Every finding on record at Richardton Health Center Inc

Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents (Residents #3 and #4). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2025, pages 3-4, stated, . Coding Instructions for N0350A. Enter in Item N0350A, the number of days during the 7-day look-back period . that insulin injections were received. - Review of Resident #3's medical record occurred on all days of survey. A physician's order, dated 10/31/25, identified weekly Mounjaro pen injections (a non-insulin hypoglycemic medication). The annual MDS, dated [DATE], showed item N0350A coded as the resident received an insulin injection during the look back period. The medical record lacked documentation the resident received an insulin injection. - Review of Resident #4's medical record occurred on all days of survey. A physician's order, dated 09/29/25, identified weekly Mounjaro pen injections. The quarterly MDS, dated [DATE], showed Item N0350A coded as the resident received an insulin injection during the look back period. The medical record lacked documentation the resident received an insulin injection.

Based on observation, review of facility policy, and staff interview, the facility failed to establish a system to account for all controlled medications and failed to effectively manage medication inventory stored in 1 of 1 medication storage rooms. Failure to assure controlled medications in the medication refrigerator are accounted for, and expired medications in the emergency medication kit are removed and replaced has the potential for loss or diversion of controlled medications and risk of administering medications that may be ineffective or harmful to the resident.Findings include:Review of the facility policy titled, Controlled Substance Administration & Accountability, occurred on 12/17/25. This policy, dated 07/18/19 stated, . Controlled substances are stored in a separate compartment of the medication cart or refrigerator lock box. Two licensed nurses account for all controlled substances and access keys at the end of each shift.Review of the facility policy titled, [Name of drugstore] Policies and Procedures, occurred on 12/17/25. This undated policy stated, . Emergency kit is maintained by pharmacy.Observation of the medication storage area occurred on 12/17/25 at 10:46 a.m. with a nurse (#5) and an administrative nurse (#2). Observation identified the following: A locked box in the medication refrigerator that contained three syringes of Ativan (a controlled medication for anxiety), one box of oral Ativan with a resident label, and one box of oral Ativan as part of the emergency medication kit. A list of medications on the outside of the cabinet door identified medications contained in the emergency medication kit and their expiration dates. The medication list identified a Lupin inhaler with an expiration date of 11/25. Upon request, the facility nurse (#5) opened the locked emergency medication kit which contained Lupin (Albuterol) inhaler with an expiration date on the label of 11/30/25.During an interview on the morning of 12/17/25 at 10:48 a.m., an administrative nurse (#2), confirmed facility staff do not count the Ativan in the medication refrigerator unless a dose is removed and agree it should be counted routinely. The nurse (#2) also confirmed the Lupin inhaler in the emergency kit as outdated, and pharmacy should have replaced.

Based on observation, record review, review of facility policy, review of professional literature, and staff interview, the facility failed to ensure 1 of 5 sampled residents (Resident #23) received the services necessary to attain the highest degree of safety possible while receiving fluids. Failure to ensure staff provided proper positioning when providing water placed Resident #23 at risk for aspiration and choking. Findings include: Review of the policy titled Meal Supervision and Assistance occurred on 10/23/24. This undated policy stated, . The resident should be positioned so his or her head and upper body are as upright as possible. in bed, use wedges and pillows to achieve a nearly upright position. [NAME] B. Swigert's The Source for Dysphagia; Third Edition, LinguiSystems, Inc., Illinois, 2007, page 125 and educational handouts identified, . During the oral intake of . foods and/or liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in a bed or in a chair. Review of Resident #23's medical record occurred on all days of survey. Diagnosis included dementia and difficulty swallowing. The resident's current care plan and a physician order, dated 06/08/24 stated, . 90 degrees for all intake . Observation on 10/22/24 at 10:10 a.m. showed two certified nurse aides (CNAs) (#3 and #4) transferred Resident #23 into bed. While in bed at an approximate 50 degree angle the CNA (#3) provided the resident with a drink of water. The resident coughed, held his breath, and his face turned red until the CNAs positioned him to a 90 degree angle. The resident then continued to cough and the CNAs called for the nurse. Nursing progress notes for 10/22/24 stated: *11:52 a.m. Resident was seen by [nurse practitioner] on rounds, new orders received . bedside swallow evaluation to be completed. Son, [name] at facility and updated on orders and episode of resident coughing on water. *2:51 p.m. Resident had a choking episode while laying in bed this AM. The episode was witnessed and CNA was able to repositioned [sic] to 90 degree angle and CN [charge nurse] assessed resident immediately. Resident back to baseline respiratory rate. During an interview on 10/23/24 at 4:25 p.m., an administrative nurse (#1) stated she expected staff to position Resident #23 to a 90 degree angle before providing the resident with a drink of water.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #22) observed during a dressing change. Failure to practice infection control standards related to enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions occurred on 10/23/24. This policy, dated 03/22/24, stated, . Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high contact care activities . High-contact resident care activities . Wound care: any skin opening requiring a dressing. Observation on 10/22/24 at 9:40 a.m. showed an EBP sign on Resident #22's door. A nurse (#2) donned gloves and changed Resident #22's heel dressing. The nurse failed to wear a gown during the dressing change. During an interview on 10/23/24 at 4:25 p.m., an administrative nurse (#1) stated she expected staff to wear a gown during a dressing change.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or resident's representative a written bed hold notice for 1 of 2 residents (Resident #21) and the notice failed to include the reserve bed payment amount for 2 of 2 residents (Resident #2 and #21) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice and include the reserve bed amount does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy Bed Hold and Transfer Notice Policy occurred on 11/08/23. This policy, dated October 2019, stated, . The facility will have a process in place to ensure residents and/or their representatives are made aware of the facility's bed-hold and reserve bed payment amount at the time of admission to the facility and prior to transferred to the hospital . The facility will provide written information about these policies to residents and/or resident representatives . upon transfer . - Review of Resident #21's medical record occurred on all days of survey. A hospital transfer occurred on 07/03/23. The bed hold notice identified facility staff obtained verbal consent to hold the bed. The record lacked documentation the facility provided the resident and/or their representative with a written bed hold notice or the reserve bed hold amount. - Review of Resident #2's medical record occurred on all days of survey. Hospital transfers occurred on 06/30/23 and 07/19/23. The bed hold notices lacked the reserve bed hold amount. During an interview on 11/08/23 at 9:20 a.m., an administrative staff member (#1) confirmed the bed hold notices lacked the reserve bed hold amount.

Based on record review, staff interview, and review of facility policies/procedures, the facility failed to ensure staff followed standards of practice for 1 of 5 sampled residents (Resident #9) with an indwelling catheter and 1 of 2 sampled residents (Resident #229) with a dressing change. Failure to update the resident's medical record with physician's orders for an indwelling catheter and failure to follow physician's orders for a dressing change may result in delayed treatment, pain and/or worsening of resident's condition. Findings include: Review of the facility policy titled Medication Orders occurred on 11/08/23. This policy, revised 10/08/19, stated, . The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). Transcribe newly prescribed medications on the MAR or treatment record. Review of Resident #9's medical record occurred on all days of survey and included a quarterly minimum data set (MDS) dated [DATE] coded for an indwelling catheter. A Hospice Certification and Plan of Care document dated 11/01/23 identified, . Hospice nurse for insertion of foley catheter using 16 french/10cc [cubic centimeter] balloon. Change every 6 weeks and PRN [as needed] dislodgement or stoppage . Review of Resident #9's physician order report and the MAR and treatment administration record (TAR) dated 10/08/23 through 11/08/23 failed to identify an order for an indwelling catheter. Observation on 11/07/23 at 12:54 p.m. showed Resident #9 with an indwelling catheter. During an interview on the afternoon of 11/08/23, an administrative staff member (#1) confirmed the staff failed to transcribe the orders for an indwelling catheter onto the resident's orders and TAR following admit to hospice. Review of the facility policy titled Clean Dressing Change occurred on 11/08/23. This undated policy, stated, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, states, . Carrying Out a Physician's Orders . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. - Review of Resident #229's medical record occurred on all days of survey. Current physician's orders identified, . Orders to Apply Mepilex [dressing] to open areas on Left mid back; monitor for signs/symptoms of infection; change Q72hrs [every 72 hours] and PRN . The current care plan included, . I have a potential for alteration in my skin integrity R/T [related to] my Braden Scale Assessment. I am at risk for sheering with my hoyer lift transfers and currently have an area of sheering to my back. Please follow the orders in the TAR for dressing changes and measure the area weekly with my skin assessments. A progress note, dated 11/05/23, stated, Two open areas noted to left middle back, which were noted upon CNA [certified nurse aide] washing resident up this morning; superior open area measures: 0.8cm [centimeter] x 0.3cm x 0cm; inferior area measures: 1.1cm x 0.8cm x 0cm; both areas are beefy red, with surrounding skin being blanchable light purple; small amount of sanguineous [containing blood] drainage noted on bedding. Orders to apply Mepilex and change Q72hrs and PRN . During an observation on 11/06/23 at 12:28 p.m., two CNAs (#3 and #4) performed personal cares on Resident #229. The resident's back was exposed and did not identify a Mepilex dressing on the resident's left mid back. During an observation on 11/07/23 at 1:04 p.m., two CNAs (#5 and #6) performed personal cares on Resident #229. The resident's back was exposed to show a small red sheering of the skin and did not identify a Mepilex dressing on the resident's left mid back. During an interview on 11/08/23 at 11:00 a.m., an administrative staff member (#1) stated she would expect staff to continue with current physician orders.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide treatment and services in a manner that maintained the highest practicable physical well-being for 1 of 1 resident (Resident #22) observed experiencing pain during cares. Failure to report and act on the resident's pain resulted in unresolved pain and decreased quality of life. Findings include: Review of the facility policy titled Pain Management occurred on 10/08/23. This undated policy stated, The facility must ensure that pain management is provided to residents who require such services . In order to help a resident attain or maintain his/her highest practicable level of well-being and to prevent or manage pain, the facility should: Recognize when the resident is experiencing pain and identifies circumstances when the pain is anticipated. Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice . Review of Resident #22's medical record occurred on all days of survey. Diagnoses included osteoarthritis, left ankle ulcer, and history of a pelvic fracture. A quarterly minimum data set (MDS), dated [DATE], indicated a brief interview of mental status (BIMS) score of 8 (moderately impaired cognition). A facility pain assessment, completed on 08/10/23, identified the resident experienced chronic pain almost all day, the pain rated as severe via a visual descriptor scale, and increased pain during wound treatments. The assessment also indicated pain decreases the resident's energy, socialization, and appetite and limits the resident's day-to-day activities. Resident #22's physician's orders included the following: *Wound Care: - Cleanse left ankle wound with 0.25% Dakins solution [an antiseptic], apply a small piece of iodoform [an antiseptic] gauze loosely in wound bed, and cover with foam dressing. Change daily and as needed (PRN). *Pain Medications: - Acetaminophen 650 milligrams (mg) scheduled twice a day - Oxycodone Extended Release 20 mg scheduled twice a day - Voltaren Arthritis Pain topical gel scheduled twice a day to shoulders, spine, knees, elbows, and ankles. - Acetaminophen 650 mg every 4 hours PRN. - Oxycodone 5 mg every 6 hours PRN. Observations of Resident #22 during cares showed the following: * 11/06/23 at 12:26 p.m., Two certified nurse aides (CNAs) (#6 and #8) transferred the resident from the wheelchair to the bed utilizing a full body mechanical lift. During the transfer and when rolling the resident back and forth in bed to remove the lift sling, the resident repeatedly moaned and stated, Ouch and Oh. Oh. Oh. * 11/07/23 at 1:46 p.m., Two CNAs (#3 and #6) transferred the resident from the wheelchair to the bed to prepare the resident for a bath. The resident moaned and groaned throughout the transfer process. As the CNAs lowered the head of the resident's bed, the resident repeated, Oh my back. Ohhhhh my back. The CNA (#3) stated, She has so much pain all over. We use two to work with her so we can carefully roll her. As the CNAs rolled the resident from side to side to remove the sling, the resident moaned and groaned. As the CNAs pulled down the resident's pants, the resident twice stated, Don't touch my ankle. The resident continued to express pain throughout the brief change and placement of the bath sling. As the CNAs transferred the resident from the bed to the shower chair, the resident placed her right hand to the right side of her neck and repeated, Oh My Head and Ouch Ouch while motioning her hand up and down the right side of her neck. * 11/07/23 at 2:25 p.m., following the resident's bath, a staff nurse (#2) completed the resident's left ankle wound treatment. The resident stated, Ouch Ouch and groaned throughout the treatment. Review of Resident #22's November 1-7, 2023 MAR identified the resident received the scheduled pain medications, PRN oxycodone on 7 occasions, and no PRN acetaminophen. During an interview on 11/08/23 at 7:50 a.m., an administrative staff member (#1) stated Resident #22's direct care staff failed to report the residents increased pain with cares to the nurse and agreed staff failed to effectively use PRN medications to help control Resident #22's pain. The facility failed to report and effectively manage Resident #22's pain during times of care and wound treatments.

Based on record review and staff interview, the facility failed to ensure residents' records contained the hospice election form and the certification of a terminal illness for 2 of 3 sampled residents (Resident #2 and #229) receiving hospice services. Failure to obtain these documents limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: - Review of Resident #2's medical record occurred on all days of survey. Resident #2 elected Hospices services on 08/29/23. The medical record lacked the hospice election form and the physician's certification of the terminal illness. - Review of Resident #229's medical record occurred on all days of survey. Resident #229 elected Hospices services on 11/01/23. The medical record lacked the hospice election form and the physician's certification of the terminal illness. During an interview the afternoon of 11/07/23, an administrative nurse (#1) confirmed the medical records lacked the election form and the certification of terminal illness related to hospice. 47896

Based on observation, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 2 of 2 observations (morning and afternoon on 01/14/20) of insulin administration. Failure to correctly prime and administer insulin via [MEDICATION NAME] has a potential for the resident to receive an inaccurate dose of insulin. Findings include: Review of the facility policy titled Insulin Pen occurred on 01/17/20. This policy, revised (MONTH) 2019, stated, . Attach safety pen needle: . Twist open and remove outer cover from the safety pen needle . Prime the insulin pen . With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Injecting the insulin: . Fully depress the plunger until the dosing numbers count back to zero. While still pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin. - Observation on the morning of 01/14/20 showed a licensed nurse (#1) set up and administered Humalog insulin via [MEDICATION NAME] to Resident #11. The nurse (#1) primed the insulin pen with the cap on while holding the pen horizontally and failed to keep the needle in the skin for 6 -10 seconds. - Observation on 01/14/20 at 12:15 p.m. showed a licensed nurse (#1) set up and administered Humalog insulin via [MEDICATION NAME] to Resident #11. The nurse (#1) primed the insulin pen holding it downward and failed to keep the needle in the skin for 6 -10 seconds. During an interview on 01/15/20 at 10:51 a.m., an administrative nurse (#4) confirmed staff failed to correctly prime the insulin pen.

Based on observation and review of the facility policy, the facility failed to follow infection control practices for 1 of 5 sampled residents (Resident #7) and one supplemental resident (Resident #9) observed during personal cares. Failure to follow infection control practices for hand hygiene has the potential to spread infection to other residents, personnel, and visitors. Findings include: Review of the facility policy titled Hand Hygiene occurred on 01/15/20. This policy, dated (MONTH) 2019, stated, . Hand hygiene is indicated and will be performed . after removing personal protective equipment (PPE), including gloves . After assistance with personal body functions (e.g., elimination . - Observation on 01/13/20 at 12:03 p.m. showed two certified nursing assistants (CNAs) (#5 and #6) assisted Resident #7 off the toilet after having a small bowel movement. The CNA (#5) performed perineal care, removed her gloves, applied a clean brief and assisted Resident #7 into the wheelchair. Without performing hand hygiene, the CNA (#5) unlocked the wheelchair brakes, adjusted the resident's clothing, covered the resident with a blanket, combed the resident's hair, collected the garbage and performed hand hygiene. The CNA (#5) failed to perform hand hygiene after completing perineal care, prior to completing other tasks. Observation on 01/14/20 at 9:52 a.m. showed two CNAs (#2 and #3) assisted Resident #7 off the toilet. The CNA (#3) performed perineal care, removed her gloves, and assisted Resident #7 into bed. Without performing hand hygiene, the CNA (#3) positioned Resident #7 in bed, gave the resident her call light and performed hand hygiene. The CNA (#3) failed to perform hand hygiene after completing perineal care, prior to completing other tasks. - Observation on 01/14/20 at 9:33 a.m. showed two CNAs (#2 and #3) provided incontinence care to Resident #9. The CNA (#2) removed the resident's brief, performed perineal care, placed a new brief, removed her gloves, and transferred Resident #9 from the bathroom to the wheelchair using a sit-to-stand lift. Without performing hand hygiene, the CNA (#2) removed the mechanical lift sling, placed foot pedals on the wheelchair, donned gloves, wiped down the mechanical lift, removed her gloves and performed hand hygiene. The CNA (#2) failed to perform hand hygiene after providing perineal care, prior to completing other tasks.

Based on observation and group interview, the facility failed to post the results of the most recent Federal and/or State surveys in a place readily accessible to residents, family members, and/or legal representatives for 3 of 4 days (December 03-05, (YEAR)) of survey. Findings include: Observation on the morning of 12/03/18 through 12/04/18 showed no binder with survey results easily accessible to residents and/or family/representatives. During the group interview on 12/04/18 at 1:30 p.m., when asked if the Federal and/or State survey results were placed in a readily accessible location where residents, family members, and/or legal representatives wishing to examine them did not have to ask to see them, all five residents (A, B, C, D, E) (identified by the facility as interviewable) responded, No. Observation on the morning of 12/05/18 showed a binder located near the nurses' station labeled as containing previous survey results. The binder failed to contain the most recent Federal and/or State survey, dated 01/11/18. The facility failed to post the (YEAR) Life Safety Code and (YEAR) Health survey results and failed to place these results in a location readily accessible to all residents, family members, and/or legal representatives.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), review of the Advisory Committee on Immunization Practices (ACIP) recommendations, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 4 of 12 sampled residents (Resident #2, #5, #20, and #126). Failure to accurately complete Section I (Active Diagnoses), Section J (Health Conditions), Section M (Skin Conditions) and Section O (Special Treatments, Procedures, and Programs) of the MDS does not allow each resident's assessment to reflect their current status/needs, and has the potential to affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised (MONTH) (YEAR), page I-11 stated, Item I2300 Urinary tract infection [MEDICAL CONDITION]: . has a look-back period of 30 days for active disease instead of 7 days. Page I-12 further stated, If the [DIAGNOSES REDACTED]. reentry into the facility . A documented physician [DIAGNOSES REDACTED]. This information may be included in the hospital transfer summary or other paperwork. Review of Resident #5's medical record occurred on all days of survey and identified a hospitalization for a UTI from 06/20/18 through 06/23/18. The hospital discharge summary, dated 06/23/18, showed a [DIAGNOSES REDACTED]. * 5-day/Significant Change in Status dated 06/30/18 * 14-day dated 07-06-18 * End of Therapy dated 07-13-18 During an interview on the afternoon of 12/06/18, an administrative nurse (#2) agreed staff failed to code Resdient #5's UTI on the above assessment dates. SECTION J: HEALTH CONDITIONS - The Long-Term Care Facility RAI User's Manual, revised (MONTH) (YEAR), page J-2 stated, . Coding Instructions for J0100B, Received PRN (as needed) Pain Medication .Code 1, yes: if the medical record contains documentation that a PRN medication was received or offered but declined. Review of section J0100B on Resident #5's quarterly MDS, dated [DATE], identified the resident received or was offered and declined a PRN pain medication in the 7-day look back period. Review of the residents medical record during the look back period failed to show a PRN pain medication was given or was offered and refused by the resident. During an interview on the afternoon of 12/06/18, an administrative nurse (#2) stated she was unable to provide any documentation Resident's #5 received a PRN medication during the look-back period. The facility failed to correctly code section J0100B for Resident #5's most recent MDS. - The Long-Term Care Facility RAI User's Manual, revised (MONTH) (YEAR), page J-24 stated, . J1300: Current Tobacco Use: . Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period. Review of Resident #20's medical record occurred on all days of survey. The recent hospital discharge summary, dated 10/12/18, contained a Social History which noted the resident currently smoked one-fourth pack of cigarettes a day and last attempted to quit on 04/25/15. An annual MDS, dated [DATE], showed staff failed to code section J1300, Yes: current tobacco use. SECTION M: SKIN CONDITIONS The Long-Term Care Facility RAI User's Manual, revised (MONTH) (YEAR), pages M-29 to M-37 stated, . Coding Instructions Check all that apply in the last 7 days. M1040H Moisture Associated Skin Damage (MASD) (superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration) . M1200H Application of Ointments/Medications Other than to Feet . Ointments/medications may include topical creams, powders, and liquid sealants used to treat or prevent skin conditions. Review of Resident #126's medical record occurred on all days of survey. The nurse progress notes showed the following: * 11/07/18 - . has red excoriated skin on his coccyx and zinc paste has been applied to the area to promote healing. * 11/08/18 - . redness to coccyx (MASD) which has z-paste applied daily as a barrier. * 11/09/18 - . redness to coccyx (MASD) which has z-paste applied daily as a barrier. * 11/10/18 - . redness to coccyx (MASD) which has z-paste applied daily as a barrier. * 11/11/18 - . redness to coccyx (MASD) which has z-paste applied daily as a barrier. * 11/12/18 - . redness to coccyx (MASD) which has z-paste applied daily as a barrier. * 11/13/18 - . redness to coccyx (MASD) which has z-paste applied daily as a barrier. Review of the significant change in status assessment (SCSA) MDS, dated [DATE], showed facility staff failed to code section M1040H and section M1200H. SECTION O: SPECIAL TREATMENTS, PR[NAME]EDURES, AND PROGRAMS The Long-Term Care Facility RAI User's Manual, revised (MONTH) (YEAR), pages O-11 to O-12 stated, . O0300: Pneumococcal Vaccine Coding Instructions O0300A, Is the Resident's Pneumococcal Vaccination Up to Date? Code 0, no: if the resident's pneumococcal vaccination status is not up to date or cannot be determined. Proceed to item O0300B, If Pneumococcal vaccine not received, state reason. Code 1, yes: if the resident's pneumococcal vaccination status is up to date. Up to date in item O0300A means in accordance with current Advisory Committee on Immunization Practices recommendations. Review of the ACIP webpage (https://www.cdc.gov/vaccines/schedules/hcp/index.html. MMWR / (MONTH) 4, (YEAR) / Vol. 64 / No. 34) stated, . For immunocompetent adults aged > (greater than) [AGE] years who have not previously received pneumococcal vaccine, ACIP makes the following recommendation for intervals between PCV13 (13-valent pneumococcal conjugate vaccine) followed by PPSV23 (23-valent pneumococcal [MEDICATION NAME] vaccine): A dose of PPSV23 should be given >1 year following a dose of PCV13. The two vaccines should not be co-administered. If a dose of PPSV23 is inadvertently given earlier than the recommended interval, the dose need not be repeated. - Review of Resident #2's medical record occurred on 12/05/18. The record showed Resident #2 received the PPSV23 vaccine on 11/14/12 (prior to admission). The record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. Resident #2's pneumococcal vaccine had not been given. Review of the quarterly MDS, dated [DATE], showed facility staff incorrectly coded section O0300, Yes: up to date. - Review of Resident #5's medical record occurred on 12/05/18. The record showed Resident #5 received the PPSV23 vaccine on 03/09/11 (prior to admission). The record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. Resident #5's pneumococcal vaccine had not been given. Review of the quarterly MDS, dated [DATE], showed facility staff incorrectly coded section O0300, Yes: up to date. - Review of Resident #126's medical record occurred on 12/05/18. The resident was admitted in (MONTH) (YEAR). The record lacked evidence the facility assessed the resident's pneumococcal immunization status on admission and provided education to the resident and/or their legal representative. Review of the SCSA MDS, dated [DATE], showed facility staff left section O0300 blank. Facility staff failed to correctly code section O0300 for Resident's #2, #5, and #126 on their most recent MDSs.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 01/11/18. Based on record review and staff interview, the facility failed to develop a comprehensive care plan for 5 of 12 sampled residents (Resident #5, #6, #19, #20, and #126). Failure to develop a care plan that includes the services to be provided to the resident may negatively impact the resident's quality of life. Findings include: - Review of Resident #19's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS), dated [DATE], identified a [DIAGNOSES REDACTED]. Review of the current care plan showed the facility failed to develop a comprehensive care plan specific with goals and interventions for Resident #19's [DIAGNOSES REDACTED]. - Review of Resident #20's medical record occurred on all days of survey. The recent hospital discharge summary, dated 10/12/18, contained a Social History which noted the resident currently smoked one-fourth pack of cigarettes a day. Review of Resident #20's current care showed the facility failed to develop a comprehensive care plan with goals and interventions related to smoking status. - Review of Resident #126's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. The nursing progress notes following two hospital returns indicated the following: * 11/06/18 - . On his right foot he has reddish/black sores on his great and 2nd toe. On the left foot he has black sore on the tip of his great and 2nd toe. has red excoriated skin (damage to the surface of the skin) on coccyx (tailbone). zinc paste was applied . heal (sic) boots applied to bilateral (both) feet. 2+ [MEDICAL CONDITION] to bilateral legs and arms . Drain has sterile dressing applied over and no drainage noted at this time. * 11/27/18 - . transfers via HOYER x 2 assist, and has 02 (oxygen) @ (at) 2 lpm (liters per minute) to keep resident satting (sic) > 90%. has +3-4 [MEDICAL CONDITION] . red, moist, & (and) excoriated buttocks/groin. Barrier cream and antifungal being applied. Wound (pluervax (sic) drain site) to left chest intact. Heel booties on while resident in bed. Review of Resident #126's current care plan showed the facility failed to develop a comprehensive care plan with goals and interventions related to the diagnoses, the skin conditions on feet and buttocks, the swelling in all extremities, the location and care of the [MEDICATION NAME] drain, the use of a Hoyer lift with assistance of two for transfers, the use of oxygen, and the use of heel protectors. The facility failed to develop a comprehensive care plan for Resident #126 following two hospitalization s. During an interview on 12/06/18 at 1:30 p.m., an administrative nurse (#2) acknowledged the care plans had not been updated to reflect current diagnoses, problems, goals, and interventions. - Review of Resident #5's medical record occurred on all days of survey and identified a hospitalized from [DATE] through 06/23/18 for a urinary tract infection [MEDICAL CONDITION]. The resident returned to the facility on [DATE] with an order for [REDACTED]. Will start [MEDICATION NAME] Keflex 250 mg daily . Review of Resident #5's current care plan showed the facility failed to develop a comprehensive care plan with goals and interventions related to the UTI [DIAGNOSES REDACTED]. During an interview the afternoon of 12/06/18, an administrative nurse (#2) acknowledged the care plan failed to reflect Resident #5's current diagnosis, problems, goals, and interventions. - Review of Resident #6's medical record occurred on all days of survey. A provider's progress note, dated 07/19/18, stated, . past history of dementia Alzheimer's type with behavioral disturbance, unspecified [MEDICAL CONDITION] and unspecified [MEDICAL CONDITION] . continues to be tearful and has frequent crying spells . Recommendations: Start [MEDICATION NAME] XR (treats [MEDICAL CONDITION]) 7 milligrams every morning . continue [MEDICATION NAME] (antidepressant) 50 mg every morning . continue [MEDICATION NAME] (antipsychotic) 0.5 mg twice a day. Nursing progress notes included the following behaviors: * 10/20/18 14:55 - . Resident has been hollering, 'water, water' repeatedly, as her water was sitting directly in front of her . staff approached resident several times and showed her that her drinks were in front of her and she stated, 'oh, shut up,' and continued hollering . * 11/17/18 14:53 - . upon sitting at the dining room table awaiting breakfast, resident kept hollering, 'I can't see.' I approached resident to see if her glasses were possibly dirty and she stated, 'shut up you damn fool.' Resident continued to call me names every time I walked past her and upon approaching her again to let her know her behavior was unacceptable, she stated, 'oh, I'm sorry . * 11/25/18 00:25 - . Resident has been hollering for help . Staff assists her and then she is yelling in her room for help and interrupting other resident's sleep. Staff helps her into her wheelchair and brings her down to the nurses station . is offered food and drinks. Resident gets upset and starts banging her right fist onto the counter. Resident stops when staff informs her that she is gong to hurt herself if she continues . Review of Resident #6's current care plan showed the facility failed to delevop a comprehensive care plan with goals and interventions related to behaviors. During an interview the afternoon of 12/06/18, an administrative nurse (#2) acknowledged the care plan failed to reflect Resident #6's current diagnosis, problems, goals, and interventions.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 01/11/18. Based on observation, and staff interview, the facility failed to properly store medications for 2 of 2 storage areas (medication room and medication cart). Failure to discard expired medications increases the risk of residents receiving outdated medications with reduced efficacy. Findings include: Observation of the medication room and medication cart occurred on the afternoon of 12/05/18 with a licensed nurse (#1). Observation identified the following expired medications and locations: Medication Cart: * Vitamin C 100 mg tabs - (MONTH) (YEAR) Medication Room: * [MEDICATION NAME] (ear drops) - 10/05/18 * [MEDICATION NAME] Inhaler - 11/17/18 * Refresh tears (eye drops) - 08/21/18 * Four unlabeled syringes contained in a biohazard bag with a hand written note Flu shots - 10/04/18 During the observation, the licensed nurse (#1) agreed the above items needed to be discarded.

Based on observation, record review, and staff interview, the facility failed to assess the safety of self-administration of medication (SAM) for 1 of 1 sampled resident (Resident #5) care planned to self-administer medications. Failure to evaluate/re-evaluate a resident's ability to safely self-administer medications may result in a medication error and/or harm to a resident. Findings include: Observation on 12/05/18 at 8:07 a.m. showed a nurse (#1) dispensed Resident #5's scheduled medications into a pill cup, placed the pill cup onto the breakfast table beside Resident #5, and then walked back to the medication cart. The nurse (#1) stated, She (Resident #5) is one person we can give medications to and can take them on her own. Review of Resident #5's medical record occurred on all days of survey. A physician order, dated 6/20/13, showed Resident #5 may self administer all drugs. A problem start date of 11/07/18 on the current care plan showed, . I self administer my own medications after they are set-up for me by the nurse . Resident #5's medical record lacked an assessment and periodic evaluation of her ability to self-administer medications. During an interview on the afternoon of 12/06/18, an administrative nurse (#2) stated she was unable to locate a facility policy or Resident #5's SAM assessment/reassessment.

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 staff interview, the facility failed to complete a status change assessment for 3 of 3 sampled residents (Resident #6, #16, and #21) who had a new mental illness [DIAGNOSES REDACTED]. Failure to complete a change in status assessment for Resident #6 and #21 and complete a recommended level II PASARR for Resident #16 may result in the residents not receiving the appropriate care and services for their mental health disorders. Findings include: The North Dakota PASARR Provider Manual, page 7 and 13, stated, . If the Level I Screen indicates that the applicant does have indicators for MI, ID, and/or RC, a Level of Care Form must be completed and forwarded to Ascend (regardless of the individual's method of payment). If the individual with MI, ID, and/or RC meets criteria for nursing facility level of care, s/he will be referred for a Level II PASARR evaluation, which then must be completed prior to the individual's admission to a nursing facility . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Ascend to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability (referred to in regulatory language as related conditions or RC)) was not identified at the Level I screen process, and that condition later emerged or was discovered. - Review of Resident #6's medical record occurred on all days of survey. The record showed an initial Level I PASARR, completed on 01/05/17, identified no [DIAGNOSES REDACTED]. The facility added a physician's [DIAGNOSES REDACTED]. The record lacked evidence of an updated Level I PASARR rescreening/change in status assessment for the new diagnosis. During an interview on the morning of 12/05/18, an administrative nurse (#2) stated staff failed to complete the required Level I PASARR rescreening. - Review of Resident #16's medical record occurred on all days of survey. The record showed a Level I PASARR, completed on 06/11/18, identified no [DIAGNOSES REDACTED]. The facility added a physician's [DIAGNOSES REDACTED]. A required Level I PASARR, completed 07/06/18, identified Resident #16, . Will require a Level II. The medical record lacked evidence of a Level II PASARR screening completed. During an interview on the morning of 12/05/18, an administrative nurse (#2) stated staff failed to complete the Level II PASARR screening. - Review of Resident #21's medical record occurred on all days of survey. Admission diagnoses identified [MEDICAL CONDITION] disorder, current episode depressed, mild or moderate severity, unspecified. Review of the admission Minimum Data Set (MDS), dated [DATE], identified diagnosed including: [DIAGNOSES REDACTED]. The record showed a completed pre-admission Level I PASARR identified no diagnoses of a MMI including [MEDICAL CONDITION] Disorder or depression (mild or situational), and . No Level II Evaluation needed. During an interview on 12/04/18 at 3:50 p.m. and on the morning of 12/05/18, an administrative staff member (#3) stated staff failed to complete the required Level I PASARR after the [DIAGNOSES REDACTED].

Based on observation, record review, and staff interview, the facility failed to review and revise the comprehensive care plan for 2 of 12 sampled residents (Resident #16 and #20). Failure to review and revise the care plan limits the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings include: - Review of Resident #16's medical record occurred on all days of survey. The care plan stated, I transfer two person stand pivot transfer x 2 with FWW (front wheeled walker) with limited weight bearing to right ankle for surface-to-surface transfers . I receive antipsychotic/hypnotic/antidepressant medications [MEDICATION NAME] HCL, [MEDICATION NAME] and [MEDICATION NAME] XL (initiated 08/13/18) . Observation on 12/03/18 at 9:32 a.m. showed a certified nursing assistant (CNA) (#9) pivot transfered Resident #16 from wheelchair to recliner with one assist, utilizing a FWW, a gait belt, and toe touch weight bearing to her right foot/walking boot. Observation on 12/05/18 at 4:05 p.m. showed an unidentified CNA pivot transfered Resident #16 from her recliner, into her wheelchair, and then to her bed with one assist, utilizing a FWW, a gait belt, and toe touch weight bearing to her right foot/walking boot. During this transfer, an administrative nurse (#2) stated to the CNA, Isn't she assist of two? The CNA responded, No, she is one. During an interview on the morning of 12/06/18, an administrative nurse (#2) stated Resident #16's transfer orders recently changed to one assist and acknowledged the care plan failed to reflect the resident's current level of assistance with transfers. The nurse (#2) also stated the physician discontinued the [MEDICATION NAME] a while ago and acknowledged the care plan failed to reflect the resident's current [MEDICAL CONDITION] medications. - Review of Resident #20's medical record occurred on all days of survey. The current care plan identified 12 problem/categories, with goals, and approaches specific to Resident #20's care and services. Nine of the 12 problem/category, goal, and approaches showed Last Reviewed/Revised dates in (MONTH) (YEAR). The facility failed to review and revise the care plan with the most recent quarterly Minimum Data Set, dated dated [DATE].

Based on record review and staff and family interviews, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 2 of 2 sampled residents (Resident #19 and #126) requiring increased assessment and monitoring. Failure to reassess new and existing skin conditions and provide timely and appropriate interventions may contribute to further skin breakdown, increased risk for infection, and pain (Resident #19). Failure to assess and promote physical strength and mobility following a hospital return may contribute to further decline in strength, endurance, and increased risk for skin breakdown, and pain (Resident #126). Findings include: The facility failed to provide a copy of a policy addressing skin issues/pressure ulcers upon request. - Review of Resident #19's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Review of the current care plan showed the facility failed to address the resident's ongoing skin issues. Review of Resident #19's progress notes and provider communication showed the following: * 08/14/18 at 10:44 p.m. - . I noted on her left foot middle toe that she has a blackened area and swelling. All toes have fungus and are in need of trimming. Bath is tomorrow and will have them looked at closer then. * 08/18/18 at 1:03 a.m. - . Resident has no new skin issues. * 08/20/18 at 8:50 p.m. - . Noted her left foot and ankle are very red and swollen with 1+ [MEDICAL CONDITION]. * 08/22/18 at 6:26 a.m. - . Left foot and ankle is still swollen and red. No warmth to touch. * 08/22/18 at 1:08 a.m. - Resident's left ankle and foot is noticeably more swollen with +2 [MEDICAL CONDITION]. It is warm to the touch. Resident is scheduled to be seen by (nurse practitioner) tomorrow regarding this. * 08/23/18 Provider communication (nine days after staff documented the toe as blackened area and swelling). Provider orders stated, [MEDICAL CONDITION] of left 3rd toe - Start [MEDICATION NAME] (antibiotic) 500 mg (milligrams) PO (by mouth) X1(times 1) dose then 250 mg PO daily days 2-10 - Also - Cleanse area (with) [MEDICATION NAME] Bid - Apply [MEDICATION NAME] to area and cover (with) absorbent dressing until healed. The facility failed to include the [DIAGNOSES REDACTED].#19's medical record. * 08/23/18 at 10:34 p.m. - . Treatment to left toe done at this time . Also noted that she has a split under the toe in the crease. * 08/24/18 at 1:27 p.m. - . Leg and foot 2+ [MEDICAL CONDITION] w(with)/leg mildly red and warmer to touch than the right. Foot care done by staff - cleansed w/[MEDICATION NAME] placed and absorbent dressing w/Coban wrap placed. * 08/25/18 at 3:22 p.m. - . Resident is receiving oral [MEDICATION NAME] antibiotic therapy for [MEDICAL CONDITION] . Left third toe has an open area to the base; wound bed is red/beefy and bleeds a scant amount upon cleansing. * 08/26/18 at 3:56 p.m. - . Base of left 3rd toe has an open area that is red/beefy in appearance; area cleansed well with [MEDICATION NAME], rinsed, patted dry and then [MEDICATION NAME] and band-aide applied. Resident tolerated procedure fairly well, as she kept stating it was painful. * 09/02/18 at 3:29 p.m. - The last dose of ABT (antibiotic) for [MEDICAL CONDITION] to LLE (left lower extremity) was given. * Documentation from 09/02/18 to 11/07/18 noted provider orders for treatment, and on 11/07/18 at 2:59 p.m. the last documentation regarding the left 3rd toe stated, Band aid and [MEDICATION NAME] applied to residents left 3rd toe. Resident did complain of pain when the toes (sic) was touched to apply the band aid. * 12/02/18 at 11:27 p.m. documentation regarding the left 3rd toe stated, . left foot 3rd toe dry and scabbed, flaking noted to bottom of toe but is intact. * 12/02/18 at 11:27 p.m., stated, . small fluid-filled blister forming to lateral right 2nd toe (is intact at this time). The medical record failed to contain any further documentation through 12/06/18 of the newly discovered blister on the right 2nd toe. During an interview on the afternoon of 12/05/18, a supervisory nurse (#2) stated she expected nursing staff to create an event for the observed right 2nd toe blister, consider implementing interventions or standing orders for skin issues if appropriate, communicate to the next nursing shift, update the physician and family, and continue to document the monitoring of the blister. The nurse also stated the facility had no specific or consistent procedure/form to report/document skin issues. The nurse indicated the resident chose her own shoes or slippers to wear each day, and staff had not determined the cause for either of the open toe (right or left foot) skin issues. The facility failed to ensure staff completed the following for Resident #19's left 3rd toe: * Initiate treatment in a timely manner which included notification of the provider regarding the left 3rd toe skin issue, identify possible reasons for the skin breakdown, and document communication of the issue with the family * Include the skin issue on the care plan to include goals and interventions for healing and prevention of further skin breakdown including [MEDICAL CONDITION] * Document the new [DIAGNOSES REDACTED]. * Create or initiate a form and/or policy/procedure for consistently documenting, monitoring, and reassessing skin issues from the initial onset and until healed including tracking treatment results The facility also failed to reassess, determine the cause, monitor, and document/communicate Resident #19's right 2nd toe blister in a timely manner. - Review of Resident #126's medical record occurred on all days of survey. A progress note, dated 11/07/18 showed Resident #126 ambulated short distances with assistance of two staff, and used a wheelchair for mobility, propelled by staff. The resident returned to the nursing home on 11/27/18 following a hospitalization for pleural effusions (fluid on the lungs). The physician orders included resident to be transferred with a Hoyer (full body mechanical lift) with assistance of two staff. Resident #126's progress note dated 12/04/18 at 8:47 a.m., prior to a physician appointment, stated, . staff report sliding out of w/c (wheelchair) upon getting into w/c. staff report possible OH (orthostatic [MEDICAL CONDITION]) syncopy ([MEDICAL CONDITION]) from transfer out of bed in in(sic) w/c. During an interview on 12/06/18 at 9:50 a.m. a family member (F) stated, Resident #126 was very weak and had not been out of bed since he returned from the hospital except for a doctor appointment on 12/04/18. The family member (F) stated, he struggled to sit up for the appointment and stated she would like to see Resident #126 sit up in a chair a few times during the day so when he goes out for appointments it is not so hard on him. During an interview on 12/06/18 at 11:30 a.m., the physical therapist (#12) stated they would evaluate a resident when there is a physician order or if a nurse orders to screen for therapy potential. During an interview on 12/06/18 at 1:30 p.m., an administrative nurse (#2) acknowledged Resident #126 had not been out of bed since the hospital return, other than going to an appointment on 12/04/18. The administrative nurse (#2) stated the resident had remained in bed because there were no physician orders indicating activity level and verified a referral to therapy for a screen or a physician order for [REDACTED].>The facility staff failed to request a therapy screen or a physician order for [REDACTED].

Based on review of the facility policy, record review, observation, and staff interview, the facility failed to assess a resident's capabilities and deficits to determine the level of supervision required to assure the safety for 1 of 1 sampled resident (Resident #20) who smoked. Failure to complete an assessment to determine the resident's safety while smoking placed all residents at risk for potential injury. Findings include: Review of the facility policy titled (name of nursing home) is a Smoke Free Facility occurred on 12/05/18. This policy, dated (MONTH) (YEAR), stated, . This policy applies to all residents, visitors, and employees, for both smokers and non-smokers. Smoking is prohibited in all areas of the facility and facility grounds. Residents and/or resident representative will be informed of the facility's 'Smoke Free' policy during the pre-admission and/or admission process. Residents with a history of smoking will be further assessed to determine whether (sic) or not interventions are needed to help them cope with the 'Smoke Free' policy. Examples include pharmacological and/or behavioral interventions to curb urges to smoke. If a resident does not abide by the smoking policy, care plan revisions shall be documented and implemented to promote safety. Progressive interventions may include room searches and discharge. During the entrance conference the morning of 12/03/18, the facility provided the following written information; Currently (name of nursing home) has no residents that smoke. Review of Resident #20's medical record occurred on all days of survey. The recent hospital discharge summary, dated 10/12/18, contained a Social History which noted the resident currently smoked one-fourth pack of cigarettes a day and last attempt to quit in 04/25/15. Resident #20's current care plan lacked problems, interventions or goals regarding smoking status. Observation on 12/03/18 at approximately 5:30 p.m. showed Resident #20 outside the facility alone and self-propelled the wheelchair toward the main entrance. During an interview on 12/05/18 at 11:30 a.m., an administrative nurse (#2) stated she read in the hospital discharge summary that Resident #20 smokes and has heard reports from the night staff that Resident #20 goes outside and returns with a smell of tobacco. The administrative nurse (#2) acknowledged the facility did not complete a safety assessment or provide supervision regarding Resident #20's smoking status. The facility failed to identify Resident #20 as a smoker and/or complete a safety assessment or follow the Smoke Free facility policy.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to offer fluids to 2 of 2 sampled residents (Resident #21 and #76) observed during cares and required staff assistance for fluid intake. Failure to provide assistance with fluid intake may result in dehydration, constipation, and urinary tract infections (UTIs). Findings include: Review of the facility policy titled RHC (facility name) Hydration occurred on 12/06/18. This undated policy stated, . 1. Staff will offer fluids at meals and periodically between meals. 2. Fluids are offered between meals and PRN (as needed). - Observation on 12/03/18 at 3:18 p.m. showed two certified nurse aides (CNAs) (#4 and #5) failed to offer fluids to Resident #21 after toileting or before transporting the resident to the sitting room where the husband had waited. Observation during the noon meal on 12/03/18 and breakfast on 12/04/18 showed Resident #21 needed total assist for consuming food and fluids. Observation on 12/05/18 at 10:30 a.m. showed two CNAs (#6 and #7) transferred Resident #21 from the wheelchair to the toilet and then to bed utilizing a mechanical stand lift. The CNAs failed to offer fluids after cares. Review of Resident #21's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS), dated [DATE], identified extensive assist of one staff for eating. The current care plan stated, . need assistance with my meals as I need cueing and physical guidance. - Observation on 12/05/18 at 9:58 a.m. showed two CNAs (#8 and #9) transferred Resident #76 utilizing a full body mechanical lift from the wheelchair to the bed. The CNAs identified no water container located in the room and failed to obtain and offer fluids after cares and before leaving the room. Review of Resident #76's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current care plan stated, . Assist/cueing/encourage as needed with oral/fluid intake. During an interview on 12/06/18 at 3:40 p.m. two administrative staff members (#2 and #3) agreed staff failed to follow the policy and to offer fluids during cares.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED ON 03/03/16, 04/01/15, 02/06/14 AND 01/31/13. URINARY TRACT INFECTION [MEDICAL CONDITION] 1. Based on record review and review of facility policy, the facility failed to provide care and services to manage a urinary tract infection [MEDICAL CONDITION] for 1 of 7 sampled residents (Resident #3) with a history of UTIs and 1 closed record (Resident #10) with a history of UTIs caused by a multi-drug resistant organism (MDRO). This resulted in Resident #3's hospitalization due to inappropriate treatment of [REDACTED].#3's overall well-being, and resulted in delayed treatment of [REDACTED]. Findings include: Review of facility policy Urinary Tract Infections/Bacteriuria - Clinical Protocol occurred on 02/02/17. The policy, dated 02/14, stated: Assessment and Recognition . The staff and practitioner will identify individuals with signs and symptoms suggesting a possible UTI. Cause Identification 1. The physician will help nursing staff interpret the significance of signs, symptoms, and lab test results. - Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS), dated [DATE], identified Resident #3 as cognitively intact, and either independent or requiring limited assistance of one person with all activities of daily living (ADLs) except bathing. A significant change MDS, dated [DATE], identified Resident #3 had moderate cognitive impairment, and required extensive assist of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toileting, personal hygiene, bathing, and walking in the room and corridor did not occur. A quarterly MDS, dated [DATE], identified the resident returned to a status of cognitively intact, and independent or limited assistance with all ADLs, except dressing and bathing. Progress notes identified the resident taken to an acute care hospital on [DATE] and returned on 05/09/16, diagnosed with [REDACTED]. The Instructions for after Discharge identified follow up with the resident's primary care physician within one week, and the hospital Lab Test Awaiting Results included urine cultures. The final culture report, dated 05/10/16, identified the organism of Escherichia coli (E coli), greater than 100,000 colony forming units/milliter. (E coli is a common organism found in patients with UTIs). The culture identified the organism resistant to Cipro. The record showed the nurse practitioner (FNP) saw resident for follow up visit; post hospital admission on 05/12/16. The primary care physician saw the resident on 05/17/16, and no new orders given. Nursing staff administered the last dose [MEDICATION NAME] the morning of 05/18/16. On 05/19/16, the FNP ordered a follow-up urinalysis (UA) for 05/20/16. Nursing staff obtained the UA on 05/20/16 via a clean catch sample and sent it to the clinic. The progress notes stated the FNP reviewed the UA results and Will send for UC (urine culture) as it appears infection has not resolved. The final urine culture, dated 05/22/16, showed the organism isolated as sensitive (verses resistant) to [MEDICATION NAME], and resistant to Cipro. On 05/23/16 at 1:16 p.m., the FNP ordered [MEDICATION NAME] for 10 days and the resident continued to have no symptoms of urgency noted. Nursing staff gave the first dose of an antibiotic on the evening of 05/23/16. Progress notes identified: * 05/24/16 at 5:42 p.m., Resident alert, oriented, presentes (sic) with nausea, shaking, 1 small emesis and complaints of stomach upset. Temp. (temperature) 99.1, P (pulse) - 91, R (respirations) - 24; b/p (blood pressure) - 171/77 . This was a significant change from earlier in the afternoon when her temp. was 97.5 and b/p - 152/84 after lunch. The physician gave orders to transfer the resident to the emergency room (ER) at 5:46 p.m. The facility sent the resident by ambulance. * 05/24/16 at 11:54 p.m., . Lab results from last UA faxed to (hospital). That last UA final culture report, dated 05/22/16, showed Escherichia coli bacteria, greater than 100,00 colony forming units/ml (milliliter). The final urine culture, from the previous UA collected on 05/08/16, showed the same organism, and also resistant to Cipro. * 05/25/16 at 2:18 a.m., (hospital) called and stated waiting for CT results to see if anything there . At 6:36 a.m., the hospital informed the facility the hospital admitted the resident with a [DIAGNOSES REDACTED]. The hospital discharged the resident back to the facility on [DATE] with [DIAGNOSES REDACTED]. Orders included an antibiotic, [MEDICATION NAME], for five days for treating the UTI. On that day and the two days following, nursing staff identified the resident as extremely confused, having hallucinations, not making sense at times, unable to feed herself, requiring total to extensive assist with all cares, and at times, with jerky and spasmodic movements, and hard to arouse. Medicare progress notes written on 06/02/16, 06/03/16, and 06/04/16 identified the resident admitted to hospital for acute [MEDICAL CONDITION] secondary to sepsis secondary to UTI. Failure to ensure follow-up and appropriate treatment occurred for a UTI identified from Resident #3's overnight hospital stay on May 08-09, 2016 resulted in facility failure to treat Resident #3's UTI with a medication to which the identified organism was sensitive. This progressed to a second hospitalization due [MEDICAL CONDITION] from an untreated UTI, as well as acute [MEDICAL CONDITION]. This resulted in a decline in the resident's ADL status, changes in cognitive status, and an overall deterioration of health. - Review of Resident #10's medical record occurred on 02/01/17. [DIAGNOSES REDACTED]. A significant change MDS, dated [DATE], identified Resident #10 had short/long term memory problems, moderately impaired daily decision-making/reasoning skills, and required extensive assist of one person for toileting and personal hygiene. The progress note, dated 10/18/16 at 12:15 a.m., identified, UA (urinary analysis) (was) collected per doctors order 0015 (12:15 a.m.) The Urine Culture, dated 10/21/16 at 12:02 p.m., identified, . Organism of Escherichia coli, > (greater than) 100,000 colony forming units/milliliter. Extended Spectrum Beta-Lactamase (ESBL) producing organism. Attention: Antiobiotic Resistant Alert. CDC (Centers of Disease Control) Recommends Contact Isolation. The panel further identified the organism was susceptible to [MEDICATION NAME]. Progress notes identified the following: * 10/24/16 at 1:24 p.m., Final Urine culture reviewed by (nurse practitioner). Written order to start resident on 100 mg (milligrams) of [MEDICATION NAME] BID (twice daily) x (times) 10 days. Recheck urine in 12 days. There was no indication in the record the facility attempted to obtain Resident #10's lab results prior to 10/24/16. * 10/24/16 at 2:16 p.m., First dose of [MEDICATION NAME] given at 1400 (2:00 p.m.) d/t (due/to) ESBL in urine. Isolation precautions are in place and being followed; resident was moved to private room and staff have been educated. * 10/26/16 - 11/02/16, Resident remains on [MEDICATION NAME] antibiotic therapy for treatment of [REDACTED]. Contact isolation precautions are in place and being followed. * 11/02/16 at 10:12 a.m., . repeat UA obtained at 1000 (10:00 a.m.) and sent to clinic for evaluation . and at 3:43 p.m., UA results received from clinic and noted to have a moderate amount of leukocytes present; NP wrote: please culture . * 11/04/16 at 10:27 a.m., At this time per (employee) in microbiology at the lab . 'there is not any ESBL organism growing .' (Employee) indicated lab results will be (sic) follow procedure for documented notification' . and at 10:30 a.m., Resident has been cleared to remove isolation precautions . resident to be moved back to prior room arrangements . The facility failed to obtain Resident #10's lab results (information about culture results and/or antibiotic resistance) in a timely fashion. This resulted in delayed treatment of [REDACTED].(including her roommate), visitors, and staff, at risk of exposure from October 21-24, 2016. BEHAVIOR MANAGEMENT 2. Based on record review, review of facility policy and staff interview, the facility failed to provide care and services to manage behavioral symptoms of dementia for 1 of 7 sampled residents (Resident #2) identified with dementia. Failure to identify and assess behaviors, implement a behavior management plan, and evaluate interventions affects and may negatively impact the resident's quality of life. Findings include: Review of the facility BEHAVIOR SYMPTOM POLICY occurred on 02/02/17. The undated policy, states, Richardton Health Center strives to meet all the needs of its residents. When behavior symptoms negatively affect the quality of life of a resident/residents, a team approach is required. the resident's behavior symptoms are assessed. Care planning is developed and implemented to maximize the resident's potential to function in a least restrictive environment. A negative behavior has an impact on the resident's overall quality of life. Behaviors that are a danger to self or others also require immediate assessment and care planning. The first priority is to pursue medical assessment . assess the resident for potential unmet needs and identify antecedents. If the resident has dementia and cannot communicate, pain must be considered as a contributor to mood and behavior indicators. this step should be completed prior to initiating any [MEDICAL CONDITION] medication. The care plan should be updated to address the change in behavior. Target behavior symptoms are identified along with potential/actual antecedents. implement approaches designed to decrease the negative behavior. The CNAs (certified nursing assistants) and/or charge nurses will document the frequency of the behavior, interventions tried and the success of those interventions. Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS), dated [DATE], identified no behaviors. A significant change MDS, dated [DATE], identified a change in the resident's behavioral symptoms which included verbal behaviors one to three days per week and rejection of care one to three days per week. The care plan identified the problem of the use of [MEDICAL CONDITION] Drug Use with approaches of Assess/record effectiveness . Monitor resident's mood and response to medication, Pharmacy consultant review. The care plan lacked evidence the facility identified a problem of behaviors which would include approaches/interventions. Current physician's orders [REDACTED]. Resident #2's progress notes identified the resident seen by a psychiatrist. The record identified the two previous visits occurred on 12/01/16 and 01/05/17. Progress notes included: * 01/01/17 at 10:46 a.m.: Resident has removed dressing to right elbow area . and this nurse has re-applied . resident removes dressing after it is applied. Resident came to nurses station and voiced, 'aren't you going to dress my arm,' I informed resident I have dressed the area x 2 and that she continues to take the dressing off; resident became very vulgar and stated, 'well aren't you just a stupid nurse, why would I take it off my arm; this nurse attempted one last time to enter residents room with a CNA accompanying and offered to dress residents arm for the third time and resident kept cursing at me and stating I was stupid, . will try to reapproach resident later once she has calmed down. * 12/20/16 at 11:56 a.m.: Significant change . does see (doctor name) of Archway Mental Health via telemd. (telemedicine) . did have the behavior of yelling at staff and rejected care 1 day. * 12/19/16 at 1:09 p.m.: . came to my office . very confused . stated she must be having a bad dream. I visited with (resident) until she appeared less stressed . * 12/18/16 at 10:39 p.m., Resident is alert. CNA's reported behaviors yelling and hurling items at staff. Nurse was able to redirect her. She denies pain at this time. * 12/17/16 at 6:13 p.m.: . At 1644 (4:44 p.m.) resident requested a pain pill and upon this nurse bring resident a PRN [MEDICATION NAME] I asked her to rate her pain and she became very vulgar and screamed. refused to take her 1700 (5:00 p.m.) scheduled medications. CNAs report resident being very non-compliant with letting them assist her and is showing excessive behaviors when CNAs explain what they need resident to do she does the complete opposite. Phoned residents son, (name) and notified him . * 12/17/16 at 9:54 a.m.: . (nurse practitioner) gave orders to discontinue (resident's) [MEDICATION NAME] (narcotic pain reliever) and restart [MEDICATION NAME]. These orders were implemented. Due to son's verbalization via telephone today, order for [MEDICATION NAME] (anti-anxiety medication) was never started. * 12/15/16 at 7:15 p.m.: . self propelling down the hallway yelling at staff. Confused about the time of day. Unable to express her needs. Staff offer to assist her back to her room or bring her a snack. The resident refused and continued to yell at staff when they pass by. Resident denies pain at this time. Staff will approach and redirect resident at a later time. * 12/15/16 at 6:36 p.m.; Provider (first name) has new orders on pt. (patient) Uncontrolled anxiety; may use [MEDICATION NAME] 0.5 mg (milligram) 1 tab (tablet) (every) 6 hours prn (as needed) monitor closely as will increase risk of falls. * 12/14/16 at 11:28 a.m.: (Resident) . stated my son (first name) hasn't been coming home at night, he hasn't been sleeping in his bed. 'and' I am very concerned because he's been running with these boy's . (resident) has some confusion about the time of day . * 12/14/16 at midnight: Resident came to the nurses station crying and yelling about a dead man under her bed. refused to sleep in her room. The facility failed to take measures to analyze the behaviors exhibited by Resident #2 including tracking and trending for the the specific behavior exhibited including; when the behavior occurred i.e. during a certain time of day/night; whether the behavior occurred in certain locations; whether the behavior was directed toward particular staff/residents; circumstances surrounding the behaviors (what triggered the behavior), and interventions utilized as effective or not. ASPIRATION PRECAUTIONS 3. Based on observation, record review, review of professional literature, and staff interview the facility failed to provide the care and services necessary to attain the highest degree of safety possible for 1 of 3 sampled residents (Resident #1) identified by the facility as having swallowing problems. Failure to supervise and/or given cues and position Resident #1 properly placed Resident #1 at risk for aspiration. Findings include: Nancy B. Swigert, The Source of Dysphagia: Third Edition, LinguiSystems, Inc. 2007, pages 9 and 125 and educational handouts, identified, . Signs and symptoms of dysphagia . drooling . coughing/choking . During the oral intake of . liquids, it is optimal for a patient to be seated at 90 degree angle, whether in bed or in a chair. Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue . Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognitive skills, supervision with set up only for meals, weight loss, and mechanically altered therapeutic diet. The current care plan identified, Problem . Assistance needed for ADL's (activities of daily living) d/t (due to) generalized weakness . Approach . Supervision and cueing during meals . Problem . Altered Nutritional Status R/T [MEDICAL CONDITION] and Impaired Swallowing and Significant Weight Loss. Approach . Remain upward in a sitting position for 30 minutes following each meal. discontinue eating/drinking if excessive coughing/vomiting occurs during meals. Take one, small bite/sip at a time. Use the chin tuck strategy to help clear foods/liquids appropriately. Wait 5 seconds between bites/drinks. Assist resident as needed. The meal cards dated 01/31/17 at 12:25 p.m. and 02/01/17 at 8:15 a.m. identified, . Texture: Puree Liquid Honey . Note: Table Cues. Take one, small bite/sip at a time. Use the chin tuck strategy to help clear foods/liquids appropriately. Wait 5 seconds between bites/drinks. Special Utensils: Divided Plate . The Speech Language Pathologist (SLP) Initial Examination dated 10/28/16 identified the following, . Primary Concern/Chief Complaint: Dysphagia . Current Functional Limitations: Swallowing: . Pureed food & pudding thickened liquids by spoon . Assessment/Diagnosis: [REDACTED]. Recommendations: . pudding thickened liquids by spoon. Patient Education: . reasons for switching to pudding thickened liquids, due to high risks of aspiration. Rehab Potential: Fair (Past history of aspiration. Swallowing/[MEDICAL CONDITION] difficulties progressing.). The Speech Language Pathologist Report, dated 11/11/16, identified the following, Therapy Diagnosis, SLP . Moderate to severe pharyngeal dysphagia (swallowing difficulty) . Onset of Problem, SLP 11/11/14 . Precautions in place . Aspiration Precautions . Difficulty swallowing . Respiratory History . Pneumonia, recurrent . Swallow Study/Video Fluoroscopic Swallow Study . Overall Impressions . Pt (patient) presents with moderate to severe pharyngeal dysphagia . and silent aspiration with nectar thick liquids . Pt successfully utilized chin tuck and multiple swallows with max cueing to improve airway protection and clear majority of residue. Swallow Positions . Swallow Recommendations . Upright 90 degrees . Allow extra time to swallow . chin tuck . upright for meals . Remain upright after meals 60 minutes . The progress notes identified the following: * 11/03/16: Coughing during breakfast . * 11/11/16: Continues to cough during drinking or during meals . * 11/11/16: Swallow Evaluation completed today . * 11/25/16: No straws or cup drinks, staff to continue close supervision during meals . * 11/27/16: Coughing and spitting noted at breakfast and noon meal . Meal observations showed the following: * 01/31/17 at 12:25 p.m.: Resident #1 sat in his wheel chair facing away from other tables towards a window alone unsupervised feeding himself. Frequently coughed and cleared his throat during the meal. * 01/31/17 at 12:40 p.m.: Unidentified staff sat down next to Resident #1. Resident continued to feed himself and cough occasionally. Staff failed to offer cues to Resident #1. * 02/01/17 at 12:15 p.m.: Resident #1 sat in his wheel chair facing away from other tables towards a window alone unsupervised drinking fluids with a spoon. Resident eating very little. Random observations showed the following: * 01/31/17 at 8:45 a.m.: During initial tour, showed a mug with a lid and a straw in the cover placed on bedside table in Resident #1's room. * 01/31/17 at 12:55 a.m.: Two Certified Nurse Assistants (CNAs) (#4 and #5) transferred Resident #1 with transfer from his wheel chair to the bed. The CNA (#4) offered Resident #1 fluids while holding a mug with a lid on it and straw in the cover. The resident accepted, drank from the straw twice, coughed and cleared his throat after each sip. The staff failed to offer cues to Resident #1 while he drank fluids. Both CNAs (#4 and #5) assisted Resident #1 to a laying position with head of bed at 30 degrees. * 01/31/17 at 3:00 p.m.: Two CNAs (#4 and #6) repositioned Resident #1 onto his left side in his bed and raised the head of the bed to thirty degrees. The CNA (#4) offered Resident #1 fluids holding a mug with a lid on it and a straw. Resident #1 then stated no, I just had some. * 01/31/17 at 4:15 p.m.: Resident #1 heard from hallway coughing with the door of his room half way closed. Observation showed Resident laying in bed with head of bed at 45 degrees holding a clear glass of yellow thickened liquid and taking sips from the glass. Resident #1 coughed and cleared throat after each drink taken and until glass was empty. Facility staff failed to supervise, offer cues, and elevate the head of the bed to a 90 degree angle during fluid intake. Observation showed a mug with a lid on it and a straw on top of the bedside table accessible to Resident #1 and a white glass bowl on the bedside table with a small amount of clear liquid and spoon in it. * 02/01/17 at 11:30 a.m.: A mug with a lid and a straw placed on the bedside table in Resident #1's room accessible to the resident. * 02/01/17 at 4:13 p.m.: A mug with a lid on it and a straw placed on the bedside table in Resident #1's room accessible to the resident. During a telephone interview on 02/01/17 at 3:00 p.m., a speech pathologist (#3) stated, Resident #1 had a video swallow completed in November 2016 and it confirmed the resident has a moderate to severe pharyngeal dysphagia. This resident should be upright at 90 degrees for eating and drinking anything. The speech pathologist (#3) confirmed Resident #1 should drink nectar honey thickened liquids with a spoon out of a cup and if the resident is not at 90 degrees in his room and especially unsupervised he shouldn't receive snacks in his room. Staff must provide supervision and should not cue him to use a straw to drink liquids. During an interview on 02/02/17 at 1:30 p.m., an administrative staff (#1) confirmed Resident #1 has had swallowing problems since he was admitted to the nursing home two years ago. Staff failed to position Resident #1's head of the bed to an approximate 90 degree angle and provide supervision and/or cues when offering liquids and during meals. PRESSURE ULCERS 4. Based on observation, record review, and staff interview, the facility failed to constantly implement pressure-relieving interventions for 1 of 1 sampled resident (Resident #1) identified with a history of pressure ulcers. Failure to float resident's heels as ordered may result in development of avoidable, facility-acquired pressure ulcers. Findings include: Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition, extensive assistance required for Activities of Daily Living (ADLs), and risk for pressure ulcers. The current care plan stated, . Problem . Assistance needed for ADL's d/t (due to) generalized weakness . Extensive assistance with bed mobility heels are floated on pillows while in bed . Problem . Category: Pressure Ulcer: . at risk for pressure ulcers R/T (related to) decrease mobility and need for assist with all transfers. Approach . Elevate off load bilateral heels off of bed. Observations showed the following: * 01/31/17 at 12:55 p.m.: Resident #1 laying in bed with his heels directly on the mattress. * 01/31/17 at 2:00 p.m.: Resident #1 laying in bed with a pillow tucked under his knees and his heels directly on the mattress. * 01/31/17 at 3:00 p.m.: Two Certified Nurse Assistants (#4 and #6) repositioned Resident #1 partially onto his left side with a pillow tucked under his knees and his heels directly on the mattress. * 01/31/17 at 4:15 p.m.: Resident #1 sitting up at 45 degrees with a pillow tucked under his knees and his heels directly on the mattress. * 02/01/17 at 10:30 a.m.: Resident #1 laying in bed with two pillows tucked under his knees and his heels directly on the mattress. * 02/01/17 at 11:30 a.m.: Resident #1 laying in bed with two pillows tucked under his knees and his heels directly on the mattress. During an interview on 02/01/17 at 5:15 p.m., an administrative staff (#1) confirmed staff should ensure Resident #1 heels are off the mattress when lying in bed.

1. Based on record review and staff interview, the facility failed to provide the necessary care and services for 1 of 1 discharged resident (Resident #8) who required hospitalization . Failure to assess the resident's condition and to promptly notify the physician resulted in the resident's admission to the intensive care unit (ICU) with [MEDICATION NAME] (medication for heart failure) toxicity [MEDICAL CONDITION] (infection in the bloodstream). Findings include: Resident #8's closed medical record, reviewed on February 5 - 6, 2014, identified [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident with a Brief Interview for Mental Status score of 15, indicating the resident cognitively intact. The record identified Resident #8 was admitted to a hospital ICU on [DATE] with chronic [DIAGNOSES REDACTED], [MEDICAL CONDITIONS] stage III, acute uncontrolled [MEDICAL CONDITION] flutter, and acute [MEDICAL CONDITION] secondary to [MEDICAL CONDITIONS]. The record showed he returned to the facility on [DATE] and his medication regimen included [MEDICATION NAME] 0.25 milligrams daily, which he also received prior to that admission. Resident #8's nurse's notes identified the following: * [DATE] at 7:10 a.m.: ". . . Res (resident) cont (continues) to c/o (complain of) 'feeling weak & (and) tired.'. . ." * [DATE] at 8:00 p.m.: "Resident spent shift resting in bed . . . Resident c/o decreased appetite and upset stomach which he said he had been dealing with 'for about 10 days.' . . ." *[DATE] at 6:10 a.m.: "Wanting to go to hospital. Says 'they will give me IV's (intravenous) to help.' Had emesis of lg (large) amt (amount) light green bile. Enc (encouraged) to eat et (and) try to get moving. Did agree to take [MEDICATION NAME]." The record lacked evidence facility staff informed the physician of Resident #8's complaints and lacked evidence staff assessed the resident's condition or obtained vital signs for 18 hours. Nurse's Notes on [DATE] identified: *12:40 a.m.: "Resident had small bright yellow/lime green colored emesis at this time. . . . Resident was cool & clammy & also pale. Productive cough noted of yellow/green sputum. Resident stated, 'I want to go to the hospital, someone has to figure out what's wrong (with) me.' Resident reassured that appropriate actions would be taken in the AM (morning) when clinic/hospital was open. Resident acknowledged waiting til (sic) morning. . . ." * 7:10 a.m.: "Res c/o still (not) feeling well & c/o (not) being able to keep even H2O (water) down. Res took PO (oral) meds (medications) as ordered." * 8:40 a.m.: "Will cont (continue) to monitor. Res c/o nausea & refusing to eat. Stated '. . . I still think I need to see the Dr. (doctor).' Encouraged res to try & eat something to help (decrease) nausea. Refused at this time." * 10:15 a.m.: "Message left for clinic to call back." This message to the clinic occurred approximately 28 hours after the resident initially voiced multiple complaints and requests to go to the hospital. The record identified a nurse practitioner saw Resident #8 on [DATE] at 2:00 p.m. and ordered medication for nausea but the medical record lacked evidence staff assessed the resident's condition or obtained vital signs for another 18 hours. Nurses notes on [DATE] identified: * 8:00 a.m.: "VS (vital signs) BP (blood pressure) ,[DATE], P (pulse) 61 . . . Resident stated that 'I want to go to the hospital. I think they'll be able to figure out what's wrong (with) me.' (physician's name) notified about request & stated, 'I'm coming over this afternoon & I'll make appointment time to see him.'" * 12 noon: "Resident's pulse was 44 when taken radially, apically was 38 & when machine was used 40. Manual BP was taken ,[DATE] machine read ,[DATE]. (Physician's name) called & ordered resident to be transferred via ambulance to (hospital name) ER (emergency room ). (Physician's name) ordered 4LO2 (4 liters oxygen) & IV (with) [MEDICATION NAME] ringers (an IV solution) be started before transport. . . ." * 7:00 p.m.: "Called (Hospital name) @ (at) this time, admitted to ICU . . ." A nurse's note, dated [DATE] at 1:40 p.m. stated, "(Hospital name) called for an update. Stated resident is still in the ICU still on a [MEDICATION NAME] (medication to treat shock) drip (IV). No change in resident condition . . ." A physician's progress note, dated [DATE], stated, "(Resident #8) is back from the hospital after an episode [MEDICAL CONDITION] and [MEDICATION NAME] toxicity. . . ." An interview occurred with two administrative nurses (#2 and #3) on the morning of [DATE]. When asked to provide any pertinent notes or vital signs from [DATE]-17, 2013, the staff members provided no additional information. The facility's failure to assess the resident's condition and promptly notify the physician of Resident #8's repeated requests to "go to the hospital" contributed to delayed [DIAGNOSES REDACTED]. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON [DATE]. 2. Based on observation, record review, review of professional literature, and staff interview, the facility failed to provide the care and services necessary to attain the highest degree of safety possible during meals for 3 of 3 sampled residents (Resident #1, #3, and #6) observed or with a history of signs/symptoms of aspiration. Failure to ensure residents were positioned properly, provided the correct consistency foods, fed bite-sized portions at a slow rate, and to ensure individuals feeding the residents were properly trained in dysphagia, resulted in Resident #1 and #6 aspirating and placed Resident #3 at risk of aspirating. Findings include: On the morning of [DATE], the survey team requested several policies from administrative staff, including the policy/procedures for dysphagia and feeding dependent residents. On [DATE] at 8:40 a.m., two administrative nurses (#2 and #3) stated, approximately six months ago, their policy manual "disappeared" and they had no policy/procedures for dysphagia and feeding dependent residents. Nancy B. Swigert, "The Source for Dysphagia: Third Edition", LinguiSystems, Inc, 2007, pages 15, 47, 125, 128, 137 and the educational handouts identified, ". . . Any patient who . . . has been diagnosed with [REDACTED]. . . . Signs of oral phase dysphagia include losing food or liquid out the front of the mouth (Observed with Resident #6 on February ,[DATE], 2013 while being fed) . . . Signs of pharyngeal dysphagia are coughing or choking during a meal (Observed with Resident #1 on [DATE] and with Resident #6 on February ,[DATE], 2013 while being fed) . . . For patients with mechanical problems in the oral phase . . . thickened liquids and pureed foods are often the easiest to swallow. . . . Generally, avoid foods that fall or break apart in the mouth . . . This precaution helps prevent small pieces of food from entering the airway. During the oral intake of . . . foods and/or liquids, it is optimal for a patient to be seated at a 90 degree angle . . . in a chair. . . . Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue (Observed Resident #1 in a reclined position on [DATE]) . . . Controlling the bolus (bite) size is important . . . As long as the bolus size is controlled to a small amount . . . the bolus can rest in the valleculae and pyriforms (parts of the throat) without aspiration during a delayed swallowing response (Observed staff and visitors presenting heaping teaspoons of food to Resident #6 on February ,[DATE], 2013). - Resident #6's medical record, reviewed on February ,[DATE], 2014, identified [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident had severely impaired cognition and required extensive-to-total assistance for all ADLs. The Nutrition Care Area Assessment (CAA), dated [DATE], identified, ". . . Receives a Pureed diet, divided plate provided for self feeding. Need extensive or total assist with meals. Eats all meals in dining room. . . ." During an interview on the morning of [DATE], an administrative nursing staff member (#3) reported the facility failed to assess Resident #6's swallow safety. The current care plan stated, ". . . Problem: Resident is limited in ability to maintain grooming/personal hygiene R/T (related to) decline in physical status secondary to advancing Alzheimer's Dementia . . . Approaches: . . . Need set up and cueing with meals. Assist as needed with hand over hand cueing or dining assistance . . . Problem: Resident requires a mechanically altered diet . . . Approaches: . . . pureed, divided plate promote self feeding, Encourage oral intake of foods and fluids, Monitor acceptance of mechanical altered diet . . . Set up assistance and assist of one for meals . . ." The physician's orders [REDACTED]. . . Diet: Pureed . . ." The nurse's notes identified the following: * [DATE] at 12:30 p.m., "CNA (Certified Nursing Assistant) called me to D/R (dining room) stating res (resident) had a swallow of milk (and) began to cough (and) 'choke' Res teary eyed (and) not actively choking now but coughing up clear thick phlegm. . . ." * [DATE] at 9:00 p.m., ". . . Occasionally spits out pieces of pills. . . ." * [DATE] at 12:30 p.m., "Res had 2 bites of meal (and) CNA states was fine, but coughed (and) started coughing up thick clear phlegm. I attended Res (and) (sic) continued to cough up lg (large) amt (amounts) of clear thick phlegm, oral cavity cleaned out of clear phlegm (and) only very scant amt of pureed food particles from teeth. . . ." The dietary progress note, dated [DATE], identified, ". . . LRD (Licensed, Registered Dietitian) observed noon meal. Resident was fed by (visitor). Resident ate quite well - no problems chewing or swallowing. . . ." Dining room observations showed the following: * [DATE] at 12:40 p.m., a visitor fed Resident #6 heaping teaspoon after heaping teaspoon of pureed food prior to ensuring the resident had swallowed the previous bite. On two occasions, Resident #6 leaned away from the spoon when it touched his bottom lip (an indication Resident #6 was not prepared for the next bite of food). The visitor also presented and Resident #6 consumed swallow after swallow of thin liquids from a glass. On one occasion, Resident #6 turned his head away from the glass when it touched his bottom lip (an indication Resident #6 was not prepared for the next swallow of liquid). Resident #6 drooled (an indication Resident #6 did not swallow his secretions) twice, throat cleared twice, and coughed/choked (an indication Resident #6 had poor vocal fold closure and secretions had entered his airway) four times; once so hard he sprayed food across his place setting and onto the visitor. * [DATE] at 8:12 a.m., a CNA (#10) fed and Resident #6 consumed heaping teaspoon after heaping teaspoon of pureed food without ensuring the resident had swallowed. At times, Resident #6 could be seen chewing the previous bite of food when the CNA (#10) fed him the next spoonful. On one occasion, Resident #6 leaned away from the spoon when it touched his bottom lip. Resident #6 drooled twice, throat cleared once, and on five occasions coughed/choked immediately following the consumption of thin liquids from a glass; once so hard he sprayed food onto the CNA. * [DATE] at 12:28 p.m., the visitor fed and Resident #6 consumed heaping teaspoon after heaping teaspoon of pureed food without ensuring the resident had swallowed. At times, Resident #6 could be seen still chewing the previous bite of food when the visitor fed him the next spoonful. Resident #6 throat cleared twice and coughed five times. While feeding Resident #6, the visitor stated, "(Resident #6) lost seven teeth with his bridge, so he chews on one side of his mouth." * [DATE] at 8:00 a.m., a CNA (#6) provided (hand-over-hand) guided assistance as Resident #6 attempted to feed himself. The resident ate heaping teaspoons of pureed food. On one occasion Resident #6 coughed on the pureed food, and on the other occasion he immediately coughed following the consumption of thin liquids. * [DATE] at 12:28 p.m., the visitor fed and Resident #6 consumed heaping teaspoon after heaping teaspoon of pureed foods without ensuring the resident had swallowed. Resident #6 throat cleared twice and coughed twice following the consumption of thin liquids from a glass. On one occasion, the visitor was seen putting food in Resident #6's mouth while he was coughing. * [DATE] at 8:10 a.m., a CNA (#11) fed breakfast to Resident #6. Resident #6 coughed twice following the consumption of thin liquids from a glass. During an interview on [DATE] at 10:00 a.m., two administrative staff members (#2 and #4) reported direct care staff had received training on dysphagia and/or aspiration. They further reported the visitor had been allowed to feed Resident #6 without receiving this same training. - Resident #1's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident had moderately impaired cognition, required limited assistance for eating, and had a mechanically altered diet. The current care plan stated, ". . . Problem: Resident is at nutritional risk d/t (due to) impaired swallowing . . . Approaches: . . . If meat is not tender needs to be ground. Thin liquids up for 30 minutes after meals . . . Avoid foods that are difficult to swallow . . . Monitor and report difficulties swallowing, Monitor for signs and symptoms of aspiration pneumonia . . . cough . . ." The physician's orders [REDACTED]. . . Liquids: Honey Thickened with ice chips for quality of life . . . Diet: Pureed . . ." The "Speech Therapy Plan of treatment for [REDACTED]. . . He has been tolerating pureed foods and honey liquids well and they would like to upgrade his diet if possible. Swallow eval (evaluation) complete may upgrade liquids to nectar thick, however diet needs to be pureed foods. . . . Upright (Position), 90 Degree Hip Flexion, Upright, 30 Minutes After Meal . . . Supervision for all Meals/Snacks. . . ." Observation on [DATE] at 1:50 p.m., showed two CNAs (#8 and #9) obtained Resident #1's room tray from the nourishment center, warmed the food, entered the resident's room, and provided tray set-up. The resident sat in his Broda (reclining) chair, which was reclined at a 45 degree angle, and fed himself. Resident #1 coughed (an indication Resident #1 had poor vocal fold closure and secretions had entered his airway) three times during the meal. The CNAs failed to position Resident #1 as close to 90 degrees as possible prior to/during his meal (placing Resident #1 at an increased risk of premature loss of food/liquid over the back of his tongue). The facility failed to 1) position Resident #1 as close to 90 degrees as possible prior to allowing him to eat, 2) control the size of the bolus (bite), offering (flat) teaspoon sized bites of food to Resident #6, 3) offer food to Resident #6 using a slow rate of presentation, 4) recognize Resident #1 and #6's signs/symptoms of dysphagia and/or aspiration (drooling, throat clearing, and/or coughing/choking) 5) assess Resident #6's swallow safety, 6) ensure Resident #6 had no complicated feeding problems and was eligible to be assisted by a visitor, and 7) properly train all individuals allowed to feed residents in the dining room. Failure to implement the above interventions resulted in the residents continuing to aspirate during meals. - Review of Resident #3's medical record occurred on February ,[DATE], 2014. The facility admitted the resident in [DATE]. Current [DIAGNOSES REDACTED]. The significant change MDS, dated [DATE], identified the resident sometimes understood others and made himself understood by others, required extensive assistance of one person for eating, had no swallowing problems, and received a mechanically altered diet. The quarterly MDS, dated [DATE], identified difficulty with swallowing. Resident #3's Nutrition CAA, dated [DATE], stated ". . . Receives mechanical soft diet with pureed meats/gravy . . . Divided plate with meals to aide in self feeding is assist of one with meals. . . ." The resident's current care plan, dated [DATE], stated "Problem, Nutritional Risk . . . Approach, Regular mechanical soft diet with pureed meats. . . ." Resident #3's Nurse's Notes stated the following: *[DATE], 12:00 a.m. - ". . . Unable to administer HS (bedtime) meds d/t lethargy and inability to open mouth and swallow. . . . no cough noted. . . ." *[DATE], 10:30 a.m. - ". . . Resident remains lethargic at times. . . ." *[DATE], 10:30 a.m. - ". . . Res. took AM (morning) meds slowly. Note res. double swallows but (without) cough." 3:00 p.m. - "Orders received for diet (change) to regular diet mechanical soft. *[DATE], 10:30 a.m. - "Resident is pocketing food and has trouble swallowing food and has cough noted (with) med administration (with) 3 attempts at swallowing. . . ." *[DATE], 1:30 p.m. - ". . . Diet (change) to pureed meats, mechanical soft. . . ." The Nurse's Notes through [DATE] and Dietary Progress Notes through [DATE] lacked any indication Resident #3 demonstrated problems with swallowing after the diet change on [DATE]. Resident #3's medical record lacked evidence of a swallow evaluation. Observation on [DATE] at 2:45 p.m. showed Resident #3 seated upright in a wheelchair in the nurse's station lounge. A CNA (#15) approached the resident and held a candy bar for him to eat. The CNA held the candy bar by the wrapper as Resident #3 bit pieces off the candy bar. Resident #3 did not demonstrate coughing or difficulty swallowing. Following this observation the CNA (#15) identified the candy bar as "Milky Way". Observation on [DATE] at 9:55 a.m. showed Resident #3 supine in bed with the head of his bed elevated approximately 30 degrees. A number of small chocolate candies were present on the floor of the room. A CNA (#6) reported she dropped the candies on the floor and had just finished feeding the resident some of the candies, identified as "M & Ms". Failure to provide chocolate snacks in a pureed or mechanical soft texture placed Resident #3 at risk for aspiration. Providing the M & Ms while partially reclined in bed further increased the risk of aspiration. During interview, on [DATE] at 9:30 a.m., two administrative staff members (#2) and (#4) agreed facility staff should offer Resident #3 snacks that are pureed or mechanically soft in texture. 3. Based on record review, review of State Agency (SA) files, and staff interview, the facility failed to provide the necessary care and services regarding monitoring of blood glucose levels and providing the appropriate interventions for 1 of 1 supplemental resident (Resident #13) who became unresponsive in the dining room after receiving insulin. Failure to assess the cause of Resident #13's unresponsiveness, the resident's blood glucose level at the time of the unresponsiveness and later in the day, and failure to assess the resident's response to the oral intake during the unresponsive episode limited the physician's ability to determine if other treatment measures were indicated and delayed medical treatment. (Refer to F157.) Findings include: Review of the SA files prior to the survey identified the facility reported an incident occurred on [DATE] described as "Nurse was inappropriate with (a) resident." During interview, on [DATE] at 1:35 p.m., an administrative nursing staff member (#2) reported the incident involved Resident #13. Review of the facility investigation file showed a certified nursing assistant (CNA) (A) submitted a confidential allegation to the facility regarding a licensed nurse (B) aggressively slapping Resident #13 and providing oral fluids to drink while the resident was unresponsive or had limited response. The allegation stated ". . . I was trying to feed (Resident #13) her breakfast but she was too out of it . . . (Licensed nurse (B)) also tried to wake her up as well. . . . (Licensed nurse (B)) said 'She needs to eat her food or at least drink her milk because I just gave (her) 20 units of insulin and I don't want her blood sugar to drop.' . . . she then grabbed the cup of milk and put it to her face and tried to get her to drink it . . . She put it up to her lips and started to dump it slowly. I had to clean up milk off her chin . . . (Resident #13) finally opened her eyes for a few seconds and closed them after taking a quick drink. . . ." The facility's investigation file included interviews with a second CNA (C) and the licensed nurse (B) which confirmed Resident #13 was unresponsive and had received her insulin. Review of Resident #13's closed medical record occurred on February ,[DATE], 2014. The facility admitted the resident in February 2013 and the resident expired on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #13's physician orders, dated [DATE], included: *Regular ADA diet, initiated [DATE], ". . . Give her whatever she wants due to no further tx. (treatment) per family request.)" *Accu check (blood glucose check) every Sunday, initiated [DATE]. *Humalog Mix ,[DATE] insulin, 100 units/milliliter (ml), 10 units, at 5:00 p.m., daily, initiated [DATE]. *Humalog Mix ,[DATE] insulin, 100 units/ml, 20 units at 9:00 a.m. every morning, initiated [DATE]. Resident #13's Medication Administration Record [REDACTED]. Resident #13's only nurse's notes, from [DATE] at 12:30 p.m., and [DATE] at 7:00 p.m. lacked information regarding the unresponsive episode on [DATE]. The nurse's note, dated [DATE] at 7:00 p.m., stated ". . . Resident's daughter is also very concerned about the resident & (and) why she's not awake more, hasn't been eating at meals & her excessive thirst. Daughter is also concerned about the resident receiving (sic) insulin & not eating to compensate for the insulin. . . ." Review of a Health care provider (HCP) (#13)'s progress note, dated [DATE], stated ". . . met with (Resident #13's family member) and (administrative nursing staff member (#2)) . . . Her (family member) last concern was that of her diabetes. . . . She thinks she is to (sic) a little more lethargic after receiving the insulin dose prior to her meal and she feels that she is probably getting that insulin too early and that it is starting to work before she is actually eating and then her blood sugars are probably dropping and so she is having a hard time eating her meals to keep that blood sugar were (sic) it should be. . . ." The progress note lacked information regarding the unresponsive episode on [DATE]. During interview, on [DATE] at 9:30 a.m., two administrative staff members (#2) and (#4) reported the facility had no additional information regarding Resident #13's unresponsive episode on [DATE]. Resident #13's blood glucose level on the morning of [DATE] is unknown. Resident #13's vital signs (blood pressure, pulse, respirations, neurological signs) are unknown. The duration of Resident #13's unresponsiveness is unknown. Failure to evaluate Resident #13's status at the time of unresponsiveness on [DATE] placed the resident at risk of experiencing a hypoglycemic episode without treatment by non-oral agents. Treatment with oral agents (milk) while unresponsive or with limited response placed the resident at risk of aspiration (choking). Failure to evaluate the resident prevented the physician or HCP from determining and implementing the most appropriate care in a timely manner.

Based on observation, record review, review of professional reference, review of facility policy and procedure, and staff interview, the facility failed to ensure 2 of 3 sampled residents with a history of pressure sores and current pressure sores (Resident #3 and #4) received the necessary treatment and services to prevent pressure sores, prevent recurrence of healed pressure sores, promote healing, and prevent infection. Failure to identify pressure sores and implement treatment resulted in delayed healing and surgical debridement of a Stage II pressure sore (Resident #3). Failure to reposition residents (Resident #3 and #4), provide a pressure relieving seat cushion and lower extremity support (Resident #3), and ordered wound dressing (Resident #4) placed these residents at risk of delayed healing of existing pressure sores and recurrence of pressure sores. Findings include: Review of the National Pressure Ulcer Advisory Panel (NPUAP), "Prevention and treatment of [REDACTED].C., 2009, occurred on 02/06/14. This document, pages 16-21, provides a reference for pressure ulcer care. Review of the facility policy and procedure, "Wound Assessment Parameters and Documentation," occurred on February 05-06, 2013. This undated document, stated "Care of the Wound, A. Goals: 1. Enhance systemic conditions . . . d. decrease stress 2. Protect from trauma, a. mechanical . . . 4. Prevent infection . . ." The policy and procedure lacked specific information regarding routine skin assessment, identification, measurement, documentation, or measurement of pressure sores and positioning of residents with existing pressure sores. - Review of Resident #3's medical record occurred on February 03-06, 2014. The facility admitted the resident in May 2009. Current [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified the resident sometimes made himself understood and understood others, required total assistance of two or more persons for bed mobility and transfers, had impaired functional limitation in range of motion of both lower extremities, had an indwelling catheter, was always incontinent of bowel, experienced an unprescribed weight loss, and had one Stage II pressure sore. Resident #3's Care Area Assessments (CAAs), dated 12/29/13, stated the following: Pressure Ulcer - ". . . total dependent with bed mobility. . . . always incontinent of stool. . . . at risk for developing a pressure ulcer. He scored a 14 (Moderate Risk) on his Braden Scale. . . . dated 12/28/13. . . . . currently has a stage 2 pressure ulcer. See weekly skin assessment sheet dated 12/26. . . . will care plan." Nutritional - ". . . Weight decreased 1.4% in 1 month and had a significant weight loss in 6 months with 11%. . . . Receives 6 oz. (ounces) Ensure plus (high calorie supplement) TID (three times a day), 4 oz. [MEDICATION NAME] Extra (high protein supplement) BID (two times a day) with 83-95% acceptance. . . ." Resident #3's current care plan, originated 12/18/13 and updated 01/10/14, stated "Problem, Resident has Stage 2 pressure ulcer to left hip. . . . Approach (updated 01/08/14), Air mattress;" and, "Approach, Avoid postioning resident on a (sic) [MEDICAL CONDITION]. . . . Position for comfort with physical support as necessary. . . . Use positioning devices to raise lesion off the support surface: wedge or pillows. . . ." Resident #3's CAAs and care plan failed to identify pressure relief approaches in the wheelchair or positioning approaches. (Refer to F280.) PRESSURE SORE TREATMENT Review of Resident #3's Nurse's Notes identified the following: *10/13/13, 3:15 p.m. - "Res. (Resident) has area to (L) (left) hip center purple in color and non-blanchable (with) outer edges red to dark pink in color and blanchable, measures 6 x (by) 6 cm (centimeters). Skin intact. Also has red area 2 x 2 cm skin intact to (R) (right) hip. Repositioning res. (every) 1-2 hrs (hours). Faxed (physician) (with) update and message left for (family member) . . . Will cont. (continue) to monitor." *10/14/13, 10:45 a.m. - "Resident seen by (health care provider (HCP) (#13)), orders to obtain culture of (L) hip blister, then place absorbent pad on. New skin condition noted to (L) knee. Blister is to have (moist occlusive dressing) placed on it per (HCP (#13)) orders. Also place (moist occlusive dressing) to red area on (R) hip. New skin condition noted to (R) buttocks, measuring 11 cm x 2 1/2 cm, (moisture barrier ointment) applied & (and) (HCP (#13)) notified." *10/29/13, 11:25 a.m. - "Dressing to (L) hip had lg (large) amount of bloody drainage at this time. Ulcer is dark purple/black in color. Condition to (L) hip is getting worse. Entire area measures 11 cm x 10.5 cm, the ulcer measure 6 cm x 6 cm. . . . New blister noted just below previous ulcer, it measures 1 cm x 1 cm. Blister is intact & (clear occlusive) has been applied. . . ." 1:45 p.m. - "(HCP (#13)) came to see resident. New orders are: ([MEDICATION NAME] ointment) to (L) hip ulcer once daily & PRN (as needed) if soiled. Cleanse (with) NS (normal saline) before applying, cover with 4 x 4 & ABD (gauze dressing)." *11/15/13 - Resident #3 was seen by a dermatologist with instructions to apply (moist occlusive dressing) to the left hip and knee, discontinue the ([MEDICATION NAME] ointment) to the right hip and "offload" the hips and left knee. *11/21/13 - Left hip wound drainage and culture positive, antibiotic "[MEDICATION NAME]" initiated. *12/09/13 - Resident #3 was seen by HCP (#13) and left hip dressing changed to clean with half strength hydrogen peroxide and normal saline, then apply (antibiotic gel dressing) and (moist occlusive dressing) daily and prn; wound cultured and orders received for antibiotic Bactrim DS one, BID for 10 days. *12/11/13 - HCP (#13) provided referral to surgeon for possible debridement of left hip wound. Appointment scheduled 12/17/13. *12/17/13 - Physician orders for daily wet to dry dressing with normal saline following debridement of left hip pressure ulcer. *12/01/13, 10:35 a.m. - "Dressing (change) was done on pt. (patient's) left hip. Area noted to be hard, draining bright red blood. Area was approx. (approximately) silver dollar size (3.8 cm diameter) with its center noted to be black in color. . . ." *12/07/13, 10:00 a.m. - " Pt. (Patient's) shower is today, removed old drsg (dressing) (L) hip, had large amt. (amount) of liquid brown-black in color foul smelling drng (drainage). After shower cleaned area (with) NS, applied (antibiotic gel dressing) et (and) (clear occlusive). Area appears tennis ball size (6.7 cm diameter), outer edge dark red (with) white center. Does not appear to cause pain while dressing pt. . . ." *12/18/13, 1:35 p.m. - "New orders from HCP (#13) . . . Insert Foley catheter & re-evaluate effectiveness in 1 wk (week); diagnosis - perineal agitation due to urinary incontinence." Resident #3's Weekly Pressure Ulcer Record identified the resident is to be repositioned every one to three hours and the resident received high protein dietary supplements and multivitamins. The Pressure Ulcer Record identified the following information, including ulcer stages and measurements: *Left hip - Date of Onset - Blank - 10/13/13 - Stage I; Size - 6 x 6 cm; Depth - 0 - 10/13/13 - Stage II; Size - 6 x 6 cm; Depth - Superficial - 10/14/13 - Stage II: Size 6 x 6 cm; Depth - Blank - 10/18/13 - Stage II; Size 7.5 x 6 cm, open area 2.8 x 2 cm; Depth - Blank - 10/24/13 - Stage II; Size 6 x 6 cm; Depth - 0 - 10/29/13 - Stage II; Size 10.5 x 11 cm; Depth - 0 - 10/31/13 - Stage II; Size 5.5 x 6 cm; Depth - Superficial - 11/06/13 - Stage II; Size 9 x 9.5 cm; Depth - Blank - 11/13/13 - No Stage; Size 7.5 x 7.5 cm; Depth - Increased; Progress - Deteriorated - 11/15/13 - No Stage; Size 4.5 x 5.5 cm; Depth - 0.1 cm; Progress - Improved - 12/01/13 - No Stage; Size 5 x 5.5 cm; Depth 0.1 cm; Progress - Deteriorated - 12/03/13 - No Stage; Size 4 x 6 cm; Depth 0.3 cm; Progress - Improved - 12/07/13 - No Stage; Size 4 x 6 cm; Depth 0.3 cm; Progress - Improved - 12/11/13 - No Stage; Size 5 cm x 5 cm; Depth 0.5 cm; Progress - Deteriorated - 12/19/13 - No Stage; Size 5 cm x 5 cm; Depth 1 cm; Progress - Improved (Surgical debridement on 12/17/13.) - 12/26/13 - No Stage; Size 5 x 5.5 cm; Depth 0.5 cm; Progress - Blank *Left hip "blister" - Date of Onset - 10/29/13 - 10/29/13 - Stage I; Size 1 cm x 1 cm; Depth - 0 - 11/13/13 - Healed *Right hip "redness" - Date of Onset - 10/13/13 - 10/13/13 - No Stage; Size 2 cm x 2 cm; Depth - 0; "Appears to be scratches." - 10/18/13 - Healed - 10/29/13 - "blister" - Date of Onset - 10/29/13 - 10/30/13 - No Stage; Size 3.5 cm x 3 cm; Depth - Blank - 11/06/13 - No Stage; Size 4.5 cm x 4.5 cm; Depth - Superficial; Progress - Deteriorated - 11/13/13 - No Stage; Size 3 cm x 3 cm; Depth - Blank; Progress - Blank - 12/01/13 - No Stage; Size 3 cm x 2 cm; Depth - Blank; Progress - Improved - 12/02/13 - No Stage; Size 3 cm x 2 cm; Depth - Blank; Progress - Improved - 12/10/13 - No Stage; Size 3 cm x 2 cm; Depth - Blank; Progress - Blank - 12/19/13 - Healed *Left buttock - Date of Onset - 12/12/13 - 12/12/13 - Stage I; Size 9 cm x 3.5 cm; Depth - 0 Undated - Healed. The Nurse's Notes lacked any further information regarding this area. *Right buttock - Date of Onset - 10/14/13 - 10/14/13 - Stage I; Size 11 cm x 2.5 cm; Depth - Blank; Pressure Relieving Interventions: Place wedge pillow behind back when lying flat. - 10/18/13 - 4 areas "blisters" - No Stages - No Change; Size 6 cm x 2 cm; 6 cm x 1.5 cm; 6 cm x 2 cm; 5 cm x 1.5 cm - 10/24/13 - Stage I; Size 11 cm x 1.5 cm; Depth - 0 - 10/24/13 - 1 "blister"; Size 2 cm x 4 cm; Depth - 0; Progress - Improved - 10/31/13 - Healed (Stage I and "blister") Observation on 02/05/14 at 9:55 a.m., showed a licensed nurse (#5) removed an occlusive dressing and underlying gauze from Resident #3's left hip and revealed an open area approximately 1.0 cm x 0.5 cm and 0.2 cm in depth. The area appeared clean with edges reddened and no odor. The licensed nurse (#5) cleaned the area with gauze saturated with normal saline, applied dry gauze, and an occlusive dressing. Failure to identify Resident #3's pressure areas until the right buttock measured 11 cm x 2.5 cm and the left hip measured 6 cm x 6 cm delayed healing and resulted in surgical debridement of Resident #3's left hip pressure sore. Failure to develop and implement consistent assessment and documentation methods resulted in inconsistent wound measurements and uncertainty regarding healing, and appropriateness of treatment. These issues further delayed healing and may have contributed to additional pressure sores. PRESSURE SORE PREVENTION Resident #3's Occupational Therapy (OT) Progress Reports stated the following: *01/24/14 - "OT consult for w/c positioning. Nursing requested trial use of blue geri (geriatric) (wheel) chair instead of current (brand name multi-position) (wheel) chair, as res. has been noted to have (decreased) positioning & safety in (brand name multi-position) (wheel) chair. Staff reports res. has been . . . 'sliding out' when sitting upright for meals. O.T. agrees to trial use of blue geri chair . . . LE (lower extremities) is (sic) fully supported by one large lg (leg) rest in the geri chair. O.T. did recommend placing built up foot squares for foot pedals if res.'s LE are not raised . . . Nursing agreed. O.T. also recommended cont. (continued) use of res.'s current w/c cushion in geri chair to (decrease) potential for skin breakdown. . . ." *01/31/14 - "O.T. consult: Res. observed in blue geri chair & appeared in comfortable position. . . . O.T. also recommended using (brand name non-skid pad) under res.'s bottom to (decrease) potential for sliding down in chair. . . ." Resident #3's Repositioning Log for the period October 2013 through February 05, 2014 identified "Reposition Every 2-3 hours." The Log included the following examples of "Up in Chair": *October 11 - 10:00 a.m. to 9:00 p.m. (11 hours) 19 - 4:00 p.m. to 9:00 p.m. (5 hours) 25 - 3:00 p.m. to 8:00 p.m. (5 hours) 29 - 3:00 p.m. to 9:00 p.m. (6 hours) *November 14 - 4:00 p.m. to 9:00 p.m. (5 hours) 15 - 4:00 p.m. to 9:00 p.m. (5 hours) *December 03 - 4:00 p.m. to 9:00 p.m. (5 hours) 11 - 10:00 a.m. to 3:00 p.m. (5 hours) 23 - 9:00 a.m. to 3:00 p.m. (6 hours) *January 04 to 24 - 4:00 p.m. to 8:00 p.m. (4 hours) *February 03 - 10:00 a.m. to 10:00 p.m. (12 hours) 04 - 4:00 p.m. to 10:00 p.m. (6 hours) 05 - 10:00 a.m. to 8:00 p.m. (10 hours) Observation on February 03-05, 2014 identified Resident #3 seated upright in a geriatric wheelchair with his knees bent and feet approximately three inches from the wheelchair foot rests. The resident's wheelchair lacked a seat cushion and a non-skid pad on all days of observation. This position placed the resident's legs in a dependent position, increased the shear force on his buttocks, and increased the potential for recurrent skin breakdown of his buttocks. Observation identified Resident #3 seated in this position for the following periods: *02/03/14, 12:20 p.m. to 3:42 p.m. (3 hours, 22 minutes) - two CNAs (#15) and (#16) reclined the chair back to approximately 60 degrees upright and elevated the leg rest to a position level with the chair seat. *02/04/14, 7:55 p.m. to 9:25 a.m. (1 hour, 30 minutes) 12:20 p.m. to 2:40 p.m. (2 hours, 20 minutes) *02/05/14, 10:10 a.m. to 2:40 p.m. (4 hours, 30 minutes) The facility identified a concern with Resident #3 sliding forward out of the wheelchair. The O.T. provided recommendations to improve seating and reduce the potential for skin breakdown related to seating position. Failure to re-position Resident #3 every two to three hours as identified on the Weekly Pressure Ulcer Record and Repositioning Log; and, failure to implement the O.T. recommendations for foot support, seat cushion, and non-skid pad placed him at risk of recurrent pressure sores and may have contributed to delayed healing of Resident #3's pressure sores. During interview, on 02/06/14 at 9:30 a.m., two administrative staff members (#2) and (#4) confirmed the facility lacked policies and procedures for measurement and treatment of [REDACTED].#3 every two to three hours, and facility staff should follow O.T.'s seating recommendations. Failure to develop and implement Resident #3's care plan regarding pressure sore prevention, monitoring, and treatment placed him at risk of developing avoidable pressure sores. (Refer to F280.) - During the initial tour of the facility, on the morning of 02/03/14, facility staff identified Resident #4 is only out of bed 45 minutes twice a day due to recent skin flap surgery to her sacrum. Resident #4's medical record, reviewed on all days of survey, identified the resident had a gluteal rotation flap and skin graft surgery for [REDACTED]. An admission MDS, dated [DATE], identified the resident as cognitively intact, had an indwelling catheter, always incontinent of bowel, at risk for pressure ulcers, had a surgical wound, pressure reducing devices for the chair and bed, on a turning/repositioning program, and receiving surgical wound care. The MDS also showed Resident #4 required extensive assistance with bed mobility and transfers. Physician's orders, dated 01/10/14 stated, "dry gauze and tape to lower coccyx area daily. Resident #4's current care plan, dated 01/09/14, included a problem: "Impaired skin integrity R/T (related to) new gluteal ulcer flap repair." Approaches to the problem included: ". . . Keep resident off sacral area. May be up for meals no more thatn (sic) 30 minutes at a time. Turn and reposition every 2-3 hours." A nurse's note, dated 01/24/14 at 2:00 p.m. stated, ". . . Occupational Therapist seen today. Told nurse 'resident is able to be up in chair for 45 min (minutes) two times a day now.' Resident spoke to nurse 'I would like to be able to get up for meals' . . ." Observation on 02/03/14 at 12 noon showed the resident in her room seated in a wheel chair. Observation then showed Resident #4 in her wheel chair in the dining room until 1:25 p.m.(one hour and 25 minutes) when two CNAs (#8 and #9) assisted the resident to bed and positioned her on her back. Observation showed the resident remained in bed on her back at 3:23 p.m. On 02/04/14 at 8:51 a.m. two CNAs (#6 and #11) assisted Resident #4 from her wheel chair to her bed and positioned her on her right side. Observation showed sutures intact to the sacral wound with no dressing in place. On 02/04/14 at 10:00 a.m. a licensed nurse (#5) entered the room and performed a dressing change to the resident's left thigh. The nurse did not apply a dressing to Resident #4's sacral wound. Record review identified staff failed to apply a dressing to Resident #4's sacrum from January 30-February 2, 2014. On 02/04/14 at 11:55 a.m. observation showed Resident #4 in bed resting on her back. Two CNAs (#10 and #11) assisted the resident from her bed to her wheel chair then to the dining room. Resident #4 remained seated in her wheel chair until 1:42 p.m. (one hour and 53 minutes) when two CNAs (#6 and #10) assisted her back to bed and positioned her on her left side. Review of Resident #4's repositioning records from January 11 - February 5, 2014 identified staff positioned the resident on her back up to six times each day. The record also showed eight days in January and three days in February when staff failed to reposition the resident every three hours. Time frames varied from four to 11 hours without repositioning. During an interview on 02/05/14 at 2:45 p.m. an administrative nurse (#2) confirmed Resident #4 should be in the chair no longer than 45 minutes twice a day and agreed the resident's repositioning records showed long time periods without repositioning.

1. Based on observation, record review, and staff interview, the facility failed to ensure the environment remained free of accident hazards for 1 of 1 sampled resident (Resident #1) who experienced 4 episodes of entrapment in or between the side rails on his bed. Failure to evaluate the risks associated with side rail use has the potential to result in resident entrapment, injury, and/or death. Findings include: On the morning of 02/06/14, the survey team requested several policies from administrative staff, including the policy/procedure for side rail use. On 02/06/14 at 8:40 a.m., two administrative nurses (#2 and #3) stated their policy manual "disappeared approximately six months ago" and they had no policy/procedure for side rail use. Resident #1's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident had moderately impaired cognition and required total assistance for bed mobility and transfers. The physician's order, implemented on 05/20/13 and discontinued on 08/02/13, identified, "1/4 side rail to Lt (left) side of bed, 1/2 side rail to upper and lower Rt (right) side of bed for mobility and positioning aide." The "Fall Risk and Side Rail Assessment," dated 06/23/13, identified, ". . . Partial Side rail(s) . . . are recommended at this time . . . due to mobility issues (and) positioning. . . ." The nurse's note, dated 08/05/13 at 5:50 a.m., identified, "Res (Resident) found (with) upper body (and) torso off bed (and) safety mat, res legs were still on bed. Has red indented area on lateral (L) (left) calf of leg from getting it caught in bottom rail. . . ." The facility failed to reassess Resident #1's ability to safely use side rails. The incident report, dated 08/05/13, identified, ". . . Description: . . . Res found by CNA (certified nursing assistant) (with) torso (and) upper body on safety mat (and) feet caught in bottom guard rail. Res states 'I crawled out myself' repeatedly. Hoyer lift (with) assist x's (times) 4 use to transfer res back in bed. . . . Injury: . . . No skin tears or other apparent injuries. Denies pain. Red indentation on lateral (L) calf, (no) c/o (complaints of) pain, no open areas. . . . Follow up plan: Monitor res for restlessness (and) movement in bed. Call placed to (Mental Health Clinic). (Physician) changed resident's meds (medications)." The facility failed to discontinue the use of the side rails on Resident #1's bed as per the 08/02/13 physician's order; instead increasing his Seroquil. The nurse's note, dated 08/10/13 at 12:30 a.m., identified, "Yelling out - waking others. Found (with) knees bent between side rails. Had turned self over as resident was on (R) side when placed in bed (after) meds at 8:00 p.m." The facility failed to reassess Resident #1's ability to safely use side rails. The incident report, dated 08/09/13, identified, ". . . Description: . . . Alarm was going off when (checked) by CNA (and) was found on floor in (sic)fall mat. . . . Injury: . . . No noted injury (at) this time. . . . Follow up plan: Staff is now trying to use lavender aroma therapy to help calm resident." The report failed to mention the resident was "found with his knees bent between side rails." The facility failed to discontinue the use of the side rails on Resident #1's bed as per the 08/02/13 physician's order. The nurse's note, dated 10/21/13 at 3:40 p.m., identified, "Resident fell out of bed at this time. (L) knee was stuck between bed rail (and) mattress. Bruising noted to inside leg, red marks to inner (and) outer leg. Resident stated, 'I'm in pain, my leg hurts.' Will continue to monitor." The facility failed to discontinue the use of the side rails on Resident #1's bed as per the 08/02/13 physician's order. The facility failed to reassess Resident #1's ability to safely use side rails, and failed to complete an incident report; identifying what they believe precipitated the incident, how it could have been prevented, whether any equipment should have been adjusted, and/or any other interventions the facility attempted in order to prevent the incident from reoccurring. The physician's order, implemented 10/21/13 and discontinued on 12/27/13, identified, "Side rails x 2 to bed for mobility, safety, and repositioning, foot side rail is not needed." The facility obtained a new order for the continued use of side rails; with the knowledge Resident #1 experienced three previous incidents of entrapment. The nurse's note, dated 11/14/13 at 5:00 p.m., identified, "Resident found on floor by CNA with neck caught in the arm rail, resident was having hard time breathing (and) wasn't able to talk. Assessment done at this time (and) nothing appears out of normal. Will monitor." The facility also failed to complete an incident report; describing the incident, identifying what they believe precipitated the incident, how it could have been prevented, whether any equipment should have been adjusted, and/or any other interventions the facility attempted in order to prevent the incident from reoccurring. The nurse's note dated 11/15/13 at 3:00 p.m., identified, "Bilat (bilateral) SR (side rails) removed from bed. Wedges in place today between bed (and) wall for cushion - fall mat on other side of bed (and) bed low to floor. Has wedge for positioning from side to side. . . ." Although the nurse's notes indicate the facility removed Resident #1's side rails on 11/15/13, the physician's order to discontinue was dated 12/27/13. The current care plan stated, ". . . Problem: High risk for falls related to cognitive impairment . . . Approaches: . . . Call light within reach, explain call light, Evaluate causes of falls, Mat at bedside, Resident rolls shoulders off bed and occassionall (sic) legs due to agitation/restlessness. Fall mat next ot (sic) bed. Bed low to floor. Not considered a fall, Bed alarm on and functional." During an interview on 02/06/14 at 10:00 a.m., two administrative staff members (#2 and #4) confirmed they were aware of all four of Resident #1's incidents of side rail entrapment. The facility failed to ensure Resident #1 received the care and services necessary to attain the highest degree of safety possible while in bed. They failed to 1) discontinue the use of the side rails on Resident #1's bed as per the 08/02/13 physician's order; instead increasing his Seroquil, 2) document the resident was "found with his knees bent between the side rails" on the 08/09/13 incident report, and 3) complete incident reports on 10/21/13 and 11/14/13; describing the incidents, identifying what they believe precipitated the incidents, how they could have been prevented the incidents, whether any equipment should have been adjusted, and/or any other interventions the facility attempted in order to prevent the incidents from reoccurring. In addition, the facility obtained a new order for the continued use of side rails on 10/21/13; with the knowledge Resident #1 experienced three previous incidents of side rail entrapment on 08/05/13, 08/09/13, and 10/21/13. The facility also failed to obtain a physician's order to discontinue the use of side rails at the time they removed the rails from Resident #1's bed on 11/15/13, and failed to care plan the use of wedges to assist with positioning/prevent futher falls. Failure to evaluate the risks associated with side rail use resulted in Resident #1's multiple incidents of entrapment with injuries. 2. Based on observation, record review, review of facility policy, resident interview, and staff interview, the facility failed to ensure safety for 1 of 1 supplemental resident(Resident #9) who was observed smoking outdoors in sub-zero degree weather conditions without supervision. Failure of the facility to ensure safety while residents smoke placed them at risk for possible accidents and/or injury. Findings: Review of the facility policy and procedure, "Smoking Policy," occurred on 02/06/14. This undated document stated, ". . . Smoking receptacles shall be placed at . . . main entrance to the health care facility . . ." Review of Resident #9's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], identified Resident #9 as cognitively intact and requiring supervision whenever he moved to/returned from off-unit locations. The "Safe Smoking Assessment," dated 04/18/13, stated, "Earlier this year (Resident #9) was smoking in (a) non-designated area (and) putting cigarettes out inappropriately! Currently not doing that anymore." The assessment identified the resident was safe to smoke unsupervised. The assessment further indicated the resident had a physician's order to smoke. Resident #9's current physician's orders failed to address his tobacco use. Resident #9's current care plan stated, ". . . Problem: Resident at risk for injury d/t (due to) smoking . . . Approaches: . . . Educate resident to wear proper attire . . ." The current care plan did not address Resident #4's need for supervision or how he would acquire assistance from staff once he'd left the facility. Observations revealed the following: * On 02/03/14 at 8:00 a.m., Resident #9 sat on his walker, smoking alone, next to the ashtray located on the sidewalk near the main entrance to the facility. He was wearing a hooded sweatshirt, pajama bottoms, and bedroom slippers. The local radio station indicated the temperature was six degrees Farenheit. * On 02/03/14 at 2:40 p.m., Resident #9 sat on his walker, smoking alone, next to the ashtray. He was wearing an unzipped coat over his hooded sweatshirt, pajama bottoms, and bedroom slippers. * On 02/04/14 at 8:20 a.m., Resident #9 requested a cigarette from the nurse, who failed to cue him on proper attire. The resident exited the building, sat on his walker in the snow, smoking alone, next to the ashtray. He was wearing a hooded sweatshirt, pajama bottoms, and bedroom slippers. The local television station indicated the temperature was four degrees Farenheit and observation showed it was snowing outside. * On 02/04/14 at 10:26 a.m. and 12:07 p.m., and on 02/05/14 at 12:00 and 1:20 p.m., Resident #9 sat on his walker in the snow, smoking alone, next to the ashtray. He was wearing an unzipped coat over his hooded sweatshirt, pajama bottoms, and bedroom slippers. * On 02/06/14 at 7:45 a.m., Resident #9 sat on his walker, smoking alone, next to the ashtray located on the sidewalk near the main entrance to the facility. He was wearing a hooded sweatshirt, pajama bottoms, and bedroom slippers. The local radio station indicated the temperature was minus four degrees Farenheit. During interview on 02/05/14 at 9:02 a.m., when asked what he thought of the designated smoking area, Resident #9 stated, "I have my own seat (walker)." When asked how he is protected from the elements, he stated, "I have a hood on my jacket." When asked how he would acquire staff assistance if something happened after he left the facility, he stated, "I have a time limit, then they (staff) come and check on me." During an interview on 02/06/14 at 10:00 a.m., two administrative staff members (#2 and #4) stated Resident #9 currently exits the building unsupervised. They reported staff are not required to check on Resident #9 while he is smoking. They further stated the facility has considered installing security cameras, but has not done so at this point in time. The facility failed to ensure Resident #9 received the care and services necessary to attain the highest degree of safety possible while smoking outside the facility. They failed to 1) ensure Resident #9 returned to the building in a timely manner, 2) ensure Resident #9's safety in the designated smoking area; which included protecting him from weather conditions, and 3) identify how Resident #9 would acquire assistance from staff once he'd left the building. THIS IS A REPEAT CITATION FROM THE SURVEY COMPLETED ON 01/13/13. 3. Based on observation, record review, review of professional reference, and staff interview, the facility failed to provide supervision and assistive devices necessary to prevent accidents for 3 of 4 sampled residents (Resident #1, #2, and #4) requiring assistance with transfers. Failure to appropriately utilize gait belts for Resident #2 and #4 has the potential for the residents to experience falls, injuries, and/or pain. Failure to carefully transport Resident #1 in a Broda chair resulted in the resident experiencing pain and could result in an injury. Findings include: On the morning of 02/06/14, the survey team requested several policies from administrative staff, including the policy/procedure for transferring and transporting residents. On 02/06/14 at 8:40 a.m., two administrative nurses (#2 and #3) stated, approximately six months ago, their policy manual "disappeared" and they had no policy/procedure for transferring or transporting residents. Kozier and Erb's Fundamentals of Nursing Concepts, Process, and Practice, 9th edition, Pearson, Boston, Massachusetts, page 1158-1162 stated, "Transferring Clients: Many clients require some assistance in transferring . . . A gait belt provides the greatest safety. A gait belt is a safety device used for moving or transferring a client. . . . Even if a client is able to partially bear weight and cooperative, it still may be safer to transfer a client with the assistance of two nurses. If so, you should position yourselves on both sides of the client . . . Grasp the client's transfer belt with the hand closest to the client, and with the other hand support the client's elbows. . . ." - Resident #1's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident had moderately impaired cognition and required total assistance for locomotion on the unit. The current care plan utilized by direct care staff failed to address Resident #1's use of a Broda (reclining) chair. On 02/04/14 at 8:40 a.m., a CNA (#11) transported Resident #1 down the hallway to his room using the Broda chair. The CNA (#11) misjudged the distance as she maneuvered Resident #1's chair through the doorway, running into the door, and bumping Resident #1's right foot against the frame. Resident #1's right foot was turned outward and he was wearing a blue heel protector with his toes exposed. Resident #1 grimaced, and stated "Ow" with rising intonation. The CNA (#11) pushed Resident #1 further into his room, parked his chair in front of the television, and placed the bedside table next to him. Resident #1 stated, "My foot hurts," to which the CNA (#11) responded, "Yeah, she'll (the medication nurse) get to that when she passes meds (medications)." The CNA exited the room and walked past the medication nurse on her way back to the dining room, without mentioning the incident. During an interview on 02/06/14 at 10:00 a.m., two administrative staff members (#2 and #4) agreed staff should use care when transporting residents. - Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified Resident #2 was cognitively intact and required extensive assistance for transfers and locomotion on the unit. The "ADL Function and Falls Care Assessment Areas (CAA)," dated 07/31/13, identified, "(Resident #2) requires limited assistance for . . . transfers . . . (Resident #2) also requires supervision for walking in room, walking in corridor, toilet use . . . She is not steady and (sic) only able to stabilize with staff assistance for balance during transition and walking . . ." The current care plan utilized by direct care staff failed to address Resident #2's need for limited assistance for transfers and while walking. Observations showed gait belt usage to be inconsistent; on 02/03/14 at 1:50 p.m., a CNA (#9) secured a gait belt around Resident #2's waist as the resident was ambulating towards her bed, on 02/04/14 at 11:58 a.m., a CNA (#6) placed a gait belt around Resident #2's waist prior to assisting her with ambulation, and on 02/04/14 at 1:15 p.m., a CNA (#10) held onto the back of Resident #2's pants as she ambulated into the bathroom, with a gait belt looped around the front of her walker. During an interview on 02/06/14 at 10:00 a.m., two administrative staff members (#2 and #4) stated they expected staff to use gait belts when transferring residents. - Review of Resident #4's medical record occurred on all days of survey. An admission MDS, dated [DATE], identified the resident required extensive assistance with transfers. Record review failed to identify a care plan regarding transfers for Resident #4. Observation on 02/03/14 at 1:25 p.m. showed two Certified Nursing Assistants (CNAs) (#8 and #9) transferred Resident #4 from her chair to the bed utilizing a gait belt. Observation showed one CNA (#9) held the gait belt and the other CNA (#8) held Resident #4 under her arm during the transfer. On 02/04/14 at 8:51 a.m. two CNAs (#6 and #11) assisted Resident #4 to transfer from her chair to the bed utilizing a gait belt. Both CNAs held the gait belt, but also held the resident under her arms during the transfer. Observation on 02/04/14 at 11:55 a.m. showed two CNAs (#10 and #11) assisted Resident #4 from her bed to the chair utilizing a gait belt. Both CNAs held the gait belt but one CNA (#11) also held the resident by her arm during the transfer. 4. Based on observation and staff interview, the facility failed to maintain an environment free of hazardous chemicals on 1 of 1 resident care unit storing chemicals on 3 of 4 days of survey (February 3-5, 2014). Failure to secure hazardous chemicals placed residents with memory loss and/or wandering behaviors at risk of exposure to those chemicals. Findings include: On the morning of 02/06/14, the survey team requested several policies from administrative staff, including the policy/procedure for chemical storage. On 02/06/14 at 8:40 a.m., two administrative nurses (#2 and #3) stated their policy manual "disappeared approximately six months ago" and they had no policy/procedure for chemical storage. On 02/03/14 at 3:25 p.m., 02/04/14 at 9:05 a.m., and 02/05/14 at 8:15 a.m., observations of the environment revealed the following: * On the floor of an unlocked closet in the bathing room: 1 container of Claire Citrus Blast Air Freshener 1 container of Lysol Disinfectant Spray 2 containers of Mastercare Disinfectant Cleaner 3 containers of Hepacide Quat II * On the windowsill of the haircare room: 1 container of Lysol Disinfectant Spray The product labels stated the following: * Claire Citrus Blast Air Freshener: ". . . concentrating and inhaling the product can be harmful or fatal. Prolonged inhalation may be harmful. . . . Harmful if absorbed through the skin . . . skin irritation and dermatitis (rash) . . . prolonged skin contact may cause allergic reactions . . . Contact with eyes may cause irritation. . . ." * Lysol Disinfectant Spray: ". . . Causes moderate eye irritation. Prolonged or repeated skin contact may result in slight to moderate skin irritation. Contains denatured alcohol; ingestion may result in ethanol poisoning . . ." * Mastercare Disinfectant Cleaner: ". . . corrosive, causes irreversible eye damage and skin burns . . . harmful if absorbed through skin . . . harmful if swallowed. . . ." * Hepacide Quat II: ". . . Causes moderate eye irritation. Harmful if absorbed through the skin. May be harmful if swallowed. Inhalation of product mist may cause respiratory irritation. . . ." During an interview on 02/05/14 at 8:15 a.m., a managerial maintenance staff member (#17) confirmed he expected chemicals to be kept locked and out of reach of the residents. 5. Based on observation, record review, and staff interview, the facility failed to ensure adequate supervision and use of assistance devices to prevent accidents for 1 of 2 sampled residents (Resident #3) with chair alarms. Failure to ensure facility staff applied a chair alarm on the resident's wheelchair to make staff aware the resident may be attempting to rise from the chair placed the resident at increased risk of falls and injuries. Findings include: On the morning of 02/06/14, the survey team requested several policies from administrative staff, including the policy/procedures for fall prevention. On 02/06/14 at 8:40 a.m., two administrative nurses (#2 and #3) stated their policy manual "disappeared" approximately six months ago and they had no policy/procedures for preventing resident falls. Review of Resident #3's medical record occurred on February 03-06, 2014. Current [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified the resident sometimes made himself understood and understood others, demonstrated physical and verbal behaviors four to six days during the seven day assessment period, required total assistance of two persons for transfers, did not ambulate, and experienced one fall with an injury since the previous MDS, dated [DATE]. Resident #3's Falls Care Area Assessment (CAA), dated 12/29/13, stated ". . . had one fall since prior assessment, which resulted in a skin tear. . . . received an antianxiety medication seven out of the last seven days. . . . has a [DIAGNOSES REDACTED]. . . . will care plan." The CAA failed to identify fall prevention measures. Resident #3's current care plan, dated 12/18/13, stated "Problem . . . High risk for falls related to cognitive impairments and immobility and poor balance. . . . Approach . . . Chair & (and) bed alarms as indicated. . . ." Resident #3's Nurse's Notes stated the following: *06/25/13, 7:50 p.m. - "Res. (Resident) tried getting out of his wc (wheelchair) & ended up on his knees on the foot rest. He had his hands on the couch. . . ." *11/05/13, 8:45 p.m. - "Resident was found kneeling on knees in front of w/c at this time. Noted a 1 cm (centimeter) x (by) 2 cm skin tear on left knuckle pinkie (fifth finger). Area (with) moderate amount of blood noted on floor. No pain noted. . . ." The Nurse's Notes for these falls lacked information regarding the presence of a chair alarm on the resident's wheelchair. Resident #3's Incident Reports for the above falls stated the following: *06/25/13, 7:50 p.m. - ". . . Alarms . . . No . . . Plan: Double check to make sure chair alarm is on. Make frequent checks. . . ." *11/05/13, 8:45 p.m. - ". . . Alarms . . . No . . . Plan: When resident is in geri (geriatric) (wheel) chair and not eating the chair should be reclined. . . ." Observation on February 03-06, 2014 identified the facility staff transferred Resident #3 to a geriatric wheelchair, at various times, and failed to apply a chair alarm. Observation showed the resident seated in the wheelchair without a chair alarm attended in the dining room and unattended in the lounge. During interview, on 02/06/14 at 9:30 a.m., two administrative staff members (#2) and (#4) confirmed facility staff should have applied an alarm to the geriatric wheelchair when Resident #3 was seated in the chair. Resident #3 had a history of [REDACTED]. Failure to apply the chair alarm limited the staff's ability to respond to Resident #3's attempts to stand from the chair and placed him at risk of injury.