Every finding on record at Sheyenne Crossings Care Center/Tcu

Based on observation, record review, review of facility policy, and staff interviews, the facility failed to follow infection control standards for 2 of 4 sampled residents (Resident #3 and #79) and 1 supplemental resident (Resident #10) on enhanced barrier precautions (EBP). Failure to follow infection control practices has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Transmission-Based Precautions occurred on 02/25/26. This policy, revised December 2024, stated, . Enhanced barrier precautions – These are used to limit or prevent the spread of resistant organisms . in addition to standard precautions gown and gloves must be worn during high-contact resident care activities such as: dressing . transferring . providing hygiene . assisting with toileting . changing linens . - Review of Resident #79's medical record occurred on all days of survey. The current care plan stated, . increased risk of infections related to presence of surgical wound and admitted with PU [pressure ulcer] to coccyx. Enhanced Barrier Precautions . Observation on 02/23/26 at 1:28 p.m. showed an EBP sign on Resident #79's door and a certified nurse aide (CNA) (#3) applied gloves and made the resident's bed. The CNA (#3) checked on Resident #79 in the bathroom and stated she needed to put on a gown. The CNA (#3) applied a gown and completed Resident #79's toileting cares. The CNA removed the soiled gloves, performed hand hygiene, applied clean gloves and assisted Resident #79 to a recliner, removed the soiled gown and gloves, performed hand hygiene and exited the room. The CNA (#3) failed to apply a gown prior to completing close contact cares and handling bed linens. Observation on 02/24/26 at 8:33 a.m. showed a CNA (#4) applied gloves and assisted Resident #79 from the bed to a scale chair and then to the toilet. The CNA (#4) made the resident's bed, provided hygiene cares, and dressed the resident. At 8:46 a.m., a nurse (#5) applied a gown and gloves, entered the room and instructed the CNA (#4) to put on a gown. The CNA (#4) removed the soiled gloves, performed hand hygiene, and exited the room, applied a gown and new gloves and completed Resident #79's cares. The CNA (#4) failed to apply a gown prior to completing close contact cares and handling bed linens. - Review of Resident #10's medical record occurred on all days of survey. The current care plan stated, . increased risk of infections related to suprapubic catheter . enhanced barrier precautions . Observation on 02/23/26 at 4:44 p.m. showed an EBP sign on Resident #10's door and a CNA (#2) combed the resident's hair, applied lotion to resident's arms and put on footwear. The CNA (#2) failed to apply a gloves and gown prior to completing close contact cares. - Review of Resident #3's medical record occurred on all days of survey. The current care plan stated, . increased risk of infections related to chronic vascular ulcers to bilateral [both] lower extremities. Enhanced Barrier Precautions . Observations on 02/24/26 showed an EBP sign on Resident #3's door and the following cares; * At 8:50 a.m. two (CNAs) (#6 and #7) entered the room, applied gloves, used a gait belt and assisted the resident out of bed, to bathroom, and onto the toilet. The CNAs changed the incontinence product, completed hygiene cares, and assisted the resident to dress. The CNAs (#6 and #7) failed to apply a gown prior to completing close contact cares. * At 1:35 p.m. the CNA (#7) entered the room, applied gloves, adjusted the blankets on the bed, used a gait belt, and transferred the resident from the wheelchair into the bed. The CNA removed the gait belt and gloves, completed hand hygiene and exited the room. The CNA (#7) failed to apply a gown prior to completing close contact cares. During an interview on 02/25/26 at 10:25 a.m., an administrative nurse (#1) confirmed she expected staff to wear proper personal protective equipment (PPE) when performing high-contact resident care activities.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 16 sampled residents (Resident #8, #9, #17, #32, and #36) and 2 supplemental residents (#7 and #46) observed during cares/dressing change. Failure to practice infection control standards related to hand hygiene, enhanced barrier precautions (EBP), during a dressing change, and disinfection of equipment has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene Policy occurred on 12/18/24. This policy, revised January 2024, stated, . Hand hygiene will be done a.) Before and After resident contact (before you leave the room) . Review of the facility policy titled Transmission-Based Precautions occurred on 12/18/24. This policy, revised January 2024, stated, . Enhanced barrier precaution - These are used to limit or prevent the spread of resistant organisms during high-contact resident care activities. In addition to standard precautions gown and gloves must be worn during high-contact resident care activities such as: . Transferring in the resident's room . Review of the facility policy titled Dressing Changes/Bandages occurred on 12/18/24. This policy, revised March of 2022, stated, . Clean area where supplies will be placed with germicidal wipes . - Review of Resident #8's medical record occurred on all days of survey. The current care plan stated, . Enhanced Barrier Precautions for indwelling catheter. Observation on all days of survey showed an EBP sign outside of Resident #8's room. Observation on 12/17/24 at 9:50 a.m. showed Resident #8 seated in a wheelchair and the certified nurse aide (CNA) (#8) transferred the resident into bed. The CNA failed to don gloves and a gown before transferring Resident #8. - Review of Resident #36's medical record occurred on all days of survey. The current care plan stated, . Enhanced Barrier Precautions in place. Observation on all days of survey showed an EBP sign outside of Resident #36's room. Observation on 12/17/24 at 9:58 a.m. showed a CNA (#9) and a nurse (#10) failed to don gloves or a gown and entered Resident #36's room to perform a transfer. The CNA and nurse used a full body mechanical lift to transfer the resident from the wheelchair to the bed. - Review of Resident #32's medical record occurred on all days of survey. The current care plan stated, . Enhanced Barrier Precautions due to ulcers to feet. Observation on all days of survey showed an EBP sign outside of Resident #32's room. Observation on 12/17/24 at 10:31 a.m. showed a CNA (#11) donned gloves and a gown to assist Resident #32 onto the toilet. A second CNA (#9) entered the room to assist with the transfer and failed to don gloves and a gown. After the transfer, the CNA (#9) failed to perform hand hygiene before exiting the room. During an interview on 12/17/24 at 10:55 a.m., an administrative nurse (#2) stated she expected staff to wear appropriate personal protective equipment when transferring residents in an EBP room and expected staff to complete hand hygiene before leaving a resident's room after assisting with a transfer. - Observation on 12/16/24 at 1:40 p.m. showed two CNAs (#5 and #13) entered Resident #17's room with a full body mechanical lift and transferred the resident from the wheelchair to the bed. While performing cares, CNA (#5) failed to perform hand hygiene between glove changes and failed to perform hand hygiene or disinfect the lift when exiting the room. - Observation on 12/16/24 at 1:54 p.m. showed two CNAs (#5 and #13) entered Resident #7's room with the full body mechanical lift the CNAs failed to disinfect during the observation and transferred Resident #7. The CNAs failed to perform hand hygiene upon entering Resident #7's room, assisted with personal cares and failed to perform hand hygiene in between glove changes, before exiting the room, and failed to disinfect the mechanical lift when exiting the room. - Observation on 12/17/24 at 10:56 a.m. showed two CNAs (#6 and #7) assisted Resident #9 to the bathroom using the full body mechanical lift. After assisting the resident, the CNA (#7) exited the resident's room without disinfecting the lift. During an interview on 12/17/24 at 11:20 a.m., a CNA (#7) stated, It is our policy to sanitize between residents. I did forget to wipe the lift down. - Observation on 12/17/24 at 1:46 p.m. showed a CNA (#14) entered Resident #46's room to perform personal cares. The CNA failed to perform hand hygiene between gloves changes with cares and failed to perform hand hygiene before exiting the room. - Observation on 12/18/24 at 12:10 p.m. showed a licensed nurse (#12) entered Resident #36's room to perform a dressing change. The nurse failed to clean the bedside table with a germicidal wipe and placed the dressing supplies directly on the resident's bedside table. During an interview on 12/18/24 at 10:30 a.m., an administrative nurse (#2) confirmed staff are expected to complete hand hygiene during resident cares and sanitize equipment after each use. 39685 46477

Based on observation and staff interview, the facility failed to ensure safe and secure storage of medications and controlled substances (narcotics) in 1 of 1 unit (Transitional Care Unit (TCU)) observed. Failure to secure medications and controlled substances may result in unauthorized access to medications. Findings include: The facility failed to provide a policy on storage of medications and controlled substances. - Observation on 12/18/24 at 1:37 p.m., of the TCU medication cart with a medication aide (MA) (#5) showed narcotic medication cards within the cart not stored in a locked box. The MA stated, When I walk away, I lock the cart and put the keys in my pocket. I do not lock these in a lock box [referencing narcotic cards]. - Observation on 12/18/24 at 1:49 p.m., showed the TCU medication storage room door and the narcotic storage cupboard door unlocked and ajar with non-nursing personnel present. A staff nurse (#4) was unaware of why both doors were unlocked and ajar. During an interview on 12/18/24 at 2:05 p.m., an administrative nurse (#2) confirmed she expected staff to lock the medication storage room door and narcotic cupboard doors, and store narcotics in the lock box in the medication cart.

Based on record review, review of facility policy, resident, family, and staff interview, the facility failed to ensure all forms of communication related to code level status accurately reflected the residents' wishes for 2 of 18 sampled residents (Resident #30 and #48) and 1 supplemental resident (#14) reviewed for advance directives. Failure to ensure the medical record and other forms of communication accurately reflected the resident's code status limited the facility's ability to communicate to direct care staff and emergency personnel the resident's choice in the event of a medical emergency. Findings Include: Review of the facility policy titled CPR [cardiopulmonary resuscitation]/AED [automated external defibrillator]/Code Level occurred on [DATE]. This policy, revised [DATE], stated, . Uniform Code Levels (Code 1 and Code 2) and cardiac arrests will be discussed with all new residents and/or responsible party upon admission, hospital return, and annually with completion of the MDS [minimum data set]. Their wishes will be obtained, the Uniform Code Level Form will be completed, and documentation will be made in the resident's chart. A provider's order must be received . This is to ensure that a resident's wishes regarding CPR are followed in a time of crisis . - Review of Resident #14's medical record occurred on all days of survey. The Uniform Code Level Directives for Cardiopulmonary Resuscitation, signed by the resident on [DATE], indicated Code Level 2. The form identified code level 2 as No intervention will be made in the event of a cardiac or respiratory arrest including defibrillation, chest compression, artificial respiration, or chemical resuscitation. Other conditions will be treated as medically appropriate The face sheet, physician order summary, and electronic medication administration record (EMAR) identified a code level 2. The care plan identified a code level 1 All available reasonable technology is used in the event of cardiac or respiratory arrest. During an interview on [DATE] at 2:15 p.m., an administrative staff member (#1) confirmed the care plan failed to identify Resident #14's current code status. - Review of Resident #30's medical record occurred on all days of survey. The Uniform Code Level Directives for Cardiopulmonary Resuscitation, signed by the resident's representative on [DATE], indicated Code Level 2. The face sheet, physician order summary, and EMAR failed to identify a code status. The care plan identified a code level 1. During an interview on [DATE] at 3:30 p.m., an administrative nurse (#2) confirmed the resident's face sheet, physician order summary EMAR, and care plan failed to identify Resident #30's current code status. - Review of Resident #48's medical record occurred on all days of survey. The Uniform Code Level Directives for Cardiopulmonary Resuscitation, signed by the resident's significant other on [DATE], indicated Code Level 2. The face sheet, physician order summary, EMAR, and care plan indicated a code level 1. During an interview on [DATE] at 5:15 p.m., Resident #48 and her significant other verified the code level 2 as accurate. 31725

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 18 sampled residents (Resident #29). Failure to accurately code the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION I: Active Diagnosis The Long-Term Care Facility RAI 3.0 User's Manual, revised October 2024, pages I-8, I-10, and I-12, states, . Coding Instructions: Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring . during the 7-day look-back period . Musculoskeletal . I4000, other fracture . Specific documentation may be found in progress notes, most recent history and physical, transfer notes, hospital discharge summary, etc. Review of Resident #29's medical record occurred on all days of survey and identified the following progress notes: * 10/25/2024 at 2:33 a.m.: Fall. Time of fall: 0125 [1:25 a.m.] . Resident self-transferring and fell . Small laceration on bridge of nose and nose is red and swollen. * 10/27/2024 at 1:23 p.m. Hospital Return. Resident admitted from: [hospital] . Reason for admission: Recent fall and nasal fracture. A significant change MDS, dated [DATE], identified staff failed to code Resident #29's nasal fracture in I4000. During an interview on 12/18/24 at 3:09 p.m., a nurse (#3) confirmed staff failed to code the nasal fracture on the significant change MDS. SECTION J: HEALTH CONDITIONS The Long-Term Care Facility RAI 3.0 User's Manual, revised October 2024, page J-34 states, . J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment . whichever is more recent. If this is not the first assessment/entry or reentry (A0310E = 0), the review period is from the day after the ARD [assessment reference date] of the last MDS assessment to the ARD of the current assessment. DEFINITION PRIOR ASSESSMENT: Most recent MDS assessment that reported on falls. . Code 0, no: if the resident has not had any fall since the last assessment. Review of Resident #29's medical record occurred on all days of survey. A discharge return anticipated MDS, dated [DATE], identified staff coded the resident's fall on item J1800. A significant change MDS, dated [DATE], identified staff coded a fall on item J1800 since the last MDS. The medical record did not identify a fall between 10/25/24 and 11/01/24. The facility miscoded Resident #29's significant change MDS for J1800 as the medical record lacked evidence of a fall occurring after the date of the prior assessment on 10/25/24. During an interview on 12/17/24 at 5:18 p.m., a nurse (#3) confirmed staff miscoded the significant change MDS for falls.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices for 1 of 2 sampled residents (Resident #1) observed during a transfer. Failure to use a gait belt during transfers placed the resident at risk for accidents, falls, or injuries. Findings include: Review of the facility policy titled Standards of Care occurred on 05/02/24. This policy, revised January 2024, stated, . A gait belt will be used for all assisted transfers and ambulation . Review of Resident #1's medical record occurred on 05/02/24. Diagnoses included history of falling and symptoms and signs involving cognitive functions and awareness. The current care plan stated, Ambulation, Transfers and Toileting: assist x [times] 1 FWW [front wheeled walker]. Observation on 05/02/24 at 11:47 a.m., showed a certified nurse aide (CNA) (#1) assisted Resident #1 from the resident's bed to the wheelchair and again from the wheelchair to the toilet without utilizing a gait belt. During an interview on 05/02/24 at 12:50 p.m., an administrative nurse (#2) stated she expected staff to use the gait belt during all assisted transfers.

Based on observation, review of the Food and Drug Administration (FDA) 2022 Food Code, and staff interview, the facility failed to store food under sanitary conditions in 1 of 1 kitchen. Failure to store food in a sanitary environment in the walk-in freezer has the potential to result in contamination of food and could result in a foodborne illness. Findings include: The 2022 Food Code, pages 81-82, stated, 3-305.11 Food Storage. FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; . 3-305.12 Food Storage, Prohibited Areas. FOOD may not be stored: . (G) Under leaking water lines, including leaking automatic fire sprinkler heads, or under lines on which water has condensed; . or (I) Under other sources of contamination. Observation on 11/13/23 at 11:41 a.m. in the main kitchen walk-in freezer showed an open box of chicken on the top shelf. The chicken stored in an open plastic bag, showed frost and ice buildup from water dripping from above condensation. During an interview on 11/13/23 at 11:46 a.m., a dietary staff member (#3) discarded the open box of chicken and stated maintenance was aware of the condenser line and will be fixing the problem. During an interview on 11/14/23 at 5:25 p.m., an administrative staff member (#2) stated she expected all food to be covered.

Based on record review and staff interview, the facility failed to ensure acceptable parameters of nutritional status for 1 of 6 sampled residents (Resident #22) with significant weight loss. Failure to change and/or implement additional interventions to prevent further loss weight loss resulted in continued significant weight loss for the resident. Findings include: Review of Resident #22's medical record occurred on all days of survey. The medical record identified the following weights: 04/28/23 - 127.4 pounds (lbs) 08/29/23 - 123.2 lbs 09/26/23 - 115.4 lbs, 6.3% weight loss in 30 days 10/31/23 - 112.2 lbs, 11.9% weight loss in six months Nutrition Assessments completed on 10/25/23 and 11/03/23 identified a daily nutritional supplement as the only nutritional intervention for weight maintenance, despite noting a continued weight loss. The facility completed a significant change minimum data set assessment on 10/25/23 due to Resident #22 having changes in activities of daily living and a significant weight loss of 5% or more. The facility notified the practitioner of a 12% weight change on 11/06/23 and identified the resident remained on a daily nutritional supplement for weight maintenance. During an interview on 11/15/23 at 2:04 p.m., a dietary member (#3) identified no further interventions have been added for Resident #22's weight loss and was waiting for today's weight before deciding what to do for Resident #22. The facility failed to identify the 6.3% weight loss in September and the resident continued to a 12% significant weight loss over six months, reported to the provider. The facility failed to add other dietary interventions and the resident continued to lose weight.

Based on observation, resident interviews, and review of resident council meeting minutes the facility failed to resolve grievances related to dietary concerns for 7 of 20 confidential residents (Residents A, B, C, D, E, F, and G) interviewed on the Transitional Care Unit (TCU). Failure to resolve the resident's concerns in a timely manner resulted in continued dissatisfaction regarding cold food. Findings include: During the afternoons of 10/17/22 and 10/19/22, Residents A, B, C, D, E, F, and G reported food is cold when served. Each resident indicated they had reported this to staff and the food is still cold when served. During the supper meal on 10/19/22 at 6:00 p.m., four residents at one table reported the roast beef and mashed potatoes were cold when delivered. Review of the Resident Council Minutes, dated 06/23/22 and 08/16/22, identified food is sometimes cold when delivered, food wait times are some days good and some days bad, and the resident's feel there is at times an issue with the delivery of meals. Observation on 10/19/22 of the evening meal served on the TCU showed the following: * First meal plated at 5:50 p.m. and the last plated meal delivered at 6:36 p.m. * After plating the hot foods the staff member put a plate on a serving tray and failed to cover the food immediately. * On two separate occasions the dietary staff member (#4) left plated foods uncovered during the time he/she retrieved more plate covers. * At times, the resident meal trays sat on the counter for several minutes before delivered. During an interview on 10/20/22 at 8:39 a.m., a dietary manager (#2) stated she expected all meals to be served within a 30 minute or so area and agreed the issue of cold foods may be related to the meal service/tray delivery process.

Based on observation, record review, review of facility policy, staff and resident interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 2 sampled residents (Resident #38) with medications observed in the resident's room. Failure to determine whether SAM is a safe practice has the potential to limit a resident's right to SAM or result in a medication error and/or harm to a resident. Findings include: Review of the facility policy titled Medication-Self-Administration of Meds [Medications] occurred on 10/19/22. This policy, revised December 2021, stated, . Ask the resident if they would like to self-administer medication . If the resident wishes to do this complete the Self-Administration of Medication Assessment . Observation on the afternoon of 10/17/22, showed two nasal spray medications on Resident #38's bedside table. The resident reported he uses the nasal sprays in the morning and at bedtime. Review of Resident #38's medical record occurred on all days of survey. A physician's order dated 02/17/22 stated, . Resident may do own nasal spray - Please observe he is doing correctly . The record lacked a SAM assessment indicating Resident #38 can safely self-administer medications. During an interview on 10/18/22 at 11:30 a.m., an administrative nurse (#1) confirmed staff failed to complete the SAM assessment for Resident #38.

Based on observation, review of facility policy, and review of professional literature, the facility failed to follow standards of infection control for 2 of 14 sampled residents (Residents #1 and #6) observed during cares. Failure to follow infection control standards has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 744, stated, . clean penis . from center outward and wash down . Use a clean area of the washcloth or a new washcloth when washing a new area. prevents cross-contamination. Wash and dry . posterior [groin] folds . tends to be more soiled than the penis because of its proximity to the rectum . This follows the principle of cleaning from the least contamination to that of the greatest. Review of the facility policy titled Gloves-Guidelines for Wearing occurred on 10/20/22. This policy, revised May 2022, stated, . Gloves are disposable, and should be changed between residents and between dirty to clean procedures on same resident. Always perform hand hygiene before and after gloving. Review of the facility policy titled Hand Hygiene occurred on 10/20/22. This policy, revised May 2022, stated, . Hand hygiene will be done a. Before and after resident contact (before you leave the room) b. Before every clean procedure c. After dirty procedure . - Observation on 10/18/22 at 8:11 a.m. showed a certified nurse aid (CNA) (#5) provided frontal perineal cares to Resident #6 while seated on the toilet. The CNA (#5) donned gloves and used a washcloth to cleanse the resident's groin. Without rinsing/folding the washcloth or obtaining a new washcloth, the CNA wiped the penis tip. The CNA removed her gloves, and without hand hygiene, applied new gloves and shaved the resident's face. The CNA (#5) then assisted Resident #1 to stand, cleansed bowel with disposable wipes, completed the back perineal cares, and removed her gloves. Without performing hand hygiene, the CNA (#5) donned new gloves, pulled up the resident's brief and pants, transferred him into his wheelchair, and moved the wheelchair to the sink. The CNA (#5) set Resident #1 up to brush his teeth and applied toothpaste on his toothbrush. The CNA (#5) then removed her gloves, and without performing hand hygiene, exited the resident's room. - Observation on 10/18/22 at 9:07 a.m. showed a CNA (#5) provided perineal cares to Resident #1 while in bed. The CNA (#5) used a washcloth the cleanse the resident's groin, and without rinsing/folding the washcloth or obtaining a new washcloth, wiped the penis tip.

Based on record review, review of facility policy, review of professional literature, and staff interview, the facility failed to follow professional standards of practice for 2 of 2 sample residents (Resident #52 and #63) reviewed with fluid restrictions. Failure to accurately transcribe Resident #52's fluid restriction order onto the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Review of the facility policy titled Fluid Restriction occurred on 10/20/22. This policy, dated October 2019, stated, . The policy of Eventide is to monitor fluid intake on residents who have provider orders for fluid restrictions. Fluids will be recorded by the following process: Nurse/TMA [medication aide] will record all fluid provided with medications and between meals on the MAR. Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 62, stated, . Carrying Out a Physician's Order. Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. - Review of Resident #52's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52's medical record identified a 6-day hospital stay in September 2022 for respiratory failure (difficulty to breath) with [CONDITION(S)] (poor oxygenation to body tissues). The physician's discharge orders stated, . Limit fluid intake to about 1500 mL [milliliters] per day [24 hours]. Review of Resident #52's MAR for September 19 through October 18, 2022 stated, 1500 ml Fluid Restriction every shift [eight hours] for Fluid Overload . - Review of Resident #363's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 1500 mL fluid restriction . Review of Resident #363's October 02-18, 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview the morning of 10/19/22, an administrative staff member (#1) and a dietary manager (#2) confirmed Resident #52 and #363's physician orders are 1500 ml per 24 hours, not per shift, the order transcribed to Resident #52's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review, review of the facility incident investigation, staff interview, and review of operator's manual, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 2 of 2 closed records (Resident #60 and #61) reviewed with Hoyer (full body mechanical lift) transfers. Failure to safely utilize a mechanical lift has the potential for injury for Resident #60 and resulted in a fall with serious injury for Resident #61, and placed all residents requiring this type of transfer at risk for accidents and/or injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the second incident. Findings include: Review of the Operators Manual for the Volara (Hoyer mechanical lift) occurred on 07/15/21. This operator's manual, dated March 2019, stated, . Lifts are designed to transfer a resident, not transport them. Raise until there is tension on the straps and then double-check to make sure the loops are nested in the bottom of the hooks. If the base is in the narrow position, adjust it to the widest position once you are clear from the bed and always before turning the lift. Use only the lift handle bars to move the lift. Pulling or pushing on the person or the beam will cause the lift to be unstable. - Review of Resident #60's medical record occurred on July 14-15, 2021. Diagnoses included [CONDITION(S)], hepatic failure, and myositis. The admission Minimum Data Set (MDS) dated [DATE], identified total dependance with assist of two for transfers. The care plan identified, . Self-care deficit related to weakness . potential for falls related to inability to transfer independently. Transfers: total assist of 2 with hoyer. Review of Resident #60's nurses notes identified the following: * 01/11/2021 at 3:11 p.m.: Time of fall: 1415. Description of event: Resident was being transferred with assist of 2 via hoyer lift from the bathroom to his bed. While turning hoyer to bed hoyer began to tip sideways hitting the floor. ROM (range of motion) in all extremities upper and lower no new bruising to back or arms, assessed head no bumps or bruises noted. denies pain at this time. Change to assist of 3 with all transfers. Review of the facility Investigation identified staff transferred Resident #60 with assist of two staff (physical therapist #2 and certified nurse assistant #3) and the Hoyer lift from the bathroom to the bed. The legs of the lift were in the narrow position due to coming through the doorway of the bathroom. The two-facility staff (#2 and #3) began to turn the lift towards the bed and the lift started to tip. Staff stated they were unable to stop the lift from tipping over with the resident in the sling. - Review of Resident #61's medical record occurred on July 14-15, 2021. Diagnoses included a broken internal right hip prosthesis, pain in right hip, and presence of right artificial hip joint. The quarterly MDS, dated [DATE], identified total dependence with assist of two for transfers. The care plan identified, . Self-care deficit related to R) [right] hip hardware malfunction, heart failure and recent CABG [coronary artery bypass grafting]. potential for falls related to decreased mobility. Transfers: Assist of 2 [sic] with hoyer. Review of Resident #61's nurses notes identified the following: * 02/18/2021 at 12:09 p.m., Time of fall: 10:45 a.m. Description of event: CNA [certified nursing assistant] notified nurses that resident had fallen on the floor. When this writer entered room resident was sitting on his bottom with his back against the bed and his legs lying flat on the floor. Resident was sitting on the hoyer sling and the lift was on hisright [sic] side tipped over and leaning over his head. The part of the lift that hooks to the sling was resting on the bed. The aids that were present were unhooking him from the sling when I walked in. The legs of the hoyer were closed and the sling being used was a ceiling lift sling. Upon assessment staff noted a superficial laceration on the top of his head on the left side which was bleeding. Resident stated the top of the hoyer hit him in the head when he fell . Resident also stated he broke his fall with his left hand and was complaining of 3/10 aching pain in his L [left] shoulder. Review of the facility investigation identified staff transferred Resident #61 with assist of two staff (CNA #8 and CNA #9) and the Hoyer lift, using the incorrect sling (ceiling sling), and transporting Resident #61 from the bathroom to the bed. The CNA (#8) moved the lift and the other CNA (#9) stood nearby assisting when the Hoyer started to tip. The legs of the lift were in the narrow position and staff were unable to stop the lift from tipping over with the resident in the sling. Resident #61 remained an assist of two staff with the Hoyer lift. CNAs (#8 and #9) received education on keeping the legs of the lift in the widest position and using the appropriate sling on 02/18/21. CNAs (#8 and #9) completed Hoyer sling application and lift use competency on 02/23/21. CNAs (#8 and #9) received a coaching and improvement plan on 02/23/21 regarding the importance of keeping the legs of the lift in the widest position. All nursing staff received Hoyer lift education and completed competency during the staff meeting on 03/04/21. During an interview on 07/15/21 at 10:00 a.m., an adminstrative nurse (#1) confirmed that Resident #60 and #61's falls were a result of improper use of the Hoyer lift and stated, we educated the staff [PT #3 and CNA #2] after the first fall, after the second fall with the hoyer we educated both CNAs [#8 and #9], and identified there was a problem. We then provided training to all staff that use any of the lifts and they completed the Hoyer competency. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the corrective action for the residents affected by the deficient practice by: *Completing an investigation with interviews of staff who assisted with the transfers on 01/11/21 and 02/18/21. *Determining the investigations showed staff failed to follow the operators manual for the Volara Hoyer mechanical lift for both incidents resulting in falls, and resident with serious injury. *Inspecting the Hoyer lift and sling involved immediately following the incident and finding the equipment to be in good working condition. *Providing 1 on 1 education immediately after the incident from 1/11/21 and 02/18/21 with involved staff regarding proper use of Hoyer lift and sling with competency and return demonstration to the DON. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: *Providing education to all nursing staff on proper Hoyer lift transfers on 03/04/21. *Auditing Hoyer lift transfers starting on 01/11/21. The facility completed audits weekly for 7 months. The survey team determined a deficient practice existed on 01/11/21 and 02/18/21. The facility implemented corrective action on 01/11/21 and 02/18/21 and completed all nursing staff education on 03/04/21.

Based on observation, review of facility menus, and staff interview, the facility failed to serve food according to prepared menus during 4 of 5 meal observations (Evening meal on Transitional Care Unit (TCU) 07/12/21, Evening meals on TCU and Long Term Care (LTC) Unit on 07/13/21, Noon meal on TCU 07/14/21). Failure to serve food according to facility's menus placed residents at risk for inadequate nutrition and unplanned weight loss/gain. Findings include: - Observation of TCU evening meal tray line occurred on 07/12/21 and showed a dietary staff member (#5) used a gloved hand to place a handful of lettuce salad on residents' plates. Review of the menu identified the correct portion size as 1 cup. - Observation of LTC Unit evening meal tray line occurred on 07/13/21 and showed a dietary staff member (#5) served creamed chipped beef for residents on a regular diet with a 2-ounce spoodle (portion spoon/ladle). Review of the menu identified the correct portion size for a regular diet as 6 ounces. - Observation of TCU evening meal tray line occurred on 07/13/21 and showed a dietary staff member (#6) served creamed chipped beef for residents on a regular diet with a 3-ounce spoodle. Review of the menu identified the correct portion size for a regular diet as 6 ounces. - Observation of TCU noon meal tray line occurred on 07/14/21 and showed a dietary staff member (#7) served residents on a regular diet the following:(Sloppy [NAME] (Beef Barbeque) - 4-ounce spoodle (menu identified 2 ounces) *Tater Tots - handful of Tater Tots in gloved hand (menu identified 4 ounces)*Carrots - large, slotted spoon with no size measurement (menu identified 4 ounces)*Fruit Salad - 3-ounce spoodle (menu identified 1/2 cup) *Cheddar mashed potatoes - heaping portion using a small spoon with no size measurement (menu identified 1/2 cup) *Pureed Chicken - heaping portion using a small spoon with no size measurement (menu identified #10 scoop)During an interview on 07/15/21 at 10:37 a.m., an administrative dietary staff member (#4) confirmed staff should follow the menu for correct serving sizes.

Based on record review, review of facility policy, and staff interview, the consulting licensed pharmacist failed to complete resident's medication regimen reviews (MRRs) at least once a month, and report irregularities to the attending physician, the facility's medical director, and director of nursing for 11 of 18 sampled residents (#6, #11, #12, #20, #24, #29, #33, #45, #46, #53, and #56). Failure of the pharmacist to complete MRRs, identify and report all drug irregularities may result in the prolonged and unnecessary use of medications and adverse consequences. Findings include: Review of the facility policy titled Medication Regimen Review (MRR) occurred on 07/15/21. This policy, revised September 2017, stated, . The pharmacist will review the residents medication regimen monthly . to identify irregularities and to identify clinically significant risks and/or adverse consequences. irregularities identified will be documented . report the irregularity to the Director of Nursing . and they will contact the attending physician. Review of Residents #6, #11, #12, #20, #24, #29, #33, #45, #46, #53, and #56's medical records from January 2020 - June 2021 (18 months), identified the licensed pharmacist failed to complete the following: *Resident #6 - 10 of 18 required MRRs. *Resident #11 - 7 of 12 required MRRs. *Resident #12 - 9 of 18 required MRRs. *Resident #20 - 10 of 18 required MRRs. *Resident #24 - 10 of 18 required MRRs. *Resident #29 - 12 of 18 required MRRs. *Resident #33 - 6 of 8 required MRRs. *Resident #45 - 8 of 16 required MRRs. *Resident #46 - 3 of 6 required MRRs. *Resident #53 - 11 of 18 required MRRs. *Resident #56 - 11 of 18 required MRRs. During an interview on 07/12/21 at 2:45 p.m., an administrative nurse (#1) confirmed the licensed pharmacist failed to complete monthly MRRs.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 18 sampled residents (Resident #12). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2019, page H-2 states, . Coding Instructions. Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances A-D were used in the past 7 days. H0100A, indwelling catheter including suprapubic catheter and nephrostomy tube). H0100B, external catheter. H0100C, ostomy (including [MEDICATION(S)], [CONDITION(S)], and colostomy). H0100D, intermittent catheterization. H0100Z, none of the above. - Review of Resident #12's medical record occurred on all days of survey. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care planned identified a [MEDICATION(S)] in place. The Quarterly MDS, dated [DATE], identified facility incorrectly coded an indwelling catheter and external catheter, and failed to code the [MEDICATION(S)]. During an interview on 07/14/21 at 2:22 p.m., an administrative nurse (#1) confirmed facility staff coded Section H of the quarterly MDS incorrectly for Resident #12's [MEDICATION(S)].

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 08/22/19. Based on record review, review of facility policy, and resident, family, and staff interviews, the facility failed to provide the necessary care and services for 2 of 3 sampled residents (Resident #24 and #48) with applying the continuous positive airway pressure ([CONDITION(S)]) mask accurately. Failure to provide oxygen as ordered has the potential for residents to experience complications related to inadequate oxygen saturation levels. Findings include: Review of the facility policy titled [CONDITION(S)], [CONDITION(S)] [bilevel positive airway pressure]/Trilogy [brand name ventilator], and AutoPAP [automatic titrating positive airway pressure] occurred on 07/14/21. This policy revised July 2018, stated, To provide appropriate respiratory/nursing care to residents on [CONDITION(S)] . - Review of Resident #24's medical record occurred on all days of survey and showed medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's current care plan stated, . has altered respiratory status/difficulty breathing. Has dyspnea [difficulty or labored breathing] at times. [CONDITION(S)] as ordered . Review of the physician's order written on 02/22/21, stated [CONDITION(S)] at NOC [at bedtime] for OSA. Review of social services note on 5/20/2021, stated [family member] did express concerns about resident's [CONDITION(S)] not being put on at night . Grievance filed and given to resident care manager . During an interview on 07/12/21 at 1:10 p.m., Resident #24 stated, she has difficulty wearing her [CONDITION(S)] at NOC because not all staff know how to apply the mask correctly and it blows all over my face or they do not put it on at all. During an interview on 07/14/21 at 2:00 p.m., an administrative nurse #1 confirmed staff applied the [CONDITION(S)] mask incorrectly and stated, I provided a reference sheet to three staff who work nights, and they were shown how to apply the [[CONDITION(S)]] mask and I have not been told of any complaints since. During a phone interview on 07/15/21 at 9:10 a.m., family member #1 stated, staff are not placing the [CONDITION(S)] on correctly or not at all, one [staff] did not want to wake her [Resident #24] up so she did not place the [CONDITION(S)] [mask] on her for the night, I talked to them in May during [Resident #24's] care conference and they are still putting it on wrong. - Review of Resident #48's medical record occurred on all days of survey. Current physician's order stated, [CONDITION(S)] at bedtime. Resident #48's current care plan stated, has impaired respiratory function including diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . acute respiratory failure with [CONDITION(S)]. uses oxygen and a [CONDITION(S)] During an interview on 07/13/21 at 11:28 a.m., Resident #48 stated staff do not know how to use the [CONDITION(S)] machine. States they over-fill the water in the machine and they don't know what settings to use, states too much oxygen and it blasts in my nose.

Based on observation, review of dish machine temperature log, review of the Food and Drug Administration (FDA) Food Code 2013, and staff interview, the facility failed to store, prepare, and serve food under sanitary conditions for 1 of 2 dish machines (Long Term Care). Failure to ensure proper sanitation of dishes and utensils may result in foodborne illness to residents, staff, and visitors. Findings include: The FDA Food Code 2013, pages 145-146, stated, . Sanitization of equipment and utensils . Hot water mechanical operations . achieving utensil surface temperature of 71 degrees Celsius (C) (160 degrees Fahrenheit (F)) as measured by an irreversible registering temperature indicator. Observation on 08/21/19 at 9:43 a.m., showed a dishwasher in use in the Long Term Care (LTC) kitchen. A hotplate thermometer, placed in the dishwasher, showed a maximum temperature of 151 degrees F on two consecutive cycles. The Dish Machine Temperatures log indicated, . Plate temperature should be at least 160 degrees. A culinary staff member (#2), who washed the breakfast dishes, identified the booster on the dishwasher was not working properly and had notified maintenance. The culinary staff member (#2) continued to operate the dishwasher knowing the proper plate temperatures were not reached. During an interview on the morning of 08/21/19, a culinary staff supervisor (#3) stated she expected dietary staff to check the dishwasher temperatures daily, notify the supervisor if the plate temperatures are below 160 degrees and take the dishes to an alternate dishwasher to clean them.

Based on observation, record review, review of facility policy, resident interview and staff interview, the facility failed to provide the necessary care and services to prevent the development of bruises for 1 of 10 sampled residents requiring extensive assist with cares (Resident #32) and at risk of developing abrasions and or bruises. Failure to assess the cause and reassess/monitor current skin issues and treatments has the potential for further skin breakdown and resident discomfort. Findings include: Review of the facility policy titled Skin Assessment occurred on 08/21/19. This policy, revised (MONTH) (YEAR), stated, . to inspect and assess all areas of the resident's skin to identify current and potential problems . Tissue Tolerance is the ability of the skin and its surrounding structure to endure the effects of pressure without adverse effects . Appropriate skin assessments will be completed by the nurse. All assessments will be documented in the medical record with problems included in the care plans . Bruises/skin Tears . the nurse must: provide appropriate treatment . if the cause is unknown, notify the designated personnel immediately regarding appropriate vulnerable adult reporting, investigate to determine the cause . in the progress notes document the presence of the bruise/skin tear and description/measurements, cause/possible cause, and who was notified . place on the eTAR (electronic treatment record) to monitor weekly until resolved. Review of Resident #32's medical record occurred on all days of survey. Current medications include, . Aspirin Tablet 81 MG (milligrams) give 81 mg by mouth one time a day. A quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident as needing staff physical assist, support of two plus persons for dressing and bed mobility, and has a Brief Interview for Mental Status (BIMS) score of 14. (BIMS score of 13 to 15 reflects intact cognition) Observation on 08/19/19 at 11:55 a.m. showed a bruise to Resident #32's right hand approximately the size of a quarter, located between the base of his thumb and pointer finger knuckle. When asked about the bruise Resident #32 stated, It just happened this morning, she holds my hand there (pointing to the area of the bruise) when she puts my shirt on. There was one (a bruise) on the other side too. Resident #32 is weepy and teary eyed when he speaks about the bruise. Nurses' notes and wound assessments stated the following: * 08/10/19, . skin check performed. No new areas of concern. * 06/01/19, . small bruise to left wrist. * 05/11/19, . continues to have bruise to L wrist. * 05/15/19, . (Resident #32) reports that when staff were trying to assist him to a seated position this morning, they were holding his wrist and he is concerned about developing a bruise from this as the location is right next to a current bruise . thinks they didn't realize how tight their hold on his wrist was. Resident #32's care plan identified, . Date Initiated: 04/13/17 Potential for skin breakdown r/t (related to) mobility secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION] . Monitor for changes in skin integrity when providing cares and provide appropriate follow up if areas of concern are noted. The medical record failed to show documentation of the current bruise on Resident #32's right hand. During an interview on 08/22/19 at 11:08 a.m., an administrative nurse (#4) agreed there was an undocumented bruise on Resident #32's right hand.

Based on record review and staff interview, the facility failed to notify the resident and/or family member, and the Office of the State Long-Term Care Ombudsman, in writing, of a transfer outside of the facility, including the destination and reason for the transfer, and the resident's right to appeal the action for 2 of 3 sampled residents (Residents #42, and #43) transferred to the hospital. Failure to provide a notice of transfer does not allow the resident and/or family member the right to make an informed choice regarding the resident's rights. Findings include: - Review of Resident #42's medical record occurred on all days of survey. The progress notes identified the facility transferred the resident to the emergency room (ER) on 05/12/19, and admitted the resident to the hospital until 05/21/19. The record lacked evidence the facility provided the resident and/or family member a written notice of transfer. - Review of Resident #43's medical record occurred on 08/21/19. The progress notes identified the facility transferred the resident to the hospital on [DATE]. The record lacked evidence the facility provided the resident and/or family member a written notice of transfer. During an interview on 08/21/19 at 5:45 p.m., a social services staff member (#1) stated staff could not locate transfer notices for residents #42 and #43's, hospitalization on [DATE] and 04/09/19 in their medical records.

Based on information provided by the complainant, record review, review of professional reference, review of facility policy, and staff interview, the facility failed to ensure 1 of 1 resident (Resident #3) remained free of a significant medication error prior to discharge. Failure of staff to administer only [MEDICATION NAME] (non-oral) medications through Resident #3's Peripherally Inserted Central Catheter (PICC) line (a catheter inserted into a large vein in the arm that carries blood to the heart) resulted in a significant medication error which required Resident #3 to be hospitalized for [REDACTED]. Findings include: Berman, Snyder, Kozier, and Erb, Fundamentals of Nursing Concepts, Process, and Practice, 10th Edition, Copyright (YEAR) by Pearson Education, Inc., New Jersey, pages 758-759, 771-772, and 1341, stated, . In oral administration, the drug is swallowed. The [MEDICATION NAME] route is defined as . by needle . Intravenous (IV) - into a vein. sterile equipment and sterile drug solution are essential for all [MEDICATION NAME] therapy. When administering a drug, regardless of the route of administration, the nurse must . Read the MAR (Medication Administration Record) carefully . Then administer the medication in the prescribed dosage, by the route ordered, at the correct time. peripherally inserted central venous catheter (PICC) . SITE CARE Use strict aseptic technique . The frequency of dressing changes is dependent on the dressing material . Assess the site for redness, swelling, tenderness, or drainage . assess for possible displacement . Change the catheter cap as indicated by agency protocol . Flush the catheter before and after each dose of medication . Do not allow anyone to take a blood pressure on the arm in which the PICC line is inserted . the arm should not be immersed in water. Review of the facility policy titled Medication - Errors (and) Drug Reactions occurred on 04/24/18. This policy, revised (MONTH) (YEAR), stated, . A Significant Medication Error is defined as an error which . jeopardizes the resident's health or safety . If the medication error is significant, the following steps will occur: A nurse will document the basic facts in the progress notes. A nurse will notify the practitioner and the Resident Care Manager/Clinical Coordinator/Director of Nursing. Take whatever steps are necessary to prevent reoccurrence of the error. The Director of Nursing will monitor medication errors for trends and will provide a report to the Quality Assurance Committee and consult with the Executive Director as needed. The Director of Nursing will determine which medication errors need to be reported to the . North Dakota Department of Health (NDDOH). Information provided by the complainant indicated facility staff failed to ensure Resident #3 received only injectable medications through his PICC line. Review of Resident #3's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. The record identified orders for chewable and/or liquid (oral) and IV forms of [MEDICATION NAME] (an [MEDICATION NAME]). The physician's orders, dated (MONTH) 1-December 11, (YEAR), identified the following: * . [MEDICATION NAME][MEDICATION NAME] HCI Liquid (generic name for [MEDICATION NAME]) Give 50 mg (milligrams) by mouth every 6 hours for itching. * . [MEDICATION NAME] 50 mg IV q (every) 6 h (hours) per PICC - OK to give chewable if no RN (registered nurse) available, every 6 hours for itching. Discontinue the Liquid [MEDICATION NAME] when the IV [MEDICATION NAME] is delivered. A Medication Error Report, dated 11/02/17, identified, . Oral [MEDICATION NAME] 50 mg given through PICC line. Wrong Route . Call Poison Control - recommend to sent to ER (emergency room ) . Sent to ER to be evaluated for contamination. The Vulnerable Adult Report also identified, . RN . self reported that she gave oral liquid [MEDICATION NAME] via resident's PICC line on 2 occasions . When . RN realized she had given the medication the wrong route, she contacted the On-Call Provider, Poison Control, Pharmacy . and Medical Pharmacy, and On-Call Manager. The Poison Control Center recommended that Provider send to ER and he was admitted to Observation Unit. A progress note, dated 11/02/17 at 7:00 p.m., identified, Order obtained to send resident (#3) to ER to run labs for possible PICC line contamination. The Hospitalist Admission Note, dated 11/02/17 at 8:19 p.m., identified, . (Resident #3) presents from nursing home with increased somnolence (sleepy/drowsy) after oral [MEDICATION NAME] was administered through his PICC line twice today. Aside from fatigue patient denies any acute complaints. The (patient) was recently discharged about 1 week ago. He had a PICC line at time of discharge in order to make comfort measure medications easier. A progress note, dated 11/06/17 at 4:24 p.m., identified, Resident (#3) readmitted from (Hospital) . The follow-up section of the Medication Error Report, dated 11/02/17, identified, . (Registered Nurse) involved in conversation/investigation. Discussed the importance of medication error (and) that we are glad she self-reported. Remove DCed (discontinued) meds (medications) from med-drawer, write clear orders, read full bottle label. Discussed medication rights. Reported to NDDOH. The follow-up section of the Vulnerable Adult Report also identified, . Nurse received update from hospital on resident on 11/03/17 and resident was doing well, had some lethargy and no significant changes in labs. PICC line was removed. Education provided to nurse on 'Medication Rights.' Pharmacy label did not have oral indicated on pharmacy label, but it was indicated on bottle directions - discussed the importance of reading all labels. Throughout the survey, the team interacted with the newly hired Administrator (#2) and interim Director of Nursing (#1). They began working at the facility one week prior to the complaint survey and approximately five and a half months after the incident under investigation. During an interview on 04/24/18 at 8:30 a.m., when asked questions pertaining to the medication error, an administrative nurse (#1) explained she had stepped into her current role approximately one week prior, and would have to do some research. Approximately two hours later, the administrative nurse (#1) provided a copy of the Medication Error report and Vulnerable Adult report pertaining to the incident. She (#1) then reported contacting Pharmacy, and they verified the route was not on the label. The administrative staff member (#1) confirmed the nurse received additional education on Medication Rights. Evidence provided by the facility on the Medication Error report identified the nurse was provided education on the importance of medication rights. She (#1) also provided copies of the nurse's employment records, showing the facility held a Skills Fair on 11/28/16 and 05/24/17. Nursing staff, including the nurse involved in the incident, received training on catheter cares (including reverse demonstration) during each fair. When asked if the rest of the nursing staff also received additional education or if the facility completed monitoring on this issue, the administrative nurse (#1) reported she had attempted to go through the previous DON's files, and wasn't able locate any additional education or monitoring documentation. She (#1) then added she had located/reviewed all of the incident reports dated (MONTH) 2, (YEAR)-April 24, (YEAR), and reported, This was the only medication error involving a PICC line. The nurse failed to administer Resident #3's medications via the route ordered resulting in a four day hospitalization .

Based on observation, record review, review of facility policy, review of a professional reference, and staff interview, facility staff failed to implement appropriate interventions to restore/maintain adequate nutritional status for 1 of 1 sampled resident (Resident #8) identified with an avoidable significant weight loss and observed to require assistance with eating. Failure to ensure staff implemented measures to avoid weight loss including providing supplements between meals and ensuring staff provided adequate assistance, consistent with the comprehensive assessment, resulted in Resident #8 experiencing significant and severe weight loss. Findings include: The Centers for Medicare and Medicaid Services (CMS) has outlined the parameters for evaluating significance of unplanned & undesired weight loss: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% Review of the facility policy "Weight Changes Assessment/Documentation" occurred on 03/19/14. The policy, dated 07/10/13, stated: "Policy: The policy of Eventide is to monitor and assess all residents who have had a significant weight change to promote optimal nutritional health. Purpose: To prevent any unplanned weight changes. Procedure: . . . Any residents experiencing significant weight gain/loss . . . will be assessed by the dietician. . . . Nutritional supplements or other nutritional interventions will be implemented by dietician as appropriate." - Review of Resident #8's medical record occurred on all days of survey. The facility admitted Resident #8 in August of 2010. [DIAGNOSES REDACTED]. The record identified the resident as being on a regular, dysphagia mechanical soft diet and a fluid intake of at least two liters per day. The record identified the resident's daughter signed a diet refusal, denying the resident had any swallowing problems. Review of Resident #8's Minimum Data Set (MDS) assessments included the following: quarterly, dated 01/04/14; quarterly, dated 10/06/13; annual, dated 08/10/13; and quarterly, dated 06/24/13. Each MDS identified the resident with short and long term memory problems, severely impaired in daily decision making, and fluctuating inattention. Each MDS identified Resident #8, at minimum, required verbal cueing to eat and drink throughout each meal, and assistance of one person on three of the four MDSs reviewed. The most current MDS, dated [DATE], identified Resident #8 required staff supervision, cueing, and reminders for meal completion, and one person assistance for eating. Resident #8's current care plan identified the problem of altered nutrition and weight loss due in part to poor meal intake, refusal of meals at times, and [DIAGNOSES REDACTED]. . . Encourage and assist as needed to consume all food, fluids, and supplements provided. Encourage fluid intake at and between meals. Honor food preferences as requested . . . Offer small portions in attempt to promote nutritional intake . . . Provide a Regular diet and monitor during meals for food consumption. . . ." The care plan identified the problem of Resident #8 wandering throughout the facility. Observation on all days of survey showed Resident #8 would propel herself in her wheelchair from the east to the west wing of the facility. Progress notes included information of her wandering behavior. On 01/03/14, a social services entry stated: ". . . Resident enjoys wheeling around the facility and will stop in the nurse's station on LTC (long term care). . . ." Review of Resident #8's weight records identified the following: * 03/23/13: 108 pounds (lbs) * 06/15/13: 98.8 lbs; a weight loss of 8.5% over 90 days * 09/14/13: 95 lbs.; a weight loss of 12% over 180 days * 12/21/13: 101 lbs * 01/02/14: 100.8 lbs; [MEDICATION NAME] 20 milligrams (mg) ordered daily * 01/17/14: 81.2 lbs; a weight loss of 19.6% (19.8 lbs) over 30 days; 14.3% over 90 days; and a 14.7% over 180 days * 02/19/14: 87.4 lbs.; a weight loss of 5.2% in 30 days * 03/15/14: 88.4 lbs.; a weight loss of 12.5% in 90 days Information obtained from facility staff on the afternoon of 03/17/14 included the schedule for meal service to residents. This included an open breakfast between 7:30 and 9 a.m.; lunch at noon; and supper at 6 p.m. Review of Resident #8's Medication Administration Record [REDACTED]. The March 2014 MAR indicated [REDACTED]. Observation and interviews on all days of survey included the following: * 03/17/14 at 3:50 p.m. after providing toileting assistance to Resident #8, two CNAs (#6 and #9) did not offer Resident #8 any fluids including a supplement * 03/18/14 at 7:40 a.m., Resident #8 sat at the breakfast table asleep in her wheelchair. A container of Boost Plus, two pieces of toast, yogurt, and a glass of Boost Plus Breeze sat at her table setting. Resident #8 remained asleep at the dining table at 8:30 a.m. One-half of the Boost Plus Breeze had been consumed. By 9:10 a.m., all the yogurt and Boost Breeze Plus had been consumed. The toast remained. Intake records showed Resident #8 consumed 240 cubic centimeter (cc) of fluid and 76-100% of the meal * 03/18/14 at 9:10 a.m., a CNA (#12) assisted toileting Resident #8 and the resident laid down in bed. No fluids were offered with the cares * 03/18/14 at 12 noon, Resident #8 sat at a table with three other table mates. A glass of Boost Plus Breeze, cup of coffee and a Magic cup sat at her place setting. Resident #8, awake, moved her wheelchair away from the table and a certified nursing assistant (CNA) moved her wheelchair back to the table and locked the brakes on the wheelchair. When Resident #8 received her meal of soup and half of a chicken sandwich, she asked her three tablemates if "anyone around here knows how to handle this soup?" One of the three residents explained to Resident #8 how to eat and Resident #8 said "well I just don't know how to do that," and then Resident #8 stated "I guess I'll just have to go hungry" and "I don't know" and "I don't know how to eat it." Resident #8 then pushed her wheelchair backwards. After more prompting/cueing by a table mate, by 12:30 p.m. Resident #8 ate between 75-90% of the soup. A CNA then delivered a bowl of peaches to Resident #8's place setting and Resident #8 stated regarding her peaches "I don't know how to eat it." During this meal time observation, two CNAs sat in this same dining area feeding other residents at different tables. Observation showed the CNAs within hearing and viewing distance of Resident #8 and her table mates. Intake records identified Resident #8 ate 51-75% of the meal and 200 cc of (unspecified) fluid * 03/18/14 at 5:15 p.m. a CNA (#13) attempted to provide Resident #8 toileting assistance just outside of the resident's bathroom door. The resident refused and the CNA did not attempt nor offer any fluids, nourishment or a supplement * 03/19/14 at 7:40 a.m., Resident #8 sat in her wheelchair at the breakfast table asleep. A glass of a red colored drink (Boost Plus Breeze) and a glass of a white colored drink (Boost Plus) sat on the table in front of her. * 03/19/14 at 8:20 a.m., Resident #8 remained asleep at the breakfast table. The glass of Boost Plus remained untouched; and one half of the Boost Plus Breeze remained in the glass. One-half of a four oz container of yogurt was consumed; and a muffin/breakfast cake sat on a plate, untouched. Intake records showed Resident #8 ate 26-50% of the meal and 120 cc of fluid * 03/19/14 at 9:05 a.m., a CNA (#10) stated she assisted Resident #8 with the yogurt served with breakfast (then observed to be empty) and said Resident #8 took half of her Boost Breeze. The CNA (#10) stated Resident #8 does not like the Boost Plus. The CNA (#10) stated Resident #8 is frequently tired for breakfast as she gets up early in the morning and stays up late. The CNA stated Resident #8 was awake by 6:30 that morning. The CNA (#10) and another CNA (#7) stated no fluids or supplements were offered to Resident #8 between 6:30 a.m. and the breakfast meal * 03/19/14 at 9:25 a.m., a staff nurse (#11) stated nursing staff do not document "every time" how much Resident #8 consumes of the supplements provided during medication pass, but will make a progress note periodically. Review of nursing progress notes between 12/16/13 and 03/18/14 lacked information on Resident #8's refusals of supplements offered * 03/19/14 at 9:30 a.m., a CNA (#7) stated more frequently than not Resident #8 is given assistance with meals but she will not always accept it. The CNA stated this morning Resident #8 pulled away from the muffin fed with a fork, yet took the yogurt. The CNA stated staff document fluid intakes after each meal and include amount of supplement taken. The CNA identified being unable to document nourishment intake between meals in the computer system utilized * 03/19/14 at 2:20 p.m., after a CNA (#10) toileted Resident #8, the CNA offered the resident no fluids, nourishment or supplement Review of nutrition progress notes stated the following: * 03/13/14: ". . . Meal intake has historically been poor thus supplements have been offered through out the days as well as snacks. Supplements are not always accepted depending on the day. . . ." * 02/25/14: "Monthly nutrition review. Weight review: 2/25 88.4# (pounds) which is up 6.2# (7.5%) from 1 month ago, down 8.8# (9%) from 3 months ago, and down 7.2# (7.5%) from 6 months ago. Recent weight fluctuations can be attributed to changes in diuretic, refusal of meds (medications) and supplements, and decreased nutritional intake. On average the past week resident has consumed only 39-62% which is pretty stable compared to last month. Supplements currently offered include Boost plus 8 oz QD (every day), Boost Breeze 8 oz TID, and magic cup or ice cream cup QD. Changes in supplements have been made related to resident stating she didn't like them or she was accepting others more than another. Changes in weight and intake maybe unavoidable d/t (due to) natural progression of her disease process. . . ." * 01/16/14: ". . . significant weight loss is noted. Weight is down 9# (9.2%) compared to one month ago. Weight loss attributed to decrease in [MEDICAL CONDITION] m/b (manifested by) starting [MEDICATION NAME] earlier in January. Resident has lost 12.4# since starting diuretic. Nutritional intake has not dramatically changed. Continue(s) to eat poor to fair at meals and varies in supplement acceptance. . . ." The nursing progress notes indicated [MEDICATION NAME], a potent diuretic, started on 01/02/14 and discontinued by 01/17/14. Refer to the review of weights and weight loss prior to and one month following the discontinuation of the [MEDICATION NAME] as well as the marked decrease of weight in a 15 day period while Resident #8 received [MEDICATION NAME] * 01/13/14: ". . . Supplements continue to be offered to assist in meeting needs d/t oral intake at meals is usually poor. . . ." * 01/07/14: ". . . Resident is a small, picky eater. Staff offer foods that (resident) will typically eat. This past week she has consumed 40-60% of what was offered. This is typically 1-2 items or small portions of a meal. . . . Anticipate with food intake she is minimally meeting her needs to maintain her weight. . . ." * 12/17/13: ". . . Resident will often foot propel herself in her wheel chair to LTC unit and have snack offered to her by staff. Nursing report resident complains of the taste of some of the supplements. . . . Will recommend to start Boost Breeze 1 container TID, Boost Plus 8 oz QD, and Magic Cup 1 container QD. . . ." The note or record lacked information on what types of snacks nursing staff offered and what Resident #8 accepted. Review of CNA charting between January 18 and March 18, 2014 identified Resident #8 received extensive assistance with meals on four occasions and total assistance on four occasions within the two month time period. The remainder of the charting showed Resident #8 received the supervision of one staff member. Observation showed Resident #8 not at an assisted table nor nearby for staff to supervise including prompt or cue Resident #8. Failure to consistently supervise/cue and/or assist Resident #8 during meals, and provide supplements between meals rather than with meals limited knowing how well Resident #8 would consume meals and determine if supplement intake would improve if offered between meals. Review of fluid intake records between March 1 and March 18, 2014, showed Resident #8 received less than 700 cc a day on 15 of 18 days. During interview on the afternoon of 03/18/14, a supervisory nurse (#3) stated Resident #8 received supplements with meals given by the nurse(s). During interview on the morning of 03/19/14, the supervisory nurse (#3) stated monitoring of fluid intake with meals included supplements. Review of the fluid intake records between March 1 and March 19, 2014 did not identify the type of fluid consumed, specifically if Resident #8 consumed any of the supplement. The record showed on 30 of 56 occasions Resident #8 consumed 200 cubic centimeters (cc) or less for the meal. Review of food intake records over the same period of time showed Resident #8 refused five meals and ate between 0 - 25% on 21 of 56 occasions. During interview on the afternoon of 03/19/14, a supervisory nurse (#3) stated staff should give supplements throughout the day, stated staff could develop the MAR indicated [REDACTED]. The facility failed to: * ensure Resident #8 received prompting/cueing or assistance to eat and drink during meals * monitor Resident #8's supplement intake as scheduled with med pass * to offer supplements between meals as an intervention developed in the care plan * to offer Resident #8 fluids between meals with personal cares * monitor nourishment intake between meals * consider Resident #8's wandering behavior would increase her caloric needs