Every finding on record at SMP Health - St Catherine North

Based on observation, record review, review of professional reference, and staff interview, the facility failed to ensure physician's orders were followed for 3 of 24 sampled residents (Resident #71, #107, and #124). Failure to follow physician orders for medication administration, and application of compression socks and ace wraps, may result in adverse health effects for the residents. Findings include: Review of professional standards included: [NAME], [NAME], and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., Massachusetts, page 68, states, . Carrying Out a Physician's Orders . If the order is neither ambiguous not apparently erroneous, the nurse is responsible for carrying it out. -Review of Resident #71's medical record occurred on all days of survey. A physician's order, dated 12/30/25, stated, . Beige knee high [NAME] compression [socks] . on in AM [morning] off HS [at bedtime] edema [swelling] . Resident #71's current care plan failed to identify the use of [NAME] compression socks. Observations of Resident #71 on 02/09/2026 at 12:46 p.m. and 02/10/26 at 10:02 a.m., showed facility staff failed to apply the compression socks. During an interview on 2/11/26 at 5:13 p.m., an administrative nurse (#1) confirmed staff failed to apply Resident #71's compression socks and update Resident #71's care plan. -Review of Resident #107's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease and dysphagia (swallowing impairment). A physician's order, dated 06/27/18, stated, CRUSH MEDICATIONS in pureed. A quarterly Minimum Data Set (MDS), dated [DATE], identified, Coughing or choking during meals or when swallowing medications. Observation of Resident #107 identified the following: *02/10/26 at 9:45 a.m. a medication aide (MA) (#6) carried a clear medicine cup containing several whole pills into the resident's room. The MA exited the room with the pills and stated the resident refused to take them. *02/10/26 at 11:10 a.m. a nurse (#3) readministered the morning medications crushed in pudding and stated, I am readministering resident 's a.m. medications crushed in pureed per physician orders due to [CMA #6] had attempted to administer medications whole and resident spit them out. The CMA (#6) failed to follow the physician's order to crush Resident #107's medications for administration. - Review of Resident #124's medical record occurred on all days of survey. A physician's order, dated 02/06/26, stated ACE wrap to R [right] upper extremity, on in AM & [and] off HS one time a day for lymphedema [tissue swelling] and remove per schedule. The electronic medication administration record (EMAR) for February 2026 identified the Ace wrap on at 8:00 a.m. and removed at 10:00 p.m. Observations on 02/09/2026 at 11:16 A a.m., 2:00 p.m., and 4:30 p.m., and 02/10/26 at 10:00 a.m. and 1:32 p.m., showed no ace wrap on Resident #124's right arm. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure staff followed standards of care for 1 of 1 supplemental resident (Resident #115) observed during administration of rapid-acting insulin. Failure to administer rapid-acting insulin within 5 to 10 minutes of a meal may result in a hypoglycemic (low blood sugar) reaction. Findings include: Review of the facility policy titled Diabetic Protocol occurred on 02/11/26. This policy, dated September 2017, stated, Administration of Rapid/Short Acting Insulin: a. Must be given 5-10 minutes before mealtime. If given to [sic] early a hypoglycemic episode could occur. Review of Resident #115's medical record occurred on all days of survey. Diagnoses included diabetes mellitus. Observation on 02/10/26 at 4:00 p.m., showed a nurse (#11) administered 18 units of Novolog insulin (rapid-acting insulin) to Resident #115 per physician's order and left the room. The resident went by herself to the dining room, arrived at 4:15 p.m., and received the meal tray at 4:40 p.m., 40 minutes after receiving Novolog insulin. During an interview on 02/11/26 at 2:02 p.m., an administrative nurse (#1) confirmed a beverage, juice, or small snack should be given within 10 minutes of administering rapid-acting insulin.

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 17 sampled residents (Resident #11, #57, and #107) and 1 supplemental resident (Resident #81) observed during cares. Failure to practice infection control standards related to disinfecting shared equipment, glove changes, and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 02/11/26. This policy, dated 01/17/18, stated, . Hand hygiene is performed: . Before and after direct resident contact . Before and after assisting a resident with toileting . After removing gloves . Review of the facility policy titled Standard Precautions occurred on 02/11/26. This policy, dated 03/24/18, stated, . All health care workers will routinely use appropriate precautions to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. Gloves are to be removed: 1. Promptly after use. 2. before touching non-contaminated items or surfaces. Hand hygiene is always performed after glove removal. Review of the facility policy titled Clean Dressing Change occurred on 02/11/26. This undated policy, stated, . It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Wash hands and put on clean gloves. remove the existing dressing. Remove gloves . wash hands and put on clean gloves. cleanse the wound as ordered . Wash hands and put on clean gloves. dress the wound as ordered. Review of the facility policy titled Isolation Precautions (Transmission-based-precautions) occurred on 02/12/26. This policy, revised 11/22/21, stated, . When possible, dedicate the use of noncritical equipment and items such as stethoscope, sphygmomanometer [blood pressure cuff], thermometer to the resident during the infectious process. If use of common equipment is unavoidable, clean and disinfect surfaces and/or items before us on another resident. -Review of Resident #107's medical record occurred on all days of survey. The care plan stated. I have tested positive for COVID-19 on 2/3/2026. Follow droplet isolation precautions. Observation on 02/10/26 at 9:45 a.m. showed a sign on Resident #107's door that identified airborne contact precautions and a cart containing appropriate personal protective equipment (PPE) supplies outside the room. A medication aide (MA) (#6) entered the room with an electronic vitals machine. Upon exiting the room, the MA (#6) wiped down the BP cuff and cord and the top of the vitals machine but failed to wipe down the entire machine. During an interview on 02/10/2026 at 9:52 a.m., an administration nurse (#1) confirmed the vitals machine should not be taken into the COVID transmission-based room, and if taken into the room, would need to be sanitized top to bottom. Observation on 02/10/26 at 10:15 a.m. showed a facility nurse (#7) prepare to enter resident's room to confirm Resident #107 had designated equipment for taking vitals. Upon exiting the resident's room, the facility nurse (#7) did confirm the designated equipment was in Resident #107's room for use and also stated he/she had cleaned and disinfected the electronic vitals machine used in Resident #107's room earlier and clarified he/she had disinfected the machine top to bottom. - Observation on 02/10/26 at 10:50 a.m. showed two certified nurse aides (CNAs) (#4 and #5) assisted Resident #11 to the shower room. The CNA (#4) applied one glove and disinfected the toilet seat and grab bars with a disinfecting wipe. The CNA (#4) removed the soiled glove, and without performing hand hygiene touched hygiene items on a storage cupboard. Both CNAs (#4 and #5) applied gloves, placed a gait belt on Resident #11, and transferred the resident to the toilet. The CNA (#5) performed perineal cares, adjusted the resident's clothing and then both CNAs transferred Resident #11 to the wheelchair. The CNA (#5) removed the soiled gloves and without performing hand hygiene, exited the bathroom to retrieve wheelchair foot pedals. The CNA (#5) returned to the shower room with the foot pedals and applied them to the wheelchair. The CNA (#4) removed her soiled gloves, both CNAs performed hand hygiene, and assisted Resident #11 from the shower room to his room. Both CNAs (#4 and #5) failed to perform hand hygiene before assisting the resident with toileting. The CNA (#4) failed to perform hand hygiene after removing gloves and before touching the other items in the shower room. The CNA (#5) failed to perform hand hygiene after removing gloves and before exiting the shower room. - Observation on 02/10/26 at 12:12 p.m. showed an enhanced barrier precaution sign on Resident #57's door and the resident lying in bed. The nurse (#3) entered the room, performed hand hygiene, applied a gown and gloves, and placed dressing change supplies on the over the bed table. The nurse (#3) removed the soiled dressing, removed the soiled gloves, and without performing hand hygiene applied clean gloves. The nurse cleansed Resident #57's wound with wound wash, removed the soiled gloves, and without performing hand hygiene, applied clean gloves, placed treatment medications in the wound bed, covered the wound with border foam dressing, and without removing the soiled gloves, adjusted the resident pants, placed pillows under the resident's legs, covered the resident with a blanket, and turned off the overbed light. The nurse (#3) removed the soiled gown and gloves, performed hand hygiene, collected the garbage and exited the room. The nurse (#3) failed to perform hand hygiene after removing soiled gloves and before applying clean gloves during the dressing change, failed to remove soiled gloves and perform hand hygiene before touching other items. -Observation on 02/11/26 at 4:15 p.m. showed Resident #81 in bed. A CNA (#9) and a nurse (#10) entered the room and applied gloves. The CNA (#9) removed the resident's soiled brief, performed perineal cares, and without removing the soiled gloves or performing hand hygiene, applied a clean brief, adjusted Resident #81's dress and blanket, removed the soiled gloves and without performing hand hygiene, exited the room. The nurse (#10) removed the soiled gloves, assisted the CNA (#9) to reposition Resident #81's dress, placed a pillow between the resident's legs, adjusted the blankets, and without performing hand hygiene, exited the room. The CNA (#9) failed to remove the soiled gloves and perform hand hygiene prior to touching other items and before exiting the room. The nurse (#10) failed to perform hand hygiene after removing soiled gloves, after touching soiled items, and before exiting the room. During an interview on 02/11/26 at 12:49 p.m., an administrative nurse (#1) confirmed she expected staff to perform hand hygiene after removing gloves and prior to touching other items or applying new gloves.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure a medication regimen free from unnecessary medications for 2 of 5 sampled residents (Resident #6 and #11) selected for medication review. Failure to attempt a gradual dose reduction (GDR) or identify contraindications for a GDR may result in residents receiving unnecessary medications and experiencing adverse consequences related to their use.Findings include: Review of the facility policy titled Drug Regimen Review occurred 02/11/26. This policy, dated 06/09/23, stated, . The consultant pharmacist will provide a written review for each resident on an antipsychotic . antidepressant . The review will evaluate dose, duration, continued need, and emergence of adverse side effects. This information will be used to assist in assessment of effectiveness of drug therapy regimens. Medication tapering should be attempted when the resident's clinical condition has improved or stabilized or the underlying cause of the symptoms has resolved . Tapering of antipsychotic [sic] should be attempted at least once in the first year followed by a 2nd attempt in a subsequent quarter that same year unless clinically contraindicated. After the 1st year tapering should be attempted once a year. The physician must document the clinical rationale for why additional attempts at dose reduction would impair the resident's function. - Review of Resident #6's medical record occurred on all days of survey. Diagnoses included schizoaffective disorder, psychosis and depression. The current physician's orders included Lurasidone, an antipsychotic medication, daily since 7/17/2024. The medical record lacked documentation to show the provider attempted a GDR or reasons why a GDR would be contraindicated from 2024 through February of 2026. - Review of Resident #11's medical record occurred on all days of survey. Diagnoses included Parkinson's Disease, dementia, and depression. The current physician's orders identified Sertraline, an antidepressant medication, daily since 11/14/24. The medical record lacked documentation to show the provider attempted a GDR reasons why a GDR would be contraindicated from November 2024 to February of 2026. During an interview on 2/11/26 at 5:45 pm, an administrative nurse (#1) confirmed Resident #6 and #11's medical records lacked a gradual dose reduction.

Based on record review, review of the North Dakota Provider Manual Preadmissions Screening and Resident Review (PASARR), Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 3 sampled residents (Resident #13) reviewed for PASARR. Failure to complete a change in status assessment with a newly diagnosed mental illness and new medication may result in the delivery of care and services inconsistent with residents' needs. Findings include:The North Dakota PASARR Provider Manual revised December 2020 stated, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability [referred to in regulatory language as related conditions or RC]) was not identified at the Level I screen process, and that condition later emerged or was discovered.Review of Resident #13's medical record occurred on all days of survey and identified the following: *A PASARR dated 07/17/25, identified diagnoses of major depression, generalized anxiety and panic disorder. Medication for mental health included Mirtazapine (antidepressant).*A progress note dated 11/28/25, stated, Medication/Dx [diagnosis]: Seroquel (antipsychotic) 25 mg [milligrams] at bedtime for paranoia, dx delusional disorder. Target Behavior monitored: Paranoia, delusions, anxiety.Resident #13's medical record lacked evidence the facility completed a PASARR related to the new diagnoses of paranoia, delusional disorder, and new order for Seroquel. During an interview on 02/11/26 at 4:55 p.m. a social services staff member (#8) confirmed the facility failed to complete a change in status Level 1 screen for Resident #13.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 7 residents (Resident #97 and #110) observed during medication administration. Two medication errors occurred during staff administration of 28 medications, resulting in a seven percent error rate. Failure of staff to properly prepare and administer medications may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health. Findings include: Review of the facility policy titled Medication Administration occurred on 10/17/24. This policy, dated 10/07/24, stated, . Medications are administered . as ordered by the physician and in accordance with professional standards of practice . Policy Explanation and Compliance Guidelines . Compare medication source . with MAR [medication administration record] to verify . dose . Administer medication as ordered in accordance with manufacturer specifications. Prescribing information found at https://www.drugs.com/pro/depakote.html, page 2, stated, . Depakote is administered orally in divided doses. Depakote should be swallowed whole and should not be crushed or chewed . and page 63, stated, . Depakote Sprinkle Capsules may be swallowed whole, or the capsule may be opened and the contents may be mixed into a small amount of soft food, such as applesauce or pudding. - Review of Resident #97's medical record occurred on 10/16/24. A physician's order, dated 07/03/24, stated. Meclizine HCl Oral Tablet . Give 25 mg [milligrams] . for Vertigo . Observation on 10/16/24 at 8:36 a.m., showed a medication aide (MA) (#3) prepared Resident #97's medications for administration. The MA referred to the resident's MAR, obtained a bottle of meclizine from the medication cart, dispensed one pill from the bottle, and placed the pill in a medication cup along with the resident's other scheduled medications. When asked to confirm the dosage of the meclizine, he/she prepared and dispensed into the cup, the MA again referred the Resident #97's MAR and compared the dosage listed on the pill bottle (which listed 12.5 mg per tablet). The MA confirmed he/she should have dispensed two meclizine pills from the bottle to equal the ordered dose of 25 mg. - Review of Resident #110's medical record occurred on all days of survey. A physician's order, dated 05/01/24, stated, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG . Give 2 capsule by mouth three times a day . Okay to open . Observation on 10/16/24 at 1:30 p.m. showed a staff nurse (#4) dispensed two Depakote Sprinkle capsules from Resident #110's medication card, placed the capsules into a cup along with other scheduled medications, poured the medications from the cup into a plastic sleeve, and crushed the medications. The nurse then poured the crushed contents into applesauce and administered the medications to Resident #110. The nurse (#4) failed to follow manufacturers prescribing instructions and crushed the Depakote Sprinkle delayed release capsules. During an interview on 10/16/24 at 3:41 p.m., an administrative staff member (#5) confirmed Depakote Sprinkles should not be crushed.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure residents remained free of significant medication errors for 1 or 1 sampled resident (Resident #110) with a significant medication error. Failure of staff to administer medications per manufacturer recommendations may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health. Findings include: Review of the facility policy titled Medication Administration occurred on 10/17/24. This policy, dated 10/07/24, stated, . Medications are administered . as ordered by the physician and in accordance with professional standards of practice . Administer medication as ordered in accordance with manufacturer specifications. Prescribing information found at https://www.drugs.com/pro/depakote.html, page 2, stated, . Depakote should be swallowed whole and should not be crushed or chewed . Page 63, stated, . Depakote Sprinkle Capsules may be swallowed whole, or the capsule may be opened and the contents may be mixed into a small amount of soft food, such as applesauce or pudding. - Review of Resident #110's medical record occurred on all days of survey. A physician's order, dated 05/01/24, stated, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG . Give 2 capsule by mouth three times a day . Okay to open . Observation on 10/16/24 at 1:30 p.m. showed a staff nurse (#4) dispensed two Depakote Sprinkle delayed release capsules from Resident #110's medication card, placed the capsules into a cup along with other scheduled medications, poured the medications from the cup into a plastic sleeve, and crushed the medications. The nurse then poured the crushed contents into applesauce and administered the medications to Resident #110. The nurse (#4) failed to follow manufacturers prescribing instructions and crushed the Depakote Sprinkle capsules. During an interview on 10/16/24 at 3:41 p.m., an administrative staff member (#5) confirmed Depakote Sprinkles should not be crushed.

Based on observation, review of facility policy/procedure, review of manufactures' label, and staff interview, the facility failed to date time sensitive thickened beverages with an opened date and to store food in a sanitary manner in 2 of 8 unit kitchenettes (3 South and 3 North). Failure to label beverages with an open date may compromise the safety and quality of the item and failure to store food in a sanitary manner can affect safety. Findings include: Review of the facility policy/procedure titled Storage of multi-use ice pack in freezers, occurred on 10/17/24. This policy, dated 07/16/24, stated . 2. Separation of Ice Packs and Food: a) Ice packs may be stored in the same freezer as food but must not be in direct contact with any food items. Ice packs should be stored on separate shelves or in containers that keep them distinct from food products. b) If separate shelves are not available, ice packs must be placed in a way to prevent them from touching food. Observations of the main kitchen and unit kitchenettes occurred on 10/16/24 at 1:45 p.m. with two administrative staff members (#1 and #2) and showed the following: - Three South kitchenette refrigerator, contained an undated opened container of thickened juice, the product label stated use within 10 days of opening. The freezer compartment contained an ice pack not separated from food items. - Three North kitchenette freezer, contained two ice packs not separated from food items. The facility staff failed to store ice packs on separate shelves from food items or in a distinct container. During the observation, an administrative staff member (#2) stated, she expected ice packs to be stored in a plastic bag. The administrative staff member (#1) disposed of the unlabeled juice and confirmed it should be dated when opened.

Based on record review, review of facility investigation, review of the facility policy, and staff interview, the facility failed to ensure adequate supervision and assistance for 1 of 1 closed records (Resident #1) reviewed for an accident with subsequent injury. Failure to provide adequate assistance with a full-body mechanical lift transfer resulted in Resident #1's injury and placed all residents requiring full-body mechanical lifts at risk for injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Safe Resident Handling/Transfers occurred on 05/21/24. This policy, revised 05/10/24, 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 for the resident while keeping the employees safe in accordance with current standards and guidelines. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action . Review of the Validation Checklist-Mechanical Lift occurred on 05/21/24. This document, dated 2024, stated, Purpose: To determine if the individual performs transfers with mechanical lifts in accordance with professional standards of practice and as per manufacturer's instructions for use. Attached the sling straps to the desires settings and ensured the straps were secure. Gently raised the resident minimally away from the bed surface and ensured that straps were still secure. Moved and positioned the lift over the respective chair, with the assistance of the second staff member, and gently lowered the resident into the chair . Review of Resident #1's medical record occurred on 05/21/24. The care plan stated, . TRANSFER: I require assist of 2 with hoyer [full-body mechanical lift] for transfers. Review of Resident #1's progress notes identified the following: * 05/09/24 at 10:39 a.m., [Resident #1] fell out of hoyer sling during transfer this morning. Pupils reactive and equal in size. Unable to assess strengths bilaterally. Resident guarding right hip and grimacing. Notification: Call placed to [provider name]. Send resident to . ER [emergency room ] for further evaluation. * 05/09/24 at 12:38 p.m., . Resident returns to facility from . ER. Neuros [neurological assessments] are as follows: Pupils are equal and brisk to react. Resident remains aphasic (baseline for her). Able to do ROM [range of motion] on all 4 extremities with some guarding during motion of her leg. * 05/10/24 at 11:40 a.m., . Resident was very sleepy during brunch. She kept placing her hand near her head and looking down. Ice pack applied for 15 mins [minutes] and Tylenol provided for comfort. Neuros have remained unchanged this shift and continue to be assessed every 2 hrs [hours]. She has a large area of bruising to the back of skull, with further bruising running down the left & [and] right neck into the collar bone region. Her scalp has a small area with dried blood on it. * 05/11/24 at 7:03 a.m., . Resident slept comfortably all shift with no s/s [signs/symptoms] of pain/infection. Back of head stopped oozing this shift. Hematoma [pool of blood or bruise] still present to back of head with edema. Neuro checks completed and are running her baseline at this time. * 05/11/24 at 1:17 p.m., . Resident slept all morning/early afternoon and was unable to be arose. Did not receive medication or any food. Resident had 75 second seizure at 1300 [1:00 p.m.] today. on-call provider . was called . Send resident in to . ER and hold bed. The facility's investigation report, dated 05/13/24, stated, . based on the demonstration of how the fall occurred and reporting of staff who witnessed the fall, investigation indicates that [certified nurse aide (#2)] did not follow the proper steps for a safe transfer by ensuring that the sling was securely hooked to the lift, having equipment in the appropriate position, and keeping her hands on the resident for guidance and/or support during the transfer . During an interview on the afternoon of 05/21/24 an administrative staff member (#1) confirmed staff failed to properly transfer Resident #1 which led to the injuries. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for the deficient practice by: * Completing an investigation with interviews of staff that determined the cause of the incident. * Providing immediate staff education on 05/09/24 to staff via e-mail regarding proper transferring with Hoyer lifts. * Completing competency validations of safe transfers for all nursing staff beginning 05/09/24. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: * Implemented weekly Hoyer transfer audits to ensure staff on all units are performing safe and appropriate transfers using mechanical lifts * Implemented weekly care plan audits to ensure Hoyer sling sizes are on each resident care plan. * On 05/10/24 all mechanical lifts were inspected to ensure they were working properly. The surveyor determined a deficient practice existed on 05/09/24. The facility implemented corrective action and completed all staff education on 05/20/24.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 24 sampled residents (Resident #9, #19 and #24). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION K: SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI User's Manual, revised October 2019, pages K-5 through K-12, stated, . K0300: Weight Loss . Coding Instructions . 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, and the weight loss was not planned and prescribed by a physician. K0510: Nutritional Approaches . K0510D, therapeutic diet (e.g., low salt, diabetic, low cholesterol) . Therapeutic diets are not defined by the content of what is provided . but why the diet is required. Therapeutic diets provide the corresponding treatment that addresses a particular disease or clinical condition which is manifesting an altered nutritional status by providing the specific nutritional requirements to remedy the alteration. to manage problematic health conditions (e.g. supplement for protein-calorie malnutrition). - Review of Resident #9's medical record occurred on all days of survey. A dietary progress note, dated 06/27/23 at 5:04 p.m., stated, . Weight of 195 lb [pounds] from 6/23/23 is down significantly 22 lb or 10.1% in the past 6 months. A quarterly MDS, dated [DATE], identified section K0300: Weight Loss coded no and K0310: Weight Gain, coded 2, yes, not on physician-prescribed weight-gain regimen. During an interview on 09/21/23 at 10:19 a.m., an administrative staff member (#3) confirmed staff failed to correctly code Section K as weight loss on Resident #9's MDS. - Review of Resident #19's medical record occurred on all days of survey. Provider orders indicated a regular diet with thin liquids. A dietary progress note, dated 08/04/23 at 9:09 a.m., stated, . Nutritional CAA [care area assessment] triggered r/t [related to] use of therapeutic diet (dx [diagnosis] mild malnutrition). A significant change MDS, dated [DATE], identified section K0510D coded for a therapeutic diet. Resident #19's medical record failed to identify a provider's diagnosis of mild malnutrition or other diagnoses to support coding of a therapeutic diet on the MDS. During an interview on 09/21/23 at 10:19 a.m., an administrative staff member (#3) confirmed staff should not have coded a therapeutic diet in Section K on Resident #19's MDS. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2019, pages N-6 and N-7, stated, . Coding Instructions . N0410E, Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). - Review of Resident #24's medical record occurred on all days of survey. Medications included Eliquis (an anticoagulant) 5 milligrams (mg) twice per day with an order date of 04/19/23. Resident #24's quarterly MDS, dated [DATE], failed to identify the use of an anticoagulant under Section N. SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS The Long-Term Care Facility RAI User's Manual, revised October 2019, page O-5, stated, . Hospice care . Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. - Review of Resident #24's medical record occurred on all days of survey. The record identified Resident #24 admitted to Hospice on 01/19/23. A significant change MDS, dated [DATE], failed to identify the Hospice admission under Section O. During an interview on 09/21/23 at 9:48 a.m., an administrative nurse (#1) confirmed staff failed to code anticoagulant use and hospice services for Resident #24. 40488

Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), the facility failed to ensure timely electronic data submission of required Minimum Data Sets (MDS) discharge assessments for 3 of 3 supplemental residents (Resident #18, #56, and #98). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual, revised October 2019, page 2-37 stated, Discharge Assessment-Return Not Anticipated . Must be submitted within 14 days after the MDS completion date. Review of Resident #18, #56, and #98's medical records occurred on 09/21/23. The MDSs showed a discharge date of [DATE] for Resident #18, 06/07/23 for Resident #56, and 06/15/23 for Resident #98. On the morning of 09/21/23, a nurse (#1) reviewed validation reports and confirmed CMS did not receive the above discharge assessments. The facility failed to submit the discharge assessments to Center for Medicare and Medicaid Services (CMS).

Based on observation, record review, and staff interview, the facility failed to provide appropriate supervision for 1 of 5 sampled residents (Resident #97) observed during a gait belt transfer. Failure to provide adequate assistance during a transfer places the resident at risk for accidents, falls, or injuries. Findings include: Review of Resident #97's medical record occurred on all days of survey. The current care plan stated, . I have an ADL [activities of daily living] self-care performance deficit r/t [related to] deconditioning, impaired mobility, arthritis . Transfer: I require 1 [assist of one] with a 4WW [four-wheel walker] for pivot transfers. Observation on 09/19/23 at 9:08 a.m. showed a certified nurse aide (CNA) (#4) applied a gait belt and brought the 4WW to Resident #97. The CNA walked beside the resident holding on to the gait belt until the entrance of the bathroom. The CNA then left the resident standing unattended to move the scale chair closer. Observation showed the resident swayed from side to side while holding the 4WW. The CNA failed to remain by the resident's side during a transfer. During an interview on 09/19/23 at 10:01 a.m., an administrative nurse (#2) confirmed staff should not leave the resident unattended.

Based on record review and staff interview, the facility failed to ensure residents' records contained the hospice plan of care and certification of a terminal illness for 1 of 3 sampled residents (Resident #106) receiving hospice services. Failure to obtain these documents limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: Review of Resident #106's medical record occurred on all days of survey. Diagnoses included hypertensive [high blood pressure] heart disease with heart failure, congestive heart failure and myocardial infarction [type of heart attack]. The resident elected and received hospice services at home for five months prior to admission to the facility in July 2023. The medical record lacked the hospice certification of terminal illness and plan of care until the hospice recertification plan of care completed on 08/16/23. During an interview on 09/21/23 at 9:30 a.m., an administrative nurse (#2) confirmed Resident #106's medical record lacked the hospice certification and plan of care for three weeks after admission.

Based on record review and staff interview, the facility failed to provide the resident or their representative and the State Long Term Care Ombudsman written notice of transfer for 1 of 2 resident closed records (Resident #120) with hospital transfers. Failure to provide a written notice of transfer does not allow the resident and/or representative to make an informed choice regarding the resident's rights. Failure to notify the Ombudsman does not allow the Ombudsman to know the resident was transferred and be alerted to possible assistance to the resident and/or representative if needed. Findings include: Review of Resident #120's medical record identified hospitalization s on 07/22/22 and 07/26/22. The medical records lacked evidence of written transfer notices given to the resident and/or their representative, or the Ombudsman. During an interview on 08/17/22 at 5:45 p.m., an administrative staff member (#3) confirmed there were no written transfer notices completed for the transfers on 07/22/22 and 07/26/22.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1) and staff interview, the facility failed to complete a Minimum Data Set (MDS) that accurately reflected the residents' status for 2 of 25 sampled residents (Resident #4 and #68). 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: Section E: Behaviors The Long-Term Care Facility RAI Manual, revised October 2019, page E-5, stated, . E0200: Behavioral Symptom - Presence & Frequency . Steps for Assessment . 1. Review the medical record for the 7-day look-back period. 2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have frequent contact with the resident. 3. Observe the resident in a variety of situations during the 7-day look-back period. Review of Resident #68's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified Resident #68 verbal behaviors occurred on 4-6 days, other behaviors occurred daily, and wandering occurred daily during the seven-day look-back period. Resident #68's medical record lacked evidence of the behaviors occurring as documented on the MDS. During an interview on the morning of 08/18/22, an administrative nurse (#1) verified Resident #68's medical record lacked necessary documentation for behavior coding. Section N. Medications The Long-Term Care Facility RAI Manual, revised October 2019, page N-3, stated, . N0350: Insulin . Steps for Assessment 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed. Review of Resident #4's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified Resident #4 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's medical record lacked a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 08/18/22 at 10:27 a.m., an administrative nurse (#4) confirmed she inaccurately coded the insulin and injection for Resident #4.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received the necessary services to maintain oral hygiene for 1 of 8 sampled residents (Resident #33) observed during morning cares. Failure to provide oral care for a dependent resident may result in poor hygiene, increased dental problems, decline in oral intake, and a decreased quality of life. Findings include: Review of the facility policy and procedure titled Standards of care occurred on 08/18/22. This policy, reviewed/revised 08/11/20, stated, . Procedure: 1. All staff are expected to provide services and care for all residents that meet the defined Standards of Care. Routine Care Each of the following is part of the routine care provided by care givers, unless otherwise directed. General Standards: . Oral care will be done in the morning and at bedtime. Observation on 0816/22 at 8:45 a.m. showed two certified nurse aides (CNAs) (#5 and #6) provided morning personal care, dressed, and transferred Resident #33 to his wheelchair using a full body lift. Prior to leaving the room, the CNA (#5) directed CNA (#6) to brush Resident #33's teeth. The CNA (#5) failed to provide oral care prior to removing the resident from his room. Review of Resident #33's medical record occurred on all days of survey. The current care plan stated, . I have an ADL [activities of daily living] self care performance deficit [related to] impaired mobility . dementia . Personal Hygiene/Oral Care: I require assist of one staff with personal hygiene and oral care. Resident #33 saw the dentist on 07/14/22, the report stated, #3 [and] #27 [dental descriptor for individual teeth] appear like probable decay. Numerous areas of likely decalcification. Tissues generalized red [and] inflamed . should have full evaluation. Needs help brushing after meals and before bed. Do the best you can. During an interview on 08/18/22 at 10:59 a.m., an administrative nurse (#7) identified oral cares are to be completed, at least, in the morning and at bedtime which is their standard of care.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure a safe environment for 1 of 2 sampled residents (Resident #34) who utilized an electric wheelchair. Failure to reassess safe use of an electric wheelchair places residents at risk for pain and/or injury. Findings include: Review of the facility policy titled Therapy Services occurred on 08/18/22. This policy last reviewed/revised dated 03/23/12, stated . If therapy is warranted after screening, the therapist or nursing will write their recommendations after evaluation and treatment. Therapists and nurses will make a notation in the progress notes any time there is a status change related to therapy. Review of Resident #34's medical record occurred on all days of survey. Diagnoses included [CONDITION(S)], dementia with behavioral disturbance, [CONDITION(S)], [CONDITION(S)] and visual hallucinations. Review of Resident #34's progress notes identified the following: * 05/10/22 at 5:38 p.m. Resident was noted to bump into the corner of the front desk with his power chair. The arm on the right side of the chair hit the counter hard enough to break off a piece of the cosmetic plastic. * 07/06/22 at 9:44 a.m. Resident then came out to dining room and ran into a table causing his power chair to get stuck under the table. Resident yelled and hit at table and accidentally hit joy stick on chair causing chair to lift table off the ground and tip table on its side. Resident then ran into door frame of his room bumping his L) [left] foot on wall. * 07/18/22 at 7:53 a.m. Area between great toe and second toe on L) foot has an open area. Some bruising noted to top of great toe and a patch of red noted to skin at 2nd joint of great toe. Wife stated resident had an injury similar to open area that resulted from toe being bumped and bent to the side. Previous injury was in same location current open area is noted. * 07/18/22 at 10:51 a.m. Physician Orders: ok to send to [name of facility] ER [emergency room ] for assessment of skin issue . open area great to L) foot . * 07/18/22 at 12:31 p.m. Return from Appointment . Physician Orders: 1. [MEDICATION(S)] [oral antibiotic] 500mg BID [twice a day] x [times] 7 days 2. dressing to remain in place until next visit on 7/22 Comments: Wound flushed, sutured, dressing applied. * 07/26/22 at 7:57 p.m. Resident very spasmatic and jerky this shift causing him to [sic] unable to control his power chair in a smooth and safe manner. At one point, resident bumped hard into his closet doors. * 08/01/22 at 10:42 p.m.1930-2030 [7:30 p.m. to 8:30 p.m.] Observed Behavior: . Resident then paced dining room (in power chair) and then the unit halls. Resident then turned chair up full speed and slammed through the double doors at end of unit and through the lobby/office areas. Resident attempted to push through door at north end of building by offices and then turned around and headed back towards unit. Resident then forcefully bumped front door with chair several times attempting to open front door. * 08/02/22 at 3:23 p.m. abrasion Location: R) [right] shin 3x3cm [centimeters] . RA noted during cares . resident unaware of abrasion . Resident has been noted to be bumping into things with power chair recently. It is thought resident may have bumped leg into something causing abrasion . * 08/15/22 at 4:45 p.m. Laceration to dorsal second left toe at first joint. Approximately 1.25cm in length. Skin tear to left second toe medial aspect at last tarsal joint. Blood blister and loose nail to third left toe tip. Abrasion to left first toe to nail bed(nail not present) . Area cleansed with sterile saline and gauze. Wrapped with sterile 2x2's and wrapped with gauze wrapping for transport to ER for evaluation. noted blood dripping from resident's left sock . Resident description: States he doesn't know what happened. Appears as if resident's toes rubbed across/caught on something. * 08/15/22 at 5:14 p.m. Physician Orders: Ok to send resident to [name of facility] ED [emergency department] for evaluation of L) foot injury to Great toe & [and] index toe . During an interview on 08/18/22 at 9:37 a.m., an administrative nurse (#1) reported facility staff are expected to complete a nursing assessment if an incident occurred where the resident ran into objects in the environment and staff would monitor the resident with independent use of the electric wheelchair. If another incident occurred, a referral to therapy would be requested. During an interview on 08/18/22 at 8:07 a.m., a facility nurse (#2) confirmed an Occupational Therapy evaluation had not been completed for Resident #34's safe use of the electric wheelchair since 02/28/22.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide assistance with activities of daily living (ADL) to 3 of 3 sampled residents with feeding tubes (Resident #38, #83, and #87) observed during cares, medication administration or routine flushes. Failure to provide appropriate assistance to residents who cannot independently carry out ADLs may result in poor hygiene and decreased self-esteem. Findings include: Review of the facility policy titled Oral Care occurred 05/27/21. This policy, revised July 2013, stated, POLICY: All residents should receive oral hygiene twice a day. Certain residents require more frequent care, they are residents who are . unable to take fluids by mouth . these residents should have oral cares every 2 hours or according to their individual care plan . - Review of Resident #38's medical record occurred all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan stated, . Total assist of one with oral cares frequently . Personal Hygiene: Total dependence assist of 1 . Observation on 05/25/21 at 10:09 a.m., showed two CNAs (certified nursing assistants) (#5 and #6) transferred Resident #38 from a chair to the bed with a hoyer [total body lift], changed brief, and completed perineal cares. The CNAs failed to provide oral cares. Observation on 05/27/21 at 9:37 a.m., showed a licensed nurse (#2) administered medications and feeding via feeding tube for Resident #38. The nurse (#2) failed to provide oral cares. - Review of Resident #83's medical record occurred all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly minimum data set (MDS) dated [DATE] stated, . personal hygiene with extensive assist with one person . Physician orders stated, . oral cares with [MEDICATION(S)] (for dry mouth) swab every (q) 2 hours while awake every day and evening shift for dry mouth . Observation on 05/26/21 at 10:50 a.m., showed a licensed nurse (#3) administered medications and feeding via feeding tube for Resident #83. The nurse (#3) failed to provide oral cares. - Review of Resident #87's medical record occurred all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan stated, . Provide mouth care as per activities of daily living (ADL) personal hygiene . The quarterly MDS dated [DATE] stated, . personal hygiene with total dependence of one person assist . Observation on 05/25/21 at 9:51 a.m. showed two CNAs (#5 and #6) transferred Resident #83 from the chair to the bed with a ceiling lift, changed brief, and completed perineal cares. The CNAs failed to provide oral cares. Observation on 05/26/21 at 3:45 p.m. showed a licensed nurse (#4) flushed feeding tube for Resident #83. The nurse (#4) failed to provide oral care. During an interview on 05/27/21 at 9:37 a.m. an administrative staff (#1) agreed staff had not performed oral cares per the facility's policy.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the appropriate care and services to prevent complications for 2 of 3 sampled resident (Resident #38 and #87) receiving medication and nutrition by a gastrostomy (tube surgically inserted) tube. Failure to verify placement of the gastrostomy tube prior to administering medications and nutrition has the potential to result in adverse events. Findings include: Review of the facility policy titled Gastrostomy tube management occurred on 05/27/21. This policy, revised June 2016 stated, . Check tube position every 4 hours when continuous feeding, before every intermittent feeding and before administering medications . Verify feeding tube position using auscultation . Draw up 10-20 cc's [cubic centimeters] of air into a 30-60 cc syringe. Insert the tip of the syringe into the feeding tube. Place the stethoscope on the left side of the abdomen just above the waist and inject the air from the syringe into the stomach. Listen for bubbling or gushing sound. Check and record amount and appearance of residual . - Review of Resident #38's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly minimum data set (MDS) dated [DATE], identified, Section K - identified a feeding tube. Observation on 05/25/21 at 11:05 a.m. showed a licensed nurse (#2) administered crushed medication and [MEDICATION(S)] per Resident #38's feeding tube. The nurse failed to check placement prior to the medication administration. - Review of Resident #87's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly minimum data set (MDS) dated [DATE], identified, Section K - Abdominal feeding tube. The current care plan identified, . requires a feeding tube related to (r/t) dysphasia (difficulty swallowing) . Check for tube placement and residual volume per facility protocol/as ordered . I receive my hydration via my feeding tube . I receive my medications via my feeding tube . Observation on 05/26/21 at 3:45 p.m. showed a licensed nurse (#4) flushed Resident #87's feeding tube with water. The nurse failed to check placement prior to the flush. During an interview on 05/27/21 at 9:37 a.m., an administrative nurse (#2) confirmed she expected staff to check placement of the feeding tube prior to medication and feeding administration.

Based on record review, review of facility policy, and staff interview, the facility failed to notify, in a timely manner, the resident's physician for 1 of 1 sampled resident (Resident #102) who experienced a fall occurring outside the facility with injuries which later resulted in fractures. Failure to promptly notify the physician limited the physician's ability to make an informed decision regarding the resident's care and may affect the resident's quality of life. Findings include: Review of the facility policy Notification of Change in a Resident's Condition or Status occurred on 06/20/19. The policy, revised 07/10/18, stated, . Facility staff will promptly notify the . attending physician . of changes in the resident's condition . The Nurse on duty will notify the resident's attending physician when: . The resident is involved in any accident or incident that results in an injury including injuries of an unknown source that requires physician intervention . Review of the facility policy titled Accidents and Incidents--Investigating and Recording occurred on 06/20/19. The policy, revised 07/19/18, stated, . The charge nurse shall: . Follow physician directives based on physician notification . - Review of Resident #102's medical record occurred on all days of survey. The Fall Report dated 04/20/19, stated, . As reported by (name). Resident was brought back from church by (name). (name) stated resident's w/c (wheelchair) hit a bump on the sidewalk. He leaned the chair back and resident leaned forward. The safety belt gave way and resident fell out on to the ground. and abruptly stopped. He bumped the right side of his forehead resulting in an abrasion and receive abrasions to his knuckles, elbows, and knees. (name) put him back in the chair and brought him to the facility . Bruise atop Lt (left) hand 5x7 cm (centimeters) (approximately 2 x 2.75 inches) . The Rosewood Practitioner Communication form, completed 04/20/19, stated, . 1730 (5:30 p.m.) time of fall . Resident fell out of his w/c outside. He has a bump and abrasion on the Rt (right) side of forehead. Abrasions on 3 fingers bruises on both hands and abrasions on knees. Vitals @ the time 100.1 (temperature) 97% RA (oxygen on room air) 21 (respirations) 68 (pulse) 150/90 (blood pressure) ice applied to forehead. c/o (complains of) pain in the Lt hand . Practitioner Response: noted - seatbelt was evaluated & working well . Date 04/22/19. Review of record showed the facility staff completed the Practitioner Communication form on 04/20/19. However, a practitioner did not see Resident #102 until 04/22/19. Review of record showed Resident #102 complained of left hand pain and swelling. On 05/01/19, an xray identified . Displaced fx (fracture) of base of second metacarpal bone, left hand, initial encounter for closed fx. Further record review of physician notes, dated 05/24/19 - 05/28/19, indicated while being hospitalized for [REDACTED]. Displaced posterior arch fx of 1st cervical vertebra, subsequent encounter for fx (with) routine healing . Other displaced fx of 4th cervical vertebrae, subsequent encounter for fx (with) routine healing. During an interview on 06/19/19 at 5:20 p.m., an administrative nurse (#1) stated she expected staff to notify the practitioner right away if a resident injury occurred.

Based on record review and staff interview, the facility failed to provide a bed-hold notice for 1 of 1 resident closed record (Resident #117) with an admission to the hospital. Failure to provide the facility's bed-hold policy does not allow residents or their legal representatives to make informed choices regarding their readmission rights. Findings include: Review of Resident #117's medical record occurred on 06/20/19 and identified the facility transferred the resident to the hospital on [DATE]. The medical record lacked evidence the facility staff provided Resident #117 and/or his/her legal representative written notice of the bed-hold policy upon transfer to the hospital. During an interview on the morning of 06/20/19, an administrative nurse (#1) confirmed the facility failed to provide the bed-hold notice.

1. Based on record review, professional reference review, and staff interview, the facility failed to provide the necessary care and services for 1 of 1 sampled resident (Resident #1) transferred to the hospital emergency room by a transportation service. Failure to recognize the emergent situation, request emergency services (ambulance) instead of a transportation service, and continue oxygen therapy during the transfer, resulted in Resident #1 experiencing acute [MEDICAL CONDITION] and requiring hospitalization . Findings include: Kozier and Erb's, "Fundamentals of Nursing, Concepts, Process, and Practice," ninth edition, Pearson Company, New Jersey, page 535, stated, ". . . Oxygen saturation is also commonly measured at the same time as the traditional vital signs. . . ." Page 567 stated, ". . . oxygen saturation . . . The pulse oximeter can detect hypoxemia (low oxygen saturation) before clinical signs and symptoms, such as a dusky color to skin and nail beds develop . . . Normal oxygen saturation is 95% (percent) to 100%, and below 70% is life threatening." Review of Resident #1's medical record occurred on all days of survey and identified a hospitalization from [DATE]-28, 2014 for acute [MEDICAL CONDITION]. Resident #1's code level, at the time of the hospitalization , identified "Code Level 1" and stated, "All available reasonable technology is used in the event of cardiac or respiratory arrest." Review of Resident #1's progress notes identified the following: *01/23/14 at 11:22 p.m. - ". . .resident having hard time breathing sats (saturation) low, O2 (oxygen) started . . . wife called to notify her of his condition . . . wife stated she would like to come up and see resident before notifying oncall physician." *01/23/14 at 11:35 p.m. - " . . . Writer alerted by RA (resident assistant) that resident had an emesis. Writer went to assess resident and resident was wheezing throughout. Coughing thick clear to light yellow sputum. O2 sats 77% on room air. O2 started and sats went to 82-90 on 2L/NC (2 liters per nasal canula). Resident continues to have labored breathing . . . Notified wife . . ." *01/24/14 at 12:25 a.m. - ". . . Order: send resident in via transit (to emergency room ) . . . Reason for order: Dyspnia, wheezing throughout. O2 sats down to 77% or (sic) room air O2 started sats at 80% on 2L/NC. Coughing thick clear/white sputum . . ." *01/24/14 - "@ (at) 12:50 a.m. . . . Transferred resident to (name of hospital) ER (emergency room ) for assessment via (name of transportation service) via stretcher. All papers sent with resident, et (and) wife will meet over in ER." During an interview on 04/03/14 at 10:45 a.m., two administrative staff members (#1 and #2) stated Resident #1 was transferred without oxygen. *01/24/14 - "@ 1:40 a.m. Received phone call from (name of facility) ER nurse RE: choice of transportation use as resident's status was poor. Informed . . . ER nurse that wife was thinking of not having resident sent to ER to be assessed. Staff encouraged wife to have resident be assessed due to ? aspiration as resident was coughing et had an emesis. Wife was in agreement to have resident transferred per (name of transportation service) stretcher." *01/24/14 at 4:22 a.m. - Received phone call from (name of doctor) from (name of hospital) with questions of how resident was before emesis et after emesis. If he's used oxygen here or not on routine or @ all . . ." Resident #1's "Hospital History and Physical", dated 01/24/14, stated, ". . . patient was brought in to the emergency department on room air. On arrival, nursing staff in the emergency department report that the patient had desaturated into the low 70's (on room air) was in a fair amount of respiratory distress. Patient was apparently febrile as well (had a temperature of 102.5 degrees Fahrenheit) . . ." Resident #1's "Discharge Summary," dated 01/28/14, identified discharge [DIAGNOSES REDACTED]. During an interview on 04/03/14 at 10:00 a.m., when asked how the facility determines which mode of transportation should be used when transferring residents to the emergency room , an administrative nurse (#3) stated the facility utilizes "a (name of a transportation service) for non-acute conditions, such as a fractured limb, and an ambulance for acute conditions, such as cardiac or respiratory distress." During an interview on 04/03/14 at 10:45 a.m., two administrative nurses (#1 and #2) agreed, an ambulance should have been called for the transfer to the emergency room because of Resident #1's acute respiratory condition. Failure of the facility to call emergency services to transfer Resident #1 to the emergency room and failure to continue oxygen therapy during the transfer resulted in acute [MEDICAL CONDITION] and hospitalization . 2. Based on record review, review of facility policy, and staff interview the facility staff failed to provide appropriate care and services following a fall for 1 of 1 sampled resident (Resident #14) who obtained a fracture with the fall. Failure to report Resident #14's fall resulted in delayed treatment. Findings include: Review of the facility policy titled "Falls Protocol" occurred on 04/03/14. This policy, dated 06/13/13, stated, ". . . PROCEDURE: . . . 8. Nursing will notify the family and provider after each fall unless otherwise indicated in the careplan. . . ." Review of Resident #14's medical record occurred on April 02-03, 2014 and [DIAGNOSES REDACTED]. Nurses' notes stated the following: * 10/11/13 at 9:50 p.m. (late entry progress note created on 10/15/13 at 3:52 p.m.): " . . . Writer enter (sic) res (resident) room Res was sitting on the floor with both legs straight facing the hand washing sink. . . . Writer assess (sic) res for injury and pain upon assessment, No injuries noted. . . ." * 10/12/13 at 3:35 a.m.: ". . . Medication Administration Note, Tylenol (given) . . . c/o (complaining of) of left hip pain. Yelling." * 10/13/13 at 6:30 a.m. (late entry progress note): "Resident complaining of increased pain in left lef/hip (sic) about 3:30 a.m. this morning. . . . PRN (as needed) tylenol was given at 4:00 a.m. . . ." * 10/14/13 at 7:00 a.m.: "Pain . . . right knee/hip . . . repositioning/PRN pain medication . . . slight relief." * 10/14/13 at 9:01 a.m.: "Call placed to daughter with update regarding residents complaint of pain to her right leg/knee/hip/buttocks. Informed daughter that resident states that she is having increased pain to her right side and that it has been that way for two days. Daughter states that she is going to be taking her to the walk in ortho clinic this afternoon to have right side checked." * 10/14/13 at 11:27 a.m.: " . . . continues to have pain. Family will be bringing her to the clinic to be evaluated." * 10/14/13 at 4:10 p.m.: "Admit to Hospital . . . L) (left) hip fx (fracture)." The facility failed to have Resident #14's right hip pain evaluated until 10/14/13 (four days after the fall). Review of the hospital discharge summary, dated 10/18/13, indicated an acute traumatic [MEDICAL CONDITION] hip. This summary identified Resident #14 underwent open reduction, internal fixation of the left [MEDICAL CONDITION] on 10/15/13. During an interview on 04/03/14 at 10:40 a.m., an administrative nurse (#12) stated the staff member on duty did not report and document the fall at the time it occurred. Failure to report Resident #14's fall resulted in unnecessary pain, delayed treatment, and investigation of possible neglect. 3. Based on record review and staff interview, the facility failed to provide the necessary care and services to manage behavioral symptoms for 4 of 5 sampled residents (Resident #7, #15, #19, and #20) who received as needed (PRN) medications. Failure to identify target behaviors, assess the reason/causative factor(s) for behaviors, implement appropriate interventions (including non-pharmacological interventions) and establish accurate on-going monitoring of the behaviors has the potential for these residents to not obtain their highest practicable physical, mental, and psychosocial well-being. Findings include: - Review of Resident #7's medical record occurred during all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairment, delusions, and hallucinations. Review of Resident #7's current plan of care identified, "Focus: I use anti-anxiety medications related to my Anxiety Disorder . . . Interventions: . . . Give anti-anxiety medication ordered by physician. Monitor/document side effects and effectiveness. . . ." The care plan failed to identify non-pharmacological interventions staff should attempt prior to administering her as needed (prn) anti-anxiety medications. The physician's order, dated 06/07/13, identified "[MEDICATION NAME] (an antianxiety medication) 2 MG/ML (milligrams/millileters) Concentrate By mouth . . . PRN ANXIETY STATE . . ." Review of Resident #7's Progress Notes identified the following: * 09/09/13 at 11:53 a.m., "[MEDICATION NAME] . . . Restless agitated, standing up in w/c (wheelchair), striking out at staff," and at 1:43 p.m., "Sleep." * 09/11/13 at 4:53 p.m., "[MEDICATION NAME] . . . resident restless and agitated," and at 9:14 p.m., "resident sitting in recliner, content." * 09/13/13 at 11:02 a.m., "[MEDICATION NAME] . . . Agitated, standing up striking out at staff," and at 12:33 p.m., "Sleeping." * 09/14/13 at 5:34 p.m., "[MEDICATION NAME] . . . increased restlessness and attempts to self transfer," and at 6:33 p.m., "res (resident) is resting quietly in her wheelchair." * 09/15/13 at 7:14 p.m., "([MEDICATION NAME]) given due to restlessness and agitation, combative with staff," and at 9:28 p.m., "Cooperative and pleasant." * 10/05/13 at 5:24 p.m., "[MEDICATION NAME] . . . Resident restless, agitated, crying, and feisty," and at 8:45 p.m., "Resident became less restless and agitated after receiving the med (medication) at 5:15 p.m." * 10/06/13 at 7:20 p.m., "[MEDICATION NAME] . . . Resident restless and agitated," and at 8:13 p.m., "Resident calm and relaxing in chair." * 10/09/13 at 6:21 p.m., "[MEDICATION NAME] . . . Resident agitated, restless and being aggressive," and at 8:07 p.m., "Resident calmed down and resting comfortably in chair." * 10/11/13 at 7:45 p.m., "[MEDICATION NAME] . . . Given at 6 p.m. for agitation and aggression, kicking, pinching and hitting staff," and on 10/12/13 at 1:15 a.m., "Quieter and cooperative." * 10/13/13 at 12:31 a.m., "[MEDICATION NAME] . . . Resident up in chair crying becoming increasingly agitated slapping at staff," and at 2:26 a.m., "Resident is in bed at this time is still wide awake and restless." * 10/14/13 at 6:04 p.m., "[MEDICATION NAME] . . . Given at 5:20 p.m. for agitation and combativeness . . ." * 10/19/13 at 6:18 p.m., "[MEDICATION NAME] . . . agitated, crying and restless," and at 7:12 p.m., "Resident is calmer and less restless." * 10/20/13 at 5:12 p.m., "[MEDICATION NAME] . . . Resident is combative, restless, kicking, hitting, pulling hair, and biting," and at 6:50 p.m., "Resident calmed down." * 10/23/13 at 6:40 p.m., "[MEDICATION NAME] . . . Resident restless, combative and agitated at 3:55 p.m.," and at 4:39 p.m., "Resident is calm, not combative and sitting in her chair." * 10/29/13 at 12:19 a.m., "[MEDICATION NAME] . . . anxious, trouble going to sleep," and at 6:46 a.m., "f/u (follow-up) able to sleep." * 11/06/13 at 3:41 a.m., "[MEDICATION NAME] . . . f/u resident had reduced anxiety." The Medication Administration Record [REDACTED]. * 11/11/13 at 5:30 p.m., "[MEDICATION NAME] . . . resident combative, hitting staff," and at 8:39 p.m., "f/u resident resting in recliner." * 11/12/13 at 4:59 p.m., "[MEDICATION NAME] . . . resident combative with transport team, med given to help calm her," and at 9:26 p.m., "Was calming as transport team took her to ER (emergency room )." * 11/17/13 at 5:53 p.m., "[MEDICATION NAME] . . . woke up crying because she didn't have the house clean and her parents were coming," and at 6:54 a.m., f/u relaxed and went back to sleep." * 01/03/13 at 4:29 p.m., "[MEDICATION NAME] . . . Agitated and weeping," and at 6:55 a.m., "f/u became more relaxed, less muttering." * 01/04/13 at 9:36 a.m., "[MEDICATION NAME] . . . increased restlessness, attempts to self transfer, combative," and at 10:18 a.m., "res. is sleeping in her chair." * 03/01/13 at 4:56 p.m., "[MEDICATION NAME] . . . attempting to transfer out of chair and unable to redirect," and at 7:08 a.m., "res. calmed down and rested in recliner." * 03/15/13 at 4:34 p.m., "[MEDICATION NAME] . . . res. kicking, grabbing out at staff and residents, attempting to self transfer, and yelling," and at 6:10 p.m., "res. is calmly sitting in her chair no further agitation noted." During an interview on 04/03/14 at 10:00 a.m., a managerial nurse (#3) confirmed facility staff failed to attempt non-pharmacological interventions prior to administering Resident #7's prn [MEDICATION NAME], and confirmed this is required. Failure to attempt non-pharmacological interventions and monitor the effectiveness of those interventions prior to administering an anti-anxiety medication does not allow staff to evaluate what interventions would be most effective to manage Resident #7's behavior. - Review of Resident #19's medical record occurred April 3, 2014. [DIAGNOSES REDACTED]. A significant change MDS, dated [DATE], identified severe cognitive impairment, on current hospice services, and the use of a daily antidepressant. Current medications included [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg every three hours prn for anxiety and restlessness, and [MEDICATION NAME] HCL ([MEDICATION NAME]) (an antidepressant) 12.5 mg every four hours prn for anxiety and restlessness. The current care plan for Resident #19 stated, "Focus I will be at Rosewood for long term. In the past, I enjoyed visiting. used to like to attend activities,but now I prefer to spend my free time in my room. I can become anxious at times. I was recently readmitted to Hospice. . . Interventions: Allow me to assist in decision making and to participate in my plan of care as best as I am able. I am of Lutheran faith and I may like to attend chapel services. I may also attend Catholic Mass as I was raised Catholic as a child. I can obsess about many different things. try to get my mind off of these things by inviting me to activities, visiting with me, taking me for a walk or wheelchair ride, etc. I prefer to spend most of my free time in my room. This is a recent change for me as I used to like to attend most activities. You may ask me to attend activities, but most likely I will decline. I have a television in my room. I love to watch (specific show and channel) on Sundays at 7:00 p.m. I have difficulty hearing when not in a quiet setting. Speak clearly and at times, close to my ear, when talking to me. I wear bilateral hearing aides, make sure they are in working order when putting them in my ears. . . . I may need cueing, re-orientation, and/or reminders from time to time. I may not always respond to it. My daughter, (daughter's name), will assist me with decision making or will make the decision for me if I am unable. She is my contact person. Call her any time with emergencies and between 9A-9P (9:00 a.m. through 9:00 p.m.) for non-emergencies. You may leave a message. My family will visit me often. They may also attend activities with me if I choose to go. When I am anxious or have anxiety, spend some one-on-one time with me. Reassure me that everything will be all right. I also have an order for [REDACTED]. . . Focus: I have a history of anxiety. I have a history of feeling like I need to use the bathroom very frequently. Some times (sic) I get anxious about coming out of my room. Sometimes I call out 'help' repeatedly. . . Interventions A suggestion to help me when you are providing cares and I am anxious is to have me count. This seems to provide me with something to concentrate on. Assess level of anxiety and restlessness. Always use a calm and consistent approach when working with me. I like to be told I am doing a good job. I respond well to being told I am doing the best job I can. Some of the things that help when I am anxious are playing cards, folding wash cloths (sic) and having you massage me (sic) neck/shoulders, hands and feet. I like you to spend 1:1 (one to one) time with me when I am anxious. I say just holding my hand or touching me helps me feel better. Medication as ordered." Review of the PRN MAR, from December 1, 2013 to March 30, 2014 identified Resident #19 received PRN [MEDICATION NAME] HCL on 41 occasions, and PRN [MEDICATION NAME] on 11 occasions. During interview on 04/03/14 at 11:35 a.m.. an administrative nurse (#3) confirmed staff are to document non-pharmacological interventions attempted prior to the administration of a PRN dose of [MEDICATION NAME] HCL or [MEDICATION NAME]. The medical record lacked evidence the facility staff attempted non-pharmacological interventions prior to the administration of the PRN [MEDICATION NAME] HCL and [MEDICATION NAME] and failed to consistently identify/document the actual behavior exhibited by Resident #19 that resulted in the administration of the medications. - Review of Resident #15's medical record occurred on April 2-3, 2014. [DIAGNOSES REDACTED]. Current medications included [MEDICATION NAME] 0.25 mg up to three times daily prn and [MEDICATION NAME] (a pain medication) 25 mg every four hours prn. The resident's current MDS, dated [DATE], identified severely impaired cognition, hallucinations, delusions, and no behavioral symptoms. Resident #15's current care plan stated, ". . . I use anti-anxiety medications ([MEDICATION NAME] prn) r/t (related to) Anxiety disorder, Adjustment issues. (date initiated 2/11/2013). . . . Interventions . . . Monitor/record/occurrence of for (sic) target behavior symptoms (pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. . . . I have a mood problem(s) r/t dementia, Delusional Disorder, [MEDICAL CONDITION]. . . . I am resistive to cares and medications when anxious. . . . (date initiated 04/01/13) . . . Interventions . . . Allow me time and encourage me to express feelings . . . Reaproach (sic) or try different staff if refusing cares/meds. (medications). . . . When anxious: Get my mind on something else, sit outside with me, listen to music, ride up and down the hall in w/c (wheelchair). . . ." Resident #15's nurses' notes stated the following: *January 2014: *01/02/14 at 1:18 a.m.: ". . . [MEDICATION NAME] - Give 0.25 mg up to 3x (3 times) daily as needed for anxiety/restlessness: very anxious and tearful as she was talking to her self and given much comfort." *01/02/14 at 1:20 a.m.: ". . . [MEDICATION NAME] - Give 50 mg . . . every 4 hours PRN: resident crying et (and) talking loudly to self with much anxiety? pain? attempted to self remove from bed when staff comforting her. . ." *01/04/14 at 12:46 a.m.: ". . . [MEDICATION NAME] . . . Resident very anxious about where her father is et (and) therapeutic fibs given with very mild success. . . ." *01/04/14 at 12:47 a.m.: ". . . [MEDICATION NAME] . . . resident rubbing legs et c/o (complains of) aching with tears in eyes. . . ." *01/04/14 at 1:25 a.m.: ". . . F/U (follow up) resident sound asleep in recliner by nurses station et calm. . . ." *01/12/14 at 11:44 p.m.: ". . . [MEDICATION NAME] . . . @ 11:15 PM resident very restless with grimace about face ? pain . . ." *01/12/14 at 11:45 p.m.: ". . . [MEDICATION NAME] . . . resident continues to be vwery (sic) restless et 'antsy.' . . ." *Facility staff administered a pain medication and an anti-anxiety medication at close intervals, which does not allow staff to determine if one medication alone would have been effective. In addition, the record lacked evidence staff attempted non-pharmacological measures prior to administering [MEDICATION NAME] and [MEDICATION NAME]. *Nurses' notes also identified the administration of prn [MEDICATION NAME] on 01/18/14 and 01/23/14. The notes lacked identification of target behaviors present that would warrant the use of prn [MEDICATION NAME], as well as identification of non-pharmacological interventions attempted prior to administration. *February 2014: *02/06/14 at 1:42 a.m.: ". . . [MEDICATION NAME] . . . Resident moaning et self removing herself from bed. ? pain. . . ." *02/06/14 at 2:55 a.m.: ". . . [MEDICATION NAME] . . . Resident in less pain but continues to talk of having to do this et that, given warmed towels @ 2:30A. Continues to fret et unable to calm resident. . . ." *The record lacked evidence of non-pharmacological interventions attempted prior to administering a pain medication and an anti-anxiety medication approximately one hour apart. *02/13/14 at 8:05 a.m.: ". . . [MEDICATION NAME] . . . Given this am (morning) thirty minutes before cares to promote calm . . ." *02/15/14 at 7:37 a.m.: ". . . [MEDICATION NAME] . . . given thirty minutes before cares to promote calm . . ." *The record lacked evidence of agitation or resistance to cares prior to the administration of prn [MEDICATION NAME] on 02/13/14 and 02/15/14, and also lacked identification of non-pharmacological interventions attempted if Resident #15 resisted cares (i.e. reapproaching or trying different staff as per the resident's care plan). *The Medication Administration Record [REDACTED] *Nurses' notes lacked identification of target behaviors present that would warrant the use of prn [MEDICATION NAME], as well as identification of non-pharmacological interventions attempted prior to administration. - Review of Resident #20's medical record occurred on 04/03/14. [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] 0.25 mg by mouth twice a day; [MEDICATION NAME] 0.5 mg by mouth every four hours PRN for anxiety; and [MEDICATION NAME] Gel 0.5 mg applied to the inner wrist every 4 hours if the resident refused the oral PRN [MEDICATION NAME]. Resident #20's care plan stated, "Focus: I have a hx (history) of depression and sometimes feel sad and confused because I am not home . . . Interventions: *Encourage me to spend time out of my room. Ask me if I would like to watch television in the south lounge area or listen to music in the chair outside my room. * I have a picture book of my family that I like to look at. Do not ask me who anybody is, as I may not always remember who they are. This may upset me. *When I am anxious or agitated, spend one-on-one time with me or check on me every 15 minutes. *When I am anxious or upset, I may calm down when I watch the Coronation of the Fargo Bishop. It is kept in the south nurse's station. *When I appear sad or worried, talk with me and offer me comfort and support. Reassure me that everything will be all right. Use therapeutic fibbing as it may be helpful." Review of the PRN MAR from January 01, 2014 to April 03, 2014 identified Resident #20 received PRN [MEDICATION NAME] on 38 occasions. The medical record lacked evidence the facility staff attempted non-pharmacological interventions prior to the administration of the [MEDICATION NAME] for 35 of the 38 occasions. Failure to identify target behaviors, assess the reason/causative factor(s) for the behavior, and implement appropriate interventions (including non-pharmacological interventions) prior to administering PRN medications does not allow staff to evaluate what interventions would be most effective to manage the behavioral symptoms of Resident #7, #15, #19, and #20.

1. Based on record review, review of professional reference, and staff interview, the facility failed to provide supervision and assistance necessary to prevent accidents for 1 of 1 sampled resident (Resident #9) with an unattended fall in the bathroom. Failure to provide adequate supervision resulted in Resident #9 experiencing a fall with a pelvic fracture. Findings include: Dugan's "Successful Nursing Assistant Care," 2nd ed., Hartman Publishing, Inc., New Mexico, page 187, stated, ". . . Toileting Transfers . . . Do not leave residents alone if you feel it is unsafe or if residents require assistance. . . ." Review of Resident #9's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) (in effect at the time of the fall), dated 04/18/13, identified short and long term memory problems, fluctuating inattention, extensive assistance from two or more people for toileting and transfers, and limited assistance from two or more people for ambulation. Resident #9's care plan (in effect at the time of the fall) stated, ". . . I am cognitively impaired and so I need cuing and supervision while doing cares. . . . I have an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Alzheimer's and can be combative with cares and toileting at times. . . . Interventions . . . Toileting: Assist of 1. May need assist of 2 when I'm upset. Can be extensive at times and up to 3 assist, due to dementia. Please assist me to the restroom every 2 hours. . . ." Resident #9's medical record identified three falls which occurred on 02/14/13 at 4:15 a.m., 04/17/13 at 6:30 a.m., and 05/30/13 at 5:15 a.m. All three falls occurred from the resident's bed and staff found Resident #9 incontinent of stool on all three occasions. Record review further identified a fall which occurred on 06/28/14 at 8:20 p.m. while the resident was alone in the bathroom. Nurses' notes stated the following: *06/28/13 at 11:09 p.m.: ". . . Notified by RA (resident assistant) that resident was on the floor. RA was making resident's bed at time of fall and resident was in the bathroom. Upon entering room resident was seen sitting in the floor. Resident was assessed and appeared to be at baseline. . . ." *06/29/13 at 2:49 p.m.: ". . . Resident alert . . . Poor weight bearing to right lower extremity. . . ." *06/30/13 at 1:32 p.m.: ". . . Called daughter . . . regarding recent fall on 06/28/2013 PM (evening) shift. Notified daughter that resident was having a hard time bearing weight to her right side. . . ." *06/30/13 at 1:45 p.m.: ". . . Tylenol - 650 mg (milligrams) PO (by mouth) PRN (as needed) . . . administered per family request for pain management. Pain upon weight bearing to right leg. Stated 'Uff.' . . ." *06/30/13 at 6:50 p.m.: ". . . Res. having increased pain to R) (right) hip/leg during transfer. Res. not bearing any weight to R) leg and sticking R) leg out in front of body during transfer. Facial grimacing noted during transfer. . . ." *06/30/13 at 7:00 p.m.: ". . . Res. having increased pain to R) hip/leg. Res. not bearing weight to R) leg at all. . . . Daughter . . . was called and updated about above. . . . would like x-ray done tonight if possible. . . ." *06/30/13 at 7:10 p.m.: ". . . Physician Orders . . . PPX (portable x-ray) of R) hip d/t (due to) pain and not bearing weight on R) leg after fall. . . ." *06/30/13 at 10:10 p.m.: ". . . PPX here and did x-ray of R) hip at (8:00 p.m.). X-ray results received and are as follows: . . . Right superior pubic ramus fracture (pelvic fracture). . . ." *06/30/13 at 10:26 p.m.: ". . . Physician Orders . . . Keep comfortable in bed through night. . . . NP/PA (nurse practitioner/physician's assistant) to see in AM and refer to orthopedics as needed. . . ." *07/01/13 at 4:19 p.m.: ". . . Resident was sent to (facility name) ER for evaluation. Resident given Keflex (an antibiotic) for treatment of [REDACTED]. Order weight bearing as tolerated d/t pelvic fracture. . . ." During an interview on 04/03/14 at 10:45 a.m., a supervisory nurse (#12) stated if residents need assistance to toilet, staff should stay with them in the bathroom. She stated the facility did not have a policy stating this, but that it is an unwritten standard of care. Failure to ensure Resident #9 (who required toileting assistance, experienced previous falls, and had Alzheimer's disease) received adequate supervision and assistance while in the bathroom resulted in an avoidable fall with pelvic fracture. 2. Based on observation, record review, facility policy review, and staff interview, the facility failed to ensure adequate use of assistive devices to prevent accidents for 3 of 12 sampled residents (Resident #1, #2, #12) and 1 supplemental resident (Resident #24) who transferred with a gait belt. Failure to properly use a gait belt increased the risk of falls, pain, or injury to the residents. Findings include: Review of the facility policy titled "Moving a Resident, Bed to Chair" occurred on 04/03/14. This policy, revised May 2013, stated, "Purpose: . . . to provide for safe transferring of the resident . . . Steps in the Procedure . . . j. Support the resident by placing a belt around the resident's waist for you to hold and steady the resident. . . ." - Review of Resident #2's medical record occurred on April 02-03, 2014 and [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], identified the resident required extensive assistance of two or more staff members for transfers. The current care plan stated, ". . . I have a Self Care Deficit . . . TRANSFERS: Assist of 2 for stand-pivot transfer to bed from w/c (wheelchair), and to w/c from bed. Assist of 3 for stand-pivot on/off commode and to/from tub chair for cleansing and brief placement. Use hoyer as needed if res. (resident) feeling weak or tired. . . ." Observation on 04/02/14 at 8:50 a.m. identified three Certified Nursing Assistants (CNAs) (#8, #9, and #10) transferred Resident #2 from his bed to his wheelchair using a gait belt. During the transfer, one CNA (#8) held on to the gait belt with one hand and lifted under the resident's left arm with her other hand. Observation on 04/02/14 at 11:00 a.m. identified three CNAs (#8, #10, and #11) transferred Resident #2 from the commode to his wheelchair using a gait belt. During the transfer, one CNA (#11) held on to the gait belt with one hand and lifted under the resident's left arm with her other hand. - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current care plan stated, "Transfers: Assist of 1 with FWW (front wheeled walker)." Observation on 04/02/14 at 8:50 a.m. showed the CNA (#5) applied a gait belt to Resident #1's waist. The CNA lifted the resident to a standing position with one hand on the gait belt and the other hand under his arm. The CNA (#5) failed to use the gait belt correctly. - Review of Resident #12's medical record occurred on April 02-03, 2014 and [DIAGNOSES REDACTED]. The current care plan stated, " . . . Transfers: Assist of 1 . . ." Observation on 04/02/14 at 9:00 a.m. showed two CNAs (#13 and #14) transferred Resident #12 from her bed to a standing position using a gait belt. During the transfer, both CNAs (#13 and #14) held on to the gait belt with one hand and lifted under the resident's arm with their other hand. - During a random observation on 04/02/14 at 8:41 a.m., Resident #24 asked the nurse (#7) for assistance to stand from a dining room chair. The nurse (#7) assisted Resident #24 to stand by pulling up on his right upper arm. Review of Resident #24's current care plan on 04/03/12 showed an approach, which stated, "TRANSFERS: . . . If you feel I need assistance, I need to wear a gait belt. . . ." The nurse (#7) failed to use a gait belt as care planned. During an interview on 04/03/14 at 10:00 a.m., an administrative nurse (#4) stated staff should avoid pulling/lifting on residents' arms and only grasp the gait belt during transfers.

Based on observation, record review, resident interview, staff interview, and review of facility policy, the facility failed to provide necessary treatment and services to prevent the occurrence and promote the healing of pressure ulcers for 2 of 5 sampled residents (Resident #6 and #7) identified with pressure ulcers. Failure to provide timely and appropriate interventions and ensure staff consistently implemented existing interventions resulted in the development of a new pressure area and the deterioration of an existing facility-acquired pressure area for Resident #6, and may resulted in the reoccurrence of pressure areas for Resident #7. Findings include: Review of the facility policy titled "Pressure Ulcer Treatment" occurred on 05/10/12. This policy, revised September 2011, stated, ". . . Key Procedural Points . . . 2. The staff nurse will initiate a care plan and initiate the PUSH tool (used to monitor the size and stage of pressure ulcers) to monitor the healing process. . . . 3. Signs of healing . . . should be evident after 2 to 4 weeks of treatment. Notify physician or mid-level practitioner if any evidence of deterioration is noted. . . . 4. The diet of the resident with a pressure ulcer should contain nutrients adequate to support healing such as increased protein. . . . 6. Avoid positioning the resident on a pressure ulcer. Use positioning devices to raise a pressure ulcer off the support surface. . . . 13. Dressings should keep the ulcer tissue moist while keeping the surrounding intact skin dry. Use the prescribed dressing type. . . ." - Review of Resident #6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], identified intact cognition and no pressure ulcers. The medical record indicated Resident #6 was hospitalized from April 16-23, 2012 with pneumonia. Review of skin assessments prior to this hospitalization revealed the following: *04/05/12 (the first indication that pressure ulcers were present): 2 pressure ulcers present on the resident's left buttock. The first area measured 1 centimeter (cm) by 1.2 cm, the second area measured 1 cm by 0.9 cm. *04/13/12: 2 left buttock ulcers, both Stage II, the first area measured 0.6 cm by 0.4 cm, the second area measured 1.4 cm by 0.6 cm. An admission MDS (completed after Resident #6's return from the hospital), dated 04/30/12, identified extensive assistance from two or more people for bed mobility and transfers, the presence of two Stage II pressure ulcers, short term memory problems, and modified independence with daily decision-making. Resident #6's current care plan stated, "Focus . . . I have the potential for and actual impairment to skin integrity r/t (related to) presence of 2 open areas to (R) (right) medial buttock (present upon admission to facility 4/23/12); alteration in mobility; require assist with transfers, ambulation, bed mobility, toileting. *4/30/12 open area (R) buttock, (L) buttock, & slit in coccyx area. *05/07/12 open areas continue in all three previously noted areas. . . . Interventions . . . I have a pressure-relieving mattress & w/c (wheelchair) cushion. . . . Reposition every 2 hrs. (hours) side to side. . . . Treatment per E-TAR (electronic treatment administration record) . . . Focus . . . I need increased protein in my diet to aid in healing my skin . . . Interventions . . . Please provide activia yogurt QID (four times per day) with med (medication) pass. . . . Please provide choc (chocolate) milk and juice with fiber BID (twice per day) with meals. . . ." The care plan initially identified the presence of 2 open areas to Resident #6's left buttock. A supervisory nursing staff member (#4) revised the care plan on the afternoon of 05/07/12 to indicate 2 open areas to the right buttock. The staff member also made the additions, dated 04/30/12 and 05/07/12, at that time. During Resident #6's hospital stay, a wound care nurse completed an assessment, dated 04/16/12, which stated: "Left medial buttock with two open areas 0.7 x (by) 1.2 cm and 0.5 x 0.5 cm . . . Coccyx has nonblanchable [DIAGNOSES REDACTED]. [MEDICATION NAME] dressing was removed as it was rolled up at edges. Will stop this and use [MEDICATION NAME] (a type of ointment used to treat pressure ulcers). . . ." Upon readmission to the facility on [DATE], nursing staff completed an initial assessment which identified two pressure areas to the right buttock, one measuring 1.4 cm by 0.4 cm, and one measuring 0.2 cm by 0.2 cm. The assessment identified no further pressure areas. During an interview on 05/08/12 at 4:00 p.m., a supervisory nursing staff member (#4) stated she was unsure as to why the facility's readmission nursing assessment conflicted with the skin assessment performed by the wound care nurse, as well as the facility's assessments prior to Resident #6's hospitalization . She also stated that it is facility policy to initiate a PUSH tool when staff discover pressure areas, and staff should have initiated one on 04/23/12. A skin assessment, dated 04/30/12, identified three pressure ulcers in three different locations: *Right buttock: 1.2 cm x 1.2 cm reddened area. Open area inside reddened area which measured 0.5 cm. *Left buttock: 1 cm x 0.5 cm area of white slough tissue. *Intergluteal cleft: 4 cm x 0.1 cm, not staged. *Staff initiated a PUSH tool for all three areas on 04/30/12. A skin assessment completed on 05/07/12 identified the three pressure ulcers as follows: *Right buttock: 1 cm x 2 cm, Stage II *Left buttock: 1.2 cm x 0.8 cm, Stage II *Coccyx: 0.5 cm x 0.3 cm, Stage II *Skin surrounding the three areas is reddened During an interview on 05/08/12 at 8:06 a.m., a licensed nurse (#20) stated the intergluteal cleft and the coccyx are the same, and that the pressure ulcer is "right on the coccyx." The above assessments identify a deterioration in the right and left buttock ulcers, and also the development of a Stage II coccyx ulcer that was identified as a "slit" on the resident's care plan, dated 04/30/12. Observation on 05/07/12 at 1:52 p.m. showed Resident #6 seated in her wheelchair and propelled by staff to an activity. Observations throughout the afternoon until approximately 5:40 p.m. showed Resident #6 seated in her wheelchair. Facility staff failed to reposition the resident every two hours as care planned, which resulted in direct pressure to Resident #6's buttocks/coccyx area for nearly four hours. Observations showed Resident #6 lying in bed on her back and not positioned on her side as care planned as follows: *05/08/12 from 7:55 a.m. to 9:49 a.m. *05/09/12 from 7:45 a.m. to 9:45 a.m. Observation on 05/08/12 at 9:49 a.m. showed two certified nursing assistants (CNAs) (#21 and #22) assisted Resident #6 with morning cares. Observation identified an open area surrounded by reddened tissue to the resident's left buttock, right buttock, and coccyx. The areas lacked any type of dressing. As the CNAs performed perineal cares, Resident #6 stated, "Can you put some cream on that (indicating her buttocks)? It's sore." Observation showed no cream available in the resident's room, and a CNA (#21) left to obtain some. A CNA (#22) then applied skin barrier cream to the resident's buttocks and coccyx areas. Observation on 05/08/12 at 2:22 p.m. showed Resident #6 lying in bed on her back. At 3:10 p.m. observation showed the resident sat in her wheelchair in the lounge area. The resident remained in her wheelchair until approximately 6:00 p.m. when observation showed the resident lying on her back in bed. The staff failed to reposition Resident #6 every two hours as care planned, which resulted in direct pressure to Resident #6's buttocks/coccyx area for nearly three hours. Observation on 05/09/12 at 9:45 a.m. showed two CNAs (#23 and #24) assisted Resident #6 with morning cares. Observation showed an open area surrounded by reddened skin the resident's left buttock, right buttock, and coccyx. The areas lacked any type of dressing. The CNA (#23) applied "[MEDICATION NAME] Dry Skin Treatment" to the resident's buttocks and coccyx area. The resident stated, "Ouch," and the CNA (#23) asked, "Does that hurt (Resident name)?" Resident #6 replied, "Yes. Oh, yes it does!" During an interview on 05/09/12 at 4:45 p.m., a supervisory nursing staff member (#4) stated [MEDICATION NAME] cream was for "dry skin" and not an appropriate treatment for [REDACTED]. Physician's orders, as well as medication administration records (MARs) and treatment administration records (TARs) for the months of April and May 2012 failed to identify treatments for Resident #6's pressure ulcers. The Care Area Assessment (CAA), dated 04/30/12, indicated staff applied [MEDICATION NAME] dressing to the pressure areas during the reference period (seven days). However, treatment records and physician's orders failed to identify the use of any dressing. During an interview on 05/08/12 at 8:06 a.m., a licensed nurse (#20) stated staff are not applying a dressing to the ulcers, only moisture barrier cream. The CAA completed on 04/30/12 conflicts with medical record review, observation, and staff interview. During an interview on 05/10/12 at 10:20 a.m., a supervisory nursing staff member (#4) stated a staff nurse reported the pressure areas to the physician, who recommended no treatment. However, record review showed no documentation of physician notification. The staff member (#4) agreed staff should have documented the conversation and was "surprised" that no dressing or treatment was in place. Dietary Progress Notes revealed the following: *04/04/12: ". . . She prefers not to have milk with meals . . ."*04/30/12: ". . . Protein: . . . Increased needs to aid in past low Alb ([MEDICATION NAME]) and to aid in healing skin . . . She likes to take her meds with Activia yogurt BID . . . (Resident name) has preferred not to have milk with meals. Will speak with (Resident name) about dietary interventions to provide increased protein. . . ." *05/02/12: ". . . Spoke with (Resident name) and her daughter this morning regarding diet plan. She is receiving yogurt QID with med pass and she would now like choc milk BID with meals. . . ." Observations of meals on the evening of 05/07/12, morning and evening of 05/08/12, and morning and evening of 05/09/12 identified Resident #6 received four ounces of chocolate milk with her meals. Upon completion of the meals, the milk remained untouched by Resident #6. Observation on the afternoons of May 7-9, 2012 identified staff failed to offer Resident #6 yogurt with her afternoon medication pass as care planned. Observation showed the dietary intervention of offering yogurt with medication pass was not listed on either the MAR indicated [REDACTED] During an interview on 05/09/12 at 3:32 p.m., Resident #6 stated she has "never really drank milk" and does not like milk, chocolate or otherwise. The resident stated, "I like my ice water and maybe tomato juice once in awhile (with meals)." The resident also indicated the pressure ulcers to her buttocks and coccyx were "sore" and "sometimes" caused her pain. Failure to ensure staff consistently implemented existing pressure ulcer interventions (e.g. repositioning and providing yogurt with medication pass), ensure the timely notification of the health care provider and prompt treatment, ensure appropriate treatment (i.e. the use of moisture barrier cream, which is not a prescribed treatment for [REDACTED].#6's likes and dislikes, and ensure the accuracy of the measurements/assessments of pressure areas resulted in the deterioration and development of facility-acquired pressure ulcers, and also resulted in Resident #6 experiencing pain and discomfort. - Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current MDS, dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment; extensive assistance from two or more people for bed mobility and transfer; frequent urinary and bowel incontinence; one State II pressure area; and one unstageable pressure area. Resident #7's current care plan stated, ". . . Focus . . . I have a (R) heel ulcer present on admission (resolved); & a stage 2 ulcer on (R) buttock present on admission (resolved); I have a pressure ulcer to my (L) heel (resolved). . . . Interventions . . . Reposition side to side every 2 hrs. and as needed. . . . I must wear my prevalon boots at all times. . . . Focus . . . I have an ADL (activities of daily living) Self-Care Performance Deficit . . . BED MOBILITY: . . . Place wedge up near her shoulder and overlap it with a pillow about half way down to position res. (resident) way up on her hip to prevent pressure on bottom. . . ." During an interview on 05/08/12 at 8:04 a.m., a nursing staff member (#20) stated Resident #7 currently had no open areas. She stated the resident's coccyx ulcer had recently healed, and the resident's right heel ulcer healed in April. Observation during the initial tour of the facility on 05/07/12 at 7:42 a.m. showed Resident #7 lying on her bed with a pillow under her calves. A pair of Prevalon boots and a wedge cushion were located on a recliner in the corner of the room. The pillow was not large enough to ensure Resident #7's heels remained off the bed; as a result, the resident's heels rested directly on the mattress. Observation on 05/08/12 at 7:58 a.m. showed Resident #7 lying on her back in bed, and the wedge cushion located on the recliner. Observations on the morning of 05/09/12 showed Resident #7 lying on her back in bed, and the wedge cushion located on the recliner. During an interview on 05/08/12 at 4:45 p.m., a supervisory nursing staff member (#4) stated Resident #7 is supposed to have Prevalon boots on at all times, and the resident's coccyx area is still fragile, so it is important to have the wedge cushion in place. Failure to ensure the consistent implementation of pressure-relieving interventions (e.g. Prevalon boots, wedge cushion) may result in the reoccurrence of Resident #7's pressure ulcers.