Every finding on record at SMP Health - Ave Maria

Based on record review, review of facility policy, review of the facility reported incident (FRI), and resident/staff interview, the facility failed to protect 2 of 2 sampled resident's (Resident #6 and #7) right to be free from physical abuse from each other. Failure to ensure residents remained free from physical abuse resulted in a physical altercation involving hair pulling, hitting, and biting which necessitated bloodborne pathogen testing. Findings include: The surveyor determined a deficient practice existed on 04/20/26. The facility implemented and completed corrective actions on 04/22/26. Review of the facility policy titled Abuse occurred on 05/20/26. This policy, revised January 2026, stated, Abuse is defined as a willful infliction of injury . intimidation . with resulting physical harm, pain, or mental anguish . Physical Abuse is defined as hitting, slapping, pinching, kicking, etc. Review of the initial FRI, dated 04/20/26, stated, . [Resident #6] and [Resident #7] were roommates at the time of this incident today. At approximately 4:50 pm, [Resident #7] (who has dementia) went over to his roommate's side of the room and started to take some of his roommate's popcorn. The two residents had an unwitnessed altercation that involved [Resident #7] being bite [sic] by [Resident #6] and [Resident #7] pulling out some of [Resident #6's] hair. Review of Resident #6's medical record occurred on all days of survey. The annual Minimum Data Set (MDS), dated [DATE], identified intact cognition. The current care plan stated, . He [Resident #6] can become irritable towards others when he feels that they are . taking something from him . Due to the incident with his roommate on 4/20/26, the IDT [Interdisciplinary Team] has determined that he will remain in a private room at this time d/t [due to] his specific preferences and his beliefs. A behavior progress note, dated 04/20/26, stated, . Author was called down to room stating that resident and his roommate were in a physical altercation. [Resident #6] reports that his roommate [Resident #7] went to his side of the room and grabbed his bag of popcorn that was sitting on his nightstand. [Resident #6] stated that he told his roommate to leave it alone and called him a thief. His roommate then started to hit him on the top of . his head and pulled his hair. He had a large clump of hair on his left arm. He [Resident #6] stated he then bit his roommate [Resident #7] which caused a small opening in the skin. Staff went to answer the light that was on in their room and immediately separated the two gentlemen . Residents' roommate [Resident #7] was immediately moved to a private room. Police were called and report was done. Due to the bodily fluids from both gentlemen (saliva from [Resident #6] and blood from the roommate [Resident #7]) our exposure plan was implemented and both gentlemen were drawn for HIV [human immunodeficiency virus], HEP [Hepatitis] B, HEP C. Review of Resident #7's medical record occurred on all days of survey. The MDS, dated [DATE], identified moderately impaired cognition. The care plan stated, . [Resident #7] . has had a history of expressing frustrations verbally by raising voice or cussing in these moments at staff . Due to incident on 4/20/26, IDT has determined that resident will be in a private room. During an interview on 05/19/26 at 11:25 a.m., Resident #7 voiced no concerns regarding the other residents. During an interview on 05/19/26 at 11:40 a.m., Resident #6 voiced no concerns regarding his safety and stated, I'm a devout Christian. I've had two previous roommates that swore. Of course, it's not against the law. My last roommate, [Resident #7], attacked me. He tried to steal my candy corn. He pulled out some of my hair, hit me five times on the top of my head, and tried to hit me in the face. I blocked him and bit his hand. I have not seen him since it happened. Interviews with seven additional residents (Resident #3, #4, #5, #8, #9, #10, and #11) occurred on 05/19/26. All voiced no concerns with other residents and felt safe. During an interview on 5/20/26 at 12:30 pm, three administrative staff members (#1, #2, and #3) confirmed there have been no further negative interactions between the two residents since the incident that occurred on 04/20/26. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions for residents who may be affected by the deficient practice as follows:* 04/20/26, moved Resident #7 to a private room on another wing of the facility to separate the residents and protect all residents. * 04/20/26, assessed Resident #6 and #7 for injuries and obtained fluid samples to test for bloodborne pathogens. * 04/20/26, reported the incident to the local authorities and State Agency.* 04/20/26, investigated the incident that occurred between Resident #6 and #7.* Updated Resident #6 and #7's care plans.* 04/21/26 and 04/22/26, re-educated staff on the facility's abuse policy, including how to report abuse if/when they witness negative interactions between residents.* Completion and on-going quality assurance and behavior tracking.

Based on record review, review of facility policy, and staff interviews, the facility failed to ensure 1 of 1 supplemental resident (Resident #35) was free from resident-to-resident abuse. Failure to assess, care plan, and follow the plan/process may result in physical harm, fear, anxiety, and psychosocial harm to all residents. Findings include: Review of the facility policy titled, Abuse occurred on 12/11/25. This policy, dated January 2025, stated, Each resident has the right to be free of verbal . abuse . To ensure these rights SMP [Sisters [NAME] of the Presentation] Health-Ave [NAME] has developed and implemented policies and procedures, which include the components of screening, training, prevention, identification, protection, investigation, and reporting/response. Verbal abuse is defined as . intimidation . mental anguish .Review of the facility policy titled, Behavior Management occurred on 12/11/25. This policy, dated January 2025, stated, . POLICY: Behavior monitoring and assessment will be carried out and documented. PURPOSE: 1. To provide a baseline of behaviors and interventions. 2. To provide a means to set up a plan of care. 3. To provide a system of communicating, assessing, monitoring and implementing interventions for challenging behaviors of residents. When a new behavior develops or an inappropriate behavior worsens, any Nurse or Social Service staff will document the occurrence. CNA's [sic] [certified nurse aides] can document in PCC [point click care] [electronic health record] . Inform physician of any significant behaviors .Initiate or revise care plan to focus/interventions with current information. Ongoing assessments to evaluate occurrences for possible causes, patterns and/or trends along with appropriate interventions . A summary of behavior monitoring is documented in the Progress Notes by Social Services staff and review care plan for changes. - Review of Resident #35's medical record occurred on 12/10/25 and identified an admission date of 10/10/25. On 10/22/25, Resident #4 moved into the same room as Resident #35.During the initial tour of the facility on 12/08/25 at 1:15 p.m., Resident #35 identified no concerns, and stated, everything is fine.During the initial tour of the facility on 12/08/25 at 4:05 p.m., When asked Resident #4 about his roommate, the resident stated, He's ok I guess. Just snores all the time.- Review of Resident #4's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], showed a brief interview of mental status (BIMS) score of 9, indicating moderate cognitive impairment. The current care plan stated, . is at risk for altered mood related to diagnoses of Anxiety Disorder . Depression . He takes prescribed psychotropic/Anti-anxiety medications . SW [social worker] will provide support as needed and review behaviors and/or mood concerns as documented by staff . The care plan failed to include interventions for Resident #4's verbal behaviors toward his roommate, Resident #35. Review of Resident #4's progress notes showed the following:* 10/28/25 at 10:17 a.m. Time behavior occurred: 0700 [7:00 a.m.] . Resident witnessed by staff calling roommate: 'He's an asshole of a monkey' . CNA told resident that he isn't being very nice calling people names Resident response to intervention: [Resident #4] simply laughed and said 'well he is' .* 11/1/25 at 2:51 a.m. upset that roommate has tv on. tv volume down. reminded resident that roommate has right to have it on. calls roommate names.* 11/24/25 at 10:24 p.m. calling room mate [sic] vulgar names and telling staff to 'knock him out' .* 12/5/25 at 4:03 a.m. Staff reported to the writer that the resident was saying to his roommate that if he knew how overweight he was, during a conversation with staff, [Resident #4] was informed that it was [not] appropriate to say things like that about other people.* 12/5/25 at 9:27 p.m. staff reported as walking by room, heard resident yelling at roommate. When confronted resident asks staff 'to pull a blanket over [Resident #35's] head' reassured resident that he can't help it and resident replies 'yes he can when I yell at him he quits' .* 12/7/25 10:30 P.m. Observed Behavior: singing loudly when roommate starts snoring . multiple occurrences of yelling at roommate when roommate is snoring.* 12/08/25 at 7:35 p.m. Time behavior occurred: afternoon on 12/6/2025 observed behavior: CNA wrote: Roommate 'was napping and [Resident #4's name] said to put a pillow over his face so he dies' .During an interview with Resident #35 on 12/10/25 at 4:35 p.m., when asked if he had any concerns with his roommate, Resident #35 stated, I'm fine I don't know and proceeded to put his head down on his chest and closed his eyes. On 12/11/25 at 8:35 a.m., a surveyor attempted to have a conversation with Resident #35 regarding any concerns with his roommate the resident was sleeping.During an interview on 12/10/25 at 5:25 p.m., when asked about Resident #4's behaviors with his roommate, a nurse (#8) stated, You mean roommates? He has been having a hard time with every roommate. We tried several times to put him with other roommates, and he always finds something wrong with them. When asked if she was aware of Resident #4's comments to Resident #35 on 11/24/25 and 12/6/25, the nurse stated, No I was not notified, and the administrator or social worker were also not notified. When asked what she expected staff to do following those behaviors, the nurse (#8) stated the nurse manager should have been called to ensure Resident #35's safety and when there's a threat like that because this is abuse. During an interview on 12/11/25 at 9:50 a.m., an administrative staff member (#3), stated a CNA (#7) had informed her on Monday 12/08/25 at approximately 8:30 a.m. about Resident #4's behaviors towards his roommate that occurred on 12/06/25 and, I told her she needed to fill out a behavior observation form. When I came to work Tuesday [12/09/25] morning the form was in the box outside of my office. The administrative staff member stated she informed the management team at the stand up meeting that morning. A behavior observation form for Resident #4, dated 12/06/25 stated, . [Resident #35] was napping and snoring. [Resident #4] said to put a pillow over his face so he dies. Told him that was not nice and rude and he [Resident #4] said 'I don't care'.During an interview on 12/11/25 at 9:28 a.m., a nurse (#8) who worked on 12/06/25 stated, I was not told about [Resident #4] behaviors and what he said to [Resident #35]. If I had known I would have called the on call unit manager.An interview with a social services staff member (#6) occurred on 12/11/25 at 10:23 a.m., when asked if she was aware of Resident #4's behaviors with his roommate on 12/06/25, the staff member stated, Just first heard about it yesterday when [staff member #2] told me. The facility failed to:* Identify Resident #4's behaviors as verbal abuse.* Protect Resident #35 from abuse.* Provide the services necessary to avoid verbal abuse. * Utilize appropriate interventions when caring for residents exhibiting behaviors.* Update Resident #4's care plan related to behaviors with past and current roommates.* Assess and monitor Resident #4's behaviors for potential causes, patterns or trends, and develop a process/plan to alleviate the behaviors. * Immediately report the abuse to administrative staff, physician, and state survey agency.

Based on record review, review of facility policy, and staff interview, the facility failed to report incidents of resident-to-resident abuse to the State Survey Agency (SSA) for 1 of 1 supplemental resident (Resident #35) who experienced verbal abuse. Failure to report resident-to-resident abuse allegations places all residents at risk of potential abuse/neglect. Findings include: Review of the facility policy titled, Abuse occurred on 12/11/25. This policy, dated January 2025, stated, Each resident has the right to be free of verbal . abuse . Procedure .Any alleged incident must be reported to the North Dakota Health Department immediately (within 24 hours or less) .- Review of Resident #35's medical record occurred on 12/10/25 and identified an admission date of 10/10/25. Resident #4 was moved to the same room as Resident #35 on 10/22/25.- Review of Resident #4's medical record occurred on all days of survey. The nursing progress notes showed the following: * 11/24/25 at 10:24 p.m., stated, . calling room mate [sic] vulgar names and telling staff to 'knock him out' .* 12/08/25 at 7:35 p.m., stated, . Time behavior occurred: afternoon on 12/6/2025 observed behavior: CNA wrote: Roommate 'was napping and [Resident #4's name] said to put a pillow over his face so he dies' .The record lacked evidence the facility reported the above incident to the SSA as possible abuse.During an interview on the morning of 12/10/25, an administrative staff member (#1) confirmed the facility did not report the above incidents to the SSA.The facility failed to recognize name calling and threatening behaviors as abuse and report to the SSA.

Based on record review, review of facility policy, and staff interviews, the facility failed to investigate an incident of resident to resident abuse for 1 or 1 supplemental resident (Resident #35) who experienced verbal abuse. Failure to investigate incidents of abuse may result physical harm, fear, anxiety, and psychosocial harm for all residents Findings include: Review of the facility policy titled, Abuse occurred on 12/11/25. This policy, dated January 2025, stated, Each resident has the right to be free of verbal . abuse . To ensure these rights . policies and procedures, which include . investigation . All alleged abuse will be investigated by the Director of Nursing .- Review of Resident #35's medical record occurred on 12/10/25 and showed an admission date of 10/10/25 and Resident #4 was moved to the same room as Resident #35 on 10/22/25.- Review of Resident #4's medical record occurred on all days of survey. Review of the progress notes showed the following: * 11/24/25 at 10:24 p.m., stated, . calling room mate [sic] vulgar names and telling staff to 'knock him out' .* 12/08/25 at 7:35 p.m., stated, . Time behavior occurred: afternoon on 12/6/2025 observed behavior: CNA wrote: Roommate 'was napping and [Resident #4's name] said to put a pillow over his face so he dies' .A behavior observation form for Resident #4, dated 12/06/25 stated, . [Resident #35] was napping and snoring. [Resident #4] said to put a pillow over his face so he dies. Told him that was not nice and rude and he [Resident #4] said 'I don't care'.During an interview on 12/11/25 at 9:50 a.m., an administrative staff member (#3), stated a CNA (#7) had informed her on Monday, 12/08/25, at approximately 8:30 a.m. about Resident #4's behaviors towards his roommate on 12/06/25 and, I told her she needed to fill out a behavior observation form. When I came to work Tuesday morning [12/09/25] the form was in the box outside of my office. The administrative staff member (#3) stated she informed the management team at the stand up meeting of Resident #4's behaviors. An interview occurred on 12/11/25 at 10:23 a.m., with a social service member (#6). When asked if she was aware of Resident #4's behaviors with his roommate that occurred on 12/06/25, she stated, Just first heard about it yesterday when [staff member #2] told me. During an interview on 12/10/25 at 5:25 p.m., an administrative staff member (#1) stated neither her, the administrator or the social worker designee, were notified of Resident #4's behaviors therefore did not investigate any of his actions as abuse and did not report them to the SSA (State Survey Agency).

Based on record review and staff interview, the facility failed to ensure staff provided necessary care and services for 1 of 1 sampled resident (Resident #4) with diabetes. Failure to follow physician orders for out-of-range blood sugar levels may result in adverse health events.Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, . It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #4's medical record occurred on all days of survey. Diagnoses included diabetes mellitus. The current care plan stated, [Resident] has Diabetes mellitus with polyneuropathy [a degeneration of peripheral nerves]. will be free from any s/sx [signs/symptoms] of hyperglycemia [high blood sugar] . will be free from any s/sx of hypoglycemia [low blood sugar] . will have no complications related to diabetes through the review date. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. A physician's order, dated 09/28/25, stated, Blood Glucose checks four times daily and as needed per nursing discretion. Notify MD [medical doctor] if Glucose is greater than 300 or less than 70. Review of Resident #4's medication administration records from November 1, 2025 through December 9, 2025, showed 16 occasions blood glucose levels were greater than 300 milligrams per deciliter (mg/dL) (ranged from 301 mg/dL to 460 mg/dL) and 4 occasions blood glucose levels were less than 70 mg/dL (ranged from 58 mg/dL to 69 mg/dL). The medical record lacked documentation facility staff notified the provider of the out-of-range blood glucose readings. During an interview on 12/11/25 at 12:21 p.m., an administrative nurse (#1) confirmed the medical record lacked documentation of provider notification. The medical record failed to show nursing staff notified the provider to ensure proper care and services were provided regarding Resident #4's out-of-range blood glucose levels.

Based on observation, record review, facility policy review, and staff interview, the facility failed to follow standards of infection control for 2 of 9 sampled residents (Resident #3 and #25) and 2 supplemental residents (Resident #50 and #70) observed during cares/dressing change and glucose monitoring. Failure to follow infection control practices during resident cares related to hand hygiene, enhanced barrier precautions (EBP), and cleaning of a glucometer has the potential to spread infection throughout the facility. Findings include: HAND HYGIENE Review of the facility policy titled Hand Hygiene occurred on 09/11/24. This policy, revised July 2024, stated, . Hand Hygiene Should Be Practiced: . Before applying and after removing gloves. Review of the facility policy titled Dressing: Clean occurred on 09/11/24. This policy, dated June 2024, stated, . [NAME] [put on] clean gloves and remove the dressing. Dispose of the gloves, perform hand hygiene and don a clean pair of gloves. Apply dressing to the area as ordered. - Observation on 09/09/24 at 4:30 p.m. showed two certified nurse aides (CNAs) (#5 and #6) assisted Resident #50 into bed and removed the soiled brief. The CNA (#5) performed perineal care, removed her gloves, adjusted the resident's clothing, arranged the resident's blankets, applied the resident's glasses, and adjusted the pillow. The CNA (#5) failed to perform hand hygiene after removing her gloves and prior to completing other tasks. - Observation on 09/10/24 at 1:35 p.m. showed a nurse (#1) changed Resident #25's dressing. The nurse removed the old dressing, removed her right glove, donned a clean glove, cleansed the wound with a perineal wipe, removed the right glove, donned a clean glove, and applied the clean dressing. The nurse (#1) failed to perform hand hygiene after removing soiled gloves and prior to donning clean gloves. During an interview on 09/11/24 at 3:15 p.m., an administrative nurse (#2) stated she expected staff to perform hand hygiene after glove removal when doing perineal care and a dressing change. 40489 ENHANCED BARRIER PRECAUTIONS Review of the facility policy titled Enhanced Barrier Precautions occurred on 09/11/24. This policy, dated March 2024, stated, . It is the policy of SMP [Sisters of the [NAME] Presentation] Health-Ave [NAME] to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident activities include: a. Dressing . c. Transferring d. Providing hygiene . f. Changing briefs . h. Wound care . Observation on 09/10/24 at 8:14 a.m. showed an EBP sign on Resident #3's door and isolation carts inside the resident's room. Observation showed a CNA (#7) wore gloves and assisted Resident #3 with changing her brief, personal hygiene, and dressing. At 8:17 a.m., a second CNA (#6) entered the resident's room, donned gloves and assisted with transferring the resident from bed to the wheelchair. The CNAs (#6 and #7) failed to wear a gown as required. During an interview on 09/11/24 at 3:25 p.m., an administrative nurse (#2) stated she expected staff to wear a gown when providing cares to residents in enhanced barrier precautions. CLEANING OF GLUCOMETER Review of policy titled Testing Blood Glucose and Meter Use occurred on 09/11/24. This policy, revised July 2024, stated, . In between uses, clean the Glucose meter using a Oxivir [disinfectant] wipe, allow surface to remain wet for one minute to ensure kill time and allow to air dry. Place monitor back in Ziploc bag. - Observation on 09/10/24 at 11:56 a.m. showed a nurse (#1) performed a glucose check on Resident #70. The nurse failed to disinfect the glucose meter using a Oxivir wipe prior to placing it back in the Ziploc bag. During an interview on 09/11/24 at 2:44 p.m., an administrative nurse (#2) confirmed she expected staff to disinfect the glucose meter prior to placing back in the Ziploc bag. 47896

Based on observation, review of the North Dakota Long Term Care Ombudsman Program Guide to Resident Rights, and staff interview, the facility failed to provide care in a manner that promoted, maintained, or enhanced the resident's dignity for 1 of 2 sampled residents (Resident #3) with a wound vacuum. Failure to cover a wound vacuum collection container does not preserve the resident's personal dignity and/or enhance their quality of life and has the potential to affect the resident's psychosocial well-being. Findings include: The North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, updated 03/21/23, page 16, stated, . The facility must treat you courteously, fairly and with dignity. Observation on 09/10/24 at 11:21 a.m. showed Resident #3 sitting in the hallway in front of the television with the wound vacuum and its contents visible. Observation on 09/10/24 at 11:44 a.m. showed Resident #3 sitting in the hallway in front of the television with a hand towel partially covering the wound vacuum canister, however, the contents of the wound vacuum canister remained visible. During an interview on 09/11/24 at 3:25 p.m., an administrative nurse (#2) stated wound vacuum containers should be covered when residents are out of their room.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 4 residents (Resident #70) observed receiving medication from an injector pen. Failure to obtain a label for an insulin pen may result in a resident receiving the wrong medication or an incorrect dose. Findings include: Review of a policy titled Medication Storage/Labeling occurred on 09/11/24. This policy, revised July 2024, stated, . Medications are labeled by pharmacy. If receiving medications from any mail order pharmacies that are not labeled individually, label with resident identification information . Observation on 07/10/24 at 8:17 a.m. showed a nurse (#1) prepared Resident #70's Novolog insulin pen for administration. The pharmacy label on the pen lacked a legible label with the resident's name or other identifying information. During an interview on 09/11/24 at 2:44 p.m., an administrative nurse (#2) confirmed Resident #70's Novolog insulin pen lacked a legible label.

Based on record review, review of facility policy, review of the facility's investigation reports, and staff interviews, the facility failed to ensure residents have the right to remain free from mental and/or physical abuse for 1 of 1 sampled resident (Resident #2) who had a rag placed in her mouth by staff to silence her. Failure to provide the services necessary to avoid mental anguish and emotional distress, resulted in an unsafe environment for Resident #2 and may result in fear, anxiety, and/or psychosocial harm. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately after hearing the concerns reported by staff. Findings include: Review of the facility policy titled Abuse occurred on 06/11/24. This policy, reviewed January 2024, stated: * Abuse is defined as . intimidation, or punishment with resulting physical harm, pain, or mental anguish, or deprivation of . services that are necessary to attain or maintain physical, mental, or psychosocial well-being. * Physical abuse is defined as . controlling behavior through corporal punishment. * Mental abuse is defined as . harassment, and threats of punishment . Review of Resident #2's medical record occurred on 06/11/24. Diagnoses included dementia with agitation and anxiety disorder. The current care plan identified, . As per therapy assessments she [Resident #2] shows severe cognitive impairment, minimal awareness, confusion and disorientation, easily distracted, shows difficulty focusing attention, requires simple commands and remains minimally directable. She has some non-sensical speech along with tangential speech during conversations in which she shows disorganized thinking processes. She has the tendency to moan/groan, speak in a nonsensical manner, make humming sounds, and she seems to do these sounds in a repetitive manner and she will make these sounds in a varying degree of volume. This could reflect internal distress, racing thoughts and/or confusion and her behaviors may be her attempt at processing her thoughts or what is going on around her. During an interview on 06/11/24 at 4:20 p.m., four managerial staff members (#6, #7, #8 and #9) provided copies of the facility's Initial Facility Reported Incident Report and Final Investigation, stating, We immediately began investigating the incident and suspended the CNA (#5) pending the results of our investigation. Review of the facility's initial report, dated 06/07/24, identified, . Staff reported to Nurse Manager that CNA [certified nurse aide] has been observed being rough while providing cares to residents. Yelling, disrespecting and belittling residents. Staff reported CNA admitting to placing towel in resident's mouth to keep her quiet and this was also witnessed by another CNA. Review of the facility's final investigation, dated 06/10/24, included the following staffs' written testimonies, dated 06/07/24: * CNA (#2) wrote, . She [CNA (#5)] admitted to putting a rag in [Resident #2's] mouth so she'd be quiet . * CNA (#3) wrote, . She [CNA (#5)] has put a towel in her [Resident #2's] mouth to make her be quiet and she will put [Resident #2] in her wheelchair with it in her mouth still. During interviews on 06/11/24 at 3:33 p.m. and 5:43 p.m., a CNA (#3) stated, [Resident #2] is completely dependent. She is one to yell continuously, not yell loud. She'd [CNA (#5)] say, 'Shut up, be quiet,' only in her [Resident #2's] room, not in the hallway. One day, she grabbed a washcloth and put it in her mouth. I took it back out. It wasn't in there long. When I took the towel out, she rolled her eyes at me. During an interview on 06/12/24 at 12:54 p.m., a CNA (#2) stated, [Resident #2] always makes sounds. She can't help it. I was changing [Resident #2] with [CNA (#5)] last week. [CNA (#5)] admitted , 'If she [Resident #2] doesn't shut up, I put a rag in her mouth.' I was speechless. It was so shocking. I couldn't believe it. I told her, 'I tell her [Resident #2] the babies are sleeping, and she quits.' She ignored me. I talked to [CNA (#3)] later on and she just said she actually seen her do it, which is awful. As per facility policy, facility staff failed to: * Provide the services necessary to avoid mental anguish and emotional distress, * Utilize appropriate interventions when caring for residents exhibiting behaviors, * Identify abusive actions (i.e.: placing a washcloth in a resident's mouth to prevent them from speaking), Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions for the residents affected by the deficient practice and put measures in place to ensure the deficient practice does not reoccur by: * Immediately contacting the CNA (#5) accused of abuse to discuss the concerns reported by staff, * Placing the CNA (#5) on suspension until further notice, pending the results of the investigation, * Interviewing all of the staff members (#1, #2, #3, and #4) that reported concerns, * Reporting the concerns to the North Dakota Department of Health and Human Services, * Reporting the concerns to local Police Department, * Re-educating all staff members of the facility's reporting expectations on 06/07/24, * Re-educating all staff members of the facility's Abuse Policy starting on 06/11/24, * Completing audits pertaining to abuse/neglect. This surveyor determined a deficient practice existed on 06/07/24. The facility implemented corrective action and all staff education by 06/11/24.

Based on observation, record review, and staff interview, the facility failed to provide treatment in accordance with the resident's plan of care for 1 of 2 sampled residents (Resident #49) with a history of a diabetic heel ulcer. Failure to apply heel protecting boots as ordered may result in the reoccurrence or worsening of heel ulcers. Findings include:Review of Resident #49's medical record occurred on all days of survey. Diagnoses included Type II Diabetes Mellitus and a history of diabetic heel ulcer (healed in August 2023). A physician's order, dated 08/22/23, stated, Prevalon boot [heel protecting soft boots] to BLE [bilateral lower extremities] when in bed. Observations on the morning of 10/10/23 and afternoon of 10/10/23 showed Resident #49 resting in bed without heel boots on her feet. Observation showed her heels rested on the mattress. During an observation on the afternoon of 10/11/23, a nurse (#2) entered Resident #49's room, gave the heel boots to two certified nurse aides (CNAs) (#3 and #4), and indicated Resident #49 needed to wear them in bed.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents' records contained the hospice election form and the certification of a terminal illness for 3 of 4 sampled residents (Resident #53, #86, and #88) 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 the facility policy titled Hospice Care occurred on 10/11/23. This policy, dated January 2022, stated, . Documentation and maintenance of the hospice record: [name of facility] will maintain its own resident documentation system . physician orders and other relevant documentation in order to facilitate communication between the caregivers. - Review of Resident #53's medical record occurred on all days of survey. Resident #53 elected Hospice services on 08/11/23. The medical record lacked the Certificate of Terminal Illness completed by the Hospice provider. - Review of Resident #86's medical record occurred on all days of survey. The resident/resident's representative elected hospice and services began on 05/26/23. The medical record lacked the hospice election form and the physician's certification and recertification of the terminal illness. - Review of Resident #88's medical record occurred on all days of survey. The resident's representative elected hospice and services began on 08/15/23. The medical record lacked the hospice election form and the certification of terminal illness. During an interview on 10/11/23 at 11:15 a.m., an administrative nurse (#1) confirmed the medical record lacked the election form and the certification/recertification of terminal illness related to hospice. 28611 46259

Based on observation, review of facility policy, and staff and resident interviews, the facility failed to follow standards of infection prevention and control for 3 of 20 sampled residents (Resident #17 #48, and #76) and 2 supplemental residents (Resident #8 and #71). Failure to follow infection control standards related to disinfecting equipment and performing aerosol-generating procedures has the potential to transmit infections to other residents, staff, and visitors. Findings include: DISINFECTING SHARED EQUIPMENT: Review of the facility policy titled Infection Prevention and Control Program occurred on 09/28/22. This policy, revised July 2022, stated, . All shared items and equipment will be cleaned in between uses using Disinfecting wipes/spray per facility protocol. - Observation on 09/26/22 at 4:50 p.m. showed two certified nurse assistants (CNAs) (#3 and #4) used a mechanical lift and transferred Resident #8 from the bed to the wheelchair. Upon completion of the transfer, the CNA (#3) removed the lift from the room and took the lift into another resident's room for use. The CNA (#3) failed to disinfect the mechanical lift after use and prior to entering another resident room. - Observation on 09/26/22 at 5:01 p.m. showed two CNAs (#2 and #3) used a mechanical lift and transferred Resident #48 from the bed to the wheelchair. Upon completion of the transfer, the CNA (#3) removed the lift from the room and placed it in a storage area by the nurse's station. The CNA (#3) failed to disinfect the mechanical lift after use. - Observation on 09/27/22 at 10:16 a.m. showed a CNA (#5) and a staff nurse (#6) used a mechanical lift and transferred Resident #17 from the chair to the bed. Upon completion of the transfer, the CNA removed the lift from the room and placed it in the hallway. The CNA (#8) failed to disinfect the mechanical lift after use. - Observation on 09/27/22 at 10:30 a.m. showed two CNAs (#7 and #8) used a mechanical lift and transferred Resident #17 from the bed to the wheelchair. Upon completion of the transfer, the CNA (#8) failed to disinfect the mechanical lift after use and prior to entering another resident room. - Observation on 09/27/22 at 1:19 p.m. showed two CNAs (#7 and #8) used a mechanical lift and transferred Resident #76 from the wheelchair to the bed. Upon completion of the transfer, the CNA (#7) removed the lift from the room and placed the lift in the hallway. The CNA (#7) failed to disinfect the mechanical lift after use. - Observation on 09/27/22 at 2:07 p.m. showed two CNAs (#2 and #3) used a stand lift and transferred Resident #8 from the wheelchair to the bed. Upon completion of the transfer, the CNA (#3) removed the lift from the room and placed it in a storage area by the nurse's station. The CNA (#3) failed to disinfect the mechanical lift after use. During an interview on 09/29/22 at 9:55 a.m., an administrative nurse (#1) stated it is her expectation that the staff sanitize the mechanical lifts as per policy. BREATHING TREATMENTS: Review of the facility policy titled Infection Control occurred on 09/28/22. This policy, revised September 2022, stated, . Avoid aerosol-generating procedures . if required, take the following precautions: Perform in private room, if possible, with door closed during and after procedure for 30 minutes. Staff wear a surgical mask and eye protection. Observation on 09/26/22 at 1:19 p.m. showed Resident #71's room door open and the resident seated in a recliner chair receiving a breathing treatment. The resident's door lacked signage for aerosol precautions. During an interview on 09/26/22 at 2:03 p.m., Resident #71 reported the staff bring the medication for the nebulizer machine to the room, and she completes the breathing treatment. Resident #71 stated, I have [CONDITION(S)] [[CONDITION(S)]] and get four treatments a day. Observation on 09/27/22 at 8:42 a.m. showed signage on Resident #71's door. The sign indicated, STOP ATTENTION: Nebulizers are given in this room. MUST wear mask and eye protection in this room during and for 30 MINUTES after administration. Door MUST remain closed during this time. Observation on 09/27/22 at 9:34 a.m. showed a medication assistant (MA) (#9) in Resident #71's room administering a breathing treatment. The MA failed to wear eye protection and close the door while interacting with the resident. At 9:35 a.m., the MA exited the resident's room, the door remained open, and the breathing treatment continued. During an interview on 09/29/22 at 9:50 a.m., an administrative nurse (#1) stated she expected staff to wear eye protection and keep the room door closed during and after a breathing treatment.

F880 IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED ON 11/14/19 and 10/21/20. 1. Based on observation, review of facility policy, review of manufacturer's directions, review of professional reference, and staff interview, the facility failed to ensure staff followed standard infection control practices for 1 of 1 resident (Resident #1) observed receiving a blood glucose test with a shared blood glucose meter and has the potential to affect other residents in the facility. Failure to clean and disinfect shared glucose meters with the appropriate disinfectant has the potential to cause cross-contamination and may result in the transmission of blood-borne pathogens to other residents. During the recertification survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on the evening of 08/04/21. The IJ potential resulted from observation of a medication aide (MA) (#4) disinfecting a shared blood glucose meter with alcohol wipes. These findings placed residents in immediate danger due to the potential for cross contamination with a blood-borne pathogen and the need for education on the appropriate/effective disinfectant to use to for a shared blood glucose meter. * 08/04/21 at 6:02 p.m., 6:14 p.m., and 6:58 p.m. - The survey team contacted the management staff at the State Survey Agency (SSA) to report the findings and to discuss a potential IJ situation. * 08/04/21 at 7:30 p.m. - The survey team notified the Assistant Administrator and Director of Nursing of the IJ situation and requested they develop a plan for abatement of the immediate jeopardy. * 08/04/21 at 8:45 p.m. - The facility provided a written plan of correction (via email) for the IJ. * 08/05/21 at 11:12 a.m. - The SSA notified the regional office of the immediate jeopardy situation. * 08/05/21 at 1:48 p.m. - The survey team reviewed and accepted the facility's revised version of the written plan of correction for the IJ. * 08/05/21 at 1:58 p.m. - The survey team determined the IJ situation at a scope/severity of K was abated and reduced to a scope and severity of E. * 08/05/21 at 3:01 p.m. - The SSA notified the regional office of the immediate jeopardy abatement. Findings include: Review of The Food and Drug Administration's (FDA) guidance for manufacturers regarding appropriate products and procedures for cleaning and disinfection of blood glucose meters, from the FDA's website (http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm 5.htm), stated, Point of care blood testing devices such as blood glucose meters should be used only on one patient and not shared. If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use following the guidelines provided in device labeling. The disinfection . should be effective against HIV, [CONDITION(S)], and [CONDITION(S)] B virus. Outbreak episodes have been largely due to transmission of [CONDITION(S)] B and C viruses. However, of the two, [CONDITION(S)] B virus is the most difficult to kill. Please note that 70% [MEDICATION(S)] solutions are not effective against [CONDITION(S)] bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device. Observation on 08/04/21 at 4:55 p.m. on Unit D showed a MA (#4) used a glucose meter to check Resident #1's blood glucose in the nurses station. The MA (#4) stated there is one glucose meter for residents on Unit D. After using the glucose meter, observation showed the MA (#4) wiped the meter with alcohol wipes. When asked what he/she used to clean the glucose meter, the MA (#4) confirmed he/she used alcohol wipes. During an interview on 08/04/21 at 5:35 p.m. with an administrative nurse (#1) and a managerial nurse (#2) regarding what disinfectant staff use for the shared glucose meters, the managerial nurse (#2) stated the facility instructed/trained staff to use Oxivir wipes. Review of the facility policy titled Testing Blood Glucose and Meter Use occurred on 08/04/21 at 5:40 p.m. This policy, dated February 2021 stated, POLICY: The Blood Glucose Monitoring System will be set up and cared for as directed by the Manufacturer's Users Manual as required. Procedure: . 7. Clean the meter using a sanitizer wipe in accordance with product dwell time and allow to air dry. The policy failed to clearly state the type of sanitizer wipe to disinfect the glucose meter. Review of the Manufacturer's User Manual for the 'Easy Touch Glucose Monitoring System' occurred on 08/04/21 at 5:45 p.m. The manual stated, . Care and Storage . 4. When cleaning the meter, gently wipe the exterior surface using a damp soft cloth. For healthcare professionals using this system on multiple patient [sic], please be aware that all items that come in contact with human blood should be handled as potential biohazards. Users should follow the guidelines for prevention of blood-borne transmittable disease in a healthcare setting for potentially infectious human blood specimens as recommended in the National Committee for Clinical Laboratory Standards, Protection of Laboratory Standards, Protection of Laboratory Workers from Instrument Biohazards and Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Approved Guideline. During an interview on 08/04/21 at 6:12 p.m., an administrative nurse (#1) and managerial nurse (#12) reported the medication aid (#4) began his shift at 2:30 p.m. and had only checked one resident's glucose level. The resident resided on Unit D. During an interview on 08/04/21 at 6:41 p.m., a licensed nurse (#11) on Unit C stated, There is a shared MA for Units C and D who will check five residents' blood sugars on Unit C using the same meter for all residents on this unit when he/she gets done on Unit D. Review of the physician's orders for the five residents on Unit C with blood glucose orders identified three of these five residents (#47, #52, #100) had the potential to be exposed to contamination from an improperly cleaned/disinfected glucose meter had the MA (#4) not been notified and instructed on the use of the appropriate disinfectant wipe. Failure to clean and disinfect shared glucose meters with the appropriate disinfectant after each resident has the potential to cause cross-contamination and may result in the transmission of blood-borne pathogens to other residents. 2. Based on observation, policy review, and staff interview, the facility failed to ensure staff followed standard infection control practices for 2 of 21 sampled residents (Resident #31 and #80) observed during resident cares. Failure to follow standard infection control practices related to hand hygiene may result in the spread of infection to residents, staff, and visitors. Findings Include: Review of the facility policy titled Hand Hygiene occurred 08/05/21. This policy, revised May 2021, stated, . HAND HYGIENE SHOULD BE PRACTICED: . b. Before and after caring for each resident. m. Before applying and after removing gloves. HAND WASHING SHOULD BE DONE: a. After any exposure to blood and/or body fluids. - Observation on 08/2/21 at 3:47 p.m., showed two certified nurses aides (CNAs) (#16 and #17) provided cares for Resident #80. The CNA (#16) removed a brief soiled with stool, performed perineal care, applied a clean brief, and without removing gloves or performing hand hygiene, turned off the pressure on the pressure relieving mattress, placed the hoyer sling under the resident and transferred Resident #80 to the wheelchair with the hoyer lift. The CNA (#16) removed her gloves, placed the resident's glasses, made the bed, and transferred Resident #80 to the nurses station without performing hand hygiene. - Observation on 08/2/21 at 4:58 p.m., showed a CNA (#16) apply a gait belt and assisted Resident #31 from the bed to the wheelchair. The CNA (#16) combed the resident's hair and transferred her to the dining room without performing hand hygiene. During an interview on 08/05/21 at 10:05 a.m., an administrative nurse (#20) stated she expected staff to perform hand hygiene after glove removal, after perineal cares and after exiting resident rooms.

Based on record review, review of the facility's investigative report, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #88) who fell during a full body mechanical lift transfer and sustained a serious injury. Failure to safely utilize a mechanical lift resulted in Resident #88 falling from the lift and sustaining a serious injury, and placed all residents requiring this type of transfer at risk for falls and/or injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of Resident #88's medical record occurred on August 2-5, 2021. Diagnoses included dementia, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] (CVA) with left [CONDITION(S)] (partial paralysis), and long term use of an anticoagulant (blood thinner). The quarterly Minimum Data Set (MDS), dated [DATE], identified total dependance on two or more staff members for transfers. The care plan identified, . [Resident #88] has an ADL [activity of daily living] Self Care Performance Deficit . [and is] at risk for falls r/t [related to] CVA with (L) [left] [CONDITION(S)] . [Resident #88] requires total assist with hoyer [full body mechanical lift] lift. Resident #88's EZ Way sling sizing chart identified, It is important that the base of the sling be positioned two inches below the tailbone and the top of the sling be parallel with the top of the shoulder line (base of neck). Sling Color Coding System: Green XL [extra large] . Maximum distance from patient's tailbone to base of neck 29 [inches] . A progress note, dated 01/29/21 at 7:59 p.m., identified, . author notified of fall, upon entry to room 2 staff present, resident sustained fall during transfer, upon assessment resident on floor with head resting against closet, sitting on buttocks with legs in front. during assessment resident was alert, range of motion to lower extremities per residents usual. No no-verbal signs of pain, abrasion to right lower back, hematoma with small laceration to right back of head. Pupils 3, [NAME] [normal oculomotor functions]. Resident taken to [facility] ER [emergency room ] by ambulance for evaluation of injuries. A hospital admission history and physical, dated 01/29/21, identified, [Resident #88] . fell during transfer with hoyer lift and hit his head. His scalp hematoma and CT scan shows interhemispheric hemorrhage. He is on [MEDICATION(S)] and aspirin due to h/o [history of] CVA, [CONDITION(S)]. No neurologic change. Needs admission tonight for observation and repeat CT [cat scan of brain] in AM. The progress notes identified the following: * 01/30/21 at 8:54 p.m., . Returns back to [facility] this evening at 5:40 p.m. following hospitalization d/t [due to] yesterday's fall from hoyer lift. Small brain bleed noted in CT upon admittance to [hospital] yesterday and another done today with no change, provider feels comfortable sending back. No skull fracture. Responds normally at this time. Refuses anything oral this evening other then a few sips of liquids. * 01/31/21 at 1:48 p.m., . Does open eyes . Does not holler out but is responsive. * 01/31/21 at 4:06 p.m., Resident is alert and oriented, he has been very tired and lethargic during shift. Contusion to back of head is scabbed over with no drainage noted. * 01/31/21 at 9:37 p.m., . Is sitting in recliner this evening does respond to staff with simple words like 'no' when staff in room attempting to give evening meds [medications] and purses lips closed tightly but is fairly sleepy as well. Does decline evening meds along with supper, takes some sips of drink of equal roughly 120 mls [milligrams] of fluids . * 02/01/21 at 3:51 a.m., . Resident doesn't respond per normal self, appears to be asleep but with eyes partially open. * 02/02/21 at 3:15 a.m., Resident is awake intermittently with little to no engagement with staff. No oral intake this shift. * 02/03/21 at 8:44 a.m., resident is alert and will speak to staff saying 'I do not want that' when staff attempt to feed him breakfast. * 02/03/21 at 10:07 p.m., . Resident does not respond with questions asked but does open his eyes with verbal stimulus. Author then asked if [family member] would like to get hospice involved at this time . * 02/04/21 at 6:03 p.m., Is now admitted to [hospital] Hospice. * 02/07/21 at 10:12 a.m., Resident remains unresponsive. * 02/08/21 at 3:09 p.m., Author walked into room to check on resident and noted that resident was not breathing at 2:50 p.m. The facility's Final Investigation Report identified, . the nurse manager identified [certified nurse assistant (CNA) (#14)] had not followed the resident's care plan and chose to use a size large sling instead of an x-large sling as noted on the resident's care plan. A copy of the Hoyer sling sizing chart was in the resident's folder in the bathroom available to all staff. Staff are trained to check the routine care sheets each shift for any changes. [CNA (#14)] was suspended immediately after the incident occurred and the facility will be terminating [his] employment. During an interview on 08/05/21 at 1:15 p.m., two managerial nurses (#2 and #15) reported, The sling did not cover part of his buttocks. It was higher up on his back because they used the wrong sized sling. We went over sling size and positioning [during all staff meetings on February 10 and 25, 2021 and March 3, 4, 11, 14, and 29, 2021]. Staff members who didn't attend the meeting read the notes. They were required to read the notes and watch the video of the meeting. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the corrective action for the resident affected by the deficient practice by: * Completing an investigation with interviews of staff who assisted with the transfer on 01/29/21, * Determining CNA (#14) failed to safely utilize an x-large sling resulting in Resident #88 falling from the Hoyer lift and sustaining a serious injury, and * Suspending CNA (#14) immediately after the incident and later terminating his employment. The facility put measures in place to ensure the deficient practice does not recur by: * Providing education to all nursing staff on February 10 and 25, 2021 and March 3, 4, 11, 14, and 29, 2021 ensuring utilization of appropriately sized slings for Hoyer lift transfers and * Auditing Hoyer lift transfers starting on 01/29/21. The facility completed audits through 03/15/21. The survey team determined a deficient practice existed on 01/29/21. The facility implemented corrective action on 01/29/21, provided staff education on February 10 and 25, 2021 and March 3, 4, 11, 14, and 29, 2021, and audited Hoyer lift transfers through 03/15/21.

Based on observation, record review, staff interview, and review of facility policy, the facility failed to offer fluids to 4 of 14 sampled residents (#47, #53, #68, and #80) who required staff assistance for fluid intake and/or are at risk for dehydration or urinary tract infections (UTIs). Failure to provide assistance with fluid intake may result in dehydration, constipation, and UTIs. Findings include: Review of the facility policy titled Standards of Care occurred on 08/05/21. This policy, revised April 2021, stated, . Encourage and offer fluids with each contact . - Review of Resident #47's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan identified, . Urinary incontinence r/t [related to] Dx [diagnosis] of dementia At risk for UTI r/t urinary incontinence . Encourage fluids . Observation on 08/03/21 at 3:36 p.m. showed two Certified Nursing Assistants (CNAs) (#6 and #7) provided perineal care, changed brief, and transferred Resident #47 to his/her wheelchair. The CNAs (#6 and #7) failed to offer or encourage fluids. -Review of Resident #53's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan identified, . risk of dehydration . provide > [greater than] 400 ml [milliliters] water in room . At risk for UTI r/t urinary incontinence . Encourage fluids . Observation on 08/03/21 at 9:30 a.m. showed a CNA (#8) provided perineal care, changed brief, transferred Resident #53 to chair, and failed to offer or encourage fluids. -Review of Resident #68's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan identified, . Urinary incontinence r/t Decreased mobility . will be free of UTI . Encourage fluids . Observation on 08/03/21 at 10:27 a.m. showed a CNA (#9) and a licensed nurse (#10) transferred Resident #68 to a shower chair, placed the shower chair over the toilet, provided perineal care, and transferred to a chair. The CNA (#9) and a licensed nurse (#10) failed to offer or encourage fluids. - Review of Resident #80's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan identified, . Urinary incontinence r/t Decreased mobility . will be free of UTI . Encourage fluids . has an ADL (activities of daily living) Self Care [sic] Performance Deficit r/t Dementia . EATING: [Resident #80] requires extensive assist of one . Observation on 08/02/21 at 3:42 p.m. showed two CNAs (#16 and #17) provided perineal care, changed the brief, and failed to offer or encourage fluids to Resident #80. Observation on 08/03/21 at 9:28 a.m. showed two CNAs (#18 and #19) transferred Resident #80 from the wheelchair to the bed, provided perineal care, changed the brief, provided oral care, lowered the bed, positioned the resident on his/her side, and failed to offer or encourage fluids. During an interview on 08/05/21 at 10:45 a.m., an administrative nurse (#5) agreed the staff should offer and encourage fluids with each contact.

Based on record review, review of facility policy, and staff interview, the facility failed to assess behaviors, develop, implement, and monitor the effectiveness of individualized approaches/interventions for 2 of 5 sampled residents (Resident #1 and Resident #3) identified with dementia and behaviors. Failure to assess, monitor and evaluate Resident #1 and #3's psychological status resulted in continued problematic behaviors, limited the facility's ability to meet the resident's physical and psychological needs, and may negatively impact the overall well-being for all residents with dementia and/or behaviors. Findings Include: Review of the facility policy titled Behavior Management occurred on 03/30/21. This policy, revised November 2019, stated, . When a new behavior or an inappropriate behavior worsens, any Nurse or Social Service staff will document the occurrence in the Progress Notes . The Nurse or Social Service staff can initiate Daily Behavior Tracking Log if it seems warranted, listing the targeted behavior . Inform physician of any significant behaviors or changes as necessary . Behavior Management Plan . Initiate or update the care plan problem with current information . After five to seven days, resident's team evaluates occurrence for possible causes, patterns and/or trends along with appropriate interventions and decisions if continued tracking is needed . A summary of tracking is documented in the Interdisciplinary Progress Notes by Social Services staff and review of care plan for changes . Refer to psychiatrist as needed with attending physician and family consent . - Review of Resident #1 medical record occurred on 03/30/21. Diagnoses included Alzheimer's Disease. The admission Minimum Data Set (MDS), dated [DATE], identified other behavioral symptoms not directed towards others. The current care plan failed to identify behaviors. Review of Resident #1's progress notes identified the following: * 01/26/21 at 7:52 a.m. - Resident seems highly agitated this early evening into the night and does not redirect. is alert with much confusion . * 01/31/21 at 9:22 p.m. - . Resident is alert with confusion . Was resistive to HS [evening] cares, not allowing staff to wash up and change clothing . Resident has been pleasant but unable to redirect easily this evening. * 02/01/21 at 11:58 a.m. - . She does show confusion and has a diagnosis of Dementia . * 02/01/21 at 6:26 p.m. - . Resident is alert with confusion . Was resistive to HS cares, not allowing staff to wash up and change clothing . Resident has been pleasant but unable to redirect easily this evening. * 02/03/21 at 8:55 p.m. - . 1930 [7:30 p.m.] . [Resident] called staff names, grabbed at staff and threatened to call police. attempted to redirect and calm her . staff left the resident alone . * 02/04/21 at 1:19 p.m. - (Social Worker) . Behavior Observation form dated 2/3/2021 at 7:30pm was routed to SW [Social Worker] for review. Staff attempted to assist her to bed for the evening and she was verbally abusive, called staff names and threatened to call the police. She physically lashed out at staff and scratched one of the arms of the staff. Staff left her alone and retuned [sic] to see when she wanted to go to bed. She continued to refuse assistance and eventually went to bed by herself. She continues to show intermittent confusion throughout the day. She does not have a diagnosis to address her cognitive status, and her physician can eventually address this issue. * 02/06/21 at 12:03 a.m. - Resident is alert with confusion. Mood was irritable prior to going to sleep. Yelling at staff and roommate to get out of her room. Reported she was going to call the police if staff didn't leave. Divider curtain was pulled and staff left room. * 02/07/21 at 10:31 a.m. - She is noted to be alert with some confusion. She becomes agitated and aggressive towards staff at times and refuses cares . * 02/20/21 at 4:53 a.m. - 2/19/21 @ 2015 [10:15 p.m.] . resident tried to get into roommates bed to sleep. Roommate told her no, and resident became very upset. She told staff that she was going to move out and proceeded to walk out of her room and down the hall. When informed she could come to the certified nursing assistant [CNA] desk to wait, resident yelled at staff and said I don't need you to tell me what I can and Can't [sic] do. calm voice, explanation of the situation, informed resident where her bed was, re-approached . Resident refused to take evening medications because she was still upset, she did however go to her own bed after a short time . * 03/04/21 at 8:15 p.m. - . 8:15pm . [Resident] Was standing with walker beside her roommates bed yelling get the hell out of my house, I never said you could come into my house. I'm calling the police on you for breaking and entering. Called her son and asked him to talk with her. He tried but she kept telling him well if your [sic] in on this funny business then your [sic] gonna [sic] get into trouble also and that's on you because I;m [sic] calling the police . Kept out of room for awhile until she calmed down then took back and put to bed she went to sleep. * 03/05/21 at 1:34 p.m. - (Social Worker) Author received a behavior observation on this resident for the dates and time of 3/4/2021 at 2015 [10:15 p.m.] stating that resident had been resting in bed prior to behavior happening. Staff found resident standing by her roommates [sic] bed yelling at her get the hell out of my house I never said you could come into my house, I'm going to call the police for breaking in entering on you. Staff got a wheelchair and took resident up to call her [son name] and let him talk with her. She didn't listen to him either, said to him if your [sic] in on this funny business you can go to jail also because I am going to call the police. * 03/19/21 at 11:49 a.m. - (Social Worker) . She has a diagnosis of dementia, and will have progressive cognitive decline due to this condition. * 03/23/21 at 3:43 p.m. - . 4-5pm . Resident was very upset that she had gotten a new roommate. She used profanity and was very agitated. She told roommate and her husband to get out of here, this is my place, I own this place. She also threatened to call the police. She stated that she paid for this farm and no one is taking it away from her. Various staff used redirection at various times between 4-5 pm. CNAs, nurse and nurse manager gave explanations and redirections without success. * 03/29/21 at 3:43 p.m. - (Social Worker) Author received a behavior observation form on resident for the date and time of 3/23/2021 at 1600-1700 [4-5 p.m.] stating that resident was unhappy about receiving a new roommate and her having her roommates husband in there visiting with the roommate. She was using profanities and stated she would call the police. This resident was moved to a private room due to this being an issue with prior roommate as well. Will continue to follow as needed. Progress Notes identified Resident #1 displayed aggressive behaviors for two months to both staff and her roommates, facility staff failed to implement a Behavior Daily Tracking Log. Facility staff also did not provide information to show the resident's team met and addressed Resident #1's behaviors or discuss a referral to psychiatry. During an interview on 03/30/21 at 1:20 p.m. an administrative nurse (#1) stated staff noticed a decline in Resident #1's cognitive condition when she moved to new room (approximately 2 months ago). During an interview on 03/30/21 at 3:40 p.m. an administrative nurse (#2) stated a psychiatrist does not currently see Resident #1. - Observation on 03/30/21 at 11:20 a.m. identified Resident #3 wandering the facility halls unassisted and without a cane. Resident #3 wandered near the front exit door. Four staff members approached, talking to the resident and attempting to assist her away from the entrance. The resident made several attempts to pull away. Staff then assisted Resident #3 away from the entrance and brought the facility dog to the resident. The resident pet the dog twice and started to walk away. Staff assisted the resident down the hallway. Review of Resident #3's medical record occurred on 03/30/21. Diagnoses included unspecified dementia without behavioral disturbance. Review of Resident #3's physician's order identified the following: * A code alert (wander guard) ordered on 03/19/21 at 11:00 p.m. * [MEDICATION(S)] (medication to treat anxiety) 0.25 milligrams (mg) by mouth as needed for restlessness/anxiety ordered on 3/30/21 at 12:00 p.m. Review of Resident #3's care plan, dated 03/19/21, identified a wander guard placed on resident's cane. Review of Resident #3's progress notes showed the following: * 03/17/21 at 3:33 a.m. - . Resident was getting agitated that staff was in [the] room bothering [Resident] . [Resident] started to strike out at CNA and CNA then called another staff member in to attempt to assist [Resident]. Resident then started swinging [the] cane at staff. Resident then got up and grabbed the clipboard and threw it across the room . Resident refused to let staff obtain vital signs and refused toileting . * 03/17/21 at 3:52 a.m. - Resident is now out of bed and throwing things around in her room . [Resident] screamed, 'I can read your mind and know you have hate inside you.' [Resident] also repeatedly stated, 'You are just thinking about hate and the hateful thing [sic] you can do to me' . [Resident] then continued to scream variations of the phrases listed above . Author attempted to provide reassurance and redirect but failed with several attempts. * 03/17/21 at 3:29 p.m. - . Resident does get fixated on a thought or idea and becomes difficult to redirect . * 03/18/21 at 2:59 a.m. - . Resident had wandered over to the Beauty Shop . Resident continued going into other individual's [resident's] rooms . Resident became more agitated .Then raised [the] cane, and began poking it at [staff] . * 03/18/21 at 4:37 a.m. - Resident went into [another resident's] room, pulled [the] blanket off him while he was sleeping. Resident was re-directed by CNA who was hit in front of other resident . * 03/18/21 at 7:45 a.m. - [Resident] has been displaying increased paranoia, agitation and has been combative/resistive with staff throughout the overnight. Currently, [Resident] is standing in the hall way [sic] behind a chair very paranoid with her cane held like a bat. She has slept minimally . * 03/18/21 at 8:30 a.m. - [Nurse Practitioner] voiced she would speak with primary care provider [PCP] and see if there is something that could be implemented into [Resident's] daily regimen to aid with overall symptom management. * 03/18/21 at 9:40 a.m. - . Indicated that [the Resident's] PCP will review the effectiveness of this medication and may opt into an order for [MEDICATION(S)] to be given as needed to aid with symptom management . * 03/19/21 at 1:09 a.m. - . [Resident] refused anything staff was trying to help her with and started to get combative. No interventions helped the situation. * 03/22/21 at 1:17 p.m. - (Social Worker) . [Resident] had physically combative behavior towards staff . Staff reported they attempted to change approach and verbal tone but did not have success in improving this situation . * 03/24/21 at 4:27 a.m. - . Resident refused staff assistance . [Resident] yelled at staff repeatedly saying, 'None of you know how to do your jobs about keeping men and women apart.' [Resident] was fixated on this and became increasingly agitated . Both staff members reapproached with no success . Resident continued to refuse cares. * 03/25/21 at 8:53 a.m. - (Social Worker) . Staff reported that [Resident] refused assistance and became agitated with them . Staff have reported several incidences in which [Resident] becomes agitated towards them when approached and offered assistance of any kind . [Resident] becomes agitated, makes paranoid statements about staff being evil, having hate inside them, [Resident] is wandering into other residents rooms, [Resident] swings her quad-cane at staff in attempts to hit them, and generally causes a bit of chaos on the neighborhood . A code alert [wander guard] was placed on [Resident #3's cane] . * 03/25/21 at 4:47 p.m. - . Resident found stripping [the] bed of linen and throwing items on the floor. Linen was saturated with water from toilet. Resident continuously talking about how toilet is broken . Resident then ambulating in and out of other residents room, attempting to sit on their furniture, hard to redirect . Resident dumped supplement on the wall in room. * 03/26/21 at 4:15 p.m. - . [Resident] is now up, hitting out at staff, throwing [her] cane, [and] throwing [her] phone . * 03/27/21 at 10:03 a.m. - . [Resident] started to kick at me [staff] . [Resident] started hitting staff on arm repeatedly . This had no effect until we [staff] were done and left. * 03/30/21 at 3:42 a.m. - . Resident has been awake and wandering the halls all night . [Resident] decided to take her shirt off and would not put one back on . [Resident] started to get agitated with staff and refused to put a shirt back on. [Resident] said things like, 'No not around the neck it reminds me of hanging people' . Staff then tried to assist [Resident] with putting on a hospital gown which was a failed attempt as well. [Resident] walked the hall bare on the top half of her body for a couple hours. Staff constantly had to keep [Resident] out of other residents' rooms and on the lane . [Resident] continues to try to leave the lane and enter other residents' rooms. [Resident] gets agitated when staff attempt to redirect, calling us [staff] stupid and swearing at us [staff] . Progress Notes identified Resident #3 displayed behavioral disturbances for the past two weeks. These behaviors included aggression towards staff, inappropriately removing her own clothing, and wandering into other residents' rooms. Facility staff failed to initiate a Behavior Management Plan was initiated, evaluate occurrences for possible causes, patterns and/or trends; and implement appropriate interventions, including continued tracking is needed, and/or a referral to psychiatry. For Resident #1 and #3, the facility failed to: * Inform the physician of any significant behaviors or changes, * Assess/address, and or obtain necessary services for resident's behaviors, * Develop and implement person-centered care plans that include and support the dementia care needs and behaviors, * Develop individualized interventions related to the resident's behaviors, and * Review and revise care plans that have not been effective when the resident has a change in condition or an increase in behaviors. These items listed place all residents with dementia and behaviors at risk for ineffective dementia/behavior management.

Based on observation, record review, review of facility's policy, and staff interview, the facility failed to follow infection control standards for 5 of 11 residents (Resident #4, #5, #6, #7, and #8) on isolation precautions. Failure to provide isolation signage for residents on isolation/enhanced precautions has the potential to spread infection to other residents, personnel, and visitors. Findings include: Review of the facility policy titled Risk, Prevention, and Response occurred on 10/21/20. This policy, dated October 2020, stated, . Prevention . post signs at the entrance instructing visitors not to visit . educate staff on proper use of personal protective equipment and application of standard, contact, droplet and airborne precautions, including eye protection . promote easy and correct use of personal protective equipment (PPE) by: . Posting signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE . considerations for admitting residents with suspected or confirmed COVID-19 . prepare to create separate wings, units, floors by moving current residents to handle hospital admissions . if the facility currently has suspected or confirmed COVID-19 cases, admit to a private room on transmission-based precautions . do not admit if the facility is unable to meet the level of care needs or the requirements for transmission-based precautions . Observation on the afternoon of 10/21/20 of the facility's three wings (Cottonwood, Dakota, Acorn) identified five residents (Resident #4, #5, #6, #7, and #8) with isolation carts outside their rooms. An administrative staff (#1) stated the residents were on isolation, enhanced precautions due to COVID-19 and [MEDICAL CONDITION] Staphylococcus Aureus (MRSA) precautions. Review of nurses notes occurred on 10/21/20 and showed Resident #4, #5, #7, and #8 to be on isolation precautions, and Resident #6 [MEDICAL CONDITION] precautions. During an interview on the afternoon on 10/21/20, an administrative staff (#1) stated the facility did not place precaution signage outside some of the isolation residents' rooms. The facility failed to place signs outside the residents' rooms indicating the type of precautions needed and required PPE.

Based on observation, the resident council group interview, and staff interview, the facility failed to actively seek a resolution to resident grievances related to failing lift batteries for 3 of 7 sampled residents (Resident #30, #63, and #91) observed during a full-body mechanical lift transfer. Failure to act upon the resident grievances regarding issues with lift batteries resulted in continued dissatisfaction with delayed care. Findings include: During the resident council group interview on the morning of 11/13/19, two residents (A and B) reported lift batteries continued to fail during lift transfers after Resident Council previously addressed the issue. - Observation on 11/13/19 at 7:38 a.m., showed two certified nursing assistants (CNAs) (#2 and #7) attached the full-body mechanical lift and started to transfer Resident #63 from the bed to the wheelchair. During the transfer the CNA (#2) noticed the battery losing power. The CNAs (#2 and #7) lowered the resident back onto the bed, the CNA (#2) left the room, returned with a different battery, and completed the resident transfer. - Observation on 11/13/19 at 9:10 a.m. showed CNAs (#8 and #9) transferred Resident #91 from the bed to the wheelchair using a full-body mechanical lift. The CNA (#8) initiated the transfer, and the battery failed. The CNA (#8) lowered Resident #91 to the bed and left the room to retrieve a new battery. The CNA (#8) returned with a new battery and transferred Resident #91 to the wheelchair. - Observation on 11/13/19 at 9:33 a.m. showed two CNAs (#1 and #2) transferred Resident #30 from the bed to the wheelchair. During the transfer, the CNA (#2) stated the battery was dying and lowered the resident down to the bed. The CNA (#2) replaced the battery, transferred Resident #30 to the wheelchair, and stated the battery was dying again as he/she completed the transfer. During an interview on 11/13/19 at 11:43 a.m., a CNA (#9) reported night staff charged batteries over night to ensure a full charge during the day and stated staff often forgot to do this. The facility failed to ensure failing batteries did not delay care provided to residents. During an interview on the morning of 11/14/19, two administrative nurses (#4 and #10) confirmed night staff should charge batteries and acknowledged failing batteries as an ongoing issue.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure staff reviewed and revised the comprehensive care plan to reflect the residents' current status for 4 of 23 sampled residents (Resident #24, #66, #82, and #91). Failure to review and revise the care plans to reflect each resident's current status limited the staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Planning occurred on 11/14/19. This policy, dated (MONTH) (YEAR), stated, . Each discipline is responsible to initiate, change, or discontinue problems on the Care Plan as they arise and prior to the Care Conference. - Observation on the morning of 11/12/19 showed a small cabinet outside of Resident #24's room. During an interview at this time, a licensed nurse (#3) stated staff use Personal Protective Equipment (PPE) of gloves and a gown when working with Resident #24's urine. Resident #24's care plan failed to identify staff needed to use PPE when working with Resident #24's urine. During an interview on 11/14/19 at 8:25 a.m., an administrative nurse (#4) confirmed staff failed to include the use of PPE on Resident #24's care plan or routine care card. - Review of Resident #66's medical record occurred on all days of survey and identified the resident wore a lapbelt while in a wheelchair. The care plan failed to reflect the current use of a lap belt. During an interview on 11/14/19 at 10:41 a.m., an administrative staff member (#5) agreed the care plan lacked the resident's current use of seatbelt/lap belt. - Observation of Resident #82 throughout the survey showed the resident ambulated with a walker, which had a wanderguard (device that alarms if passed through an unapproved area) attached to the walker frame. Review of Resident #82's medical record occurred on all days of survey. A physician's order, dated 08/09/18, stated, Check Wanderguard on walker q (every) shift. The quarterly Minimum Data Set (MDS), dated [DATE], identified a wander/elopement alarm used daily and wandering behavior occurred on four to six days of the seven-day look-back period. Resident #82's care plan, dated 05/14/18, stated, . She shows impairment in her memory, decision making skills, thought processes, judgement and safety awareness and has been showing periods of paranoia and agitation which contribute to behaviors. She has been noted to wander into other rooms - however easily redirected most times. Staff will help orientate her to her room when she is wandering into other rooms with helpful reminders and explain to her where her room is. The care plan failed to include the use of a wanderguard. During an interview on 11/14/19 at 9:06 a.m., a nurse manager (#11) agreed Resident #82's care plan should include the wanderguard. - Observation throughout survey showed Resident #91 ate nothing by mouth (NPO), and staff failed to provide oral cares. Review of Resident #91's record occurred all days of survey. A document titled Dysphasia Evaluation Results, dated 01/11/19, stated, . pt (patient) to remain NPO (nothing by mouth) . A progress note, dated 11/4/19, stated, requires tube feedings and is NPO. Review of Resident #91's current care plan occurred all days of survey and stated, . Resident has potential for nutritional risks r/t (related to) weight gain of 5% or more in the last month and receiving Mechanically altered diet, Tube feeding,[MEDICAL CONDITION] . Offer menu alternatives, provide when possible. OT (occupational therapy) to screen and provide adaptive equipment for feeding as needed. Resident #91's care plan failed to identify his/her current status of NPO and additional interventions required for a resident with an NPO status such as oral cares. During an interview on the morning of 11/14/19, two administrative nurses (#4 and #10) confirmed Resident #91's NPO status and agreed his/her current care plan did not reflect his/her current status and need for oral cares.

Based on observation and staff interview the facility failed to establish a system to secure/store controlled medications for 1 of 1 MedSafe collection system. Failure to assure all controlled medications collected for destruction are appropriately secured/stored at all times has the potential for medication loss or diversion of medications. Findings include: Observation of the MedSafe collection system occurred on the morning of 11/14/19 with an administrative nurse (#6). Observation showed a locked collection receptacle in the Cottonwood nurses' station. The administrative nurse (#6) stated, When the inside container/box is full, two nurses close and seal the box, it is then stored in the Director of Nursing (DON) office. The administrative nurse (#6) reported it takes a few days until the MedSafe company arrives to collect and remove the box from the facility. The facility failed to properly secure/store controlled medications after removed from the MedSafe collection system and prior to the medications removed from the facility.

Based on observation, record review, and review of the manufacturer's guidelines, the facility failed to properly use assistive devices during transfers for 1 of 1 (Resident #11) sampled resident who experienced a fall with injury. Failure of staff to use the correct size of sling and ensure correct placement of the sling when transferring Resident #11 resulted in a fall with significant injury. Findings include: Review of the manufacturer's guidelines titled E/Z Way Smart Lift occurred on 11/22/17. Pages 6-7 of the guidance stated, . the back of the sling is positioned properly behind the patient's back and under their tailbone to provide support. (The top of the sling must reach just above the patient's shoulders and the base of the sling should be 2 inches below their tailbone.) . Review of Resident #11's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current care plan stated, . Transfers with full body mechanical lift. Leave sling in w/c (wheelchair) for safety reasons. Total assist (2) needed for transfer. The routine care sheet further identified, . lg (large) sling . The progress note, dated 11/20/17 at 1:20 p.m. (on first day of survey), identified, . transferring resident from wheelchair to bed via hoyer and she slid between the hoyer straps onto the floor. has a 3 cm (centimeter) laceration to the left side of her cranium (head); bruising and swelling surrounding laceration with bruising extending downward behind left ear. denied pain to extremities with first assessment but later admitted to right knee discomfort. cleansed laceration and applied ice pack and pillow beneath head. agreeable with evaluation at ER (emergency room ). Vitals are normal. Neuro (neurological) checks initiated and normal. The fall report, dated 11/21/17 11:08 a.m., identified, . resident was lying on the floor. CNA reports . were transferring her (resident) from wheelchair to bed via hoyer and that she slid through the straps. Upon investigation, staff noted that a medium size sling was used early this AM (morning) . same sling remained in place until now. Resident requires a size L (large) sling. Resident was on the floor with blood on left side of cranium. laceration approx. (approximately) 3 cm length and swelling surrounding the laceration at left cranium. redness/bruising behind left that extends downward behind ear lobe. The investigation reported, dated 11/22/17 4:20 p.m., identified, . she (resident) was seen in the emergency room . Her x-rays showed that she had sustained a fracture of the tibia. staples were applied to her laceration, which was approximately 1.25 inches in length. Based on the following information, non-compliance at F323 is considered past non-compliance. The facility addressed the corrective action accomplished for Resident #11 affected by the deficient practice by: * Incident reported to the Department of Health on 11/20/17. * Investigation completed/submitted to the Department of Health on 11/22/17. * 1 on 1 education provided immediately after incident with the day and evening shift CNAs working on Acorn Lane regarding proper use of the full body mechanical lift and the importance of ensuring staff utilize the appropriate sling size for each resident based on their assessment. The facility addressed identification of other resident having the potential to be affected by the deficient practice by: * The QAPI Coordinator developed a form indicating the appropriate sling size required by each resident who utilizes a full body mechanical lift for transfers. The form is kept with the routine care sheet behind each resident's bathroom door. * A list of all residents utilizing a full body mechanical lift, along with the appropriate sling size each resident required, was placed in the Laundry and Utility rooms on each neighborhood. * All of the residents on each neighborhood were re-measured to assure the correct sling size. * Additional education was provided to the CNA staff on all neighborhoods on 11/21/17. The facility addressed measures put in place and systemic changes made to ensure the deficiency practice does not recur by: * All of the residents on each neighborhood were re-measured to assure the correct sling size. * Additional education was scheduled to be provided to CNA staff facility wide within the following week.

Based on record review and staff interview, the facility failed to ensure 1 of 1 closed record resident (Resident #18) identified with severe weight loss, received the necessary care and services in a timely manner to maintain adequate nutritional status. Failure to assess for underlying causative factors, implement appropriate and effective interventions, and promptly notify the physician regarding the resident's poor intake, resulted in Resident #18 experiencing an unplanned severe weight loss in less than one month. Findings include: Review of Resident #18's medical record occurred on [DATE]-20, 2016. Resident #18 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and extensive-to-total assistance of one or more persons for all activities of daily living (ADLs). The care plan, dated [DATE], identified, . Self Care deficit r/t (related to) Dow[DIAGNOSES REDACTED] . Eating: Extensive . Potential alteration in nutrition r/t weakness, lethargy . Dietary evaluation, Eats in Dining room, Monitor and record meal intakes, Not approved for a PFA (paid feeding assistant), Weight on admission two times per week for 2 weeks. Resident #18's hospitalization record identified the following: * Admission report, dated [DATE], . This gentleman was transferred here from Jamestown in regard to a small-bowel obstruction. * Progress note, dated [DATE], . He appears well-developed and well-nourished. No distress. Small Bowel Obstruction - Resolved. The physician's progress note, dated [DATE], identified, (Resident #18) is admitted to the nursing home. He has had problems with an ileus following a redo of a [MEDICAL CONDITION] and bowel obstruction. He actually has done pretty well here. The staff really does not have any concerns as to how he is getting along. During an interview on [DATE] at 3:00 p.m., a licensed/registered dietitian (#1) reported the Point Click Care program generates a Nutrition/Weight Change report which staff utilize during the weekly Nutrition-At risk meetings. Staff discuss the resident's status, possible causes for weight loss, and intervention needs. Resident #18's weight report identified the following: * [DATE], 110 pounds (weight upon admission to the facility) * [DATE], 108 pounds * [DATE], 102 pounds (-8.0 pounds = -7.2% severe weight loss in 23 days) * [DATE], 99 pounds (-11.6 pounds = -10.5% severe weight loss in 28 days) * [DATE], 94 pounds (-16.6 pounds = -15% severe weight loss in 29 days) The interdisciplinary progress notes identified: * [DATE] at 3:20 p.m., . (Group home) staff . are really hoping that (Resident #18) can return to (Group home) when he gets some strength back. * [DATE] at 10:45 a.m., (Dietary) . Res (Resident) diet order is Liberal Geriatric . Pureed per MD (medical doctor). The Nutritional Risk Assessment, dated [DATE], identified, Weight: 109 lbs. Receives . Pureed (diet). Visited with (Group home) caregiver for food preferences. Plan: Added Carnation Instant Breakfast to snacks. Continue to individualize diet and accommodate requests. Will monitor weight & (and) meal intakes. The interdisciplinary progress notes further identified: * [DATE] at 4:44 p.m., . The team met today to review his care plans. (Resident #18's) Legal Guardian . and . RN (Registered Nurse) . (who) managed his healthcare needs and concerns . Discussed his appetite, and weight loss concerns. He will have ensure 3 times per day, and nursing assured his care providers that we discuss concerns with dietary staff regularly and have scheduled meetings every other week. His care providers wanted to ensure that (name of provider) would continue to be his primary care physician. * [DATE] at 10:49 p.m., . Catheter went well with 55 cc (cubic centimeters) output of yellow mucous drainage. * [DATE] at 6:04 a.m., . catheter . Had immediate output of cloudy yellow urine returned approx. (approximate) 75 cc . * [DATE] at 8:14 p.m., Ensure . Offered but only took in sips. * [DATE] at 11:47 a.m., . only sips of ensure. * [DATE] at 10:29 p.m., . He refused . supper. Took in minimum amount of fluids. * [DATE] at 5:51 p.m., Ate and drank less than 10% supper. The record failed to show staff notified Resident #18's physician regarding his -8.0 pounds = -7.2% severe weight loss [DATE]. * [DATE] at 9:28 p.m., resident was very incont (incontinent) of urine and there was no urine in the Foley cath (catheter) bag. Irrigated the catheter with 60 cc of sterile water and the urine that returned was very white, thick matter. * [DATE] at 9:06 p.m., Resident refused supper and has refused fluids this shift. * [DATE] at 9:13 p.m., Resident had minimum amount of urine output. Resident refused supper and has refused fluids this shift. * [DATE] at 10:30 p.m., . Resident has been refusing fluids. He had minimal output this shift. The Fax Tracking Log identified a fax had been sent to Resident #18's physician on [DATE]. The issue/concern read, FYI (not) eating drinking . The log failed to identify when (what time of day) the fax was sent and the physician's response. The interdisciplinary progress notes further identified: * [DATE] at 9:55 a.m., (Dietary) WEIGHT WARNING: . (7.2% (weight loss) .) Meal intakes poor. Res (resident) receives C/B (Carnation Instant Breakfast) with meals and snacks. This was the first Dietary note entered since [DATE]. * [DATE] at 6:26 p.m., Continues to eat and drink poorly. Today's weight was 99.0 lbs (pounds). Will do a reweight tomorrow and update MD (medical director) of weight loss if weight is accurate. * [DATE] at 7:00 p.m., Ensure . drank just a sip. The record failed to show staff notified Resident #18's physician regarding his -16.6 pounds = -15% severe weight loss in less than one month (February 25 - [DATE]). * [DATE] at 10:24 p.m., Resident refused food, fluids . this shift. * [DATE] at 7:30 a.m., CNA (Certified Nursing Asssistant) . found resident without respirations (Resident #18 expired.). The facility failed to recognize Resident #18's severe weight loss, failed to promptly notify Resident #18's physician regarding his poor meal/fluid intake, and failed to implement appropriate interventions per his physician and/or the interdisciplinary team which resulted in continued weight loss/dehydration.

PAIN 1. Based on medical record review, review of professional literature, review of facility policy, family interview, and staff interview, the facility failed to provide the necessary care and services to promote the optimal well-being for 1 of 1 sampled resident (Resident #1) who experienced continued uncontrolled pain secondary to a femur fracture. Failure to inform the attending physician of the resident's continued uncontrolled pain did not allow the physician the opportunity to ascertain the cause of and/or prescribe treatment for [REDACTED].#1 experiencing avoidable pain. Findings include: Review of the American Academy of Orthopaedic Surgeons "OrthoInfo - Distal Femur (Thighbone) Fractures of the Knee," orthoinfo.aaos.org, copyright 2011, stated, ". . . Distal femur fractures vary. The bone can break . . . into many pieces (comminuted fracture). Sometimes these fractures extend into the knee joint and separate the surface of the bone into a few (or many) parts. . . . The most common symptoms of distal femur fracture include: Pain with weightbearing, Swelling and bruising, Tenderness to touch . . . In most cases, these symptoms occur around the knee . . ." Review of the facility policy titled "Pain Management" occurred on 10/02/14. This policy, revised May 2013, stated, ". . . Pain will be treated promptly to assure that the resident may obtain the highest level of pain relief possible. . . . Have the resident rate his pain using the pain log until the resident has had 48 hours of pain rated at an acceptable level or less . . . If the resident's pain is not relieved by current interventions, the nurse will contact the physician to discuss other options and interventions. . . ." During an interview on 09/29/14 at 4:20 p.m., a family member (#1) reported the facility had "dropped" Resident #1 "in the beauty salon." The family member (#1) stated, "I think they dropped her. The force of falling on her knee, pushed it (the bone) up and cracked it. Her knee was swollen. It was huge. She kept complaining of pain. She had alot of pain. (They) xrayed her shoulder and hip (immediately after the fall and her) knee the next week. She wore a brace for six months." - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], identified intact cognitive skills. Resident #1's current care plan identified, ". . . Interventions: . . . Give [MEDICATION NAME] PRN (as needed) for pain. . . ." The progress note, dated 01/10/14 at 2:21 p.m., identified, ". . . resident had fallen out of her wheelchair. Resident was laying on right side . . . unable to move left leg due to increased pain. . . . Rates pain 10/10 to the left leg. . . . (Physician) notified and gave order to transport to (emergency room ) for evaluation via ambulance. . . ." The emergency room evaluation, dated 01/10/14 at 3:20 p.m., identified, ". . . staff found her lying on her side . . . (Resident #1) was complaining of most of the pain in her hip but also pain through her anterior left shoulder. . . . No swelling, bruising or injury to the knee is noted. . . . She was given a prescription for [MEDICATION NAME]/APAP ([MEDICATION NAME]) (an [MEDICATION NAME]) . . . every 4-6 hours for severe pain . . ." The Medication Administration Record [REDACTED]." The MAR indicated [REDACTED]. In all instances but one, staff charted the medication was effective. The progress notes identified the following: * 01/10/14 at 5:02 p.m., "Resident came back from (hospital) with orders. . . . Resident has a bruise to her left knee and it is swollen which happened at facility." * 01/10/14 at 8:46 p.m., "[MEDICATION NAME]-[MEDICATION NAME] . . . Resident c/o (complains of) pain 9 out of 10 to her left knee. Ice pack is applied and was used to try to help pain." * 01/10/14 at 10:15 p.m., ". . . Resident is still c/o pain 8 out of 10 and facila (sic) expressions." * 01/11/14 at 2:57 a.m., "[MEDICATION NAME]-[MEDICATION NAME] . . . per resident request for c/o 9/10 left knee pain." * 01/11/14 at 3:24 a.m., ". . . No complaints of pain other than to left knee. Left knee continues to be swollen. . . ." * 01/11/14 at 8:11 a.m., "[MEDICATION NAME]-[MEDICATION NAME] . . . c/o left knee pain." * 01/11/14 at 12:28 p.m., ". . . helped some." * 01/11/14 at 2:10 p.m., ". . . C/O pain to left knee 9/10 area is swollen and bruised. Resident did not want to get out of bed as knee really hurting. . . . Gave PRN (as needed) hydro ([MEDICATION NAME])/APAP and ice to knee for pain . . ." * 01/11/14 at 4:06 p.m., ". . . 10/10 left knee pain." * 01/11/14 at 9:18 p.m., "[MEDICATION NAME]-[MEDICATION NAME] . . . c/o 8/10 left knee pain." * 01/11/14 at 10:05 p.m., ". . . C/O pain to left knee 8/10 area is swollen and bruised. Resident remained in bed this shift and sat up in bed for some of shift and for supper. Gave PRN hydro/APAP and ice to knee for pain with some relief . . ." The MAR indicated [REDACTED]. Staff charted all four doses were effective which conflicts with the information documented above. * 01/12/14 at 1:59 p.m., "REsident complains of some soreness in (L) (left) knee. Continues with bruising to area. She is asking why it is sore . . ." * 01/12/14 at 8:55 p.m., "[MEDICATION NAME]-[MEDICATION NAME] . . . Resident rated her pain an (sic) 7/10. . . . she was helped into bed and HS (hour of sleep) cares were performed and it aggravated her left leg." * 01/13/14 at 11:27 a.m., "[MEDICATION NAME]-[MEDICATION NAME] . . . Given per request for pain in (L) leg level 8 of 10." * 01/13/14 at 1:09 p.m., "Resident continues with some pain and swelling of (L) knee. Resident transferred with standing lift. She beared weight most of the time with transfers. FAX to MD (medical doctor) (three days post fall and after Resident #1 complained of severe pain on nine occasions) regarding leg and swelling and possible xray of knee." * 01/13/14 at 1:59 p.m., ". . . Resident states knee is better now that (she) is laying down." * 01/13/14 at 7:34 p.m., "[MEDICATION NAME]-[MEDICATION NAME] . . . Resident requested for pain of 7/10, currently resting in bed rubbing area where it hurts. Room darken . . ." The MAR indicated [REDACTED]. Staff had charted both doses were effective which conflicts with the information documented above. * 01/14/14 at 11:28 a.m., "[MEDICATION NAME]-[MEDICATION NAME] . . . c/o 7/10 left knee pain." * 01/14/14 at 3:20 p.m., ". . . yes it helped." * 01/14/14 at 9:23 p.m., "[MEDICATION NAME]-[MEDICATION NAME] . . ." * 01/14/14 at 10:26 p.m., "Gave PRN pain medication which was effective. (Resident #1) voiced her left knee is feeling a little better." * 01/15/14 at 9:41 p.m., "[MEDICATION NAME]-[MEDICATION NAME] . . . Resting quietly in bed." * 01/15/14 at 10:12 p.m., "Appt (appointment) made to see (physician) 1-16-14 . . . Left knee pain from post fall 1-10-14 . . ." * 01/16/14 at 1:36 p.m., "Resident returned to facility (six days post fall and after Resident #1 complained of severe pain on eleven occasions) . . . received call from (physician) that resident has a bad distal fx (fracture), keep immobilizer on at all times . . ." During an interview on the morning of 10/02/14, a managerial nursing staff member (#13) confirmed Resident #1's physician was contacted three days post fall regarding her continued uncontrolled pain and staff failed to follow-up until the sixth day post fall. The facility failed to inform Resident #1's attending physician of her continued uncontrolled left knee pain as evidenced by: * her left knee being bruised and swollen * her demonstrating pain through facial expressions and/or verbalizing being in pain * her requests for medication/ice to relieve the knee pain/swelling * her refusal to get out of bed due to her "knee really hurting" and reports of her knee "feeling better when she was laying down" * staff reports of her refusing to consistently bear weight and her reports of her knee being "aggravated" during transfers. The facility's failure to inform the attending physician of Resident #1's continued uncontrolled pain which did not allow him/her the opportunity to ascertain the cause of and/or prescribe treatment for [REDACTED].#1 experiencing avoidable pain. Resident #1 expressed discomfort/pain in her left leg beginning on 01/10/14, and her femur fracture was not diagnosed until 01/16/14 (6 days post fall). SWALLOWING 2. Based on observation, record review, review of facility policy and procedure, resident/family interview, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #1) with a history of aspiration pneumonia and 1 of 1 sampled resident (Resident #13) at risk of aspirating received the care and services necessary to attain the highest degree of safety possible while being fed. Failure to ensure residents were positioned properly prior to offering/giving liquids, control the size of the bolus (bite), allow adequate time for residents to eat/chew their food, and recognize the signs/symptoms of dysphagia/aspiration resulted in Resident #1 aspirating during meals and placed Resident #13 at risk of aspirating. Findings include: Review of the facility policy titled "Assisting the Resident to eat" occurred on 10/02/14. This policy, revised November 2013, stated, "Be sure the resident is (as much as possible) in proper positioning for eating. . . . If a resident remains in bed, the resident should be resting on his/her back, head of bed elevated at a 90 degree angle. . . . Allow the resident plenty of time to eat and chew foods. Provide small bites and sips of liquids. . . . Be observant of the resident during the feeding process. Watch for signs of choking. . . ." - During an interview on 09/29/14 at 4:20 p.m., a family member (#1) reported and Resident #1 confirmed she felt "rushed during meals." They reported feeling staff "push her to be done," even though she wished to continue eating. Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], identified intact cognitive skills, the need for extensive assistance of one person at meals, and a mechanically altered diet. The current physician's orders further identified, ". . . Mechanical soft with ground meat and thin liquids. . . ." Resident #1's current care plan identified, ". . . Focus: . . . nutritional problems . . . [MEDICAL CONDITION] . . . dementia . . . dysphagia . . . slow eater . . . gradual unplanned weight loss . . . Interventions: Allow time to eat and finish meal to the extent that res (resident) wishes . . . Provide liberal geriatric (diet) - mech (mechanical) soft - pureed per MD (medical doctor) . . ." Observation showed the following: * On 09/30/14 at 10:20 a.m., a CNA (#11) gave Resident #1 a drink of water as she lay in bed (with the head of the bed raised to an approximate 25 degree angle - placing Resident #1 at an increased risk of premature loss of food/liquid over the back of her tongue). Drool ran down the left side of Resident #1's face and neck (an indication Resident #1 did not swallow her secretions). The CNA failed to raise Resident #1's bed to 90 degrees prior to offering her water. * On 09/30/14 at 12:45 p.m., a CNA (#20) assisted Resident #1 during the noon meal. The CNA (#20) held a heaping spoonful of food three inches from Resident #1's mouth and repetitively prompted her to take another bite of food, as Resident #1 continued to chew the previous bite of food in her mouth (placing Resident #1 at an increased risk of aspirating during a delayed swallowing response). Resident #1 drooled (an indication Resident #1 did not swallow her secretions), coughed twice (an indication Resident #1 had poor vocal fold closure and secretions had entered her airway), and began to hiccup. The CNA (#20) failed to provide small bites of food/small sips of liquids, allow the resident adequate time to eat/chew her food, and watch for signs/symptoms of dysphagia/aspiration. * On 10/01/14 at 9:10 a.m., a CNA (#21) assisted Resident #1 during the breakfast meal. The CNA (#21) held a spoonful of food three inches from Resident #1's mouth and repetitively prompted her to take another bite of food, as Resident #1 continued to chew the previous bite of food in her mouth (placing Resident #1 at an increased risk of aspirating during a delayed swallowing response). Resident #1 drooled (an indication Resident #1 did not swallow her secretions). The CNA (#21) failed to allow the resident adequate time to eat/chew her food and failed to watch for signs/symptoms of dysphagia/aspiration. * On 10/01/14 at 1:00 p.m., a CNA (#19) assisted Resident #1 during the noon meal. The CNA (#19) asked Resident #1, "Are you ready to go then?" Resident #1 shook her head "No" and coughed as she continued to drink cocoa from a straw (an indication Resident #1 had poor vocal fold closure and secretions had entered her airway). The CNA (#19) then stated, "Ok, I have to sit here until you're done. Are you ready?" Resident #1 again shook her head "No," continued to drink her cocoa, and demonstrated a delayed cough (an indication Resident #1 had poor vocal fold closure and secretions had entered her airway). During the next five minutes, the CNA (#19) asked Resident #1, "Are you all ready (Resident #1)? No? Not yet? Are you all done? Can we go back to your room?" Resident #1 shook her head and/or stated "No" three times and began coughing (an indication Resident #1 had poor vocal fold closure and secretions had entered her airway). She presented with a "wet" vocal quality (an indication Resident #1 did not swallow her secretion and secretions had entered her airway). The CNA (#19) asked Resident #1, "Are you ready (Resident #1)? Can we head back? No?" Resident #1 did not respond to the questions and continued drinking her cocoa. The CNA (#19) then asked Resident #1, "Can you put your napkin up here, so we can head out?" Resident #1 shook her head "Yes." The CNA (#19) failed to allow the resident adequate time to drink her liquids and failed to watch for signs/symptoms of dysphagia/aspiration. * On 10/02/14 at 9:10 a.m., a CNA (#22) watched as Resident #1 fed herself breakfast. Drool ran down Resident #1's chin (an indication Resident #1 did not swallow her secretions). The CNA (#22) failed to watch for signs/symptoms of dysphagia/aspiration. - Resident #3's medical record, reviewed September 29-October 2, 2014, identified [DIAGNOSES REDACTED]. Observation on 09/30/14 at 10:35 a.m., showed a CNA (#14) gave Resident #3 a drink of water as he lay in bed (with the head of the bed raised to an approximate 45 degree angle - placing Resident #3 at an increased risk of premature loss of food/liquid over the back of his tongue). The CNA failed to raise Resident #3 bed to 90 degrees prior to offering him water. During an interview on the morning of 10/02/14, a managerial nursing staff member (#13) confirmed staff are expected to position residents as close to 90 degrees as possible prior to offering a drink, provide small bites of food/small sips of liquids, allow the residents adequate to eat/chew their food, and watch for signs/symptoms of dysphagia/aspiration. The facility failed to 1) position Resident #1 (with a recent history of aspiration pneumonia) and Resident #3 as close to 90 degrees as possible prior to offering/giving them liquids, 2) control the size of the bolus; offering teaspoon sized bites of food, 3) allow Resident #1 plenty of time to eat/chew her food (especially considering her diagnoses), and 4) recognize Resident #1's signs/symptoms of dysphagia/aspiration (drooling, coughing/delayed coughing, etc.) Failure to implement the above interventions resulted in Resident #1 aspirating during meals and placed Resident #13 at risk of aspirating. URINARY TRACT INFECTIONS 3. Based on record review and staff interview, the facility failed to ensure 1 of 2 sampled residents (Resident #3) received the care and services necessary to attain the highest practicable physical well-being possible after being diagnosed with [REDACTED]. Failure to ensure a resident with a known UTI received appropriate treatment following a laboratory culture resulted in Resident #3 experiencing increased urinary frequency/discomfort. Findings include: The facility failed to provide a copy of their policy regarding urinary tract infections upon request. - Resident #3's medical record, reviewed September 29-October 2, 2014, identified [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], identified intact cognition and need for extensive assistance of two or more persons for toileting. The progress note, dated 04/28/14 at 6:03 a.m., identified, "Straight cath (catheter) done at 5:55 a.m. for UA/UC (urinary analysis/urinary culture). Obtained slightly cloudy yellow urine. No odor or sediment noted. Will send to (Hospital) for analysis. Resident did c/o (complain of) some discomfort with catheter insertion, otherwise no complaints." The laboratory report, dated 04/28/14 at 10:15 a.m., identified, ". . . Criteria has been met for ordering the urine culture test. . . ." The progress notes identified the following: * 04/28/14 at 2:40 p.m., ". . . received UA results and UC has been set up. resident complaints (sic) of frequency but is willing to wait until the culture returns before the MD (medical doctor) decides if treatment is warranted. . . ." * 04/29/14 at 10:19 a.m., ". . . contact isolation pending UC results. . . ." * 04/29/14 at 8:15 p.m., "(Physician) updated on recent UC, waiting to here (sic) back results." The laboratory report, dated 04/30/14 at 3:15 p.m., identified, ". . . Organism: [MEDICATION NAME] aerogenes (a bacteria) . . . Interpretation: Sensitive . . . Antibiotic: . . . [MEDICATION NAME] . . . [MEDICATION NAME] . . . [MEDICATION NAME] . . . Peperacillin/Tazobactam . . . [MEDICATION NAME]/[MEDICATION NAME] . . ." The progress notes identified the following: * 04/30/14 at 6:36 p.m., ". . . Resident did complain of urinary frequency and asked if U/C was back yet. . . ." Staff failed to inform Residnet #3 of the above lab results. * 05/01/14 at 4:39 a.m., "Received final UC results. (Approximately 13 hours prior to this entry.) Fax prepared to update MD on UC results, and copy of results placed in chart." * 05/02/14 at 2:44 p.m., ". . . complaints of frequency and requesting to be started on something (This was the second time Resident #3 approached staff.) call placed to clinic x (times) 2 and also refaxed the UA/UC. (No evidence was found in the resident's medical record showing a previous fax had been sent to the physician.) taking fluids well. . . ." The facility received a fax from Resident #3's physician, dated 05/02/14 at 4:46 p.m. (2 hours after receiving the phone calls/"second" fax), which identified, "Cipro 250 (2 po (orally) tonight then 1 po BID (twice daily) x (four more days)." The progress notes identified the following: * 05/02/14 at 9:12 p.m., "Cipro 250-2 pills tonight then 1 pill PO BID for four more days." * 05/02/14 at 10:23 p.m., ". . . Antibiotics started for UTI (5 days after the UA was obtained.)" During an interview on the morning of 10/02/14, a managerial nursing staff member (#13) confirmed staff are expected to notify a physician of the resident's continued symptoms/complaints and of the results of a culture.

FALLS 1. Based on observation, record review, review of a manufacturers pamphlet, review of professional literature, review of facility policy, family interview, 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 a fall with fracture in the beauty salon. Failure to ensure a safe environment resulted in Resident #1's comminuted femur fracture and failure to determine external causative factors for the injury has the potential to place her and other residents at risk of further injury. Findings included: Review of the "Wheelchair Recline unit (Platform Model)" www.WheelchairRecline.com, patent pending, stated, ". . . An innovative way for the wheelchair bound person to be reclined while staying in his or her own wheelchair. The versatile Wheelchair Recline unit can be used for shampooing hair in a beauty shop . . . The Wheelchair Recline platform elevates 5 inches! . . . Locking castors allow for easy maneuverability and are positioned to balance and support the weight of the occupant. . . ." The manual lacked specific instructions for the use of this product. Review of the American Academy of Orthopaedic Surgeons "OrthoInfo - Distal Femur (Thighbone) Fractures of the Knee," orthoinfo.aaos.org, copyright 2011, stated, ". . . Distal femur fractures vary. The bone can break . . . into many pieces (comminuted fracture). Sometimes these fractures extend into the knee joint and separate the surface of the bone into a few (or many) parts. . . . A lower-force event, such as a fall from standing, can cause a distal femur fracture in an older person . . ." Review of the facility policy titled "Fall Prevention/Safety Protocol" occurred on 10/02/14. This policy, revised December 2013, stated, ". . . Prevention . . . Environment will be assessed ongoing with any identified hazards removed or corrected. . . . Occurrence . . . If a Fall . . . should occur: . . . A licensed nurse will complete a Variance Report. It will include an . . . investigation of the incident and possible contributing factors . . . and action needed to prevent future falls. . . ." During interview on 09/29/14 at 4:20 p.m., a family member (#1) reported the facility had "dropped" Resident #1 "in the beauty salon." The family member (#1) stated, "I think they dropped her. They said she had slipped. The force of falling on her knee, pushed it (the bone) up and cracked it. One (staff) person, not two, transferred her. She (the staff person) was new." - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], identified intact cognitive skills, the need for extensive assistance of two or more persons for transfers and locomotion on the unit, and impaired range of motion in the lower extremities. Resident #1's current care plan identified, ". . . Focus: . . . risk for falls r/t (related to) history of falls . . . Interventions: . . . Ensure a safe environment . . . Focus: . . . ADL (activities of daily living) Performance Deficit . . . Interventions: (Resident #1) requires a pivot transfer with 2 assist. . . . Hoyer for toileting. . . ." The current "routine care sheet" provided to staff further identified, ". . . (Resident #1) is non-ambulatory . . ." The progress note, dated 01/10/14 at 2:21 p.m., identified, "Type of Fall: . . . Observed, Time of Fall: 1:45 p.m., Location: Beauty shop, Description of Incident: Author was called into beuaty (sic) shop after resident had fallen out of her wheelchair. Resident was laying on right side when author arrived. Resident unable to move left leg due to increased pain. Resident did state that she bumped her head. Resident is alert able to verbalize needs. Rates pain 10/10 to the left leg. . . . Notification: (Physician) notified and gave order to transport to (emergency room ) for evaluation via ambulance. . . ." The fall incident report, dated 01/10/14 at 1:45 p.m., further identified, ". . . No witnesses found. . . . Re-education to staff done." The incident report failed to identify environmental hazards that had been removed/corrected, a summary of the investigation including possible contributing factors, or the actions taken to prevent future falls. The emergency room evaluation, dated 01/10/14 at 3:20 p.m., identified, ". . . Apparently she was going to the salon today and was waiting to have her hair done. She generally requires assistance to transfer but staff found her lying on her side with her wheelchair. Apparently the chair was on its side. The fall was not witnessed and when she was found (Resident #1) was complaining of most of the pain in her hip but also pain through her anterior left shoulder. She does have a known history of osteoporosis with a total hip replacement on the right and open reduction, internal fixation of the left hip and a known rotator cuff tear on the right shoulder. . . . No swelling, bruising or injury to the knee is noted. . . . Assessment: Fall with contusion of left hip and shoulder . . ." The progress notes identified the following: * 01/10/14 at 5:02 p.m., "Resident came back from (hospital) with orders. . . . Resident has a bruise to her left knee and it is swollen which happened at facility (approximately one hour 30 minutes after returning to the facility)." * 01/15/14 at 10:12 p.m., "Appt (appointment) made to see (physician) 1-16-14 . . . Left knee pain from post fall 1-10-14 . . ." * 01/16/14 at 1:36 p.m., "Resident returned to facility without incident. (six days post fall and after Resident #1 complained of severe pain on ten occasions) . . . received call from (physician) that resident has a bad distal fx (fracture), keep immobilizer on at all times . . ." The radiology report, dated 01/16/14, identified, ". . . IMPRESSION: Comminuted angulated fracture in the distal femur potentially extending into a joint space although difficult to confirm. . . ." During an interview on 10/02/14 at 8:10 a.m., a managerial nursing staff member (#13) reported, "(Resident #1) was in the wheelchair lift (when she fell ). The lift reclines the wheelchair so they (beauticians (#23 and #24)) can put their (the resident's) head in the sink. It's unclear if she (the beautician (#24)) didn't lock it or if she bumped the lock. The chair went sideways. Staff (the beauticians (#23 and #24)) were re-educated on the lift. Two beauticians (#23 and #24) were in the room (at the time of the fall)." The information obtained during the interview (regarding the resident having been in a lift and facility staff being present at the time of the the fall) directly conflicts with the incident report and the emergency room evaluation. During observation/interview on 10/02/14 at 8:30 a.m., an administrative staff member (#17), a managerial nursing staff member (#13), and beautician (#23) used straps to secure the front wheels and J-hooks to secure the back wheels of a wheelchair to the wheelchair recline unit (lift). The beautician (#23) reported, although present the day of the fall, she "didn't see (Resident #1) fall." She reported turning around and seeing the wheelchair to the left of the lift and Resident #1 lying on the floor to the right. She stated, "The (second beautician (#24) (who is no longer employed at the facility)) said she didn't strap the front two (wheels)." (At the time of this interview the administrative staff member (#17) was unaware of this fact.) The beautician (#23) unstrapped the front wheels of the wheelchair per request, and this surveyor attempted to dislodge the wheelchair from the lift with only the J-hooks in place. The administrative staff member (#17), the managerial nursing staff member (#13), and the beautician (#23) confirmed the wheelchair was secure. The information obtained during the observation/interview (regarding the resident having been partially secured in the lift and facility staff being present at the time of the the fall) directly conflicts with the incident report and the emergency room evaluation. During interview on 10/02/14 at 10:27 a.m., an administrative staff member (#17) and beautician (#23) confirmed they were unable to provide proof of staff education (prior to and/or following the 01/10/14 incident). During interview on 10/02/14 at 10:40 a.m., a beautician (#23) provided additional information regarding the 01/10/14 incident. She reported she was giving "a perm and didn't hear anything." When the (second beautician (#24)) called out to her, and she turned to see "(Resident #1) already on the floor." The beautician (#23) reported stating, "You didn't have her strapped," to which the (second beautician (#24)) responded, "Yes I did." (This statement directly conflicts with her earlier statement.) The beautician (#23) also stated, "It makes sense. She (#24) couldn't have strapped (Resident #1) in. She (#24) couldn't have undone the straps and moved the wheelchair before I turned around." The facility failed to: * thoroughly investigate and determine the external causative factor(s) of Resident #1's fall and resulting fracture, placing her and other residents at risk of further injury. The incident report failed to identify environmental hazards that had been removed/corrected, a summary of the investigation including possible contributing factors, or the actions taken to prevent future falls. In addition the information obtained from interviews directly conflicted with the incident report and the emergency room evaluation. * educate staff on the proper use of the "Wheelchair Recline" unit. The "Wheelchair Recline" pamphlet lacked specific instruction on how to properly use the unit. ELOPEMENT 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the safety of 1 of 1 wandering resident (Resident #2) who exited the facility while wearing a wanderguard bracelet. Failure to provide adequate supervision and/or evaluate the effectiveness of the interventions the facility had put in place, allowed Resident #2 to elope from the facility on eight separate occasions, and on one of those occasions sustain a head injury. Findings include: Review of the facility policy titled "Missing Residents" occurred on 10/02/14. This policy, dated April 2014, stated, ". . . 3. Upon return of the resident to the facility, the Charge Nurse should . . . b. Examine the resident for injuries; c. Contact the primary physician and report findings and conditions of the resident; d. Notify the resident's legal representative; e. Complete and file an incident report; and f. Make appropriate entries into the resident's medical record." The policy failed to address the need for an investigation focusing on how the resident was able to exit the facility unsupervised, and failed to address any interventions required to prevent a reoccurance. During the initial tour of the facility on the morning of 09/29/14, an unidentified staff member reported Resident #2 wanders and had exited the facility on more than one occasion. Subsequent observations made throughout the survey (September 29-October 2, 2014) showed Resident #2 wearing a name tag and wandering throughout the facility. Resident #2's medical record, reviewed September 29-October 2, 2014, identified [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and need for supervision with locomotion on/off the unit. The current physician's orders identified, ". . . Wanderguard on Check q (every) shift and change as needed. . . ." The current care plan identified, ". . . Focus: (Resident #2) has potential for elopement due to dementia. . . Interventions: . . . Wanderguard placed on person. . . Door alarm. . . ." The routine care sheet (provided to direct care staff) further identified, ". . . Res. (Resident) is high elopement risk. Has Code alert and also wears a name tag that identifies her as a Resident. Please monitor that she wears this when she is up and walking around. Will take it off frequently." The progress notes identified the following: * 10/30/13 at 3:59 p.m., "Code alert was alarming. Went to check to see who it was. Res. (Resident) (#2) was walking over with another resident from the (Assisted Living Center). . . . * 12/27/13 at 12:03 p.m., "Resident walked over to (Assisted Living Center) x 2 this AM. She states she was just out walking and wanted to go back and see everyone. Wanderguard did not trip alarm. Wanderguard is checked and in working order. Changed wanderguard to (L) (left) wrist." The wanderguard failed to alert staff Resident #2 had exited the facility. Nursing staff failed to complete an incident report for each of the incidents. * 03/03/14 at 5:00 p.m., "Resident was found in (room on A Lane) with door closed. Resident was taking her blouse off. Room was empty. . . ." * 03/02/14 at 10:20 p.m., "Resident went in (room on D Lane). Sat in resident's chair and 'fiddled' with some of the occupant's things. Was taken back to her room . . ." * 03/06/14 at 1:36 p.m., "Resident found at (Assisted Living Center) by staff . . . over there and brought resident back to her room and reported to me. Door alarmed as she brought resident back into facility. Will continue to monitor on 15 min (minute) checks. Wanderguard on and working now." The wanderguard failed to alert staff Resident #2 had exited the facility. * 07/24/14 at 10:51 a.m., ". . . No episodes of leaving her designated area recently although she does follow people when they are walking towards the (Assisted Living Center) and needs cues to turn around when she gets to the door. . . . Resident continues to use a wanderguard bracelet to prevent elopement from the building. This is non purposeful when it does happen, and resident will turn around if the alarm sounds at the door. . . ." * 07/29/14 at 4:03 p.m., "Wanderguards all checked good in a.m., resident was found in tunnel going to the (Assisted Living Center) by (Assisted Living Center) staff. Tried and was able to also walk out the front door. New wanderguard placed on resident . . . this one did lock the door. . . ." The wanderguard failed to alert staff Resident #2 had exited the facility. The 07/29/14 incident report was submitted at 2:45 p.m. (approximately 1 hour 15 minutes prior to the progress note), and the "close record observation" log for that day showed staff made no entries from 2:00 p.m. to 2:45 p.m. "hall" was recorded at 2:45 p.m. The time the nurse documented on the incident report conflicts with the entries made by the CNAs on the "close record observation" log. The progress notes identified the following: * 08/11/14 at 8:00 p.m., "Resident was sitting on the curb at (Park) on 19th Street which is the street that runs in front of the nursing home. Someone driving by saw her there and stopped to help her. She couldn't get up off the curb, she had gross (sic) on the back of her shirt, and said, 'I smacked the back of my head pretty good.' The lady was unable to help her get up off the curb by herself so a couple of high school boys stopped and helped her get (Resident #2) into her car. (Resident #2) was able to tell her she lived at the (Assisted Living Center). (Resident #2) has a 5 cm superficial abrasion to her scalp in the middle of the back of her head which is elevated. Resident did not want to hold a cold pack to the area. Resident did not want to sit in her recliner. She said, 'I've got to keep moving.' Resident stated she left the building with a bunch of people. Neuro checks were initiated per facility policy. Resident is on 15 minute safety checks/close observation. A prayer service was being held in the nursing home chapel and there was a large, noisy crowd of people and was a change to (Resident #2's) usual environment and routine. She talked about feeling really foolish and embarrassed about what happened. Reassurance was given numerous times -- she felt like she had done something wrong. We assured her that she had done nothing wrong." The wanderguard failed to alert staff Resident #2 had exited the facility. The incident report, submitted 08/11/14 at 7:50 p.m., further identified, "At approximately 7:50 p.m., a young woman . . . brought resident (#2) into the nursing home. . . . (Resident #2) later said that she walked out of the nursing home with a bunch of people. . . . Resident (#2) is always on 15 minute checks. . . . At 7:00 p.m. there was a prayer service being held in the chapel and there was a large, noisy crowd of people. This change in routine or in her environment bothered her and she was sort of nervous. About 6:45 p.m. her wanderguard had set off the alarm to the (Assisted Living Center). We went over and got her and returned her to her neighborhood. About 10 minutes later, her wanderguard set off the alarm at the front door where she was found in the large crowd of people in the chapel. She came back to the neighborhood again. When she left the building, her wanderguard did not set off the alarm and it did not come over the pagers. She said that she left with a bunch of people. The batteries on the wanderguards had already been checked on our shift. . . . 08/12/14 ID (identification) bracelt (sic) on wrist. . . . 08/12/14 Name tag given to resident to alert others that she is a resident at (Facility). . . . 08/15/14 Placement to a more appropriate facility is being looked at." The 08/11/14 incident report was submitted at 7:50 p.m., and the "close record observation" log for that day showed Resident #2 was in the "hall by the kitchen" at 7:45 p.m. and "outside" at 8:00 p.m. The time the nurse documented on the incident report conflicts with the entries made by the CNAs on the "close record observation" log. The progress notes identified the following: * 09/25/14 at 3:25 p.m., "(Family) updated on Elopment (sic) episode on 09/24/14 (at) 11 p.m. . . . Spoke with (Family) regarding recent elopement. She approved sending information to (another nursing home) for potential placement in their Memory Care unit. . . ." * 09/26/14 at 11:00 p.m., "Door alarm placed this shift for NOC (night)'s and per shift at nurse discretion. . ." * 09/26/14 at 11:26 p.m., ". . . Resident followed staff outside, evening of the 24th. She was assisted back into the building without further attempts." The wanderguard failed to alert staff Resident #2 had exited the facility. The incident report, dated 09/24/14, further identified, "(CNA) called to inform nurse that (Resident #2) went out the back door and (another CNA) brought her back into the building. . . . Wanderguard was checked earlier this shift and in working order. Checked again and is still in working order. . . . 09/25/14 Upon further investigation it was noted that (Resident #2) walked out after pm staff were leaving (The incident report indicated this occurred at 11:00 p.m.), using the employee exit. When (CNA) was backing out her car she noticed (Resident #2) heading towards the maintenance shop. (Another CNA) escorted Resident (#2) back into building. Alarm didn't sound related to staff exiting building and using code to exit. Continue with code alert and need for placement in a secured facility related to high risk of elopement. . . . 09/26/14 Door alarm placed during NOC shift and all other shifts per nursing discretion. . . . 09/30/14 Clarification . . . door alarm motion sensor placed to her room. . . . 09/30/14 Moving to (another facility)." The 09/24/14 incident report was submitted at 11:00 p.m., and the "close record observation" log for that day showed Resident #2 was in the "hallway" at 10:45 p.m. and "outside" at 11:00 p.m. The time the nurse documented on the incident report conflicts with the entries made by the CNAs on the "close record observation" log. During an interview on 09/30/14 at 5:00 p.m., a nurse (#16) reported, "The only way to get to (Assisted Living Center) is through the tunnel." She explained, "It requires a key or phone (to be) beeped in (if you try to enter the building from the outside.)" She also indicated the wanderguard should sound when exiting the facility, but would not sound when entering the facility from the Assisted Living Center. During an interview on 09/30/14 at 5:15 p.m., an administrative nurse (#1) walked the surveyor through the tunnel and explained where each of the nine doors in the tunnel led. One door led to the Assisted Living Center, one led to a flight of stairs, three led to adjoined garages, and one led outdoors, and once closed would not allow re-entry. During an interview on 10/01/14 at 2:40 p.m., two administrative staff members (#1 and #17) and three managerial staff members (#7, #13, and #18) reported "up until this summer (Resident #2) always went to the ((Assisted Living) Center) which is staffed 24 hours a day." They stated, "We got serious about a locked unit after she got outside. After she followed three staff members out into the parking lot, we had to do something. Her family wasn't happy. They wanted her to stay, but she's not safe here." They also explained "(Resident #2) doesn't look like a resident. (She) followed the crowd out the front door after attending the service in the chapel. Once the front door is opened it doesn't alarm." They described 19th street as a "high traffic" area, and reported the resident was returned to the facility "(with)in 15 minutes." The facility's "elopement" policy failed to address the need for an investigation focusing on how the resident was able to exit the facility unsupervised, and failed to address any interventions required to prevent a reoccurance. The facility failed to revise the resident's care plan if/when they initiated a new intervention (an identification bracelet, a name tag, and/or motion sensor.) The nursing staff failed to complete incident reports for two of Resident #2's elopements on 12/27/13. The CNA staff failed to monitor Resident #2's whereabouts every 15 minutes. The nursing documentation on the incident report conflicts with the entries made by the CNAs on the "close record observation" logs. The wanderguard failed to alert staff Resident #2 had exited the facility on eight separate occasions, and was outdoors on three of the eight occasions. The facility failed to provide adequate supervision and/or evaluate the effectiveness of the interventions they had put in place, which allowed Resident #2 to elope from the facility, and on one of those occasions sustained a head injury. GAIT BELT/MECHANICAL (EZ STAND) LIFT TRANSFERS 3. Based on observation, record review, review of operating instructions, review of facility policy, and staff interview, the facility failed to ensure appropriate use of assistive devices to prevent accidents for 2 of 8 residents (Resident #3 and #9) who required extensive staff assistance for transfers. Failure to properly use a sit-to-stand (E-Z Stand) lift (Resident #3) and gait belt (Resident #9) increased the risk for falls, pain, and injury to residents. Findings include: Review of the facility policy titled "Mandatory Lift" occurred on 10/02/14. This policy, dated April 2014, stated, "POLICY: Gait Belts or mechanical lifts will be used for all residents requiring assistance with transfers . . . PROCEDURE: The nursing or therapy staff will evaluate individual resident's ability to assist with transfer . . . Gait belts should be used with all assisted transfers unless contraindicated or resident refusal. . . ." - Review of Resident #9's medical record occurred on September 29-30, 2014 and [DIAGNOSES REDACTED]. The current care plan stated, "Focus: Decreased ADL (Activities of Daily Living) function . . . Intervention: . . . extensive to total assist with bed mobility, transfers and ambulation depending on her day. . . ." Observation on 09/30/14 at 3:55 p.m. identified two certified nursing assistants (CNAs) (#5 and #6) transferred Resident #9 from her wheelchair to the toilet using a gait belt. Both CNAs (#5 and #6) held the gait belt with one hand and lifted under Resident #9's arms with their other hand. Observation on 09/30/14 at 4:05 p.m. identified two CNAs (#5 and #6) assisted Resident #9 from the toilet to her wheelchair using a gait belt. One CNA (#6) lifted under Resident #9's arm to assist her to a standing position from the toilet. As Resident #9 ambulated to her wheelchair, observation showed the gait belt was loose and bunched up in the CNA's hand. During an interview on the afternoon of 10/02/14, an administrative nurse (#2) stated staff should grasp the gait belt during transfers and avoid pulling on the resident's arms. Review of the manufacturer's guideline "EZ Stand Operating Instructions" occurred on 10/02/14. The instructions, revised January 2001, stated, ". . . The EZ Stand was designed specifically for toileting and changing briefs of patients. The EZ Stand can also be used for transferring the patient from chair, wheelchair or bed. . . . Patients should be able to bear some weight." - Review of Resident #3's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], identified intact cognition and need for extensive assistance of two or more persons for transfers. The current care plan addressing Resident #3's transfer needs identified, ". . . Interventions: . . . (Resident #3) requires extensive assistance for transfers with use of standing lift. . . . Stand lift at all times. . . ." Observations showed the following: * 09/30/14 at 12:35 p.m., a CNA (#11) transferred Resident #3 from the toilet to his wheelchair using the EZ Stand lift. The resident did not bear weight and was in a seated position as he hung from the harness. As the harness straps pulled upward into Resident #3's axillae (armpits), his shoulders raised to ear level. * 09/30/14 at 3:30 p.m., a CNA (#12) transferred Resident #3 from his wheelchair to the bed using the EZ Stand lift. The resident did not bear weight and was in a seated position as he hung from the harness. As the harness straps pulled upward into Resident #3's axillae, his shoulders raised to ear level. Staff failed to cue Resident #3 to stand, ensure he was able to bear weight throughout the stand lift transfer, and report his inability to bear weight to the nurse. - Observation on 10/02/14 at 11:05 a.m. showed a CNA (#9) assisting Resident #14 from her wheelchair to the toilet utilizing a stand lift. While securing the harness hook to the end of the EZ Stand arm, she discovered a missing "safety stopper" on the right side. Using her pager, the CNA (#9) requested assistance and an unidentified CNA came to the resident's room to give her (#9) the safety stopper she had removed from another EZ Stand located at the nurses station. Per request, following cares, the CNA (#9) showed this surveyor the EZ Stand with the missing "safety stopper." The unidentified CNA had failed to label the machine "disabled" after removing the "safety stopper," and the EZ Stand remained available for use. Upon inspection, it was discovered that both "safety stoppers" were missing from the machine. During an interview on the morning of 10/02/14, a managerial nursing staff member (#13) confirmed a resident should be able to bear his/her own weight if a sit-to-stand lift is used. She also confirmed equipment should be labeled "disabled" if parts are missing.