Every finding on record at SMP Health - St Aloisius

Based on observation, review of facility policy, and resident and staff interviews, the facility failed to maintain acceptable hot water temperatures for 1 of 2 units (Unit A) observed for water temperature. Failure to ensure acceptable hot water temperatures has the potential for burn injuries to residents, visitors, and staff. Findings include: Review of the facility policy titled Hot Water Temperature Check occurred on 03/04/25. This policy, dated 12/21/11, stated, The domestic hot water must be kept at 110 degrees or less for the safety of our patients, visitors, and employees. The water temperature will be monitored at various locations throughout the facility to ensure that it stays at 110 degrees or less. The temperature in the tank will be monitored by the gauge on the tank. 2. A thermometer will be used at various sinks throughout the facility. Observation on 03/04/25 showed the following water temperatures in resident bathrooms: 09:41 a.m. - room [ROOM NUMBER] 125 degrees Fahrenheit (F) 09:42 a.m. - room [ROOM NUMBER] 124.5 degrees F During an interview on 03/04/25 at 10:08 a.m., two maintenance staff members (#2 and #3) stated staff check the water temperature gauge at the distribution valve where the hot and cold water mix and not in the resident rooms. The staff members stated they expected water temperatures in resident rooms at 110 degrees F or less. Observations on 03/05/25 at 8:15 a.m. showed 23 resident rooms on Unit A with water temperatures between 119.3 - 123.8 degrees F. During a confidential interview on 03/05/25 at 8:40 a.m., Resident A stated the water has been pretty hot. When asked if he/she ever received a burn from the hot water, Resident A stated, No. During an interview on 03/05/25 at 8:54 a.m., a maintenance staff member (#2) reported the water temperature at 124 degrees F at the distribution valve.

Based on observation, record review, and resident interviews, the facility failed to provide appropriate dementia care and services for 1 of 1 sampled resident (Resident #65) with a diagnosis of dementia and wandering behaviors. Failure to adequately assess for necessary care and services, and monitor behaviors and implement effective behavior management interventions resulted in a decreased level of psychosocial well-being for Resident #65 as well as other residents affected by the behaviors. Findings include: The facility failed to provide a policy on dementia care. Review of Resident #65's medical record occurred on all days of survey. Diagnoses included dementia, psychotic and mood disturbance, anxiety and restlessness, and agitation. Current physician's orders included: * Seroquel (an antipsychotic) 50 milligrams (mg) by mouth three times a day (started on 12/29/23) related to dementia, psychotic and mood disturbance and anxiety. * Remeron (an antidepressant) 0.75 mg tablet by mouth one time a day (started on 01/17/24) related to restlessness and agitation. Resident #65's current care plan stated, . Focus . Alteration in thought process . and impaired communication related to Dementia . Interventions . Accept memory deficits . Assess individuals stress level . Call resident by name . Cue and supervise as needed . Repeat information . Give simple direct directions . Focus . Alteration in behavior as indicated by restlessness, insomnia, agitated, combative, easily annoyed and angered, has been noted to wander throughout the unit daily . Encourage resident to attend and participate in activities . NP [nurse practitioner] to consult . Secure care lock [device to notify staff if the resident attempts to exit the building] . [Resident's name] likes to carry rosary with her and it provides comfort . [Resident's name] loves animals and responds well to sitting with the animatronic cat . INTERESTS: her dog . Introduce resident to staff and residents. Show resident where activity calendar is in activity room, where activity board and menu are located in hallway and where activities will take place . Staff will do 1:1 visits as needed . Resident #65's nurses' notes identified the following: * 01/03/24 at 11:29 a.m. Narrative: 12-28-23 @ [at] 18:10 [6:10 p.m.] Nurse was informed that this resident was in the room of another resident. She was found lying on the floor between the bed and the window. * 01/04/24 at 4:39 p.m. Resident removed her slip on and urinated on the side of her bed. She then wandered out to the common area. Writer assisted her back to her room and into the bathroom, cares provided. A new slip on [incontinent product] and pants put on. Resident then pulled the pants and slipon [sic] down to her ankles and attempted to walk. Writer removed pants and underwear she had around her waist; put on the slip on. * 01/08/24 at 1:58 p.m. Resident has been wandering the unit most of shift. She has been going into other residents rooms and at times picking up items- she took and wore a pair of glasses . * 01/08/24 at 10:03 p.m. Resident has wandered a lot this shift especially the first half of shift. She has been in numerous resident rooms going [sic] resident drawers and picking up personal items. * 01/09/24 at 4:48 a.m. Resident made a direct and concentrated attempt to exit through the new entrance. Two staff persons intervened to direct her away and back towards safety before she could get out. Resident became combative and started yelling. * 01/09/24 at 1:45 p.m. Resident has been in and out [sic] multiple residents rooms this shift. Resident was found rummaging through other residents belongs when she was in their rooms. Staff has assisted resident back to her room multiple times. Resident was in her room and voided on floor. When staff was cleaning up the urine, resident stated, Is he still in here? CNA [certified nurse aide] said, there is no one else in here. Resident pointed to the urine on the floor and stated that [expletive]. * 01/09/24 at 3:12 p.m. Continually going into other Residents room this afternoon, other Residents are becoming upset. It is getting harder to redirect this Resident. * 01/09/24 at 3:27 p.m. Resident went into another Residents room and took his shoes, throwing them into hallway. * 01/09/24 at 6:40 p.m. Resident has been in and out of other residents rooms, removing items (ie: shirt). Moving furniture in the common area. Walked down towards the kitchen pulled down her pants and pooped on the floor. * 01/10/24 2:58 p.m. Resident wandered across the hall. She was found laying on top of the resident in bed 1 with her pants and slip-on between the door and the bed and urine in the trashcan [sic] next to it. Resident difficult to redirect to her room. * 01/11/24 at 1:54 a.m. Resident was found standing in room with her fists up. 2 staff entered room and calmed resident down. Resident had removed her pants and slip on. She then urinated next to the bed on the floor. She then placed her Christmas tree in the urine. Staff cleaned up the resident and the room. She was assisted back to bed. About 10 minutes later she wandered out to the common area. * 01/11/24 at 8:43 p.m. Resident has been wandering the unit throughout the shift. She is wandering into other resident's rooms and going through their belongings. She then went into a different residents room and laid down at the foot of the bed. Difficult to redirect. * 01/12/24 at 3:36 a.m. Resident is on contact precautions for Influenza, she has no concept of what this means. She exited her room and was found in [another room]. She had voided on the floor [in this room]. She was found sitting on the resident [in this room] having a bowel movement. * 01/12/24 at 8:31 a.m. Addendum: Visited with nursing staff [staff name] to confirm and resident appeared to be sitting at the foot end of the bed on residents leg. Other resident appeared unaware of situation of being defecated on. * 01/16/24 at 11:12 p.m. Resident wandered this shift . assisted into bed twice and resident got up and went across the hall to another room. CNA found her with her pants down sitting on another residents bed. * 01/17/24 at 7:59 p.m. Resident wandering halls and into other resident's rooms. Swinging at anyone who attempts to redirect her. She wandered over to unit A Meadow Lane dayroom and sat in recliner and fell asleep. she was found in a resident's bed up on A [unit A]. * 01/18/24 at 7:36 a.m. Resident wander [sic] out of her room and into the activity room around 430 [4:30 a.m.] and urinated on a chair. Staff assisted her back to her room and cleaned her up. She went back to bed for another hour then got up and wandered the unit. Resident is not willing to talkto [sic] writer and walks faster when writer attempts to talk to her. Review of Resident #65's activity logs showed only six 1:1 activities with Resident #65 in the last 30 days. Observations on all days of survey showed Resident #65 wandering throughout the facility including several resident rooms, therapy room, dining room, and other areas within the facility. During a confidential interview on 01/16/24 at 2:45 p.m. Resident A stated, woken up a few nights ago by Resident #65 who had entered the resident's room in the middle of the night. During an observation on the afternoon of 01/17/24 showed two CNAs (#4 and #5) entered Resident #31's room to assist her from bed. Resident #65 followed the CNAs into the room. Resident #31 stated, Oh that [expletive]. Get her out of here. The CNA (#4) stated, Ok, ok, she's going, and assisted Resident #65 from Resident #31's room. The facility failed to assess and monitor patterns and trends of behaviors in an effort to minimize Resident #65's behaviors, recognize unmet needs, or prevent situations/triggers which may lead to behaviors or physical aggression toward staff and other residents. The facility failed to develop an effective behavior management program, consistently implement purposeful and meaningful activities in an attempt to manage the behaviors exhibited by Resident #65, evaluate the behavior management program on a continuous basis, and modify interventions as needed. The facility failed to ensure Resident #65 did not infringe upon the rights of others while still allowing her to achieve her highest level of well-being.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of controlled medications for 4 of 4 medication carts (Cart #1 and #2 on Unit A and Cart #1 and #2 on Unit B) and failed to lock 1 of 4 medication carts (Cart #2 on Unit B) observed during medication administration. Failure to store medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Medication Storage occurred on 01/18/24. This policy, dated August 2021, stated, . 1. General guidelines: a. All drugs and biologicals will be stored in locked compartments. c. During medication pass, medications must be. locked in the medication storage area/cart. Review of the facility policy titled Medication Administration occurred on 01/18/24. This policy, dated September 2021, stated, . 5. The medication cart is used for medication pass. It is locked when not visualized. No medications are to be accessible on top of the cart. Observation of medication aide (MA) (#9) assigned to medication pass on Cart #1/Unit A on 01/16/2024 at 2:37 p.m. showed gabapentin (nerve pain medication) not under dual lock in the medication cart. Observation of MA (#10) and nurse (#8) assigned to medication pass on Cart #1 and Cart #2 on Unit B on the afternoon of 01/16/2024 showed controlled medications not under dual lock in the medication cart. Nurse (#8) stated, The scheduled controlled drugs are in each person's section. It is the same in every med cart in this facility. Observation of Cart #2 on Unit B occurred on 01/16/24 at 4:48 p.m. showed a nurse (#8) left a tube of Diclofenac gel (topical pain relief gel) on top of the unlocked medication cart and walked into Resident # 60's room.

Based on observation, record review, review of professional reference, policy review and staff interview, the facility failed to follow standards of infection control for 1 of 12 sampled residents (Resident #28) and 1 supplemental resident (Resident #39) observed during perineal cares and 1 of 1 sampled resident (Resident #65) on transmission-based precautions (TBP). Failure to follow infection control standards during perineal cares and with TBP has the potential to transmit infections to residents, staff, and visitors. Findings include: PERINEAL CARES Review of the policy/procedure titled Perineal cares (Peri-Cares) occurred on 01/18/24. This policy/procedure, dated June 2023, stated, .Washes genital area, moving from front to back. dries genital area moving from front to back. Review of Resident #39's medical record occurred on 01/17/23. Diagnoses include urinary incontinence, retention of urine, and history of urinary tract infection. During an observation on 01/16/24 at 12:58 p.m., a certified nurse aide (CNA) (#3) assisted Resident #39 with incontinence cares. The CNA (#3) wiped the resident's perineum from the back to the front three times. The CNA failed to provide proper perineal cares to prevent risk of infection to the resident. Review of Resident #28's medical record occurred on all days of survey. Diagnoses include urinary incontinence. During an observation on 01/16/24 at 1:10 p.m., a certified nurse aide (CNA) (#3) assisted Resident #28 with incontinence cares. The CNA (#3) wiped the resident's perineum from the back to the front three times. The CNA failed to provide proper perineal cares to prevent risk of infection to the resident. During an interview on 01/18/24 at 11:21 a.m., an administrative nurse (#1) stated she expected staff to follow policy/procedures. TRANSMISSION BASED PRECAUTIONS Review of the facility policy titled ISOLATION/TRANSMISSION BASED PRECAUTIONS occurred on 01/18/24. This policy, dated June 2019, stated, .It is our policy to take appropriate precautions including isolation to prevent transmission of infectious agents. Contact Precautions: . Intended to prevent transmission of infectious agents, including epidemiolgically [sic] important micro-organisms, which are spread by direct or indirect contact with the resident or the resident's environment. The CDC guidance found at: https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm, dated 11/14/23. The guidance stated, . Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. Because residents with influenza may continue to shed influenza viruses while on antiviral treatment, infection control measures to reduce transmission, including following Standard and Droplet Precautions, should continue while the resident is taking antiviral therapy. - Review of Resident #65's medical record occurred on all days of survey and a physician's order, dated 01/12/24, for Oseltamivir Phosphate [antiviral medication] oral capsule 75 mg (milligrams) by mouth two times a day related to Influenza A. Progress notes for Resident #65 showed the following: * 01/11/24 at 4:55 p.m. [Doctor's name] notified of resident hoarse sounding in voice & [and] nasally sounding like coming down with an URI [upper respiratory infection]/cold. Temp [temperature] check x2 [twice] with temporal [forehead] thermometer with readings of 99.9 and 100.2 [degrees Fahrenheit]. * 01/11/24 at 6:03 p.m. [Resident #65's family name] updated . Positive for Influenza A. * 01/11/24 at 8:43 p.m. Resident has been wandering the unit throughout the shift. She is wandering into other resident's rooms and going through their belongings. She then went into a different residents room and laid down at the foot of the bed. * 01/12/24 at 3:36 a.m. Resident is on contact precautions for Influenza, she has no concept of what this means. She exited her room and was found in [another resident's room]. She had voided on the floor by [one of the beds]. She was found sitting on the resident [of the other bed] having a bowel movement. The facility failed to limit Resident #65's movement within the facility while isolation/TBP with Influenza A. 40489

Based on observation, record review, and staff interview, the facility failed to provide the necessary treatment/services to prevent and/or promote healing or worsening of a pressure injury for 1 of 3 sampled residents (Resident #63) observed with a pressure injury. Failure to identify/report a skin issue may result in the development/worsening of a pressure injury and delayed treatment of Resident #63's pressure injury. Findings include: Review of Resident #63's medical record occurred on all days of survey. Diagnoses included dementia, Parkinson's disease, and diabetes. The admission Minimum Data Set (MDS), dated [DATE], identified at risk of developing pressure ulcers, required a pressure reducing device for chair, and no pressure ulcers/skin issues. The care plan stated, . Potential for impaired skin integrity related to Bladder Incontinence, Bowel incontinence, Impaired Mobility . Inspect skin daily with cares and report any impairment. The record failed to show assessment, monitoring or documentation for a pressure injury since admission. On 01/17/24 at 9:57 a.m., a certified nurse aide (CNA) (#7) provided incontinence care for Resident #63. Observation showed a small black scab/injury to coccyx directly over a bony prominence surrounded by skin discoloration. The CNA indicated nursing was aware of this scab/injury. Observation of Resident #63 pressure injury occurred on 01/18/24 at 7:56 a.m. with an administrative nurse (#2) present. The administrative nurse (#2) agreed that it is an area of concern and reported being unaware of this skin issue. During an interview on 01/18/24 at 11:21 a.m., an administrative staff member (#1) stated she expected staff to follow facility procedures and report any skin concerns to nursing staff.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 10 residents (Resident #55 and #60) observed during medication administration. Three medication errors occurred during staff administration of 29 medications, resulting in an 10.14% error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions. Findings include: Review of the Prescribing information for NovoLog insulin, found at www.novo-pi.com/novolog.pdf) occurred on 01/18/24. This undated document, stated, Instructions for use. E. Turn the dose selector to select 2 units. F. Hold your NovoLog FlexPen with the needle pointing up. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to zero. Observation of medication administration on 01/16/24 at 4:25 p.m. showed a nurse (#8) prepared a Novolog insulin pen and a Novolog 70/30 insulin pen for Resident #55. The nurse (#8) applied a needle to each pen, removed the needle caps, and held each pen horizontally to prime. Observation of medication administration on 01/16/24 at 4:48 p.m. showed a nurse (#8) prepared a Novolog insulin pen for Resident #60. The nurse (#8) applied a needle, removed the needle cap, dialed the pen, and held the pen horizontally to prime. The nurse (#8) failed to prime the insulin pens vertically. During an interview on 01/18/24 at 10:45 a.m., an administrative staff member (#1) confirmed the nurse failed to prime the insulin pens correctly.

Based on observation, review of facility policy, and staff interview, the facility failed to provide privacy and confidentiality of medication administration records (MAR) for 1 of 7 residents (Resident #63) observed during medication administration. Failure to lock the MAR may result in unauthorized viewing of confidential resident records by other residents, unlicensed staff, and/or visitors. Findings include: Review of facility policy titled Medication Administration occurred on 01/11/23. This policy, revised September 2021 stated, . electronic medication administration records (eMars) are kept locked when not in direct use. Observation on 01/11/23 at 11:10 a.m. and 11:22 a.m. showed a nurse (#1) left the medication cart unattended, walked down the hall, and entered the resident's room leaving the MAR visible. During an interview on 01/12/23, an administrative nurse (#1) confirmed nursing staff should close the computer screen when they leave the medication cart unattended.

Based on observation, facility policy, and staff interview, the facility failed to prepare and serve food under sanitary conditions during 2 of 3 days of meal service observations (09/13/21 and 09/14/21) for Unit B. Failure to follow proper hand hygiene and glove use during meal tray service has the potential to result in foodborne illness to residents. Findings include: Review of the facility policy titled Gloves occurred on 09/14/21. This policy, dated March 2016, stated, . Food preparation shall be done using sanitary precautions . Hands should never touch food in ready-to-eat form . Gloves shall be worn when coming into contact with food during food preparation and serving . Gloves shall be taken off, discarded and hands washed before going to another task. Review of the facility policy titled Food Service Glove Use occurred on 09/15/21. This policy, revised February 2021, stated, . Gloves will be worn when handling ready to eat foods and while serving meals . Hands will be washed before putting on clean gloves . Gloves will be taken off, hands washed and clean gloves put on after touching possible unclean surfaces. Observations showed the following: * 09/13/21 at 11:38 a.m. - A dietary staff member (#2) wore gloves while prepping meal trays, opened the freezer door with gloved hand, and took a piece of bread from the bread bag with the same gloved hand. * 09/13/21 at 11:49 a.m. - A dietary staff member (#2) wore gloves while prepping meal trays, fixed placement of face mask, and took piece of bread from the bread bag with the same gloved hand. * 09/14/21 at 7:46 a.m. - A dietary staff member (#3) wore gloves while prepping meal trays, opened the fridge door, then picked up a piece of toast to butter using the same hand. * 09/14/21 at 7:55 a.m. - A dietary staff member (#4) wore gloves while transporting a cart into the kitchenette. The staff member wiped her gloved hands with a wet cloth, picked up a banana, cut off the ends, and placed it on a resident tray. The staff member touched a cupboard door, wiped gloved hands with a wet cloth, and continued prepping trays using the same gloved hand. * 09/14/21 at 8:00 a.m. - A dietary staff member (#3) wore gloves while prepping meal trays. The staff member removed a bagel from its wrapper and sliced it, touched trays, removed a piece of bread from the bread bag, placed it in a toaster, touched cereal container, removed the bread from the toaster, and touched plates using the same gloved hand. During an interview on the morning of 09/15/21, a dietary manager (#5) stated she expected staff to wash their hands and change gloves when gloves are contaminated or switching tasks.

Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 3 of 7 sampled residents (Resident #8, #23, and #38) and 1 supplemental resident (Resident #59) during observation of perineal cares and mechanical lift transfers. Failure to practice infection control related to hand hygiene and glove use and disinfecting equipment has the potential for transmission of communicable diseases and infections to residents and staff. Findings include: Staff failed to provide a copy of the policy addressing disinfecting equipment. Review of the facility policy, Hand Hygiene occurred on 09/15/21. This policy, revised 03/22/21, stated, . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residence [sic], and visitors. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. After handling items potentially contaminated with body fluids . During resident care, moving from a contaminated body site to a clean body site . after assistance with personal body functions . Observations showed the following: * 09/13/21 at 3:24 p.m., two certified nursing assistants (CNA #5 and #6) transferred Resident #23 from the bed to her wheelchair with a Hoyer (full body mechanical lift). The CNAs placed the lift in the hallway to use with another resident and failed to disinfect the lift. * 09/13/21 at 3:56 p.m., two CNAs (#5 and #6) transferred Resident #38 from the bed to his wheelchair with a Hoyer. The CNAs failed to disinfect the lift after use. * 09/14/21 at 8:57 a.m., a CNA (#3) changed Resident #8's brief soiled with urine and performed perineal care, then cleansed the resident's back and assisted with pants. The CNA (#3) failed to perform hand hygiene and change gloves between tasks. * 09/14/21 at 11:40 a.m. a CNA (#3) changed Resident #59's brief soiled with feces and performed perineal care. The CNA transferred the resident with a Hoyer, touching the lift sling, lift handles, and hand controls with contaminated gloves. The CNA (#3) failed to perform hand hygiene and change gloves between tasks and disinfect the lift equipment between residents. During an interview on 09/15/21 at 3:05 p.m., an administrative nurse (#2) confirmed she expects staff to perform hand hygiene and change gloves after providing cares and disinfect lift equipment between residents.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to ensure residents could safely self-administer medications for 1 of 1 sampled resident (Resident #45) observed with medication at the bedside. Failure to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the policy titled Self Administering Medications occurred on 09/15/21. This policy, dated June 20, 2019, stated, . The Interdisciplinary team will determine who is responsible for storage location and documentation of self administration of medication on an individual basis. This will be documented on the resident's care plan . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 09/13/21 at 10:43 a.m. identified a medication cup on the resident's bedside stand containing 2 white pills. During interview, Resident #45 stated the cup contained Tylenol and to leave the medication where it was. Review of Resident #45's medical record occurred all days of survey. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .m Review of September's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/14/21 at 3:02 p.m., a facility nurse (#1) confirmed facility staff should not leave medication in Resident #45's room.

Based on record review, facility policy review, and staff interview, the facility failed to monitor and assess the continued need for [CONDITION(S)] medications for 2 of 2 sampled residents (Resident #38, and #68) with as needed (PRN) [CONDITION(S)] medications. Failure to limit PRN antipsychotic medication orders to 14 days and ensure the physician evaluates residents prior to renewal may result in the residents receiving unnecessary medications and experiencing adverse reactions. Findings include: Review of the facility's policy titled Use of Psychoactive Drugs occurred on 09/15/21. This policy, dated April 2018, stated, . Procedure: . PRN orders for [CONDITION(S)] drugs are limited to 14 days, except as provided if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. He or she should document their rationale in the resident's medical record and indicate the duration for the PRN order . - Review of Resident #38's medical record occurred on all days of survey. Diagnoses included dementia with behavior disturbance. The record identified a physician order, dated, 07/14/21, Lorazepam [antianxiety medication] Tablet 0.5 MG [milligrams]. Give 0.5 tablet by mouth as needed for severe restlessness related to unspecified dementia with behavioral disturbance. - Review of Resident #68's medical record occurred on all days of survey. Diagnoses included anxiety and dementia. The record identified a physician order, dated 08/20/21, Lorazepam Tablet 0.5 mg. Give 1 tablet by mouth as needed for anxiety. The medical record lacked a physician's order to discontinue the PRN Lorazepam after 14 days or re-evaluate Resident #38 and #68's need for continued use. During an interview on 09/15/21 at 3:00 p.m., a supervisory nurse (#1) confirmed the facility staff failed to discontinue or re-evaluate the need for Resident #38 and #68's Lorazepam.

Based on observation, manufacturers' labeling, and staff interview, the facility failed to properly store beverages in 2 of 3 food preparation areas (Snack refrigerator main kitchen and Unit A kitchenette). Failure to dispose of expired beverages has the potential to result in altered consistency of beverages provided and/or foodborne illness. Findings include: Review of the manufacturers' label showed the following: * Honey and nectar thickened water and juice beverages: use within 10 days of opening. Observation during the dietary tour on [DATE] at 1:40 p.m. with two dietary staff members (#1 and #2) showed the following opened and expired items: - Main Kitchen: honey thick apple drink opened [DATE] (11 days); honey thick cranberry drink opened [DATE] (12 days); and nectar thick water opened [DATE] (23 days), one, two and 13 days beyond expiration. - Unit A kitchenette: nectar thick apple drink opened [DATE] (41 days), 31 days beyond expiration. During an interview on [DATE] at 4:11 p.m. a dietary staff member (#2) identified she expected staff to follow manufacturers recommendations and discard opened thickened beverages not used within 10 days.

Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 2 of 12 sampled residents (Resident #65 and #36) observed during personal cares and a random observation of water distribution. Failure to practice infection control related to hand hygiene/glove usage has the potential for transmission of communicable diseases and infections to residents and staff. Finding include: Review of the facility policy titled Hand Hygiene occurred on 08/23/18. This policy, dated 07/10/18, stated, . situations that require hand hygiene . before and after assisting a resident with personal care . after removing gloves . after handling soiled equipment or utensils . - Observation on 08/21/18 at 3:44 p.m. showed two certified nursing assistants (CNA) (#2 and #3) provided perineal care to Resident #65 after an incontinent bowel movement. The CNAs (#2 and #3) removed their gloves after perineal care and transferred the resident from the bed to his wheelchair. The CNAs (#2 and #3) failed to perform hand hygiene after removing their gloves and prior to completing other tasks. - On the morning of 08/21/18, an observation showed a CNA (#5) provide perineal care to Resident #36 after a bowel movement. The CNA pulled up the resident's brief and pants, transferred him with a gaitbelt into his wheelchair, and then pushed the resident from the bathroom into his room before removing her gloves and performing hand hygiene. During an interview on 08/22/18 at 3:58 p.m., an administrative nurse (#1) stated she expected staff to perform hand hygiene after removing their gloves. - An observation on 08/20/18 at 2:05 p.m. showed a staff member (#4) enter multiple resident rooms with fresh water mugs and exit with the old water mug. The staff failed to sanitize her hands between the handling of clean and dirty water mugs. During an interview on 08/22/18 at 3:58 p.m., an administrative nurse (#1) stated she expected staff members to perform hygiene between handling dirty and clean water mugs.

Based on observation, review of facility policy, and resident interviews, the facility failed to provide care for 3 of 14 sampled residents (Resident #3, #7 and #9), and 1 supplemental resident (Resident #18) in a manner and environment that maintained, enhanced, and respected each resident's dignity and individuality. Failure to knock on doors and wait for a reply before entering a resident's room does not preserve the residents' personal dignity or enhance their quality of life and places them at risk of embarrassment or emotional harm. Findings include: Review of the facility policy titled, Proper Entrance to Resident Rooms occurred on 08/30/17. This policy, dated August 2012, stated, Before an employee enters a resident's room, the following will be done: 1. Knock, 2. Wait for acknowledgement to enter, 3. Enter as acknowledged. 4. Many residents are unable to acknowledge knock, if no response initially, knock again, announce self and quietly look into room and ask for permission to enter or note if appropriate to enter. -Observation on the afternoon of 08/28/17, showed a CNA (#3) knocked on Resident #9's door while entering the room. The resident was using a bedside commode and was exposed from the waist down. The CNA (#3) failed to announce herself and/or wait for acknowledgement to enter the room. - During a confidential interview on the afternoon of 08/28/17, Resident A identified staff do not always knock on her door, especially her bathroom door. The resident stated, They just come barging in; it scares me. - Observation on 08/28/17 at 5:40 p.m. showed an unidentified facility staff member entered Resident #18's room without knocking or announcing herself and/or waiting for acknowledgement to enter the room. - Observation on 08/29/17 at 7:42 a.m. showed an unidentified certified nurse assistant (CNA) knocked once on Resident #3's door and entered the room without announcing herself and/or waiting for acknowledgement to enter the room. - Observation on 08/29/17 at 10:03 a.m. showed an unidentified facility staff member knocked on Resident #3's door as she entered the room during morning cares. She failed to announce herself and/or wait for acknowledgement before she entered the room. During an interview on 08/30/17 at 9:15 a.m., Resident #7 identified staff knock on her door and enter her room without announcing himself/herself and/or waiting for acknowledgement to enter the room.

TRANSFERS 1. Based on observation, record review, policy review, and staff interview, the facility failed to ensure staff appropriately used assistive devices for 5 of 8 sampled residents (Resident #1, #2, #5, #6, and #9) observed during a transfer. Failure to properly use a gait belt (Resident #1, #2, and #5), utilize wheelchair foot pedals (Resident #6), and lock brakes on a bedside commode (Resident #9) increased the risk for sustaining a fall or injury. Findings include: Review of the facility policy titled Gait Belt occurred on [DATE]. This policy, revised [DATE], stated, . Procedure: . 2. To use gait belt: a. Place gait belt securely around resident's waist. b. Grasp gait belt with an underhand grasp to provide support for the resident. c. Assist resident to transfer or ambulate. - Review of Resident #1's medical record occurred on all days of survey. The current care plan stated, Impaired mobility and ADL (activity of daily living) deficit related to chronic back pain, impaired balance, . progressive dementia, resistant to cares . Nurse directed PAL Lift (type of stand-up mechanical lift) PRN (as needed). Transfers with assist of gait belt and assist of 2 in room. On [DATE] at 3:50 p.m., observation showed Resident #1 in a recliner with her eyes shut. Two certified nurse aides (CNAs) (#11 and #12) entered the resident's room, attempted to waken and explain to the resident the plan to assist her to the bathroom, and placed a gait belt around her upper waist. Resident #1 kept her eyes closed and mumbled um hum. One CNA (#11) stated, She is kind of sleepy. The two CNAs held the gait belt to lift Resident #1 from the recliner and pivot her to the wheelchair. Observation showed the gait belt loose on the resident's waist and sliding up her back during the transfer first to the wheelchair, then to the toilet, and back to the wheelchair. The resident showed poor weight bearing and kept her eyes closed throughout most of the transfers. The CNAs failed to snug the gait belt around the resident's waist or consult the nurse if a mechanical lift should be used due to the resident's sleepiness/lethargy. On [DATE] at 7:53 a.m., observation showed a CNA (#13) transported Resident #1 from the dining room to her room after unsuccessfully trying to get the resident to wake up and eat. Two CNAs (#13 and #14) applied a gait belt, lifted Resident #1 who only beared minimal weight, and pivoted her onto the bed. The CNAs failed to consider an alternative means of transfer (mechanical lift at nurse's direction) for Resident #1 who was lethargic. - Review of Resident #2's medical record occurred on all days of survey. The current care plan stated, Impaired mobility and ADL deficit related to dementia, impaired cognition, impaired balance, unsteady gait, vision and hearing deficit, incontinence, hx (history) of fractures (toes) . Hoyer (full body mechanical lift) PRN per nurse discretion . Pivot transfer assist of one . On [DATE] at 3:12 p.m., observation showed two CNAs (#15 and #16) placed a gait belt around Resident #2, but failed to snug it around her waist. As the CNAs attempted to assist the resident to stand, the resident would not stand upright causing the CNAs to lift and pivot her onto the toilet. The resident cried, I'm sorry I can't stand or use my feet. The gait belt slid up the resident's back during the transfer. One CNA (#15) asked the other CNA if they should use a third person or ask the nurse if they should use the lift, because this is hard on both our backs. The CNA (#16) asked a third CNA (#11) to assist. The CNAs failed to snug the gait belt around the Resident #2's waist or consider asking the nurse if a mechanical lift should be used in the transfer. During an interview on [DATE] at 12:05 p.m., an administrative nurse (#17) stated a gait belt should be snug during transfers. - Review of Resident #5's medical record occurred [DATE]-30, 2017. A significant change Minimum Data Set (MDS), dated [DATE], identified Resident #5 required extensive assistance from two or more staff members for transfer. On [DATE] at 8:47 a.m., observation showed two CNAs (#1 and #2) assisted Resident #5 to transfer from her wheelchair to a dining room chair. The CNAs applied a gait belt around the resident's waist as she sat in her wheelchair. As the CNAs (#1 and #2) assisted her to stand, the gait belt slid up to Resident #5's upper chest. The CNAs transferred the resident to the dining room chair with the CNAs hands holding the gait belt at the level of Resident #5 shoulders. - Review of Resident #6's medical record occurred [DATE]-30, 2017. The medical record showed Resident #6 fractured her right hip on [DATE]. After lunch on [DATE], observation showed a nurse (#10) transported Resident #6 from the dining room without the wheelchair foot pedals in place, and without cueing her to lift her feet. Resident #6's feet bounced across the floor, the right foot more than the left, during transport to the central common area. The pedals for Resident #6's wheelchair hung in a bag on the back of her wheelchair. The nurse failed to remind the resident to hold her feet up or place foot pedals on the wheelchair before transporting the resident. During an interview on [DATE] at 11:50 p.m., an administrative nurse (#9) stated a gait belt should be snug around the resident's waist, and staff should use foot pedals when transporting a resident in a wheelchair. - Observation on [DATE] at 4:30 showed a CNA (#4) assisted Resident #9 to transfer from her bed to the commode chair. Observation showed Resident #9 unsteady, and her right knee buckled during the transfer. The commode chair rolled back as Resident #9 sat down, and the CNA steadied the chair by putting her foot behind one of the wheels. The CNA failed to engage the commode chair brakes prior to assisting Resident #9 with a transfer. SAFE HANDLING OF HOT LIQUIDS 2. Based on observation and record review, the facility failed to provide adequate supervision and the necessary safety devices to prevent injury from a second coffee spill for 1 of 3 sampled residents (Resident #8) observed who required covered mugs for hot liquids. Failure to provide Resident #8 proper safety devices while consuming hot liquids placed the resident at risk of injury. Findings include: Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition and an acute change in mental status. The current care plan stated, Focus: . Progressive Dementia and has significant cognitive deficits and requires cues, supervision, and assistance with activities of daily living (ADL's) . hot liquids served in a covered mug . Resident #8's meal card identified hot fluids in a covered mug. A occupational therapy (OT) progress note, dated [DATE], identified OT completed a hot beverage screen due to a nurse's report of spilled coffee. OT recommended Resident #8 utilize lidded mugs for hot beverages and the record identified dietary informed of the recommendation. Observation during the breakfast meal on [DATE] at 8:25 a.m. showed Resident #8 received coffee in a cup without a lid. Observation during the lunch meal on [DATE] at 12:21 p.m. showed Resident #8 received coffee in a cup without a lid. Observation during the lunch meal on [DATE] at 12:06 p.m. showed Resident #8 received coffee in a cup without a lid. The facility failed to follow recommendations to ensure Resident #8 handled hot liquids safely. Failure to follow current interventions on care plan/meal card placed Resident #8 at greater risk for a hot liquid spill, and burns.

Based on observation, review of facility policy, review of the Food and Drug Administration (FDA) Food Code, and staff interview, the facility failed to ensure appropriate sanitization of dishware in 2 of 3 dishwashers (unit A kitchenette and unit B kitchenette). Failure to maintain utensil surface temperatures above 160 F (degrees Fahrenheit) and properly use a dishwasher thermometer has the potential to increase the risk of foodborne illness and can affect all residents who consume food prepared with these dishes. Findings include: The FDA Food Code 2013, page 145, stated, . Sanitization of equipment and utensils . Hot water mechanical operations . achieving a utensil surface temperature of 160 F as measured by an irreversible registering temperature indicator. Review of the facility policy titled Dishwasher Temperatures occurred on 08/30/17. This policy, dated 04/13/16, stated, Policy: It is the policy of this facility to check and record for spray type dishwasher temperatures to ensure sanitation of items in the dishwasher. 1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 4. Temperatures below required temperature will require corrective actions, maintenance will be notified. 5. Water temperatures will be measured prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes and recorded on the Dishwasher Temperature Chart. Observation during the dietary tour on 08/30/17 at 10:00 a.m. showed the following: * No dishwasher temperatures charted in unit A and B kitchenettes. * A hotplate thermometer placed in unit B dishwasher showed the maximum utensil temperature of 157 F was reached after three attempts. During an interview on 08/30/17 while conducting the dietary tour, two administrative dietary staff members (#7) and (#8) stated staff use the dishwashers in the kitchenettes only for breakfast and they did not expect dietary staff to check the dishwasher temperatures in the kitchenettes before use. The facility is responsible to ensure staff monitor/record dishwasher temperatures in the kitchenettes. Failure to use a dishwasher thermometer and maintain dishwasher surface temperatures at 160 F may result in a foodborne illness.

Based on review of Resident Council meeting minutes, resident interview, and staff interview, the facility failed to provide reasonable accommodation of needs for 1 of 4 sampled residents (Resident #11) who ambulated independently in their room. Failure to attempt to individualize a resident's environment to provide access to personal items (such as clothing) may result in falls, injuries, or a loss of independence. Findings include:During the group interview on 08/28/17 at 3:00 p.m., Resident #11 identified she has difficulty reaching the clothing that is hung on the top rod of her closet. Resident #11 stated, Even if they (the staff) would lower it six inches, I could reach. The resident identified she brought up the concern a couple months ago, but I never heard anything about it. Review of Resident Council meeting minutes, dated 04/24/17, identified, . Suggestion box - There were two (2) suggestions in the box this month. 1. Possible to set the top rod in the closet down 6-8 inches? OT (occupational therapy) & PT (physical therapy) looked into this; currently there is nothing available to meet the safety requirements. The minutes identified Resident #11 did not attend that Resident Council meeting. During an interview on 08/30/17 at 11:08 a.m., an activities staff member (#18) stated she did not follow up with Resident #11 directly after receiving the resident's suggestion regarding the closet rod. The staff person also stated, (Maintenance staff member) said it couldn't be done (lowering the closet rod). During an interview on the morning of 08/30/17, a maintenance staff member (#19) stated he did not remember receiving a work order for Resident #11's closet. During an interview on 08/30/17 at 11:30 a.m., an occupational therapy staff member (20) stated he was not aware there was a problem with Resident #11's closet and confirmed he had not done an evaluation. The staff member stated if he had received a request, he would have done an assessment on Resident #11's closet to see if there was something he could do.

Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services for 1 of 3 sampled residents (Resident #9) with physician's orders [REDACTED]. Findings include: Review of Resident #9's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current care plan stated . alteration in cardiac and respiratory status . Oxygen via n/c (nasal cannula) at 2L (liters) continuously. A physician's orders [REDACTED]. On 08/28/17 at 4:26 p.m., observation showed a certified nurse aide (CNA) (#4) placed a gait belt around Resident #9's waist, removed the oxygen from the resident's nose, placed a walker in front of the resident, assisted the resident to stand and ambulate to the bed side commode. While sitting on the commode, observation showed Resident #9 restless, moaning and straining to have a bowel movement. At 4:38 p.m., the CNA assisted Resident #9 to her bed and placed the oxygen on the resident. Staff failed to provide Resident #9's oxygen for 12 minutes. On 08/29/17 at 11:00 a.m., observation showed two CNA's (#5, #6) assisted Resident #9 to a sitting position at the edge of her bed. The CNA (#6) removed the resident's oxygen and assisted the resident to a recliner chair to complete morning cares. While washing the resident's arms and back, Resident #9 inhaled a deep breath and sighed. As the CNA assisted the resident with dressing, a CNA (#6) stated,you're getting tired on me. At 11:05 a.m., the CNA (#6) placed oxygen on the resident. Staff failed to provide Resident #9 oxygen for five minutes. During an interview on 08/30/17 at 12:00 p.m., an administrative nurse (#9) stated staff should keep Resident #9's oxygen on at all times.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 08/20/2015. Based on observation, record review, review of policies/procedures, and staff interview, the facility failed to provide care in a manner that maintained or enhanced dignity for residents on 1 of 2 care units (Unit A). Failure to ensure dignity while feeding (Resident #12 and #15) and failure to maintain visual privacy of a brief (incontinence underwear) during ambulation (Resident #8) did not promote the residents' dignity or enhance their quality of life. Findings include: Review of the facility policy titled Feeding resident who cannot feed self occurred on 08/25/16. This policy, dated 2013, stated, . C.N.A. (certified nurses assistant) sits facing resident during feeding . cleans Resident's mouth and hands with wipes . - Review of Resident #12's medical record occurred on August 24-25, 2016. [DIAGNOSES REDACTED]. The resident's current care plan identified, . Setup and supervision required. assist with eating as needed. Observation showed the following: * On 08/24/16 at 12:09 p.m., Resident #12 sat at an assisted table with a CNA (#5) seated next to her. Resident #12 drooled down the left side of her face, dropped food onto her clothing protector, and scooped the food from her clothing protector and ate it. The CNA (#5) also scooped food from Resident #12's clothing protector, mixed the food back into the food on her plate, and eventually fed it to her. The CNA failed to wipe Resident #12's face with a napkin and failed to removed the dropped food items from the resident's clothing protector/tray. * On 08/24/16 at 5:28 p.m., Resident #12 sat at an assisted table with a CNA (#5) seated next to her. Resident #12 drooled down the left side of her face. The CNA failed to wipe Resident #12's face with a napkin. * On 08/25/16 at 7:55 a.m., Resident #12 sat at an assisted table with three unidentified CNAs present. Resident #12 drooled down the left side of her face. The three unidentified CNAs failed to wipe Resident #12's face with a napkin and/or failed to cue her to do so. * On 08/25/16 at 8:05 a.m., A CNA (#9) stood next to Resident #12 as she fed her breakfast. Resident #12 drooled down the left side of her face. The CNA (#12) failed to sit while feeding Resident #12 and failed to wipe her face with a napkin. - Review of Resident #15's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The resident's current care plan identified, . uncoordinated movement and impaired finger dexterity. assist to complete meals . Meal observations on August 22 - 23, 2016 showed two unidentified CNAs standing next to Resident #15 as they fed him. The unidentified CNAs failed to sit while feeding Resident #15. Observations on 08/24/16 at 12:09 p.m. and 12:22 p.m., showed a CNA (#5) assisted Resident #15 with his noon meal. Resident #15 dropped food onto his clothing protector. The CNA (#5) then scooped the food from the clothing protector and immediately fed it to Resident #15 or mixed the food back into the food on his plate, eventually feeding it to him. The CNA (#5) failed to remove the dropped food items from the resident's clothing protector/tray. During an interview on the morning of 08/25/16, an administrative staff member (#7) confirmed staff members are expected to sit while feeding residents. During a second interview on the morning of 08/25/16, two staff members (#6 and #7) confirmed Resident #15 should not be fed food that dropped onto his clothing protector. - Observation on 08/23/16 at 8:48 a.m. showed three CNA's (#1, #2, and #3) assisted Resident #8 to stand and walk in the hallway. Resident #8's brief was exposed through the zipper of her pants. One CNA (#2) closed Resident #8's zipper after she took multiple steps. During an interview on 08/25/16 at 10:05 a.m., an administrative nurse (#4) confirmed staff failed to properly maintain visual privacy of Resident #8's brief.

Based on record review and staff interview, the facility failed to provide residents the most current information regarding Medicare coverage for 3 of 4 resident (Resident #13, #19, and #20) records reviewed. Failure to maintain the correct contact information limited residents' and families' access to the Medicare intermediary involved in the appeal process. Finding include: Review of the facility's Mandatory Denial Notice form occurred on the afternoon of 08/24/16. This form, provided by the facility, contained information regarding the appeal process; including contact information for the Medicare intermediary. Record review showed Resident #13, #19, and #20 (all residing on Unit A) received Mandatory Denial Notices which contained outdated contact information for the Medicare intermediary. During an interview on 08/24/16 at 3:00 p.m., a social services staff member (#8) identified the Mandatory Denial Notice form utilized on Unit A contained outdated contact information for the Medicare intermediary.

1. Based on record review and staff interview, the facility failed to provide the necessary care and services to ensure treatment for 1 of 1 sampled resident (Resident #2) diagnosed with [REDACTED].#2 receiving unnecessary psychoactive medications for agitation. Findings include: The "Nursing Weekly Assessment . . . Charting Tips" stated, "PAIN - use 1-10 scale, or mild, moderate, severe - have resident describe - sharp, stabbing, dull, - Location - does it radiate? - Frequency - daily, frequently, only at night - if they report pain and you offer them medication do they refuse it - does anything make pain better or worse IF THEY REPORTED PAIN DID YOU DO ANYTHING - ACTION/RESULT! . . . COMMUNICATION/ADL ABILITIES - . . . can they make needs known, do they make requests for pain medication . . . MOOD & BEHAVIORS - BE DESCRIPTIVE! restless . . ." - Resident #2's medical record, reviewed July 30-August 2, 2012, identified [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition, limited assistance required for transfers and walking in room, history of falls, and scheduled and/or prn (as needed) pain medications. The current care plan stated the following, ". . . Problem: . . . Pelvic fx (fracture) . . . Alteration in comfort . . . Assess location, characteristics and severity of pain, Observe for verbal and nonverbal signs of pain, Medicate for pain as ordered, Monitor for relief of pain . . . Assist resident to identify things that precipitate pain . . ." Review of Resident #2's medical record identified the following: * 04/22/12 at 10:05 a.m., "Found sitting on floor - says she hurts all over - but moves about well - walks - was some hesitation (L) leg!" . . . at 1:00 p.m., "c/o (complains of) more severe pain (L) leg - (Dr.) notified - Resident to ER (emergency room ) - Xray done" . . . at 2:30 p.m., "Back to room - more comfortable" . . . at 5:40 p.m., "Pain: denied pain, not until tried to stand . . . unable to stand . . . c/o pain left leg (with) trying to stand . . ." * 04/23/12 at 2:15 a.m., "ROM (Range of motion): WNL (within normal limits) but left leg stiff . . . Pain: left leg" . . . at 10:00 a.m., "Pain: all over" . . . at 8:00 p.m., "Pain: generalized . . ." The physician's progress report, dated 04/23/12, stated, ". . . She was taken over (sic) the ER and her hip was x-rayed. It was negative . . . Physical Assessment: . . . Pelvic bones appear stable. No pain with walking motion." Review of Resident #2's medical record identified the following: * 04/24/12 at 4:20 a.m., "Pain: (L) side . . . Comments: stated why can't I move my (L) leg - however she had just ambulated to (and) from the BR (bathroom)" . . . at 10:00 a.m., "Pain: left leg . . ." * 04/25/12 at 12:01 a.m., "Pain: left leg" . . . at 7:40 a.m., "Pain: left leg . . . stated weakness with standing - assist to (change) position" . . . at 7:45 p.m., "Pain: left leg." * 04/26/12 at 12:40 a.m., "Unable to settle. Very anxious about not feeling well. (Up and down) multiple x's (times). [MEDICATION NAME] provided for coverage. Also provided (one) Tylenol for pain." . . . at 3:10 a.m., "She was again up to the BR (and) requested something for pain" . . . "Up to BR x 2 b/4 (before) 10:00 a.m. Called for help - (and) waited for help b/4 going to BR . . . When walking to BR - stepped (with) (L) foot - - dragged (R) (right) foot!" . . . "gait slow, c/o (R) leg pain, drags (R) foot." * 04/28/12 at 1:00 p.m., ". . . Remained in bed thru (through) out the shift except to amb (ambulate) to toilet (with) walker (and one) assist . . . " * 04/30/12, "Monitor . . . for cont. (continued) pain to (L) leg." * 05/01/12, "Resident c/o having terrible pain in hip/leg. Tylenol ES (extra strength) given (at) 2:30 p.m., resident states she doesn't think it will help . . . Resident cont to complain of pain in L) hip/leg. Also res (resident) seems very anxious d/t (due to) pain - prn anxiety med (medication) given, resident continued to be anxious, restless - warm pack placed to L hip/leg (without) relief. Res unable to sit in chair comfortably - Res has been unable to settle down to sleep . . ." * 05/02/12 at 12:15 a.m., "Resident has been very anxious (secondary to) her (L) leg pain. She can't understand why it doesn't get better. She has a very difficult time finding a comfortable position. [MEDICATION NAME] given to help with the anxiety." * 05/04/12 at 6:00 p.m., ". . . states she doesn't feel well . . . pain all over (and) in left leg." * 05/06/12 at 5:00 p.m., ". . . Favors left leg (and) c/o pain (with) weight bearing or movement - up for supper . . . but slept the rest of the shift." * 05/08/12, ". . . Stary (sic) eyed . . . She stated she just wasn't hungry anymore." * 05/09/12, "Resident rested most of the morning, up and ate some dinner then rested." . . . "w/c for mobility for distance." * 05/10/12, "Seems very tired! Says she just can't take her pills!" . . . at 5:00 p.m., "Appetite is very poor - unable to get her to take fluids . . ." The physician's progress report, dated 05/10/12, stated, ". . . She does state her legs hurt her at times . . . Nursing has concerns regarding her decrease in activity . . . We will get a CT (computerized tomography) of her hips . . ." The radiology report, dated 05/11/12, identified "fractures involving the inferior and superior pubic ramus on the left with fractures also present in the pubic symphyseal region." The electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] * 04/22/12 at 11:40 a.m., "[MEDICATION NAME] . . . pain due to her fall" * 04/23/12 at 2:16 a.m., "[MEDICATION NAME] . . . left leg" * 04/24/12 at 11:54 a.m., "[MEDICATION NAME] . . . pain everywhere" * 04/26/12 at 12:35 a.m., "[MEDICATION NAME] . . . anxious about not feeling well - up and down" . . . at 3:14 a.m., "[MEDICATION NAME] . . . c/o L hip/leg pain. Had refused scheduled (spit out) but was really hurting and took this one" * 04/28/12 at 3:43 p.m., "[MEDICATION NAME] . . . agitation" * 04/30/12 at 8:35 a.m., "(Nurse practioner) . . . updated on residents . . . pain cont L leg" * 05/01/12 at 5:28 p.m., "Tylenol . . . stated she has pain in her left hip that is driving her crazy" . . . at 5:29 p.m., "[MEDICATION NAME] . . . anxiety over the pain she is having in her left hip . . . at 9:12 p.m., "[MEDICATION NAME] . . . very little relief r/t (related to) pain in legs" . . . at 9:14 p.m. "Tylenol . . . res cont to complain of pain" * 05/02/12 at 12:11 a.m., "[MEDICATION NAME] . . . anxious - lots of pain with no med to give" . . . at 5:31 a.m., "[MEDICATION NAME] . . . partially effective - still lots of pain" . . . at 1:00 p.m., "Resident has been complaining, as documented, of pain that has not been relieved by current medications. Spoke with (Nurse Practitioner) regarding this and orders received . . . [MEDICATION NAME]" * 05/04/12 at 6:06 p.m., "Tylenol . . . c/o pain in legs and all over" * 05/05/12 at 3:03 a.m., "Tylenol . . . pain to legs" . . . at 11:37 p.m., "[MEDICATION NAME] . . . unable to sleep" * 05/06/12 at 1:29 a.m., "[MEDICATION NAME]" * 05/09/12 at 1:19 a.m., "Tylenol . . . c/o bilat (bilateral) leg pain" . . . at 9:29 p.m., "[MEDICATION NAME] . . . Tylenol . . . only took part of medication, is lying quietly and calm in bed with eyes closed" Review of Resident #2's medical record identified the following: * [MEDICATION NAME] 0.5 mg (milligram) prn (every six hours as needed) for anxiety (Ordered 10/20/11) * Tylenol 1000 mg tid (three times daily) and prn (one extra in 24 hours) for pain (Ordered 04/30/12 - increased from 500 mg twice daily beginning 10/20/11) * [MEDICATION NAME] 7.5-200 mg every eight hours and prn (one extra in 24 hours) for pain (Ordered 03/27/12) * [MEDICATION NAME] HCL 50 mg prn for femur fracture (Ordered 06/01/12 - decreased from 100 mg three times daily beginning 05/02/12) * [MEDICATION NAME] 25 mcg/hr (micrograms/hour) for femur fracture (Ordered 07/23/12 - increased from 12 mcg/hr beginning 06/01/12) Failure of facility staff to assess, identify, and treat Resident #2's continued and increasing pain resulted in the resident experiencing avoidable pain and resulted in the resident being medicated with an antianxiety medication in an effort to treat Resident #2's anxiety related to unresolved pain. 2. Based on record review, review of facility information, review of a professional reference, and staff interview, the facility failed to provide interventions to promote regular bowel elimination for 4 of 14 sampled residents (Resident #6, #7, #8, and #9). Failure to implement the bowel program according to the facility's protocol resulted in the manual extraction of stool for Resident #8, and may result in unrelieved constipation for other residents. Findings include: Review of the facility document "NIGHT NURSE DUTIES 11PM (11:00 p.m.) TO 7AM (7:00 a.m.)" occurred on 08/02/12. This undated document stated, ". . . check bowel elimination records-make a list of residents who need a laxative-count every third day . . ." Taylor, Lillis, and LeMone, "Fundamentals of Nursing, The Art & Science of Nursing Care," 4th ed., Lippincott Williams & Wilkins, Pennsylvania, page 1193, states "Nursing measures for patients without specific bowel elimination problems are directed toward the patient's achievement of the following goals. . . . Have a soft, formed bowel movement every 1 to 3 days without discomfort . . ." During an interview on 08/01/12 at 4:30 p.m., a supervisory nursing staff member (#13) stated constipation is generally managed by giving prune juice on the second day without a bowel movement and giving a suppository on the third day without a bowel movement. - Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. Resident #8's current care plan stated, ". . . Alteration in elimination (secondary to) bowel and bladder incontinence R/T (related to) Alzheimers (sic) dementia . . . slowed mobility . . . Gets up from toilet before she evacuates bowels - constipation . . . OBJECTIVE . . . Resident will have adequate bowel elimination through . . . 10/17/12 . . . Approaches . . . Duccolax (sic) suppos (suppository) prn constipation . . . Fruit Mix BID (twice per day) . . . MOM 30 (mL) prn . . . Senna S (two) tabs (tablets) in a.m., (one) @ HS . . ." Review of the daily report log (used by the nurses to give report to the next shift) for 04/19/12 revealed the following hand-written entry next to Resident #8's name: "Had Manual BM (bowel movement) Removal." Resident #8's medical record did not include any information related to the above incident, and facility staff were unable to provide additional information. Review of Resident #8's BM records showed the following inconsistencies related to the management of the resident's constipation according to facility policy: *April 7-8, 2012: No BM for two days, suppository given on the 9th (day three), no interventions attempted prior to the suppository *April 10-13, 2012: No BM for four days, prune juice given on the 11th and 12th, nothing given on the 13th, and a suppository given on the 14th (day five) with results *April 15-17, 2012: No BM for three days, suppository given on the 18th with results unclear. *April 19, 2012: (Manual extraction of stool at noted above on the daily report log) *April 20-21, 2012: No BM for three days; prune juice given on the 19th, 20th, and 21st; suppository given on the 22nd (day four) with results *May 8-12, 2012: No BM for five days, no interventions given. Resident #8 had an extra large BM on the 13th (day six) *May 14-19, 2012: No BM for six days, no interventions given. A hand-written note on the May 20th daily report log stated, "Last BM 5/13*. . . Needs supp (suppository) in a.m. . . ." Records showed that Resident #8 had a large BM on the 20th (day seven) without intervention *May 22-27, 2012: No BM for six days, no interventions given. Resident #8 had a large BM on the 28th (day seven) *May 29-June 1, 2012: No BM for four days, suppository given on the 2nd (day five) with results *June 3-5, 2012: No BM for three days, MOM given on the 5th (day three), suppository given on the 6th (day four) with results *June 7-10, 2012: No BM for four days, suppository given on the 11th (day five) with results *June 12-14, 2012: No BM for three days, suppository given on the 15th (day four), no interventions attempted prior to the suppository *June 19-20, 2012: No BM for two days, suppository given on the 21st (day three), no interventions attempted prior to the suppository *June 22-24, 2012: No BM for three days, suppository given on the 25th (day four), no interventions attempted prior to the suppository *July 4-6, 2012: No BM for three days, prune juice given on the 5th and again on the 6th, suppository given on the 7th (day four) with results *July 25-27, 2012: No BM for three days, prune juice given on the 26th, no intervention on the 27th, prune juice again given on the 28th, and a BM on the 28th *July 29-30, 2012: No BM for three days, prune juice given on the 30th and 31st, suppository given August 1 (day four) with results. - Review of Resident #6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #6's current care plan stated, ". . . Constipation . . . hx of having loose stools (with) possible IBS (irritable bowel syndrome) & incontinence prio (sic) to admission . . . OBJECTIVE . . . Resident will have adequate bowel elimination the majority of the time through 8-8-12 . . . Approaches . . . [MEDICATION NAME] suppository rectally prn constipation . . . Senna fruit mix one tablespoon daily . . . [MEDICATION NAME] tab one po (by mouth) daily . . .MOM 30 (ml) po prn bowel care . . . Senna tea one half cup prn constipation . . ." Review of Resident #6's BM records showed the following inconsistencies related to the management of the resident's constipation according to facility policy: *April 12-13, 2012: No BM for two days, suppository given on the 14th (day three), no interventions attempted prior to the suppository *April 15, 2012: No BM, suppository given on the 16th (day two) with results *April 23-25, 2012: No BM for three days, prune juice given on the 25th (day three), and a BM on the 26th *April 27-29, 2012: No BM for three days, suppository given on the 30th (day four), no interventions attempted prior to the suppository *May 9-11, 2012: No BM for three days, no interventions given. Resident #6 had a small BM on the 12th (day four). *May 21-22, 2012: No BM for two days, suppository given on the 23rd (day three), no interventions attempted prior to the suppository *June 6-8, 2012: No BM for three days, suppository given on the 9th (day four), no interventions attempted prior to the suppository *June 23-25, 2012: No BM for three days, suppository given on the 26th (day four), no interventions attempted prior to the suppository - Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The resident's current care plan stated, ". . . Problem: . . . Constipation . . . Objective . . . Resident will have adequate elimination every 2-3 days thru (sic) 10-24-12 . . . Approaches . . . MOM 30 (mL) po PRN constipation . . . [MEDICATION NAME] S 2 tabs po daily . . . 1 tbsp (tablespoon) fruit mix dly (daily) . . . Prune Juice dly (with) breakfast . . . Ducolax (sic) suppos (rectally) PRN constipation . . ." Review of Resident #7's BM records showed the following inconsistencies related to the management of the resident's constipation according to facility policy: *May 28-30, 2012: No BM for three days, no interventions given. Resident #7 had a large BM on the 31st (day four) - Review of Resident #9's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included Senna S two tablets twice a day (increased from one tablet daily to one tablet in the morning and two tablets at bedtime on 05/01/12 and increased again on 06/29/12 to the current dosage), and [MEDICATION NAME] (a pain medication which may cause constipation). Resident #9's current care plan stated, ". . . Alteration in elimination . . . has constipation . . . Objective: Resident will have adequate bowel elimination every 2-3 days . . . Approaches: Senna S . . . Ducolax suppository 10 mg (rectally) PRN constipation. MOM 30 cc (cubic centimeters) PRN constipation. Senna Fruit mix daily . . ." Review of Resident #9's BM records showed the following inconsistencies related to the management of the constipation according to facility policy and staff interview: *April 30-May 3, 2012 - No BM for four days, MOM given on the 3rd (day four) without results, suppository given on the 4th (day 5) with results. *May 6-8, 2012 - No BM for 3 days, suppository given on the 9th (day four) with results. *May 16-18, 2012 - No BM for 3 days, suppository given on the 19th (day four) with results. *May 22-24, 2012 - No BM for 3 days, suppository given on the 25th (day four) with results. The facility failed to implement a consistent bowel management program to help prevent constipation and attempt less invasive interventions before administering suppositories. During an interview on the afternoon of 08/01/12, a supervisory nursing staff member (#10) agreed bowel management was inconsistent and staff should attempt other interventions before administering a suppository.