Observation showed the daily nursing staff data posted in a closed binder, hanging on a wall adjacent to the dining room, in a hallway leading to the kitchen and laundry. Facility staff failed to post nursing staff data regarding the number of licensed and unlicensed staff directly responsible for resident care at the beginning of each shift on August 30th and 31st, 2021. During an interview on 08/31/21 at 5:00 p.m., an administrative nurse (#1) confirmed she expected facility staff to post the daily staffing report in a timely manner.

Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 3 of 11 sampled residents (Resident #2, #18 and #21) observed during personal care and during 1 of 3 days of medication administration (11/05/19). Failure to provide infection control practices related to hand hygiene/glove usage during cares and/or medication administration has the potential for transmission of microorganisms to residents and staff. Findings include: Hand Hygiene During Perineal Care Review of the facility policy titled Hand Hygiene occurred on 11/06/19. This policy, dated (MONTH) (YEAR), stated . Times to Perform Hand Hygiene are, but not limited to . Before and after assisting a resident with personal cares . Before and after assisting a resident with toileting . - Observation on 11/03/19 at 3:58 p.m. showed Resident #2 stood and began attempted to perform his own perineal cares following a bowel movement (BM). Certified nursing assistant (CNA) (#8) donned gloves and completed Resident # 2's perineal cares. The CNA (#8) removed her gloves, assisted resident to sit down and offered him fluids. The CNA (#8) failed to perform hand hygiene after providing perineal care, prior to offering the resident fluids, and prior to exiting the room. The CNA (#8) failed to offer/assist Resident #2 with his own hand hygiene. - Observation on 11/04/19 at 9:22 a.m. showed two CNAs (#1 and #2) assisted Resident #21 to the bathroom using a sit-to-stand lift. While seated on the toilet, Resident #21 repeatedly touched in and around her nose. One of the CNAs (#1) offered the resident a tissue, but the resident refused. Observation showed Resident #21 was incontinent and also voided and had a bowel movement in the toilet. The other CNA (#2) donned gloves, threw the resident's wet brief in the garbage, performed perineal care, and removed her gloves. After placing a clean brief and pulling up the resident's pants, the CNAs transferred Resident #21 into her recliner using the sit-to-stand lift. One of the CNAs (#2) covered the resident with a blanket, gave her the call light, left the resident's room, and immediately entered another resident's room. The CNA (#2) failed to perform hand hygiene after providing Resident #21's perineal cares. The CNAs (#1 and #2) failed to offer/assist Resident #21 with her own hand hygiene. - Observation on 11/04/19 at 3:49 p.m. showed two CNA's (#2 and # 7) completed Resident #18's perineal cares. The CNAs (#2 and #7) failed to perform hand hygiene after providing perineal cares and prior to exiting the room. During an interview on 11/06/19 at 9:38 a.m., an administrative nurse (#3) stated that she would expect staff to perform hand hygiene prior to and after completing perineal cares, when handling secretions, prior to and after meals, and on any resident contact. Hand Hygiene During Medication Pass - Observation on 11/05/19 at 4:39 p.m. showed a nurse (#6) administering medications on the memory care unit. The nurse (#6) went from one resident's room to another touching personal items in each resident's room. The nurse (#6) failed to perform hand hygiene before and after administering medication, and/or prior to exiting each room. During an interview on 11/06/19 at 9:55 a.m., an administrative nurse (#3) stated staff should be performing hand hygiene prior to and after administering medications and between residents.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide necessary treatment and care for 1 of 2 sampled residents (Resident #44) with skin breakdown. Failure to assess, monitor, and implement interventions may result in delayed healing of skin breakdown or the development of additional skin breakdown. Findings include: Review of the facility policy titled Skin Risk Assessment occurred on 11/06/19. This undated policy stated, . If a pressure ulcer or any other type of wound is observed, a separate Skin Event Form and Pressure Ulcer/Wound Record Form will be initiated for each pressure ulcer or other type wound by a licensed nurse. Licensed nurses will conduct a full body inspection of every resident's skin at a minimum weekly. Nursing Assistants will continue to observe resident's skin daily; notifying licensed staff of any skin issues. Review of Resident #44's medical record occurred on all days of survey. A skin assessment, dated 10/10/19, identified total dependence for bed mobility, no skin problems, and a Braden score of 13 (indicating a moderate risk for the development of pressure ulcers). Resident #44's current care plan identified, . Resident is at risk for pressure ulcers R/T (related to) requires assistance with bed mobility. Has air flow mattress in place at this time. Report any signs of skin breakdown (sore, tender, red, or broken areas). Observation on 11/04/19 at 11:55 a.m. showed two certified nursing assistants (CNAs) (#2 and #9) gave Resident #44 a bed bath. Observation showed a blackened scab with surrounding redness to the resident's left toe, a raised reddened area to the right toe, and redness/irritation to the resident's left lateral ankle. The CNAs placed a small cushion between the resident's ankles to prevent his left ankle from resting on the top of his right foot. Observations throughout the survey showed Resident #44 in bed. At times, staff placed a small cushion between his ankles and at other times, no cushion was present. Resident #44's care plan lacked information related to this intervention. A nurses' note, dated 11/04/19 at 10:45 a.m., stated, . Res (resident) in bed, eyes closed, but responding verbally with repetitive speech, often non-nonsensical (sic). Res responded no when asked about pain, . L (left) great to has a pea sized black scab. No new symptom concerns. The medical record lacked evidence of assessment/monitoring of the resident's skin breakdown/redness prior to this nurses' note. During an interview on 11/06/19 at 10:13 a.m., a supervisory nurse (#3) stated CNAs are expected to report skin issues to the nurse, and staff should monitor Resident #44's skin breakdown.

Based on record review and staff interview, the facility failed to ensure prompt treatment of [REDACTED].#19). Failure to promptly assess and monitor residents with symptoms of a UTI may result in delayed treatment and unnecessary discomfort. Findings include:Review of Resident #19's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Nurses' notes identified the following: *8/16/2019 at 7:06 a.m.: . URINARY: Resident complained to CNA (certified nursing assistant) that she had some burning with urination. No blood noted. Resident's urine normally smells strong. Temp 97.3. Water given throughout the night. AM blood sugar 125. *8/17/2019 at 9:46 p.m.: . STATUS: Resident complains of burning urination, said that she experienced it since last night. Encouraged fluids, will monitor over the weekend. *8/19/2019 at 10:26 a.m.: . Reviewed nursing documentation from the weekend regarding c/o (complaints of) dysuria (painful urination) and strong smelling urine. Resident last treated for [REDACTED]. Currently afebrile; however, will monitor vital signs for the next 3 days for any changes or elevation in temperature. Fax sent to physician regarding status. Resident #19's medical record lacked further evidence of monitoring/assessment or recording of vital signs except the temperature and blood sugar recorded on 08/16/19. *8/19/2019 at 10:16 p.m.: . Received order from (provider name). Collect UA (urinalysis) with microscopic with reflex to culture and will treat based on results. Please notify clinic if resident develops a fever. *8/20/2019 at 6:26 a.m.: . UA was collected this morning via straight cath (catheter). *8/20/2019 at 5:57 p.m. (five days after Resident #19 first complained of dysuria): . Called daughter to let know that resident will be starting Keflex (an antibiotic) 500 mg (milligrams) twice a day (BID) for 5 days for UTI. *8/21/2019 at 1:45 p.m.: . Preliminary UA report back. Shown mixed flora present, subculture preformed. *8/21/2019 at 6:13 p.m.: . States has urinary burning around urethra with urination. On Keflex with no adverse reaction noted. Taking extra fluids offered. *8/23/2019 at 10:12 a.m.: . Lab RESULTS: Urine Culture (final) - Pseudomonas Aeruginosa, 90,000-100,000 CFU/ML (colony-forming units per milliliter) Dr faxed: Patient was prescribed Keflex 500mg BID X 5 days. This should treat her UTI well: Notify clinic if she still has dysuria. During an interview on the morning of 11/06/19, a supervisory nurse (#3) stated staff should have done vitals/monitored the resident when she was symptomatic.

MEDICATION STORAGE Based on observation, review of facility policy, and staff interview the facility failed to store all medications in a secure manner 1 of 3 days of survey (11/04/19) and were left unattended. Failure to store all medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled, Storage of Medications, Controlled Medication Storage occurred on 11/06/19. This policy, revised (MONTH) 2014, stated, . Schedule II controlled medications are stored separately from other medications under double lock . the access system to separately stored controlled medications is not the same as the system giving access to other medications . Review of the the facility's policy titled Administering Medications occurred on 11/06/19. This policy, revised (MONTH) 2014, stated . Medication cart is to be locked at all times when unattended . Observation of the Subiaco Unit's medication cart took place on 11/04/19, at 5:04 p.m. A nurse (#4) opened a single locked drawer in the medication cart and showed the surveyor a schedule II medication cartridge containing [MEDICATION NAME]. When asked questions pertaining to storage of [MEDICATION NAME], the nurse (#4) admitted removing the controlled medication out of the double locked medication cabinet at the start of the shift and placed the cartridge in a single locked drawer in the medication cart for easy access during medication pass. During an interview on 11/06/19 at 9:55 a.m., an administrative nurse (#3), confirmed staff are to store schedule II medications such as [MEDICATION NAME] under double locks at all times. On 11/04/19 at 4:37 p.m., observation showed a nurse (#4) left an unlocked medication cart sitting in between the dining and living areas on the Subiaco Memory Care Unit. A resident (#45) stood next to the medication cart, attempting to open the top drawers on the cart. At 4:47 p.m., a staff nurse (#5) walked by and observed Resident (#45) touching different drawers on the medication cart and re-directed the resident to the dining room. A nurse (#4) returned to the cart and was asked if the cart had been left unlocked and unattended. Both nurses (#4) and (#5) confirmed staff should lock the cart when unattended.

Based on policy review, record review, and staff interview, the facility failed to assess each resident's pneumococcal status and provide education to residents and/or their legal representatives regarding the benefits and potential side effects of receiving the vaccination for 1 of 5 sampled residents (Resident #6) reviewed for immunization status. Failure to offer pneumococcal vaccine to all residents, provide education to residents and their legal representatives, and document the administration or refusal has the potential for non-immunized residents to contract pneumonia and also spread the infection to other residents, visitors, and staff. Findings include: Review of the facility policy titled Pneumococcal Vaccines for Residents occurred on 11/06/19. This policy, dated (MONTH) (YEAR), stated, . Policy: It is the policy of BHS (Benedictine Health System) communities to provide education and administration of the PPSV 23 ([MEDICATION NAME] vaccine) and PCV13 (Prevnar vaccine) to the residents of the facility according to CDC (Centers for Disease Control and Prevention) recommendations. Procedure: 1. Upon admission and throughout a resident's stay, education monitoring, and administration of Prevnar 13 and/or [MEDICATION NAME] 23 will be provided. Review of Resident #6's medical record occurred on all days of the survey. The resident was admitted on [DATE]. The record showed Resident #6 had not received either of the pneumococcal vaccinations. The record lacked evidence the facility assessed the resident's pneumococcal immunization status and/or provided education to the resident and/or their legal representative. The facility failed to follow their policy for pneumococcal vaccine administration. During an interview on 11/06/19 at 9:45 a.m., an administrative nurse (#3) verified the facility failed to assess Resident #6 for pneumococcal immunizations.

Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures For Long Term Care Services, and review of facility policy, the facility failed to complete a status change assessment for 1 of 2 sampled residents (Resident #17) with a newly diagnosed mental illness. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASARR Provider Manual page 13 states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Ascend (contracted service provider for screening process)to update the Level l screen for determination of whether a first time or updated Level ll evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability (referred to in regulatory language as related conditions or RC)) was not identified at the Level l screen process, and that condition later emerged or was discovered . Review of the facility policy titled Admission Prescreening for Individuals with Mental [MEDICAL CONDITION] or Mental Illness - ND occurred on 10/10/18. This policy stated, . 7. The nursing facility staff must notify the state mental health authority . promptly after a significant change in the mental or physical condition of a resident who has a mental disorder . for resident review. Review of Resident #17's medical record occurred on all days of survey. The record showed an initial PASARR was completed in (MONTH) 2014 and identified no PASARR Level ll needed. The facility added a [DIAGNOSES REDACTED]. The record lacked evidence of an updated Level l screening/change in status assessment with these added diagnoses.

Based on observation, review of facility policy, record review, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 14 sampled residents (Resident #27 and #35). Failure to revise the care plan limited staff's ability to communicate care needs and ensure continuity of care for each resident. Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered occurred on 10/10/18. This policy, dated (MONTH) (YEAR), stated, . The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan will: . Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Incorporate identified problem areas; Incorporate risk factors associated with identified problems; . Reflect treatment goals, timetables and objectives in measurable outcomes; . Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan: . When the resident has been readmitted to the facility from a hospital stay. -Review of Resident #27's medical record occurred on all days of survey and identified the following: * 08/05/18 at 4:07 p.m.: admitted to (hospital). Aspiration pneumonia. * 08/06/18 at 11:42 a.m.: Spoke with (hospital RN). Resident continues on AB (antibiotic) therapy for suspected pneumonia. * 08/09/18 at 8:30 a.m.: . Lungs with LLL (left lower lobe) crackles, some clearing noted with deep, breath, and cough. Was not noted to cough during eating. * 08/16/18 at 12:17 a.m.: Resident has frothy saliva at mouth at this time. Repositioned at (sic) she coughed up small amount of bright red blood. O2 is on at 3 l/nc (liters per nasal cannula). Sats (saturation) 85. Resident has a moist congested cough. * 09/15/18 at 12:57 p.m.: It was reported to this nurse that resident had an episode at the dinner table where she turned really red and coughed/spit up a good amount of food. When questioned resident noted that she was having some trouble swallowing. Lung sounds are dim and shallow. Will continue to monitor for s/sx (signs and symptoms) of aspiration following event. * 09/15/18 at 7:05 p.m.: Resident assessed for s/s of aspiration. Lung sounds clear after clearing throat. * 09/17/18 at 10:21 a.m.,: Reviewed resident coughing spell over the weekend. Currently being evaluated by speech therapy. * 09/21/18 at 11:00 p.m.: . occ. (occasional) cough while earting supper meal . * 09/30/18 at 10:39 a.m.: Upper lobes have clear air exchange bilaterally. Lower lobes are very diminished, very little air flow heard. * 09/30/18 at 2:10 p.m.: . Resident impulsive with intake needing firm redirection . * 09/30/18 at 7:09 p.m.: . Resident quickly ate the soup and than began coughing needed to be reminded not to eat so fast. Because of her coughing ended up removing the soup . Takes liquids quickly and after them will again cough. * 10/02/18 at 8:44 p.m.: . lungs (sic) sounds have crackles in them bilaterally. * 10/03/18 at 6:26 a.m.: Lungs aerate diminished with moist crackles noted bilaterally . Coughing up green colored sputum. * 10/04/18 at 2:00 p.m.: . Has a moist harsh productive cough with lt (light) green sputa (sic) noted on sheets. Lung sounds are diminished to lower lobes. A Speech therapy note dated 08/17/19 at 2:42 p.m., identified a treatment [DIAGNOSES REDACTED]. The current care plan stated, . swallowing problems r/t (related to) aggressive eating pattern . encouraged to avoid talking while eating, eat slowly alternating bites and sips. Resident occasionally laps into an eating pattern where she eats very fast therefore increasing risk of choking/aspiration . During an interview on 10/10/18 at 11:09 a.m., an administrative nurse (#1) verified resident #27 should be care planned for lung assessment and respiratory concerns. The facility failed to address and implement interventions related to resident #27's chronic respiratory concerns. - Review of Resident #35's medical record occurred on all days of survey. The Quarterly Minimum Data Set ((MDS) dated [DATE] identified staff observed Resident #35 to have vocal complaints, and facial expressions of pain or possible pain daily. The MDS indicated the resident received PRN (as needed) pain medication. The Annual MDS, dated [DATE], identified the resident as having protective body movements 1-2 out of 7 days regarding pain. A physicians order, dated 06/18/18 stated, . Tylenol . tablet 325 mg (milligrams) . give 650 mg (2 tablets) oral Special Instructions: For pain or fever. Twice A Day - PRN. The progress notes showed the following: * 08/25/18 10:43 a.m., Resident is alert and is not able to verbalize her needs. Noted resident had difficulty with walking this morning and was given PRN Tylenol 650 mg which was somewhat effective as she ambulated slightly better after breakfast. * 06/10/18 11:49 a.m., PAIN: CNA (certified nurse aid) states resident irritable and slow/stiff moving with bathroom prior to breakfast when questioned to (sic) pain stated all over. PRN Tylenol given. More relaxed and moving more easily after meal. Review of Resident #35's care plan failed to address and implement interventions related to the resident's pain.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure the availability of emergency medications to meet the needs of residents in 1 of 1 emergency medication box. Failure to ensure that emergency medications are available for residents in the event of an emergency has the potential to result in adverse effects for the resident. Findings include: Review of the facility policy titled Emergency Drug Box (Supply) occurred on [DATE]. This policy, dated (MONTH) 2014, stated, Purpose: 1. To obtain drugs on a prompt and timely basis. 2. Immediate availability of emergency drugs. Policy: . 2. A portable emergency drug box will be available for immediate administration of a medication not otherwise obtainable in the time required. Procedure: . 5. The pharmacy will be notified that the emergency box has been opened prior to the next scheduled delivery, but at least within 24 hours after breaking the seal. Observation of the medication room occurred on [DATE] at 8:03 a.m. with an administrative staff member (#1). A list of medications for the emergency medication box identified [MEDICATION NAME] (medication used to block the effects of an opioid pain medication overdose) with an expiration date of (MONTH) (YEAR). Observation of the medications in the box showed the absence of [MEDICATION NAME]. The administrative staff member (#1) confirmed the absence of the medication. During an interview later in the morning on [DATE], the administrative staff nurse (#1) provided information to verify the [MEDICATION NAME] expiration date as (MONTH) (YEAR), not (MONTH) (YEAR), and provided a Pharmacy Order Form dated [DATE], identifying the expired [MEDICATION NAME] and pharmacy replacement request. The facility failed to ensure the pharmacy promptly replaced the expired [MEDICATION NAME].

CONTRACTURES 1. Based on observation, record review, and family and staff interviews, the facility failed to accommodate the needs of 1 of 1 sampled resident (Resident #1) who required an assistive device to prevent contractures. Failure to apply a wedge between Resident #1's legs while in bed placed her at risk for contractures and/or skin breakdown. Findings include: During an interview on 10/10/17 at 4:00 p.m., when asked questions pertaining to Resident #1's physical condition (comfort, positioning, etc.), a member of her family (A) expressed concern, stating, (There) should be a pillow between her legs. Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and extensive assistance of two persons required for bed mobility. The current care plan stated, . use wedge and place between resident's legs to prevent contractures to legs. The care card further stated, . put wedge between legs when in bed . Observations on 10/09/17 at 4:13 p.m., 10/10/17 at 1:20 p.m., and 10/11/17 at 9:45 a.m., showed Resident #1 lying on her right side in bed. On all three occasions, facility staff failed to place a wedge between Resident #1's legs prior to exiting her room. During an interview on 10/12/17 at 9:45 a.m., an administrative nurse (#1) reported, (Resident #1) was having hip pain due to how she positions her legs. We thought the wedge would help to reduce her pain. (Facility staff) should have put the wedge between her legs as care-planned. CALL LIGHT 2. Based on observation, review of facility policy, and staff interview, the facility failed to accommodate the needs of 2 of 12 sampled residents (Resident #10 and #11) who requested assistance. Failure to respond to call lights in a timely manner may result in the loss of dignity and poor quality of care for all residents who reside in facility. Findings include: Review of the facility policy titled Answering the Call Light occurred on 10/12/17. This policy, revised October 2010, stated, . If you have promised the resident you will return with an item or information, do so promptly. if assistance is needed when you enter the room, summon help by using the call signal. - Review of Resident #11's medical record occurred on October 11-12, 2017. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition and extensive assist of two required for transfers. During an interview on 10/09/17 at 2:30 p.m., when asked if staff respond to her needs in a timely manner, Resident #11 stated, I wait sometimes. They come in, turn the light off, and leave. - Review of Resident #10's medical record occurred on October 11-12, 2017. [DIAGNOSES REDACTED]. A significant change MDS, dated [DATE], identified moderately impaired cognition and extensive assist of two required for transfers. Observation on 10/11/17 at approximately 9:45 a.m. showed a nurse (#3) entered Resident #10's room and turned off his call light. The nurse (#3) told Resident #3 he required the assistance of two certified nursing assistants (CNAs) and assured him they would be in shortly. During an interview on 10/11/17 at approximately 10:00 a.m., a nurse (#2) stated once the call light is turned off, the CNAs would not know a resident needs assistance unless a staff member told them so. The nurse (#2) then enter Resident #10's room and asked him what he needed, and reported he wanted to lay down. Observation on 10/11/17 at 10:07 a.m. showed two CNAs (#4 and another unidentified CNA) entered Resident #10's room and assisted him to lie down. Resident #10 received assistance approximately 22 minutes after pushing his call light. During an interview on 10/11/17 at 10:46 a.m., one of the CNAs (#4) reported she was just following her morning routine of laying the residents down, and was not aware Resident #10's call light had been on earlier.

Based on record review, the facility's mechanically altered diet chart, and staff interview, the facility failed to provide the appropriate consistency of food for 1 of 3 sampled residents (Resident #9) with a physician's orders [REDACTED]. Failure to provide the appropriate consistency resulted in Resident #9 experiencing a choking episode requiring the [MEDICATION NAME] maneuver. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of Resident #9's medical record occurred on October 11-12, 2017. The facility admitted Resident #9 on 07/05/17 and [DIAGNOSES REDACTED]. The current care plan stated, . Problem . chewing difficulty r/t (related to) no teeth . Approach: . M/S (mechanical soft) diet . A physician order, dated 07/05/17, stated, Mechanical Soft diet. Resident #9's nurses' note, dated 07/10/17 at 6:59 p.m., stated, Resident . eating his fruit when all of a sudden he was grabbing at his throat. [MEDICATION NAME] (maneuver) was done three times and resident finally coughed up a whole grape and (a piece of) pineapple. Resident stated that it was the grapes because he was having trouble chewing them as he has no teeth. Will leave note for dietary not to bring up whole fruit or fruit that is hard and not soft to eat. The occurrence report, dated 07/11/17, identified regarding Resident #9, . on 7-10-17 at 6:50 p.m. resident was accidentally served whole grapes & pineapple (pieces) w/ (with) supper meal. Choked on whole grape, nurse intervened and provided [MEDICATION NAME] maneuver. Relieved of object. Licensed dietician met w/ cook to review. Review of the facility mechanically altered diet chart, provided by an administrative nurse (#1) on 10/12/17, showed foods to avoid on a M/S diet included whole grapes and chunk pineapple. On the morning of 10/12/17, an administrative nurse provided the meal tray card in effect for Resident #9 on 7/10/12. The card stated, Diet Order: M/S . chop vegetable. The meal tray card failed to specify any fruit restrictions. During an interview on 10/12/17 at 10:50 a.m., an administrative nurse (#1) verified Resident #9 received whole grapes with his meal on 07/10/17, as the cook didn't realize he couldn't have them. Failure to provide the appropriate diet consistency/restrictions contributed to Resident #9's choking episode and staff performance of the [MEDICATION NAME] maneuver. Based on the following information, non-compliance at F309 is considered past non-compliance. The facility addressed the corrective action accomplished for Resident #9 affected by the deficient practice by: * Risk management completed a thorough investigation. * Education provided to culinary staff regarding Resident #9's diet. * Meal tray card changed to Diet Order: M/S . Chop All fd (food)/ veg (vegetable), fruit . The facility addressed identification of other residents having the potential to be affected by the deficient practice by: * Review of all residents at risk due to altered diets including review of their meal tray cards for accuracy The facility addressed measures put in place and systemic changes made to ensure the deficient practice does not recur by: * The dietician, speech therapist, and occupational therapist met to determine more comprehensive guidelines for mechanically altered diets, including a detailed chart of foods allowed and what to avoid in all food categories. * Posted the mechanically altered diets chart on all three units and in the kitchen. * Education provided to nursing staff regarding mechanically altered diets on 07/18/17. * Education provided to culinary staff regarding mechanically altered diets on 07/19/17. * Culinary staff completed a Dysphagia Diet Summary puzzle. * Culinary staff trialed and purchased several food choppers to determine which worked best for different food items. The facility plans to monitor its performance to ensure solutions are permanent by: * Audits performed of residents' meal trays for correct diet (appropriate food items/consistency), cuing needed by staff, observations made, and whether re-audit needed.

Based on record review and staff interview, the facility failed to notify the resident and/or the resident's family/legal representative, in writing, of a transfer, including the destination and the reason for the transfer, and the resident's right to appeal the action for 3 of 3 sampled residents (Resident #4, #5, and #12) transferred to the hospital. Findings include: - Review of Resident #4's medical record occurred on all days of survey and identified the facility transferred the resident to a hospital on [DATE] and 05/03/16. The record lacked evidence the facility provided the resident and the resident's guardian with a written notice of transfer. - Review of Resident #5's medical record occurred on all days of survey and identified the facility transferred the resident to a hospital on [DATE]. The record lacked evidence the facility provided the resident and the resident's guardian with a written notice of transfer. - Review of Resident #12's medical record occurred on August 18-19, 2016 and identified the facility transferred the resident to a hospital on [DATE]. The record lacked evidence the facility provided the resident and the resident's family with a written notice of transfer. During an interview on 08/17/16 at 5:45 p.m., a supervisory staff member (#2) stated the facility failed to complete a notice of transfer for any residents transferred to the hospital and failed to have a policy for this process.

SWALLOWING 1. Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to maintain the resident's highest practicable physical well-being for 1 of 4 sampled residents (Resident #5) with altered diet requirements. Failure to assess, evaluate, and implement diet orders and specific interventions during meal times placed Resident #5 at risk for choking and aspiration. Findings include: Review of Resident #5's medical record occurred on all days of the survey. Review of the significant change Minimum Data Set (MDS), dated [DATE], and the quarterly MDS, dated [DATE], identified coughing/choking and difficulty/pain with swallowing. A physician's order, dated 07/25/16, stated, Regular liquids with regular diet. General safe swallow guidelines: Encourage small bites and small sips of liquids. Staff to cut food into small bites - cut no more than 1/4 (inch) to 1/2 in size. The current careplan stated, Category: Nutrition Status, Resident has [DIAGNOSES REDACTED]. Specialized diet. Approach: dated 06/09/2016, Resident to be encouraged to take small bites and to clear mouth completely prior to next bite. Resident to cough or clear throat if vocal quality becomes gurgly. Approach dated 07/21/2016, (food cut into 1/2 inch size pieces and thickened liquid d/c (discontinue) 7/2016). Category: ADL (activities of daily living). Function / Rehabilitation Potential. Approach Start Date: 07/21/2016, Eating: resident eats per self with set up and supervision, remind resident to take small bites and small sips of liquids, also to drink slowly. Review of nurses' progress notes showed the following: * 02/27/16 at 9:00 a.m., Audible crackles without stethoscope. With a stethoscope crackles heard mainly in the upper lobes bilaterally. Temp. (temperature) 101. Respirations 40. Wet non-productive cough. * 02/29/16 at 4:36 p.m., PA (physician assistant) notified Residents not improving. Order to send to (hospital) for evaluation. * 03/07/16 at 11:12 p.m., Hospital return at 1730 (5:30 p.m.). * 03/09/16 at 12:41 p.m., ST (Speech Therapy) recommends honey thick liquids and mechanical soft diet. Resident to take small bites. Crush all crushable medications. * 06/09/16 stated, Regular, sugar substitute diet with food cut into 1/2 inch size pieces with nectar thick liquids. * 07/14/16 at 10:42 a.m., Swallow study done. Report states that Resident is safe to upgrade to regular solids, thin liquids. To take small bites/sips, slow rate of intake . * 07/25/16 at 10:25 a.m., Upgraded to regular solids, thin liquids. General safe swallow guidelines to include: small bites/sips, slow rate of intake, due to Resident's mental health and cognition, staff will be asked to continue to cut Resident's food into 1/4-1/2 pieces for Resident's safety. * 07/25/16 at 6:50 p.m., Resident was coughing at the table waiting for her supper. Had only drank some liquids. Did note when she was eating that she was coughing so unsure if she just swallowed wrong prior to her meal. Will monitor. * 7/26/16 at 8:54 a.m., Noted that Resident was coughing with her liquids at breakfast. Reminded her to take small sips and tuck her chin when swallowing. Review of the Swallow Study, dated 07/14/16, showed Impression: . Based on the results of this study, the patient is judged to be safe to upgrade to regular solids, thin liquids. General safe swallow guidelines to include: Small bites/sips, slow rate of intake . Observation on 08/16/16 at 11:03 a.m. showed Resident drinking a cup of coffee with slight coughing while swallowing. Staff failed to supervise, assess or intervene. Observation on 08/16/16 at 12:23 p.m. showed Resident received a dinner tray that contained corn on the cob, sliced beets, breaded chicken breast on the bone, and a piece of cake. The food items were not cut into 1/4 - 1/2 pieces as ordered. Resident had occasional cough while drinking of fluids. Staff failed to supervise, assess or intervene. Observation on 08/17/16 at 7:52 a.m. showed a nurse (#1) administered Resident #5's oral medications. The resident experienced episodes of coughing when drinking. The nurse reminded the resident to take small sips and stated the resident had just recently been taken off thickened liquids. Observation on 08/17/16 at 8:15 a.m. showed the resident seated at the dining room table and had frequent episodes of coughing when drinking liquids. Staff failed to supervise or remind the resident to take small sips. During an interview on 08/18/16 at 8:55 a.m., an administrative nurse (#2) stated she expected staff to monitor and remind/cue the resident to take small bites/sips. CONSTIPATION 2. Based on record review, review of physician's standing orders, review of facility policy, and staff interview, the facility failed to follow their bowel protocol to promote regular bowel elimination for 2 of 3 sampled residents (Resident #3 and #7) receiving as needed (PRN) bowel medications. Failure to follow the bowel protocol may have contributed to these residents experiencing constipation, discomfort due to delayed bowel elimination, and manual extraction of stool. Findings include: Review of the facility policy titled Prince of Peace Care Center Standing Orders occurred on 08/17/16. This policy, dated November 2013 stated, . medications: [REDACTED]. 6) Milk of Magnesia 1-ounce PO (by mouth) PRN bid (twice daily) for constipation times 2 days. Review of the facility policy titled Constipation, Treatment/Prevention Of occurred on 08/17/16. This undated policy stated, Procedure: . 7. If resident has had no bowel movement in 2-3 days, the standing orders will be initiated for constipation. Bowel status will be assessed for presence of bowel sounds, and rectal check will be completed to check for impactions. All deviations will be referred immediately to the physician. - Review of Resident #3's medical record occurred on all days of the survey. [DIAGNOSES REDACTED]. Review of nurses' progress notes and PRN Medication Flow Sheets identify the following: *02/04/16 at 7:56 a.m.: (Progress Note), No BM (bowel movement) times 4 days. [MEDICATION NAME] suppository given. *02/13/16 at 2:35 p.m.: (Progress Note), No BM for 3 days. Suppository given. *03/15/16 at 6:58 a.m.: (Progress Note), Resident hasn't had a BM in three days, was given [MEDICATION NAME] suppository rectally-felt hard stool in rectum. *04/30/16 at 6:44 a.m.: (Progress Note), No BM for 3 days. [MEDICATION NAME] suppository given. No stool to rectum. *05/21/16 at 7:25 p.m.: (Progress Note), Gave MOM d/t (due to) no BM for 2 days. Had large BM after noon meal. *06/23/16 at 5:00 a.m.: (Flowsheet), [MEDICATION NAME] supp.(suppository) 10mg. Reason: No BM. *07/04/16 at 5:30 a.m.: (Flowsheet), [MEDICATION NAME] supp. 10mg. Reason: for no BM. *07/09/16 at 5:30 a.m.: (Flowsheet), [MEDICATION NAME] supp 10mg. Reason: for no BM. *07/18/16 at 6:00 a.m.: (Flowsheet), [MEDICATION NAME] supp 10mg. Reason: no BM. *08/01/16 at 6:00 a.m.: (Flowsheet), [MEDICATION NAME] supp 10mg. Reason: for no BM. *08/05/16 at 6:41 a.m.: (Progress Note), Resident hasn't had a BM in 3 days. Was given [MEDICATION NAME] suppository this morning without difficulty. *08/05/16 at 5:00 a.m.: (Flowsheet), [MEDICATION NAME] supp 10mg. Reason: no BM x 3 days. *08/15/16 at 4:36 p.m.: (Progress Note), No BM in 3 days. Was given a [MEDICATION NAME] suppository at around 3 p.m. No BM felt in rectum. *08/15/16 at 3:00 p.m.: (Flowsheet), no BM x 3 days. The facility failed to implement the physician's standing orders for Resident #3's constipation and to follow their constipation protocol/policy. - Review of Resident #7's medical record occurred on all days of the survey. [DIAGNOSES REDACTED]. Medications to prevent constipation included Senna 8.6 mg one tablet daily, Milk of Magnesia 30 cc once a day PRN, and [MEDICATION NAME] suppository 10 mg rectal once a day PRN. Review of Resident #7's PRN Medication Flowsheet from 04/30/16 through 07/23/16 identified the following interventions * 04/30/16: [MEDICATION NAME] 10 mg suppository at 4:30 a.m. Reason: No BM for 4 days * 05/05/16: [MEDICATION NAME] 10 mg suppository at 5:20 a.m. Reason: No BM for 3 days * 06/15/16: [MEDICATION NAME] 10 mg suppository at 6:00 a.m. Reason: No BM * 07/23/16: [MEDICATION NAME] 10 mg suppository at 6:00 a.m. Reason: No BM for 4 days During an interview on 08/18/16 at 8:00 a.m. an administrative nurse (#2) stated she had no explanation why staff administered a [MEDICATION NAME] suppository before trying MOM. The facility failed to implement the physician's standing orders for constipation and to follow their constipation protocol/policy.

Based on observation, record review, and staff interview, the facility failed to offer fluids with cares for 1 of 3 sampled residents (Resident #7) who required assistance with fluid intake. Failure to offer fluids during cares increased the risk of dehydration, constipation, and urinary tract infections. Findings include: Review of Resident #7's medical record occurred on all days of the survey. [DIAGNOSES REDACTED]. Current medications included [MEDICATION NAME] (diuretic) 20 milligrams daily. The current care plan stated, . ADL (activity of daily living) Function . Requires assistance with ADL's r/t (related to) dx (diagnosis) of Dementia . requires assistance of 1 with all oral intake. Nutritional Status Resident is limited in ability to eat or drink as doesn't feed herself. Assist resident with feeding providing encouragement cueing and physical assistance with all meals/snacks. Observation on 08/16/16 at 8:00 a.m. showed Resident #7 asleep in the recliner. Two certified nursing assistants (CNA's) (#3 and #4) transferred Resident #7 into a wheelchair and wheeled the resident into the dinning room. Staff failed to offer Resident #7 water with cares. Resident #7 received her breakfast tray at 8:30 a.m. Observation on 08/16/16 at 11:47 p.m. showed two CNA's (#3 and #5) toileted Resident #7 and transferred the resident via wheelchair to the dinning room. Staff failed to offer Resident #7 water with cares. Resident #7 received her dinner tray at 12:42 p.m. Observation on 08/17/16 at 8:00 a.m. showed Resident #7 in the recliner. Two CNA's (#5 and #6) assisted the resident to the toilet and transferred Resident #7 via wheelchair to the dinning room. Staff failed to offer Resident #7 water with cares. Resident #7 received her breakfast tray at 8:40 a.m. During an interview on 08/18/16 at 8:25 a.m. an administrative nurse (#2) stated she expected staff to offer fluids with cares for Resident #7.

Based on record review, review of facility policy, and staff interview, the facility failed to provide medically-related social services for 1 of 1 closed resident record reviewed (Resident #12) and 1 supplemental resident (Resident #19) who exhibited and/or experienced physically abusive behaviors. The facility failed to: 1. Implement the facility's policy to identity residents and/or situations with potential for the occurrence of injury, prevent resident to resident injury, and protect residents from recurring resident to resident injury. 2. Adequately assess resident behaviors, including monitoring for patterns/trends, causative factors (time, place, persons involved, and happenings prior to and at the time of the behavior), and implement appropriate interventions to prevent behaviors from escalating. 3. Monitor the effectiveness of interventions and revise interventions as appropriate. 4. Implement an interdisciplinary approach to address behaviors which have the potential to result in resident to resident altercation. Failure to adequately assess and monitor residents' behaviors, implement effective interventions, and review/revise current interventions to prevent further behaviors resulted in an avoidable bruise to Resident #12, an avoidable split lip to an unidentifed resident, and continued aggressive behaviors between Resident #12 and Resident #19. This behavior has the potential for other residents to become victims of physical, verbal, and mental abuse. Findings include: Review of the facility policy titled Behavior Assessment and Monitoring occurred on 08/05/15. This undated policy stated: Policy Statement: 1. Problematic behavior will be identified and managed appropriately. Assessment and Cause Identification: . 4. New onset or worsening behavioral symptoms will be identified . 5. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. 6. The interdisciplinary team will thoroughly evaluate new or worsening resident behavior in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition including: . Functional, social or environmental factors. Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. 2. The interdisciplinary team will develop a care plan . 3. The care plan will include, as a minimum: a. Interventions for the behavioral and/or psychosocial symptoms of the resident; b. Specific and measurable goals for targeted behaviors; and c. How the staff will monitor for effectiveness of the interventions. Monitoring: 1. If the resident is being treated for [REDACTED]. 2. The staff will continue to document . specific information about problem behaviors or moods. 3. Interventions will be adjusted . Resident #12 and #19's progress notes, dated 01/26/15 through 05/14/15, revealed 15 physically aggressive altercations between Resident #12 and #19 (12 initiated by Resident #19 without retaliation by Resident #12); 16 physically aggressive altercations between Resident #19 and other residents; and two physically aggressive altercations/behaviors between Resident #12 and other residents. - Review of Resident #12's medical record occurred on August 04-05, 2015. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment; physical and verbal behaviors, and other behaviors such as hitting, rummaging, disrobing, and pacing; rejection of cares; and wandering during the assessment period. The resident's care plan stated, Problem: Behavioral Symptoms: Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety) . Approach: . *Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). *Maintain a calm environment and approach to the resident . *Remove resident from other resident's rooms and unsafe situations . Resident #12's progress notes, dated 07/24/14 (admission to Subiaco) to 01/25/15, revealed behaviors such as urinating on the floor and other inappropriate places, resisting cares, combative with staff, and wandering about the unit. On 01/22/15, Resident #19 moved to Subiaco from another unit in the facility. The progress notes revealed altercations between Resident #12 and Resident #19 began on 01/26/15. Resident #12's progress notes identified the following: *02/02/15 at 2:45 p.m. - Appeared to be talking to a female resident (Resident #19) when she pushed him. He then hit her with an open hand on the left arm . *02/02/15 at 3:00 p.m. - Was again talking to same female resident and she pushed him to (sic) that he fell backwards onto the couch . *02/02/15 at 3:30 p.m. - Was again pushed by same female resident. Did not lose balance enough to fall . *02/02/15 at 4:40 p.m. - Was lying in another resident's bed when staff came in to get him up. A female resident (Resident #19) followed staff into room and she hit resident on the right leg trying to get him out of the bed. he then kicked out and kicked her in the stomach . *02/11/15 at 11:16 p.m. - This resident was hit in the chest by another resident (Resident #19) @ (at) 4pm . *03/01/15 at 11:49 p.m. - Wander this a.m. into other rooms and lounge area. Another resident (Resident #19), female slapped him on his back. Resident did not react to being slapped and kept on walking. *03/06/15 at 9:30 p.m. - Female resident (Resident #19) struck him and shoved him in the chest . He did not retaliate. *03/09/15 at 1:20 p.m. - Resident had an altercation with female resident (Resident #19) on the unit. Resident clawed his finger nails in female's right hand leaving 2 claw marks. Female resident had smacked resident's hat . Separated two residents . *03/17/15 at 12:30 p.m. - Altercation: Resident was hit by a female resident (Resident #19) . Separated two residents. *03/20/15 at 8:09 p.m. - This resident was hit in the chest by a female resident (Resident #19) . this resident was sitting in a chair, not bothering female resident. Staff separated . *04/12/15 at 11:25 p.m. - Resident has been very restless all pm . At (5:15 p.m.) staff found resident in another male residents (Resident #18) and he had a pillow over his face and was pushing down on it. Staff intervened and removed resident from his room . *04/14/15 at 10:20 a.m. - Resident is quite combative and aggressive (sic) at this time. Yelling at staff and hitting out. Wandering into other resident's rooms. Keeps going into the other room connected to his bathroom and is 'looking for that guy' . *04/14/15 at 12:00 p.m. - . very resistive . was in and out of other resident rooms, spilled a drink on another resident's bedcover, twisted nebulizer tubing around furniture in another resident's room, walked up an (sic) down hallway rapidly, voided on the floor in 2 other residents' rooms. At this time resident is sitting quietly in a chair. *04/15/15 at 1:07 p.m. - Resident seen today by Dr. (name) . Reviewed resident medications, . recent mood/behaviors . NEW ORDERS: (orders included medication changes) . Start a Behavioral plan to closely monitor patient . *04/15/15 at 1:30 p.m. - Social worker called (name of facility) screener to staff (i.e. discuss) with them residents behaviors and the possible need for in-patient psychiatric hospitalization due to behaviors. Social worker let screener know that facility is open to hearing other suggestions that may work as interventions before considering an admission . *04/16/15 at 4:17 p.m. - Received a call back from (name of facility) Screener who stated the state hospital is not willing to consider admitting resident at this time, due to over flow . Suggested to consider pharmacy review recommendations, consulting with psychiatry, and trying different interventions such as time outdoors in enclosed patio area . *04/22/15 at 2:10 p.m. - . resident and another female resident (Resident #19) were yelling at each other. Female resident pushed this resident, resident did not fall . This resident was going to hit female resident back and CNA (Certified Nursing Assistant) intervened. Separated residents. *04/22/15 at 2:30 p.m. - Reported by CNA that a female resident (Resident #19) had thrown the basket that the colored pegs are stored in at him and hit him on the nose. He has a bruise to the bridge of his nose measuring .3 x .5cm (0.3 by 0.5 centimeters) . *04/22/15 at 2:35 p.m. - Arguing with female resident (Resident #19). Resident's seperated (sic). *05/07/15 at 12:00 a.m. - initially the night (sic) resident was out in the common area. He and another female resident (Resident #19) were bickering. Staff did intervene . *05/08/15 at 1:23 p.m. - Resident stopped to work on pegs and board and was shoved by another resident (Resident #19) and did raise fist as if to strike, but did not . *05/09/15 at 2:15 p.m. - . Did have a verbal altercation with female resident (Resident #19) and swatted her on the back. Resident's (sic) were separated . *05/10/15 at 2:15 p.m. - Resident and a female resident (Resident #19) had verbal and physical altercation early on during shift. This resident tried taking something the female resident had and female resident swung and hit this resident and grabbed his arm. No bruising or injury noted. Resident swatted back but didn't hit female resident. Resident's (sic) were separated . *05/10/15 at 3:15 p.m. - . He exhibits aggressive and agitated behaviors. He came up behind a female resident (Resident #20) who was seated at a dining room table and struck her hard in the mid upper back with a wooden candle holder . *05/11/15 at 5:51 p.m. - Resident over by a female resident (Resident #19) and they had gotten into a fight, unknown what about. The female resident had then pushed this resident and this resident hit back at the female resident. Both were separated . *05/12/15 at 5:05 a.m. - Resident awake at around 4 AM and wandering around . Had been with another resident (unidentified) and she hit him on the shoulder. He turned and left . *05/12/15 at 9:00 a.m. - Call placed to (name of facility) screener for possible admission to (name of hospital) Provided presenting problems resident is experiencing . *05/12/15 at 10:25 p.m. - Was playing nicely with pegs and blocks when another female resident (Resident #20) came up to him and was yelling/cursing at him and taking things away from him. Unable to redirect female resident away from this resident so staff moved this resident to a different task . *05/13/15 at 12:50 p.m. - Resident seen by Dr. (name) . Reviewed current medications, vitals and mood/behaviors for the past month. IDT (Interdisciplinary Team) has met several times and have implemented many changes to meet the needs of resident. Resident continues to have verbal and physical aggression to staff and other residents. Behaviors spontaneous, . After discussing . it is agreed that the best care plan for resident at this time is to seek acute mental health interventions as all attempts to improve the physical, psychological and mental health needs have been less than beneficial . Resident #12's medical record failed to identify the many changes implemented to meet the his needs. *05/14/15 at 12:03 p.m. - resident discharged . - Review of Resident #19's medical record occurred on 08/05/15. [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified long and short term memory problems, physical and verbal behaviors, and wandering during the assessment period. Resident #19's progress notes identified the following altercations with other residents in addition to the above mentioned altercations with Resident #12: *01/26/15 at 8:39 p.m. (A progress note from Resident #19's medical record) - This resident (Resident #19) began to get upset with other residents shortly after supper. This resident was playing with the peg board and another male resident (Resident #12) approached her and was going to play as well. She got upset with him and stated, 'You better get out of here! You want another bruise?' Assisted male resident away from this resident . *02/08/15 at 12:54 p.m. - Reported by CNA that resident was yelling at another male resident (unidentified) while eating lunch because male resident was getting into her space . *02/15/15 at 9:36 p.m. - . was wandering into other resident rooms, . Had angry verbal confrontations with at least three different residents (unidentified) stating to one 'if you try that again I'll rip your damned face off!' At one point resident was holding a small rolling pin in her hand and was in pursuit of a male resident (unidentified) stating 'come back here you little son of a [***] and I'll show you what hurts.' Staff intervened . *02/18/15 at 8:45 a.m. - Reported by CNA that resident slapped another resident (Resident #21) on the face when the other resident took the newspaper from this resident's hand. Other resident then slapped this resident back in the face . *02/27/15 at 6:00 p.m. - A male resident (Resident #12) walked up to where she was working with the colored pegs. She was stacking them in rows. Took a row of the pegs and hit the male resident in to head . *03/03/15 at 3:08 p.m. - Resident sitting at the table coloring and a male resident (unidentified) walked up to her. She told him to get the hell out of here and tried to hit him . *03/07/15 at 10:06 p.m. - Before supper this pm, resident struck out at another resident (unidentified) when the other resident picked up a plastic peg from the table they were sharing . *03/08/15 at 12:16 p.m. - Resident was sitting at the table waiting for lunch . Another resident (unidentified) sitting at the table was talking about lunch and how it is good to be able to eat the food and not have to cook it. This resident told other resident, 'Shut your (profanity) mouth or I will put my fist through it' . *03/08/15 at 9:20 p.m. - Resident got into verbal altercation with another female resident (unidentified). The other resident had told her to go away and leave her alone. She responded by striking the other resident and stating 'You just shut your (profanity) mouth.' . staff seperated (sic) the two. A few minutes later nurse observed resident standing behind a male resident (unidentified) seated at a table. She forcibly shoved his shoulders forward and stated 'I've told you 3 (profanity) times to move . *03/19/15 at 3:12 p.m. - Resident was upset with male resident (unidentified) on the unit. Did slap his arm . *03/22/15 at 5:33 p.m. - Resident was combative and slapped another resident (unidentified) in his face . *03/25/15 at 1:10 p.m. - Reported by CNA and activity staff that this resident had made rude remarks to activity staff working on the unit and other female resident (unidentified) was hitting this resident. This resident back handed other female resident causing other resident to have a cut on her mid upper lip . *03/26/15 at 12:05 a.m. - This resident slapped another resident (unidentified) at 7:05pm . *03/28/15 at 5:00 p.m. - Resident has been agitated and combative with other residents and staff. Striking out and pulling hair . *03/30/15 at 7:15 p.m. - . Resident had an altercation with a male resident (unidentified) at activity table where she slapped him and he slapped her . *04/01/15 at 10:53 p.m. - Resident aggressive with other resident's (sic) approximately half dozen times . *04/02/15 at 11:57 a.m. - Working with pegs and board and another resident (unidentified) nearby reached for some of the pegs and she called him an ass-hole' and struck out without physical contact . *04/04/15 at 9:21 p.m. - Resident was combative at 5:25 pm another resident approached her to ask what she was doing hit him in the abdomen and told him to get the hell out of here. Other resident was going to hit her back but staff intervened . Ten minutes later resident was going to open the shade and another resident stated for her to leave it alone. She picked up residents walker and started to jab her with it. Staff again intervened . *04/09/15 at 9:45 p.m. - Reported by CNA that resident had gone into room across the hall and struck another female resident on the right upper arm while she was lying in bed . *04/21/15 at 3:14 p.m. - Resident had an apparent altercation with another female resident on the unit. This nurse not present, nor was CNA staff. This resident was said to have hit another resident with a peg . *04/29/15 at 7:50 p.m. - Staff reported that this resident and another female resident were arguing over a blanket and tugging back and forth. This resident slapped resident on the rt (right) cheek . *04/30/15 at 9:49 a.m. - Became agitated, when another resident took her breakfast food away before she was finished. Resident struck out at other resident, but missed . *05/14/15 at 9:58 p.m. - Resident was quite agitated and agressive (sic) this afternoon. Was going up to other residents and getting in their faces, wanting them to get out of her spot and would lightly hit their arms . *05/27/15 at 5:21 p.m. - Did get into a verbal argument with another female resident . *06/06/15 at 1:53 p.m. - Very restless and touching other residents. Noted patted a male resident's buttocks, causing male resident to be angry and yelled at resident . Review of the interdisciplinary team notes occurred on 08/05/15 with an administrative nurse (#7). The notes identified the following concerns: *02/02/15 - Resident #12 taking apart the stove - needs one to one, redirection and activities to stay busy *04/20/15 - Resident #19 behavior plan by occupational therapy for redirection and busy activities to keep out of other residents' way *04/27/15 - Resident #12's behaviors include spitting and urinating/defecating on the floor *05/11/15 - Resident #12 has behaviors affecting female residents and family concerned of safety for others During an interview on the afternoon of 08/05/15, an administrative nurse (#7) stated the Wellness department (staff members from different disciplines, i.e. activities and occupational therapy) changed hours in February so they would be in the Subiaco unit later in the evening. Their new hours were 10:30 a.m. to 7:00 p.m. four days a week. The nurse (#7) stated the Wellness department set up individualized activities for Resident #12 and #19 and tried to keep them separated as much as possible. Upon request, the nurse (#7) provided a list of individualized activities designed for Resident #19 but failed to provide one for Resident #12's needs. The facility failed to evaluate the behaviors between Resident #12 and #19, identify the underlying causes of the behaviors, implement effective interventions to manage conflict between Resident #12 and #19, and review/revise interventions as needed to prevent future behaviors. These failures resulted in injury to Resident #12 and an unidentified resident and, repeated physical and verbal altercations between Resident #12 and #19, and placed all residents in Subiaco at risk for physical and verbal abuse.