Every finding on record at SMP Health - Maryhill

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to ensure safety for 2 of 4 sampled residents (Resident #2 and #9) observed during transfers and ambulation. Failure to utilize gait belts and the required staff assistance placed the residents at risk for accidents and/or injury. Findings include: Review of the facility policy titled Safe Resident Handling/Transfers occurred on 09/25/25. This policy, dated May 2025, stated, . It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience . Review of the facility policy titled Standards of Care Policy occurred on 09/25/25. This policy, dated August 2025, stated, . Gait belt will be used when resident needs assistance with walking and transferring. - Review of Resident #2's medical record occurred on all days of survey. The care plan stated, . MOBILITY: I use a w/c [wheelchair] for mobility. [NAME] PRN [as needed] when able with staff assist. TRANSFER: I need assist of two [staff] with gait belt and pivot for transfers . I have impaired Cognitive Function . A quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition. Observation on 09/23/25 at 4:02 p.m. showed a certified nurse aide (CNA) (#6) assisted Resident #2 to the edge of the bed, applied a gait belt, and assisted to stand in front of a front wheel walker (FWW). The resident lightly held onto the walker handles, leaned back into the CNA's hand and away from the walker, and began to walk towards the bathroom. The resident vocally expressed fear of falling. The CNA (#6) stated, She [Resident #2] is a walk-to-dine but we will need to use the wheelchair. She didn't do very well [transfer/ambulate]. After toileting, the CNA (#6) assisted the resident to stand with the gait belt and directed him/her to hold onto the walker handles. The CNA utilized the gait belt and pivoted the resident to the wheelchair. Review of Resident #2's ADL care sheet, dated 09/22/25, identified the resident required two staff assistance with a gait belt with pivot transfers. The care sheet failed to identify walk-to-dine. The CNA (#6) failed to follow Resident #2's plan of care for two staff assistance with transfers and utilize a wheelchair for mobility to the bathroom ensuring the resident's safety. During an interview on 09/25/25 at 10:25 a.m., an administrative staff member (#1) confirmed Resident #2 required two staff for transfers. - Review of Resident #9's medical record occurred on all days of survey. Diagnoses included dementia and repeated falls. The care plan stated, . I am an assist of one and a pivot transfer. I am unable to walk due to decreased strength and mobility . I am at risk for falls r/t [related to] Gait/balance problems and hx [history] of falls. A quarterly MDS, dated [DATE], indicated maximum assistance required with toilet transfer and chair/bed - to - chair transfer. Review of Resident #9's ADL care sheet, dated 09/22/25, showed the resident required one staff assistance and a gait belt for transfers. Observation on 09/22/25 at 1:14 p.m. showed a CNA (#4) placed both hands on Resident #9's buttocks/hips to turn the resident's body when transferring from a wheelchair to the toilet, from the toilet back into the wheelchair, and from the wheelchair into a recliner. The resident was hunched over during the transfers. Observation on 09/23/25 4:46 p.m. showed a CNA (#3) placed both hands on Resident #9's buttocks/hips to turn the resident's body when transferring from a wheelchair to the toilet and from the toilet back into the wheelchair. The CNA (#3) stated, He [Resident #9] is not one we use the gait belt on. How he does [transfers] depends upon how tired he is. Both CNAs (#3) and (#4) failed to utilize a gait belt when transferring Resident #9. During an interview on 09/25/25 at 12:00 p.m., an administrative staff member (#1) stated, she expected staff to follow the ADL care sheet and use a gait belt for Resident #9's transfers.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 4 sampled residents (Resident #2, #27, and #28) observed during cares. Failure to practice infection control standards during personal cares has the potential to spread infection throughout the facility.Findings include: Review of the facility policy titled Infection Prevention and Control Program occurred on 09/25/25. This policy, revised May 2025, stated, . Institutional factors may also facilitate transmission of infections among residents. Direct/indirect contact with equipment used to provide care. Improper hand hygiene. Improper glove use. Hand hygiene continues to be the primary means of preventing the transmission of infection. Glove Hygiene . Remove and discard gloves . after every procedure that involves potential exposure to blood or body fluids. Perform hand hygiene immediately after removal of gloves . Resident dressings and supplies should be properly stored to maintain their integrity . - Observation on 09/23/25 at 11:10 a.m. showed a certified nurse aide (CNA) (#4) entered Resident #28's room, performed hand hygiene, applied gloves, removed the resident's clothing and a soiled brief, and completed perineal cares. With the same gloves, the CNA (#4) applied a clean brief, washed and dried the resident's legs and feet, applied clean socks and pants, assisted the resident into a wheelchair, removed a shirt, washed the resident's back, and applied a clean shirt. The CNA (#4) then removed the soiled gloves and performed hand hygiene. The CNA (#4) failed to remove their soiled gloves, perform hand hygiene, and apply new gloves between clean and dirty tasks. - Review of Resident #27's medical record occurred on all days of survey and identified the resident on enhanced barrier precautions related to wounds. Observation on 09/23/25 at 1:50 p.m. showed a nurse (#5) applied personal protective equipment (PPE) inside Resident #27's room, obtained wound supplies from a basket in the room, and placed the supplies onto an overbed table visibly soiled with dried liquid/food. While the resident laid on the bed, the nurse sprayed wound cleanser onto a weeping abdominal wound, dried the wound with gauze, and without removing their soiled gloves, opened clean dressing supplies, used the scissors to cut one of the dressings to fit the wound, placed it into the wound, and covered the area with a foam dressing. The nurse then removed the soiled gloves, performed hand hygiene, applied new gloves. After applying another wound dressing, the nurse removed the soiled gloves, performed hand hygiene, applied clean gloves, and placed the bottle of wound cleanser and the scissors back into the wound supply basket without sanitizing them. The nurse placed the overbed table beside the resident without sanitizing the surface, removed their PPE, performed hand hygiene, and exited the room. The nurse (#5) failed to place the wound supplies onto a clean surface, remove their soiled gloves, perform hand hygiene, and apply clean gloves after cleansing a wound and before applying a clean dressing, sanitize the wound cleanser bottle and scissors before placing them back into the basket, and sanitize the overbed table. - Observation on 09/23/25 at 4:02 p.m. showed a certified nurse aid (CNA) (#6) performed hand hygiene, applied gloves, assisted Resident #2 to the bathroom, removed a soiled brief, performed perineal cares, applied a clean brief, pulled up the resident's pants, and transferred the resident into a wheelchair. Without removing their soiled gloves, the CNA combed the resident's hair, adjusted their clothing, and moved the wheelchair from the bathroom to the room doorway. The CNA removed their soiled gloves, performed hand hygiene, and exited the room. The CNA (#6) failed to remove their soiled gloves and perform hand hygiene after perineal care and before to moving onto other tasks and failed to disinfect the wheelchair handles after touching them with soiled gloves. During an interview on 09/25/25 at 10:25 a.m., an administrative staff member (#1) stated she expected staff to place the wound supplies onto a clean surface, remove soiled gloves after cleaning wounds and before applying clean dressings, sanitize the wound cleanser and scissors before placing them back into the wound supply basket, sanitize the overbed table after wound cares, and remove gloves/perform hand hygiene after perineal care and before moving on to other tasks.

Based on observation, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to sanitize surfaces in 1 of 1 facility dining room. Failure to ensure the concentration of quaternary (quat) sanitizing solution is within manufacturer's guidelines may result in an incorrect solution concentration, inadequate sanitization of dining room surfaces, and places residents at risk for foodborne illness. Findings include: Review of the facility policy titled Cleaning Tables and Counters occurred on 09/11/24. This policy, revised February 2023, stated, . (counters, tables), apply a 200-400 ppm [parts per million] quaternary solution with a cloth . making sure that the surface remains completely visibly wet for at least 60 seconds and let air dry. Review of manufacturer's instructions for Oasis 146 Multi-Quat Sanitizer identified a concentration of 150 ppm - 400 ppm active quat for effective sanitizing. Observation in the dining room on 09/09/24 at 11:40 a.m. showed a dietary staff member (#5) wiping the kitchen serving counter and dining room tables/chairs with the Oasis 146 quat sanitizing solution. When asked to test the solution, the dietary staff member (#5) tested the solution twice showing a concentration of 50 ppm. During an interview on 09/09/24 at 11:58 a.m., a dietary supervisor (#4) stated she expected staff to mix the quat solution in the correct concentration.

Based on record review and staff interview, the facility failed to comply with the North Dakota Administrative Code (NDAC), Chapter 33-43-01-20 Medication assistant I and II initial registration and renewal for 1 of 1 staff member (#4) administering medications to residents as a medication assistant (MA). Failure to ensure qualified staff administered medication increases the risk for adverse consequences. Findings include: NDAC, Section 33-43-01-20 Individuals may not be employed as a medication assistant I or medication assistant II or hold themselves out to be a medication assistant I or medication assistant II unless the individual holds a registration as a medication assistant I or medication assistant II on the department's nurse aide registry. Individuals with delegated responsibility for administration of medication to a client as a medication assistant II must hold a current status on the department's registry as a certified nurse aide . 3. Individuals may obtain initial medication assistant II registration by successfully completing a department-approved medication assistant II program. Review of staff member #4's employee file occurred on 04/03/24 and lacked verification of a current North Dakota MA registry. Review of facility schedules for the dates of October 29, 2023, to December 02, 2023, showed staff member (#4) scheduled as a MA on 17 shifts and for the dates of January 28, 2024, to February 24, 2024, for 12 shifts. Review of facility electronic medication administration records (MAR) showed staff (#4) administered medications from July 2023, through February 2024 to residents. During an interview on 04/03/24 at 4:45 p.m., an administrative staff member (#1) confirmed staff member (#4) administered medications and the facility failed to verify medication assistant registration. Based on the following information, non-compliance at F836 is considered past non-compliance. The facility addressed the corrective action accomplished for the MAII and all facility residents affected by the deficient practice by: * The facility pursued a Human Resources portal through their payroll company to ensure staff licensing/registration information tracked for license/registry verification/expiration. This process began on 02/05/24. * On 02/23/24 the facility found staff member #4 lacked a current North Dakota MA registry. Facility management immediately removed staff member #4 from MAII duty. * On 02/26/24 facility management revised the policy/procedure titled License Verification. This policy, currently dated March 2024, stated, . All personnel that require a license of certification shall be verified through the appropriate issuing agency upon employment and renewal thereafter during the term of employment. The policy outlined the process and responsibility for license verification effective 03/01/24. * On 02/27/24 and 02/28/24 clinical staff education regarding License Verification policy/procedure. * On 03/21/24 all staff education regarding License Verification policy/procedure. The surveyor determined the facility discovered the deficient practice on 02/23/24. The facility implemented corrective action on 02/23/24 and completed clinical staff education on 02/27/24 and 02/28/24, and all staff education on 03/21/24.

Based on observation, review of facility policy, record review, and staff interview, the facility failed to ensure the competency of nursing staff for 1 of 1 nursing staff (#7) observed during insulin administration (#143) . Failure to provide a meal or juice with in 5-10 minutes after administering short acting insulin, administering insulin to a nonarousable resident, and failure to notify a nurse of a resident's altered status may result in harm to facility residents. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 10/03/23 at 2:00 p.m. The IJ resulted from a medication aide administering short acting insulin to a resident not alert enough to consume food thus, putting the resident at risk for a reaction from low blood sugar. The staff member who administered the insulin lacked awareness of the side effect of failing to provide food after administration of short acting insulin. The staff also failed to notify the nurse of Resident #143's altered status. * 10/03/23 at 2:34 p.m., The survey team contacted the State Survey Agency (SSA) to report the findings and discuss potential immediate jeopardy (IJ). The survey team was instructed to verify further details. * 10/03/23 at 3:49 p.m., The survey team contacted the SSA again for further discussion regarding the potential IJ situation and verified the presence of IJ. * 10/03/23 at 4:08 p.m., The SSA contacted the survey team after discussion with the CMS (Centers for Medicare & Medicaid Services) location and verified the presence of IJ. * 10/03/23 at 5:15 p.m., The survey team notified the administrator, and the director of nursing (DON), of the IJ situation, provided them with the IJ template, and requested they develop a plan for removal of the immediate jeopardy. * 10/04/23 at 8:55 a.m., The administrator, and the DON presented the IJ removal plan for the survey team to review. The removal plan contained the following: * DON completed a comprehensive assessment including vitals, attempted to arouse the resident, attempted to offer food and drink, and updated Resident #143's medical provider. * Inservice and education on facility policy/procedure for administering short acting insulin, appropriate actions/interventions to ensure resident safety with the staff member directly involved in the deficient practice, all nursing staff on duty, and on-coming staff. * Review of facility policies and resources for questions/concerns. * 10/04/23 at 11:16 a.m., The survey team reviewed and accepted the facility's removal plan for the IJ. The survey team verified the implementation of the removal plan as of 10/03/23. The deficient practice remained at an D scope and severity following the removal of the IJ. Findings include: Review of the facility policy titled Insulin occurred on 10/05/23. This policy, dated February 2022, stated, . Policy: It is the policy of this facility .to prevent adverse effects on a resident's condition. short acting insulin should be administered at the start of the meal. (10 minutes max [maximum] prior to the start of eating). If a resident doesn't eat after getting insulin the charge nurse should be notified and proper, follow up and monitoring completed. Review of Resident #143's medical record occurred on all days of survey and included a diagnosis of diabetes mellitus. A physician's order, dated 09/28/23, stated, . Novolog 20 units subcutaneous four times a day . Observations on 10/03/23 showed the following: * 11:57 a.m. a medication aide (#7) entered Resident #143's room to check his blood sugar and administer insulin. The MA (#7) said the resident's name and he would open his eyes and fall back asleep. The medication aide attempted to wake the resident by rubbing his arms and cheek with no response from the resident. The medication aide checked the resident's blood sugar with the results of 174 milligrams per deciliter (mg/dl), administered 20 units of Novolog insulin [a fast acting insulin], and exited the room. * 1:04 p.m. a Certified Nurse Aide (CNA) (#4) attempted unsuccessfully to awaken Resident #143 to provide the meal. Staff returned the tray to the kitchen. * 1:12 p.m. This surveyor informed an administrative staff member (#1) of the situation concerning Resident #143. The administrative staff member informed the MA she needed to check Resident #143's blood sugar at this time. * 1:19 p.m. The administrative staff member (#1) and MA (#7) checked Resident #143's blood sugar with the results of 136 mg/dl. *1:21 p.m. The administrative staff member (#1) went to the kitchen to get Resident #143 some food. * 3:07 p.m. a MA (#7) checked Resident #143's blood sugar with a result of 102 mg/dl. * 3:17 p.m. a MA (#7) stated,I did not know that [the resident needs to eat with in 5-10 minutes after administering a rapid acting insulin] until they told me [earlier today]. * 4:23 p.m. a MA (#8) checked Resident #143's blood sugar with a result of 86 mg/dl. During an interview on 10/03/23 at 5:27 p.m., an administrative staff member (#1) confirmed she expected staff to administer short acting insulin with a meal, inform the nurse if a resident is not eating after short acting insulin administration, and if a resident is nonarousable.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 6 sampled residents (Resident #3 and #18) observed during personal cares. Failure to practice infection control standards related to hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the policy titled Infection Prevention and Control Program occurred on 10/04/23. This policy, dated May 2023, stated, . Glove Hygiene (Always make sure that resident is safe prior to glove removal and washing hands) . Perform hand hygiene immediately after removal of gloves . - Observation on 10/04/23 at 11:55 a.m. showed two certified nurse aides (CNAs) (#2 and #3) assisted Resident #3 with a check and change. One CNA (#3) donned gloves and performed incontinence care as the other CNA (#2) assisted with turning the resident. After removing her gloves the CNA (#3) repositioned the resident's bedside table, opened the curtain, repositioned the resident's call light, placed a pillow behind the resident's head and right arm, touched the resident's headset and remote, moved the wheelchair, and covered the resident with a blanket before performing hand hygiene. - Observation on 10/04/23 at 4:00 p.m. showed two CNAs (#2 and #3) transferred Resident #18 onto the toilet. One CNA (#3) performed perineal care as the resident stood near the toilet. With visible stool on the wipe, the CNA (#3) completed perineal cares and assisted the resident into the wheelchair. After removing her gloves the CNA (#3) positioned the wheel chair at the sink, obtained a hand towel for the resident, repositioned the wheelchair, assisted the resident into the recliner, moved the resident's fluids closer to the resident, and covered the resident with a blanket before performing hand hygiene. The CNA (#3) failed to perform hand hygiene after glove removal and before completing other tasks. During an interview on 10/05/23 at 2:00 p.m., an administrative nurse (#1) stated she expected staff to perform hand hygiene after glove removal after the resident is in a safe position. 40489

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician of a change in condition for 1 of 1 sampled resident (Resident #3) who experienced a change in bowel status. Failure to notify the physician of these changes may have prevented the physician from altering the treatment/care provided to the resident. Findings include: Review of the facility policy titled Notification of Changes occurred on 10/05/23. This policy, dated 07/04/23, stated, . The purpose of this policy is to ensure the facility promptly . consults the resident's physician . Circumstances requiring notification include: . 3. Circumstances that require a need to alter treatment. Review of Resident #3's medical record occurred on all days of survey. Diagnoses included cirrhosis of the liver and metabolic encephalopathy (a brain disease). A physicians order, dated 06/02/23, stated, Lactulose Solution (a medication known to cause loose stools) 10 GM [grams]/15ML [milliliters] Give 30 ml by mouth three times a day Review of a fax sent to the facility from Resident #3's Geriatric Internist on 09/29/23 stated, . With the lactulose, he needs to be having 3 or 4 BM's [bowel movements] per day. follow number of BM's per day and if not having enough we can increase the lactulose dose. Review of Resident #3's BM record showed the following: * 09/29/23 - Two BMs * 09/30/23 - No BMs * 10/01/23 - One BM * 10/02/23 - No BMs * 10/03/23 - One BM The medical record lacked documentation the facility updated Resident #3's geriatric internist regarding his lack of BMs. During an interview on 10/04/23 at 5:39 p.m., an administrative nurse (#1) confirmed she was not aware of the lack of BMs the resident had since the physician's order on 09/29/23.

Based on observation, record review, review of facility policy, and resident, family, and staff interviews, the facility failed to assess, develop, and implement interventions to promote dignity for 1 of 1 sampled resident (Resident #3) with concerns regarding toileting/incontinence. Failure to determine appropriate toileting methods caused Resident #3 embarrassment and/or psychosocial harm. Findings include: Review of the facility policy titled Standard of Care Policy occurred on 10/05/23. This policy, dated August 2023, stated, . Each resident is treated with dignity and respect. During an interview on 10/02/23 at 4:02 p.m., Resident #3 verbalized frustration when staff utilized that sling thing [full body lift] to get up and down. They [staff] told me to go to the bathroom in my pants. During an interview on 10/02/23 at 4:03 p.m., a family member (A) reported Resident #3 has been upset since staff started utilizing the Hoyer lift (full body mechanical lift) and stopped toileting the resident in the bathroom. A current physician ordered medication caused several loose stools per day. The resident is upset when unable to utilize the bathroom and is incontinent even when attempting to hold it. Review of Resident #3's medical record occurred on all days of survey and showed a physician's order, dated 06/02/23 for lactulose (a medication known to cause loose stools) to be administered three times per day. The current care plan stated, . TOILET USE: I require assistance to use toilet. The current certified nurse aide (CNA) Activities of Daily Living (ADL) sheet identified staff assist with scheduled toileting every 2-3 hours. Observation on 10/04/23 at 11:55 a.m. showed two CNAs (#2 and #3) completed an incontinence check/change for Resident #3. The CNAs transferred the resident from the bed to the wheelchair utilizing the Hoyer lift. Staff failed to offer the resident any other options for toileting to avoid incontinence. During an interview on 10/05/23 at 9:27 a.m., a CNA (#3) stated, . We just have [Resident #3] go in his pants and check and change him in bed. The facility failed to toilet Resident #3's according to his abilities/preferences which resulted in a loss of dignity, frustration, and avoidable incontinence. See F690

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 3 of 15 sampled residents (Resident #9, #12, and #35). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 10/05/23. This policy, revised August 2022, stated, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . the care planning process will begin upon admission and ongoing with changes. - Review of Resident #9's medical record occurred on all days of survey. Diagnoses included type 2 diabetes mellitus. The physician's orders included short-acting insulin with blood glucose monitoring three times a day. Resident #9's care plan lacked problem, goals, and interventions related to diabetes mellitus. - Review of Resident #12's medical record occurred on all days of survey. Diagnoses included type 2 diabetes mellitus. The physician's orders included long-acting insulin with blood glucose monitoring twice a week and as needed. Resident #12's care plan lacked problem, goals, and interventions related to diabetes mellitus. - Review of Resident #35's medical record occurred on all days of survey. Diagnoses included type 2 diabetes mellitus. The physician's orders included blood glucose monitoring daily. Resident #35's care plan lacked problem, goals, and interventions related to diabetes mellitus. During an interview on 10/05/23 at 2:00 p.m., an administrative nurse (#1) stated she expected staff to update the care plans to include diabetes mellitus and interventions. 31725 40489

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice regarding medication administration and monitoring blood sugars for 1 of 2 sampled residents (Resident #143) and 1 supplemental resident (Resident #8) observed during medication pass. Failure to ensure the resident eats within 5-10 minutes of receiving a rapid acting insulin and failure to monitor blood sugars per physician orders may result in a hypoglycemic reaction (low blood sugar), diabetic coma and/death and failure to ensure residents receive the correct medications may result in serious adverse health effects. Findings include: Review of the facility policy titled Insulin occurred on 10/05/23. This policy, dated February 2022, stated, . Policy: It is the policy of this facility .to prevent adverse effects on a resident's condition. short acting insulin's should be administered at the start of the meal. (10 minutes max [maximum] prior to the start of eating). If a resident doesn't eat after getting insulin the charge nurse should be notified and proper, follow up and monitoring completed. Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 831-832, stated, . Administer only medications personally prepared . pages 838-840 stated, . Administering Oral Medications . Gather the MAR(s) [medication administration records] for each client together so that medications can be prepared for one client at a time. Rationale . reduces the chance of errors. - Review of Resident #143's medical record occurred on all days of survey and included a diagnosis of diabetes mellitus. A physician's order, dated 09/28/23, stated, . Novolog 20 units subcutaneous four times a day . - Observations on 10/03/23 showed the following: * 11:57 a.m. a medication aide (MA) (#7) entered Resident #143's room to check the resident's blood sugar and administer insulin. The MA (#7) said the resident's name and he would open his eyes and fall back asleep. The MA attempted to wake the resident by rubbing his arms and cheek with no response from the resident. The MA then checked the resident's blood sugar, obtained a result of 174, administered 20 units of Novolog insulin [a rapid acting insulin], and exited the room. The resident failed to arouse during the finger stick or the injection. * 1:04 p.m. a certified nurse aide (CNA) (#4) entered Resident #143's room to bring him his dinner tray, 59 minutes after the MA administered his insulin. When the CNA stated the resident's name, the resident responded by opening his eyes and immediately went back to sleep. The CNA attempted to awaken the resident without success stating his name repeatedly, rubbing his arms and hands. The CNA took the resident's dinner to the MA (#7) and stated, [Resident #143's name] is zonked, could you take his dinner tray to the kitchen to keep it warm. The MA took the resident's tray to the kitchen and failed to notify the nurse of the situation. The facility failed to ensure the resident ate after administering rapid acting insulin, and notify the nurse about being unable to arouse Resident #143. Refer to F726 - Observation of medication pass occurred on 10/04/23 at 8:45 a.m. with a MA (#5). The MA prepared Resident #8's medication as a licensed nurse (#6) entered the medication room and stated, she needed [Resident #24's] medications. The MA (#5) stopped preparing the medications for Resident #8 and prepared Resident #24's medications, while the nurse (#6) stood on the opposite side of the medication cart. The MA (#5) crushed the medications, added pudding to the cup and handed the medications to the nurse. The nurse (#6) administered medications prepared by the MA (#5). During an interview on 10/05/23 at 2:00 p.m. an administrative nurse (#1) stated she expected staff to administer medications they had prepared. BLOOD SUGARS Review of the facility policy titled Diabetic Blood Glucose Checks occurred on 10/05/23. This policy, dated August 2023, stated, . PURPOSE Any resident with diabetes will have his/her blood glucose monitored as ordered by the physician. - Review of Resident #143's medical record occurred on all days of survey and included a diagnosis of diabetes mellitus. A physician's order, dated 09/28/23, stated, . Novolog [a rapid acting insulin] 20 units subcutaneous four times a day for Diabetes If BS [blood sugar] is under 150 do not give Novolog . The staff administered rapid acting insulin without verifying Resident #143's blood sugar was over 150 on the following dates and times: * 10/02/23 at 8:00 p.m. * 10/03/23 at 8:00 p.m. * 10/04/23 at 8:00 a.m. During an interview on 10/05/23 at 2:32 p.m., an administrative nurse (#1) stated she expected staff to check blood sugars before administering the insulin.

Based on observation, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 2 of 6 sampled residents (Resident #12 and #143) observed during a gait belt transfers. Failure to use a gait belt during transfers placed the residents at risk of accidents and injury. Findings include: Review of the policy titled Use of Gait Belt occurred on 10/04/23. This policy, dated May 2023, stated, It is the policy of this facility to use gate belts with residents that require hands on extensive assist to ambulate or transfer for the purpose of safety. Observations showed the following: * 10/03/23 at 9:49 a.m., a certified nurse aide (CNA) (#4) transferred Resident #143 from the wheelchair to the recliner without a gait belt. The CNA (#4) lifted under both of the resident's arms while the resident held onto the CNA's elbows. * 10/03/23 at 11:45 a.m., a CNA (#2) transferred Resident #12 from the toilet to the wheelchair without a gait belt. The CNA (#2) pushed upward on the resident's back and held onto the waist band of the resident's pants during the transfer. The CNA (#2) transferred the Resident #12 to the recliner by holding the resident's hands and pulling the resident up to a standing position. During an interview on 10/05/23 at 2:00 p.m., an administrative nurse (#1) stated she expected staff to use a gait belt with transfers. 40489

Based on observation, record review, and resident, family, and staff interviews, the facility failed to provide appropriate services and assistance to maintain bowel/bladder continence for 1 of 6 sampled residents (Resident #3) observed during toileting/incontinence care. Failure to provide toileting assistance may result in unnecessary incontinence, a loss of dignity, and avoidable skin issues. Findings include: Review of the facility policy titled Bowel and Bladder Program occurred on 10/05/23. This policy, dated April 2023, stated, . PURPOSE: [Facility Name] will provide appropriate programs and treatments for our residents . to restore and maintain as much normal bowel and bladder function as possible. During an interview on 10/02/23 at 4:02 p.m., Resident #3 verbalized frustration when staff utilized that sling thing [full body lift] to get up and down. They [staff] told me to go to the bathroom in my pants. During an interview on 10/02/23 at 4:03 p.m., a family member (A) reported Resident #3 has been upset since staff started utilizing the Hoyer lift (full body mechanical lift) and stopped toileting the resident in the bathroom. A current physician ordered medication caused several loose stools per day. The resident is upset when unable to utilize the bathroom and is incontinent even when he has tried to hold it. Review of Resident #3's medical record occurred on all days of survey. The care plan stated, . TOILET USE: I require assistance to use toilet. The certified nurse aide (CNA) Activities of Daily Living (ADL) sheet identified staff assist with scheduled toileting every 2-3 hours for Resident #3. Progress notes included the following: * 08/15/23 at 2:26 p.m., . Discharge: Physical Therapy . Patient finished therapy with the current transfer status of Pivot transfer into his chair, bed, and bathroom ModA [moderate assist] x1 [with one staff]. He was able to do this many times and consistently. * 08/28/23 at 12:55 p.m., . Therapy . UPDATE: OTR [Occupational Therapist Registered] has been notified from several staff that pt [patient] is having increased difficulty transferring with 1 person assist consistently and safely. Recommending 2 person assist for all transfers at this time. * 09/08/23 at 11:16 a.m., . Nurse note . Focus: room change/transfer Observation: RA's [restorative therapy aides] reported res [resident] having difficulties with transfers since room change. Action: Will use a pal-lift [sit to stand lift] at this time and have PT/OT [physical therapy/occupational therapy] assess. * 09/08/23 at 12:28 p.m., . Therapy . UPDATE: OT completed transfer assessment with restorative. Recommend standing lift at this time for all transfers. * 09/24/23 at 3:14 p.m., . Nurse note . Observation: resident noted to have increased weakness, loss of appetite, and overall decline during shift. resident [sic] currently having difficulty using PAL stand lift; staff requesting to use hoyer lift for resident transfers until resident can be evaluated by therapy. Action: resident switched to 2 person hoyer lift for transfers d/t [due to] increased weakness and decline for safety until evaluation. The record lacked evidence of a PT/OT evaluation since 09/24/23. During an interview on 10/04/23 at 5:39 p.m., an administrative staff member (#1) verified Resident #3 had not received a PT or OT evaluation for transfer methods since 09/24/23. Observation on 10/04/23 at 11:55 a.m. showed two CNAs (#2 and #3) completed an incontinence check/change for Resident #3. The CNAs transferred the resident from the bed to wheelchair utilizing the Hoyer lift. Staff failed to offer the resident any other options for toileting to avoid incontinence. During an interview on 10/05/23 at 9:25 a.m., a CNA (#4) reported staff have not attempted to utilize a Hoyer toilet sling for Resident #3. During an interview on 10/05/23 9:27 a.m., a CNA (#3) reported no knowledge of a toilet sling and no bathroom toileting since Resident #3 changed to a hoyer lift for all transfers. The CNA stated, . We just have him go in his pants and check and change him in bed. During an interview on 10/05/23 at 9:29 a.m., a CNA (#5) reported staff have not attempted to toilet Resident #3 with a toilet sling and stated, [The resident] is a check and change. Facility staff failed to provide/attempt alternate toileting methods consistent with Resident #3's verbalized needs/requests, which resulted in avoidable incontinence, decreased dignity, and risk of skin breakdown. See F550

Based on observation, record review, review of facility policy, and staff interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 4 sampled residents (Resident #23 and #143) receiving oxygen by nasal cannula. Failure to administer oxygen according to the physician's order may result in complications and compromise the residents' respiratory status. Findings include: Review of the facility policy titled OXYGEN ADMINISTRATION OF occurred on 10/05/23. This policy, dated February 2022, stated, Procedure: 1. Check physician's orders . for flow rate . - Review of Resident #23's medical record occurred on all days of survey and identified a physician's order, dated 05/15/23, stated, Oxygen at 2-4 liters continuous for dyspnea per nasal cannula . Observations showed the following: * 10/04/23 at 10:26 a.m. Resident #23 received oxygen per nasal cannula at 1.5 liters per minute (LPM). * 10/05/23 at 9:29 a.m. Resident #23 received oxygen per nasal cannula at 1.5 LPM. During an interview on 10/05/23 at 9:29 a.m., a medication aide (#5) verified Resident #23's oxygen was set at 1.5 LPM. - Review of Resident #143's medical record occurred on all days of survey and identified a physician's order, dated 9/28/23, stated, O2 [oxygen] @ [at] 4 LPM per nasal cannula continuous . Observations showed the following: * 10/02/23 at 5:07 p.m. Resident #143 received oxygen per nasal cannula at 3 LPM. * 10/04/23 at 10:38 a.m. Resident #143 received oxygen per nasal cannula at 3.5 LPM. * 10/04/23 at 4:25 p.m. Resident #143 received oxygen per nasal cannula at 3.5 LPM. * 10/05/23 at 12:01 p.m. Resident #143 received oxygen per nasal cannula at 3.5 LPM. During an interview on 10/05/23 at 12:01 p.m., a licensed nurse (#6) verified Resident #143's oxygen per nasal cannula was set at 3.5 LPM and turned the oxygen to 4 LPM. During an interview on 10/05/23 at 2:35 p.m., an administrative staff member (#1) stated she expected staff to administer oxygen at the rate ordered by the physician.

Based on observation and staff interview, the facility failed to post complete and accurate daily staff information for 3 of 4 days of survey (October 02-04, 2023). Failure to post accurate staffing data does not allow residents and visitors knowledge of the number of licensed and unlicensed staff on duty each shift. Findings include: Observation on October 02-04, 2023, showed the daily staff posting outside of the nurse's station. The posting showed staffing data for the night shift only, and no staffing for the day and evening shift the entire day. During an interview on 10/05/23 at 2:00 p.m., an administrative nurse (#1) stated she expected night shift to complete the staffing form and staff to make changes if needed.

Based on observation, policy review, review of menus, and staff interview, the facility failed to serve food according to prepared menus during 1 of 1 observation of tray line (noon meal on 09/14/22). Failure to serve food according to menus may result in inadequate nutrition and weight loss. Findings include: Review of the facility policy titled Altered Portions occurred on 09/15/22. This undated policy stated, . Altered portion sizes will be served upon request however, small or double portions require a physician's order. Small portions are planned on the menu to meet nutritional needs. Observation of the noon meal tray-line on 09/14/22 showed the following portion sizes served to residents and what the menu required: * Regular diet - Wax beans: 3 ounce (3/8 cup). Staff served less than the menu's required amount of 1/2 cup. * Small diet - Roast beef: 1/2 slice (about 1.5 ounces). Staff served less than the menu's required amount of 2 ounces. During an interview on 09/14/22 during the noon meal, a dietary staff member (#5) stated for small portions she cuts the serving size in half. She stated the staff sliced the roast beef but didn't weigh the meat or know what a slice weighed. During an interview on 09/14/22 at 3:04 p.m., a dietary supervisor (#6) stated the staff should have weighed the meat slices to ensure a size of 3 ounces.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY CONDUCTED ON 07/22/21 Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the status for 6 of 15 sampled residents (Residents #9, #11, #20, #21, #24, and #28). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 09/14/22. This policy, revised September 2022, stated, . The care planning process will begin upon admission and ongoing with changes . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. - Observation on 09/13/22 at 11:04 a.m. showed a certified nursing assistant (CNA) (#2) and a nurse (#3) pivot transferred Resident #9 from the bed to the recliner. One CNA (#2) stated . resident should be reassessed for transfer. Review of Resident #9's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], indicated extensive assistance of two or more staff for transfers. A Stop and Watch progress note, dated 05/23/22, stated, . it was very difficult transferring resident with 2 assist from her bed to wheel chair, wheel chair to toilet and then getting her off the toilet, resident had no strength and went limp, . Action: . transferred with pal [mechanical sit-to-stand] lift with assist of 2 . The care plan stated ADLS [activities of daily living]: I have, limited physical mobility r/t [related to] Disease Process . Refer to ADL sheet . The ADL sheet, dated 09/13/22, stated, Transfers . A1 [assist with one]. The care plan and/or ADL sheet did not accurately reflect Resident #9's transfer needs. During an interview on 09/15/22 at 12:36 p.m., an administrative nurse (#1) confirmed Resident #9's care plan and/or ADL sheet failed to reflect current transfer needs. - Review of Resident #20's medical record occurred on all days of survey. A physician's order, dated 12/21/21, stated, Accucheck qid [four times a day] and 2am BS [blood sugar] < [less than] 60 or > [greater than] 500, if BS consistency over 400, notify physician . The care plan, dated 08/02/22, stated, BS's [sic] as ordered. Report to MD [medical doctor] BS's [sic] <40 and >600. The care plan failed to accurately reflect the physician's order. During an interview on 09/14/22 at 08:49 a.m., an administrative nurse (#1) confirmed staff failed to update Resident #20's care plan to coincide with the physician's orders. - Review of Resident #24's medical record occurred on all days of survey. The progress notes from 06/19/22 to 09/12/22 showed nine falls. During the timeframe, the falls precautions in place included a call light within reach, frequent rounding, the bed in a low position, the room free of clutter, and if the resident recently toileted. The care plan, dated 07/27/22, stated, . TRANSFER: I use assist of one for transfers. I do not always call for assistance. Be sure my call light is within reach and encourage me to use it for assistance as needed. It is noted that I may not always call for assistance when needed. The ADL sheet, dated 09/13/22, stated, Fall Prevention . BL [bed in lowest position when in bed]. The care plan and/or ADL sheet did not identify the documented interventions to decrease the risk of falls in the progress notes related to the resident's falls. During an interview on 09/15/22 at 1:45 p.m., an administrative nurse (#1) confirmed the care plan and/or ADL sheet failed to include the additional interventions identified in the progress notes related to Resident #24's fall risk. - Review of Resident #11's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified one fall without injury and one fall with injury. The progress notes showed the resident fell while ambulating independently in her room, once in May requiring neurological checks due to hitting her head on the wall and once in June without injury. The care plan stated, . I may have an ADL Self Care Performance Deficit r/t Dementia. I have a hx [history] of hip and pelvic fracture. I like to be independent and often refuse staff assistance. The care plan failed to have a problem, goals, and interventions to address the resident's fall risk. During an interview on 09/13/22 at 4:43 p.m., an administrative nurse (#1) stated Resident #11 had a prior falls care plan, was unsure why it was deleted, and agreed the resident's current care plan should address falls. - Review of Resident #21's medical record occurred on all days of survey. Review of Resident #21's January 1 through September 13, 2022 progress notes showed behavior entries related to wandering into other resident rooms and verbal and/or physical aggression towards residents and staff. Resident #21's care plan lacked problems, goals, and interventions to address these behaviors. - Review of Resident #28's medical record occurred on all days of survey. The record showed Resident #28 experienced four falls 06/10/22 through 08/26/22. Resident #28's care plan lacked a problem, goals, and interventions to address the falls.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure food is stored, prepared, and served in a sanitary manner for 2 of 2 kitchens (Main and Activity Room kitchen) and 2 of 2 nourishment stations (West and North). Failure to store food properly, maintain clean cooking/storage areas, use food by best by date, and label food may result in the spread of foodborne illness to residents, staff, and visitors. Findings include: Review of the following undated facility policies occurred on [DATE] and stated the following: * Food Storage . Plastic container with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, . All containers must be legible and accurately labeled. All refrigerator units are kept clean . All food should be covered, labeled and dated. All foods . will be consumed by their safe use by dates, or frozen (where applicable) or discarded. * Cleaning Instructions: Ranges . The range will be cleaned after each use. Spills and food particles will be wiped up as they occur. * Cleaning Instructions: Ovens . Ovens will be cleaned as needed and according to the cleaning schedule (at least once every two weeks). * Cleaning Instructions: Microwave Oven . The microwave oven will be kept clean, sanitized and odor free. Observation of the main kitchen occurred on [DATE] at 11:20 a.m. and showed the following: - gas stove top and inner oven soiled with baked-on food and debris - counter/tray next to gas stove covered with food debris - three-door freezer with food debris/residue on inside floor - one can of 50-ounce cream of chicken soup with a Best By date of [DATE] and five cans with Best By dates of [DATE], with one can dented on top seam - open/folded over bag of Spanish rice in a 36-ounce box with spilled rice covering the bottom of the box. The rice lacked an open date. - box with eight sprouted potatoes The dietary tour occurred on [DATE] at 3:04 p.m. with a dietary supervisor (#6). Observation showed the following: * Main Kitchen: - three-door freezer continued to have food debris/residue on the inside floor. The dietary supervisor stated she might have missed this pantry freezer when she updated the cleaning schedules. She later verified the cleaning list lacked this freezer. - gas stove top, oven, and counter/tray remained soiled - The dietary supervisor stated staff do first in, first out with new deliveries and wrote the date on the can when received. The cream of chicken cans with the Best By dates of [DATE] and [DATE] contained receipt dates of [DATE] and [DATE] respectively. The dietary supervisor was uncertain why staff accepted the cans as they would typically return outdated, broken or dented cans. - a precooked ham in the walk-in refrigerator lacked a date when taken from the freezer. * Activity Room kitchen: - undated and open unsealed bags of brown sugar, chocolate chips, white sugar, and box of baking soda - undated container of liquid butter alternative - undated and unlabeled clear plastic container of white substance, identified by the dietary supervisor as sugar - expired jar of marshmallow cream, with date of [DATE] * West Nourishment station: - microwave soiled on inside - four containers of ready-to-eat jello with expiration dates of [DATE]. * North Nourishment station: - microwave soiled and peeling paint on inside - bottom of oven soiled - two containers of ready-to-eat jello with expiration dates of [DATE]. During an interview on [DATE] at 1:15 p.m., a dietary supervisor (#6) stated the facility had no policy on discarding potatoes and they are to use their best judgement. She confirmed the sprouting potatoes should have been discarded.

Based on observation, review of facility policy, review of professional literature, and staff interview, the facility failed to follow professional standards of practice for 2 of 2 sampled residents (Resident #1 and #15) who received insulin during medication pass. Failure to disinfect the rubber seal of insulin pens increases risk of infection to residents and failure to indicate an open date and/or expiration date on insulin pens may result in reduced efficacy of the insulin. Findings include: Review of the facility policy titled Insulin Pen occurred on 09/15/22. This policy, revised February 2022, stated, Insulin pens must be clearly labeled with the . expiration date. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation. Review of information found at https://pi.lilly.com/us/[MEDICATION(S)]-kwikpen-um.pdf, stated, . [MEDICATION(S)] KwikPen . Preparing your Pen . Wipe the Rubber Seal with an alcohol swab. Review of information found at https://www.[MEDICATION(S)].com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8aba629a/[MEDICATION(S)]-[MEDICATION(S)]-pen-guide.pdf, stated, . HOW TO STORE YOUR OPENED [MEDICATION(S)] [MEDICATION(S)] PEN . after 28 days, throw your opened [MEDICATION(S)] pen away . Review of information found at https://uspl.lilly.com/[MEDICATION(S)]/[MEDICATION(S)].html#ug0, stated, . [MEDICATION(S)] KwikPen . Do not use your Pen . for more than 28 days after you first start using the Pen. Observation on 09/14/22 at 9:24 a.m. showed a medication aide (#4) prepared Resident #15's [MEDICATION(S)] insulin pen. The aide failed to disinfect the rubber seal on the pen prior to attaching the needle. Observation during review of the north medication cart on 09/14/22 at 9:37 a.m. showed Resident #1's [MEDICATION(S)] insulin pen and Resident #15's [MEDICATION(S)] insulin pen showed both pens lacked an open and/or expiration date. During an interview on 09/14/22 at 2:35 p.m. an administrative nurse (#1) stated she expected staff to label insulin pens with expiration dates.

Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), the facility failed to complete a Minimum Data Set (MDS) that accurately reflected the resident's status for 1 of 2 sampled residents (Resident #27) reviewed for weight loss. Failure to accurately code the MDS may negatively affect the development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2019, page K-5 to K-6 stated, . K0300: Weight loss . compare the resident's weight in the current observation period to his or her weight in the observation period 30 days ago. If the current weight is less than the weight in the observation period 30 days ago, calculate the percentage of weight loss . compare the resident's weight in the current observation period to his or her weight 180 days ago. If the current weight is less than the weight in the observation period 180 days ago, calculate the percentage of weight loss. Coding Instructions . Code 0, no or unknown: if the resident has not experienced weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days . Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days . Review of Resident #27's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified section K0300 coded for weight loss. Review of Resident #27's weight documentation identified the following: * 01/28/22 weight 126 lbs (pounds) * 06/27/22 122 lbs * 07/28/22 117 lbs (4% weight loss in 30 days and 7% in 180 days) The facility staff failed to accurately code the quarterly MDS as 0 indicating Resident #27 did not have a 5% weight loss in 30 days or a 10% weight loss in 180 days.

Based on observation, record review, review of facility policy, staff and resident interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 1 sampled resident (Resident #13) with medications observed in the resident's room. Failure to determine whether SAM is a safe practice has the potential to limit a resident's right to SAM or result in a medication error and/or harm to a resident. Findings include: Review of the facility policy titled Medication Self-Administration occurred on 09/14/22. This policy, dated 07/2015, stated, . Policy: Resident's who desire to and are assessed capable may self-administer their medications.Upon completion of the BIMS [Brief Interview for Mental Status], with a score 13 or greater, the physician will be contacted for the appropriateness of self-administration and an order obtained. An individualized care plan will be developed for the implementation of the self-administration program based on the resident's abilities. Observation on 09/13/22 at 9:22 a.m. showed a medication cup containing multiple pills and a plastic cup containing white powder located on the table in front of Resident #13. The resident reported she was waiting for her breakfast to arrive. During an interview on 09/13/22 at 9:22 a.m., Resident #13 stated she had an inhaler to use for her asthma symptoms. When asked where she keeps the inhaler, she reported it is kept in her room, she then retrieved an [MEDICATION(S)] inhaler from her personal bag and stated, I took it with to my appointment yesterday, I usually keep it on my night stand next to my phone. Observation on 09/14/22 at 12:20 p.m., showed the [MEDICATION(S)] inhaler located in Resident #13's room on the bedside stand. Review of Resident #13's medical record occurred on September 13-14, 2022. The record identified a BIMS score of 15 an indication of intact cognition. The record lacked a SAM assessment, a provider order, and documentation on the care plan indicating Resident #13 can safely self-administer medications. During an interview on 09/14/22 12:25 p.m., an administrative nurse (#1) confirmed staff failed to complete the SAM for Resident #13.

PAIN 1. Based on record review and review of facility policy, the facility failed to provide the necessary care and services to promote the optimal well-being for 1 of 1 closed record resident (Resident #12) who experienced uncontrolled pain secondary to a femur fracture (which went undiagnosed for 13 days). Failure to properly manage Resident #12's pain and provide adequate pain control measures resulted in continued unresolved pain for 24 days. Findings include: Review of the facility policy titled "PAIN MANAGEMENT" occurred on 10/16/14. This policy, revised 09/13, stated, ". . . 6. Administer prn (as needed) pain medications and document observations in the nurses notes. . . . 9. A Pain Assessment will be done on admission and readmission. Residents will be reassessed monthly, with each MDS (minimum data set) assessment, and as necessary. 10. Assessment and intervention should continue until pain is resolved or at the acceptable level for the resident. 11. The PRN Pain Med and Laxative form will be completed monthly by the night nurse. It will alert staff to contact the physician for scheduled pain medication for pain management. This form tracks use of 6 or more PRN pain meds (medications) in a 30 day period." Review of Resident #12's medical record occurred on 10/16/14. [DIAGNOSES REDACTED]. The annual MDS, dated [DATE], identified long and short term memory problems, experienced pain daily, and used PRN pain medication and non-medication interventions for the following pain indicators: non-verbal, vocal, expression, and body/posture. The current care plan stated, ". . . Focus: I was diagnosed with [REDACTED]. 3-18-14 pain of R (right) leg. . . . Interventions: . . . 3-18-14 I am started on [MEDICATION NAME] for pain . . ." A progress note, dated 02/23/14 at 1:29 a.m., stated, "2310 (11:10 p.m.) 2/22/14 Main nurses station lounge. . . . (Resident #12) started yelling out again and attempting to get out of the recliner chair and PM CNA (certified nurse assistant) . . . was sitting in the main nurses station lounge and (Resident #12's) chair alarm sounded and (name of CNA) turned and stated she witnessed (Resident #12) slide out of the recliner chair onto the carpeted floor when the legrests (sic) were in upright position and the back of the chair was reclined. . . . didn't bump his head . . . No new reddened areas and no new bruising observed. Passive range of motion to all extremities within normal limits with no gestures of pain. No verbalizations of pain when inquiries made by writer. . . . Will fax (name of physician). . . ." Resident #12's progress notes stated the following: * 02/25/14 at 9:03 p.m., ". . . Said his leg hurt when using the lift to take him to the bathroom." * 02/26/14 at 3:08 p.m., "When laying (Resident #12) down in his bed, nursing noted a bruise on the right outer thigh. Approximately 6 cm (centimeters) diameter. Also noted that the right leg is almost 2 times the size of the left leg from ankle to upper thigh. Given Tylenol . . . for discomfort and faxed (physician assistant) with our assessment and concern. Will continue meds for discomfort and wait for orders from PA (physician assistant)." * 02/27/14 at 10:47 a.m., "Order: Ultrasound to rule out [MEDICAL CONDITION] ([MEDICAL CONDITION] . . . Pain to right leg, swelling, bruise." * 02/27/14 at 1:52 p.m., "Resident out for . . . ultrasound of right leg. . . ." * 02/28/14 at 12:17 a.m., ". . . PAL lift (sit to stand mechanical lift) used to get up to te (sic) bathroom and States leg hurts. . . ." * 02/28/14 at 7:38 a.m., ". . . Right leg from upper thigh to mid-shin area remains swollen. no reddened areas. leg and foot are. warm to touch. Resident is calling out loudly. c/o (complaining of) leg hurting with no apparent relief from Tylenol. . . . pa (physician assistant) faxed about increased pain. . . ." * 02/28/14 at 2:29 p.m., "Ultrasound report. Received report, no right lower extremity [MEDICAL CONDITION]." * 03/02/14 at 2:29 p.m., ". . . Leg continues to be swollen and upper thigh is bruised from outside to inside going behind leg. Does move leg but minimally. . . . Continue to use PAL lift for transfers and use Tylenol for pain. After resident has Tylenol he quiets down and appears to be more comfortable." Facility staff continued to use a sit to stand mechanical lift contributing to additional pain and potentially causing additional trauma to the fractured femur. * 03/02/14 at 9:20 p.m., ". . . Tylenol is Effective for approx (approximately) 2 hours before resident starts yelling ow ow ow again." * 03/03/14 at 5:00 p.m., "Received (sic) f/u (follow up) call from (physician assistant) regarding res cont (continue) to have pain to his Rt leg/thigh. Res has been receiving (sic) PRN tylenol routinely due to discomfort and medication is not helping much. . . . [MEDICATION NAME] 5/325 mg . . . Q (every) 6hrs (hours) PRN moderate pain. . . . Ordered XRAYS for Rt Tib (tibia), fib (fibula), Femur, and RT hip for tomorrow AM. . . ." * 03/04/14 at 10:00 a.m., ". . . Resident had xray done . . . that indicates a right femur fracture. . . . needs to get an orthopedic consult. . . ." * 03/17/14 at 1:38 p.m., "Nursing is requesting that resident have something more scheduled for pain control. Resident has occasional (sic) break through discomfort especially if the prn doses are not given every 6 hours. Faxed a request to (physician assistant) . . ." * 03/18/14 at 11:01 a.m., "[MEDICATION NAME] Patch 25mcg/hr (microgram per hour), change every three days. . . . Pain from right leg fx (fracture)." Resident #12's Medication Administration Record [REDACTED]. Facility staff failed to thoroughly assess Resident #12's complaints of right leg pain and provide adequate relief. As a result, Resident #12 experienced unresolved pain for a period of 24 days. 2. Based on record review and staff interview, the facility failed to provide the necessary care and services to manage behavioral symptoms of dementia for 2 of 2 sampled residents (Resident #3 and #10) identified with behaviors and on psychopharmacological medications. Failure to thoroughly assess the residents' behaviors and attempt non-pharmacological interventions prior to administering psychopharmacological medications may result in decreased physical, mental, and psychosocial well-being and negatively impact these residents' quality of life. Findings include: - Review of Resident #3's medical record occurred on all days of survey and identified an admission date of [DATE]. [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] (an antipsychotic medication) twice daily and [MEDICATION NAME] (an antianxiety medication) PRN. Resident #3's admission Minimum Data Set (MDS), dated [DATE], identified long and short term memory problems. The current care plan stated, "FOCUS: . . . anxiety GOALS: I will be comfortable et (and) free of restlessness INTERVENTIONS: I will receive meds (medications) per drs. (doctors) orders. I have toys that I like to have in my lap to help keep my hands busy, family brings me toys." Review of Resident #3's nurses' notes and Medication Administration Record [REDACTED]. - Review of Resident #10's medical record occurred on October 16, 2014. [DIAGNOSES REDACTED]. Resident #10's quarterly MDS, dated [DATE], identified long and short term memory problems and no behavioral signs or symptoms during the seven day assessment period. The current care plan stated, "FOCUS: . . . I use antipsychotic medications dx (diagnoses) of anxiety/hx (history) of psychotic behaviors/depression . . . I have a hx of wandering into residents rooms/and other behavioral issues but that has improved greatly. I enjoy to walk up and down the halls by my room . . . INTERVENTIONS: Administer medications as ordered. Monitor/document for side effects and effectiveness . . . Monitor/record occurrence of behavior symptoms (Specify: pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document . . . I love cats and love to talk about my cats . . . Please use these interventions to calm me: . . . Sit and visit with me; get me something to eat or drink; walk with me, try toileting me. Please document the effectiveness of these interventions . . ." Review of the nurses' notes and (MAR) from April 01 through October 15, 2014 identified Resident #10 received [MEDICATION NAME] seven times. Three of the seven times facility staff failed to attempt non-pharmacological interventions prior to the administration of the [MEDICATION NAME]. During an interview of the afternoon of 10/16/14, an administrative nurse (#11) stated she expected facility staff to attempt non-pharmacological interventions before administering psychopharmacological medications.

Based on observation, record review, review of a professional reference, and staff interview, facility staff failed to implement appropriate interventions to restore/maintain adequate nutritional status for 1 of 1 sampled resident (Resident #7) identified with severe weight loss. Failure to implement interventions and/or evaluate the effectiveness of current interventions resulted in Resident #7 experiencing severe weight loss. Findings include: The Centers for Medicare and Medicaid Services (CMS) has outlined the parameters for evaluating significance of unplanned & undesired weight loss: Interval Significant Loss Severe Loss 1 month 5% (percent) Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% Review of Resident #7's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. Daily medications included [MEDICATION NAME] (both antipsychotic medications), [MEDICATION NAME], and [MEDICATION NAME] (both diuretic medications). The admission Minimum Data Set (MDS), dated [DATE], identified Resident #7 had both long and short term memory problems and independent with eating. Resident #7's care plan stated, "Nutrition Hydration, [MEDICAL CONDITIONS](hypertension), Significant weight loss . . . Interventions: 8 oz (ounce) choc (chocolate) Ensure Plus (a nutritional supplement initiated on 10/30/13) pm and hs (bedtime). Offer snacks prn (as needed); Hot choc with meals (initiated on 10/09/13); Regular diet . . ." Resident #7's initial nutritional assessment, dated 08/27/13, identified a weight and height of 127.6 pounds and 54 inches; no weight loss during the last three months; suffered psychological stress or acute disease in the past three months; no psychological problems such as dementia or depression; and at risk for [MEDICAL CONDITION]. Review of Resident #7's weights (tub scale) revealed the following: * 08/22/13 - 127 pounds * 09/22/13 - 118 pounds * 10/24/13 - 101.1 pounds * 11/07/13 - 100 pounds These weights identified a 27 pound weight loss (21%) in 11 weeks. Review of Resident #7's dietary progress notes identified the following: * 08/27/13 - "Heart Healthy diet. Eating (greater than) 75% of meals. Eating per self. Weight 127# (pounds). . . . [MEDICAL CONDITION], weight up and down approx (approximately) 7-10# secondary to [MEDICAL CONDITION] and diuresis." * 09/03/13 - "Heart healthy diet due to Dx (diagnoses) of [MEDICAL CONDITION] . . . Eating (greater than) 50% 2 out of 3 meals daily. Is refusing some meals. Eats per self. Weight 129# is on [MEDICATION NAME] wt may fluctuate . . ." * 09/04/13 - " . . . Visited with resident and wife regarding low sodium foods . . . Weight 120# and down 9# due to diuresis" * 09/18/13 - "Diet change to Regular." * 10/02/13 - ". . . down 9# past week and down 21# past 3 weeks." * 10/9/13 - "Likes chocolate. Offer chocolate milk prn and hs. Hot choc with meals . . . Weight 109# and stable past week. Down 8# past 3 weeks." * 10/16/13 - ". . . Weight 108# and stable past 3 weeks." * 10/21/13 - ". . . Offering chocolate milk prn and hs. Hot choc with meals . . ." * 10/31/13 - ". . . Weight 101#. Down 8# pawt (sic) 3 weeks. Not always able to make needs known. Nursing requesting Ensure Plus chocolate pm and hs." * 11/6/13 - ". . . Hot choc with meals. Weight 102#. Not always able to make needs known. Ensure Plus chocolate pm and hs." Resident #7 lost an anticipated seven to nine pounds (depending on the scaled used) related to [MEDICAL CONDITION] and diuresis as identified in the dietary progress note dated 09/04/13. The dietary notes identified an additional 19 pound weight loss from 09/04/13 to 10/31/13. On 10/30/13, per nursing request, the dietician added Ensure Plus to Resident #7's diet. The dietician conducted no further assessment of the resident's needs and failed to monitor her consumption of the Ensure. Observations on 11/13/13 at 9:55 a.m., 12:05 p.m., and 5:00 p.m. showed Resident #7 in the dining room for meals. The facility staff failed to serve her hot chocolate or chocolate milk. During an interview on 11/14/13 at 10:05 a.m., the dietary manager (#2) stated the dietary card did not identify Resident #7 received hot chocolate with every meal but the dietary staff are expected to serve it with every meal. He stated the resident receives Ensure twice a day but the staff do not document her consumption. Failure of the facility to assess Resident #7's weight loss, implement dietary interventions in a timely manner, and monitor intake resulted in the resident experiencing a severe weight loss or 27 pounds in an 11 week time period.