Every finding on record at SMP Health - St Catherine South

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free of significant medication error for 1 of 1 sampled resident (Resident #7) reviewed for medication errors. Failure to ensure medications are administered according to physician's orders places resident at risk for adverse drug effects.Findings include:Review of the facility policy titled Medication Administration occurred on 08/27/26. This policy, revised August 2026, stated, . Medications are administered by licensed nurses, or other staff. as ordered by the physician and in accordance with profession standards of practice. 8. Obtain and record vital signs, . per provider orders. When applicable, hold medication for those vital signs outside the provider's prescribed parameters.Review of Resident #7's record occurred on all days of survey. A provider's order, dated 05/26/26, included Midodrine (a medication to treat low blood pressure) 5 milligrams (mg) by mouth once daily (in morning) and hold if systolic blood pressure (SBP) is greater than 120 millimeters of mercury (mm Hg).Review of Resident #7's August 2026 electronic medication administration record (eMAR) showed facility staff administered Midodrine on 08/01/26 with a documented SBP of 144mm Hg and on 08/15/26 with a documented SBP of 135mm Hg.The facility staff failed to hold Midodrine when Resident #7's systolic blood pressure showed a measurement of greater than 120 mm Hg.During an interview on 08/26/26 at 3:10PM, an administrative nurse (#6) stated she expected staff to follow parameters/physician orders as written.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 20 sampled residents (#10, #35, and #191) observed during personal cares. Failure to practice infection control standards related to hand hygiene/glove use and enhanced barrier precautions has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 06/12/25. This policy, revised May 2024, stated, . Hand hygiene is indicated and will be performed under the conditions listed . Before applying and after removing personal protective equipment (PPE), including gloves . After assistance with personal body functions (e.g., elimination) . Review of the facility policy titled Enhanced Barrier Precautions occurred on 6/12/25. This policy, revised June 2025, stated, . Enhanced barrier precautions (EBP) are used to limit or prevent the spread of resistant organisms during high-contact resident care activities. These may be indicated for residents with . indwelling medical devices (e.g. central lines . ) . when performing transfers . EBP should be used for the duration of the affected resident's stay in the facility . until the resolution or discontinuation of the indwelling medical device that placed them at higher risk . - Observation on 06/10/25 at 9:15 a.m. showed two certified nurse aides (CNAs) (#2 and #3) applied gloves and the CNA (#3) removed Resident #10's brief, soiled with bowel movement, provided perineal cares, and placed a new brief under the resident. The CNA (#3) removed the soiled gloves, and without performing hand hygiene, applied new gloves. Both CNAs (#2 and #3) repositioned Resident #10, adjusted/secured the brief, and removed their gloves. The CNA (#3) handed the phone to the resident, placed a wedge under the resident's legs, placed a nasal cannula, attached the call light to the resident's side pillow, and then performed hand hygiene. - Observation on 06/10/25 at 9:00 a.m. showed a CNA (#1) applied gloves, removed Resident #35's soiled brief, performed perineal cares, and removed the soiled gloves. Without performing hand hygiene, the CNA (#1) applied new gloves, applied barrier cream to the resident's buttocks, and placed a new brief under the resident. The CNA (#1) removed the soiled gloves, and without performing hand hygiene, applied new gloves, adjusted/secured the resident's brief, adjusted the resident's pants, removed the gloves, and then performed hand hygiene. - Review of Resident #191's medical record occurred on all days of survey. Medical diagnoses included osteomyelitis (infection of the bone) and staphylococcus (infection of the skin). The current care plan stated, . on Enhanced Barrier Precautions r/t [related to] indwelling device PICC Line [a peripheral central catheter inserted into a vein in the upper arm] . use appropriate PPE when providing high level ADL's [activities of daily living] . use hand hygiene when visiting me . Observation on 6/09/25 at 4:04 p.m. showed an EBP sign on Resident #191 door. An unidentified CNA and a nurse (#5) entered Resident #191's room without performing hand hygiene or applying PPE. The CNA assisted Resident #191 out of a chair and the nurse (#5) applied a gait belt, and walked the resident to the bathroom. OPbservation showed the nurse (#5) touched areas of the resident's body, the walker, and the door during toileting cares and transfer assistance. The nurse (#5) admitted she should have performed hand hygiene and applied PPE prior to entering the room. During an interview on 6/11/25 at 3:48 p.m., an administrative nurse (#4) stated she expected staff to follow appropriate EBP.

Based on observation and staff interview, the facility failed to post the actual hours worked by nursing staff directly responsible for resident care on 2 of 4 days of survey (June 10-11, 2025). Failure to post the actual hours worked by licensed and unlicensed nursing staff per shift and in a visible location does not allow residents and/or their families to be aware of the number of staff on duty. Findings include: Observations on 06/10/25 at 4:10 p.m. and 06/11/25 at 4:05 p.m. showed the posting of staff forms on the unit manager's open door, resulting in the forms inside the office and not visible to residents and/or their families. The forms contained staffing data for the day shift, but not the p.m. shift. During an interview on 06/11/25 at 5:15 p.m., an administrative nurse (#4) confirmed the day shift hours are from 6:00 a.m. to 2:30 p.m. and the p.m. shift hours are from 2:00 p.m. to 10:30 p.m. The facility failed to ensure updated staffing information for every shift and post it in a visible location.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 12 sampled residents (Resident #28 and #79) and one supplemental resident (Resident #43) observed during cares. Failure to practice infection control standards related to use of personal protective equipment (PPE) and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 06/13/24. This policy, revised April 2024, stated,. Enhanced barrier precautions will be implemented for residents with any of the following . indwelling medical devices (e.g. [for example], . feeding tubes [G-tube, a tube inserted into the gastrointestinal tract], tracheostomy [a surgical opening in the trachea that allows a tube to assist with breathing] .) . Infection or colonization with a CDC [Centers for Disease Control and Prevention]-targeted MDRO [multidrug resistant organism] . face protection may also be needed if performing activity with risk of splash or spray (i.e. [that is], . tracheostomy care). PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include . Device care or use . feeding tubes, tracheostomy . Review of the facility policy titled Hand Hygiene occurred on 06/12/24. This policy, dated May 2024, stated, . Hand hygiene is indicated and will be performed . after assistance with personal body functions (e.g. elimination .) . Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 678, stated, . Hand hygiene is important in every setting . It is important for both the nurses' and the clients' hands to be cleansed . after the hands have come in contact with any body substances . ENHANCED BARRIER PRECAUTIONS Review of Resident #28's medical record occurred on all days of survey. The current care plan stated, I am on enhanced barrier precautions r/t [related to] indwelling device: Tracheostomy, G-Tube, and a history of a MDRO. Use appropriate PPE when providing high levels of ADLs [activities of daily living]. Observation on 06/12/24 at 8:52 a.m. showed a nurse (#5) gathered supplies to complete Resident #28's G-tube dressing change. The nurse donned gloves, and without donning a gown, removed the soiled G-tube dressing, cleansed the G-tube site with warm soapy water, removed his/her gloves, performed hand hygiene, donned new gloves, and emptied the basin. The nurse (#5) then donned a gown and acknowledged he/she forgot to apply it earlier and continued with cares. Observation on 06/12/24 at 11:21 a.m. showed a nurse (#5) performed tracheostomy cares for Resident #28. During the cares, the resident began to cough and expelled mucus through the cannula (tube inserted into the tracheostomy hole) across the foot of his/her bed. The nurse (#5) failed to apply face protection before providing tracheostomy cares. During an interview on 06/12/24 at 3:18 p.m., an administrative staff member (#1) stated she expected staff to follow enhanced barrier precaution as stated in the facility policy. HAND HYGIENE Review of Resident #79's medical record occurred on all days of survey. The record identified a colostomy and dependence on staff for colostomy cares. Observation on 06/10/24 at 12:50 p.m. showed a certified nurse aide (CNA) (#7) performed colostomy cares for Resident #79. The resident periodically assisted the CNA by touching/positioning the colostomy bag and the graduate the bowel emptied into. After completing the cares, the CNA removed his/her gown and gloves and performed hand hygiene. The CNA failed to offer/provide hand hygiene to Resident #79. Observation on 06/11/24 at 11:22 a.m. showed a CNA (#2) performed incontinence cares for Resident #43 after a bowel movement. The CNA (#2) transferred the resident to a recliner, unhooked the leg straps and the mechanical lift sling, collected the garbage, and then removed the soiled gloves and performed hand hygiene. During an interview on 06/12/24 at 3:18 p.m., an administrative staff member (#1) confirmed she expected staff to provide Resident #79 hand hygiene after the colostomy cares and expected staff to remove gloves and perform hand hygiene after incontinence cares. 40488

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 3 sampled residents (Resident #28) observed receiving insulin. Failure to administer insulin according to a physician's order may result in adverse health effects for the residents. Findings include: Review of the facility policy titled Insulin Pen occurred on 06/13/24. This policy, revised June 2024, stated, . Prime the insulin pen . Set the insulin dose: a. Turn the dose selector to ordered dose. A click will be heard for each unit dialed. Check the dose a second time. Review of Resident #28's medical record occurred on all days of survey. Diagnoses included type-2 diabetes mellitus with hyperglycemia (high blood sugar). Physician's orders included 46 units of aspart insulin at 12:00 p.m. Observation on 06/11/24 at 11:39 a.m. showed a nurse (#6) primed Resident #28's aspart insulin pen by the medication cart in the hallway outside the resident's room. The nurse entered the resident's room, cleansed an area of the abdomen, and without dialing up the ordered dose of insulin (46 units), removed the insulin pen needle cover, inserted the needle into the resident's abdomen, and pushed the pen's plunger. When asked by the surveyor, the nurse (#6) acknowledged she failed to prepare and administer the ordered 46 units of insulin. The nurse (#6) then attached a new needle to the pen, primed the pen, dialed up the 46 units of insulin, and administered the insulin.

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 3 sampled residents (Resident #28) dependent on staff for oral cares. Failure to provide oral care for a dependent resident may result in poor hygiene, increased oral/dental problems, and potential for adverse health effects. Findings include: Review of the facility policy titled STANDARDS OF CARE occurred on 06/13/24. This policy, dated May 2023, stated, Each of the following is part of the routine care provided by caregivers . Oral care will be done in the morning and at bedtime. Daily Morning Cares . Provide oral care . Review of Resident #28's medical record occurred on all days of survey. The current care plan stated, . I have ADL [activities of daily living] deficit related to: inability to communicate needs, Impaired mobility . ORAL CARE: I require complete help with mouth care. Observation on 06/11/24 at 8:51 a.m. showed two certified nurse aides (CNAs) (#3 and #4) provided Resident #28's morning cares. The CNAs failed to provide oral cares. Observations on 06/12/24 at 8:23 a.m., 8:52 a.m., and 11:21 a.m. showed a nurse (#5) provided cares to Resident #28. A dry white substance covered part of the resident's upper and lower lips and a wet white substance on the inside of the lips when he/she opened his/her mouth on each of these observations. The nurse failed to provide oral cares. During an interview on 06/12/24 at 3:18 p.m., an administrative staff member (#1) stated she expects staff to provide oral cares twice a day and as needed.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11) and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 20 sampled residents (Resident #35 and #79). 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 A: IDENTIFICATION INFORMATION & SECTION J: HEALTH CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, page A6, stated, . Coding Instructions for A0310E, Is This Assessment the First Assessment (OBRA, Scheduled PPS, or OBRA Discharge) since the Most Recent Admission/Entry or Reentry? . Code 1, yes: if this assessment is the first of these assessments since the most recent admission/entry or reentry. Pages J-30 and J-31, stated, . J1700. Fall History on Admission/Entry or Reentry. Complete only if . A0310E = 1 . Coding Instructions for J1700A, Did the Resident Have a Fall Any Time in the Last Month Prior to Admission/Entry or Reentry? . Code 1, yes: if resident or family report or transfer records or medical records document a fall in the month preceding the resident's entry date item (A1600). Review of Resident #79's medical record occurred on all days of survey and identified the resident experienced a fall on 04/22/24. An X-ray performed on 05/03/24 identified a left femoral neck fracture. The resident transferred to the hospital on 05/03/24 and returned to the facility on [DATE]. Review of Resident #79's completed MDSs are as follows: * 05/03/24, Discharge Return Anticipated (an OBRA assessment) * 05/07/24, Entry (back to the facility) * 05/13/24, Quarterly (an OBRA assessment) Review of the 05/13/24 quarterly MDS identified the facility coded A0310E as 0, no even though this is the first assessment since reentry on 05/07/24. Review of J1700A identified the facility coded 0, no falls in the last month prior to reentry. Resident #79's medical record identified a fall on 04/22/23. The facility failed to accurately code A0310E and J1700A on Resident #79's quarterly MDS. SECTION N: MEDICATIONS The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, revised October 2023, pages N-6 and N-7, stated, . N0415: High-Risk Drug Classes: Use and Indication . Coding Instructions . N0415E1. Anticoagulant (e.g., [for example] warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period . Review of Resident #35's medical record occurred on all days of survey and showed a physician's order for Eliquis, an anticoagulant. The annual MDS, dated [DATE], showed staff failed to identify Resident #35 received an anticoagulant during the look-back period. During an interview on 06/13/24 at 10:01 a.m., an administrative staff member (#8) confirmed staff failed to code the MDS for an anticoagulant. 46963

Based on observation and review of facility policy, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #46) observed during personal cares and application of a dressing. Failure to follow infection control practices regarding hand hygiene during cares and dressing application has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: Review of the facility policy and procedure titled Hand Hygiene occurred on 06/22/23. This policy/procedure, dated December 2017, stated, Procedure: Hand hygiene is to be performed: . h) After removing gloves. Review of the facility policy and procedure titled Dressing Change: Nonsterile occurred on 06/22/23. This policy/procedure, dated June 2023, stated, . Procedure: . 2. Assemble all equipment in apartment [resident room]. 3. Establish clean field for dressing change. 5. Perform hand hygiene and apply and change gloves as appropriate during procedure. Observation on 06/20/23 at 9:10 a.m. showed a certified nurse aide (CNA) (#2) performed morning cares for Resident #46. The CNA (#2) changed gloves while providing care but failed to complete hand hygiene before donning clean gloves. When the CNA (#2) completed the resident's cares and cleaned up the supplies removed her gloves. Without performing hand hygiene, the CNA (#2) handed Resident #46, the phone, bed controls, call light, moved the overbed table, and handed the resident a drink, which the resident drank. The CNA (#2) failed to perform hand hygiene after and before performing other tasks. During this same observation, the nurse (#3) provided the application of a new dressing to Resident #46's sacral area. The nurse (#3), upon entering the room, set the clean supplies for the dressing on top of the soiled linen hamper. When the CNA (#2) finished, the nurse (#3) moved the supplies to the bedside stand. The nurse (#3), working from the bedside stand, donned gloves, cleansed the skin with sterile saline and gauze, removed gloves, donned clean gloves, and applied the foam dressing. The nurse (#3) failed to set up a clean field and failed to perform hand hygiene between glove changes.

Based on record review, review of facility policy, and staff interview, the facility failed to identify a resident's history of trauma, and/or triggers for 1 of 3 sampled residents (Resident #26) reviewed for Post-Traumatic Stress Disorder (PTSD) and/or Trauma. Failure to identify a resident's history of trauma, and/or triggers may cause re-traumatization. Findings include: Review of the facility policy and procedure titled Trauma Informed Care occurred on 06/21/23 at 2:04 p.m. This policy/procedure dated November 2019, stated, .The facility will account for residents' experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Review of Resident #26's medical record occurred on all days of survey and identified a diagnosis of PTSD. The record lack documentation of an assessment and the development of a plan of care that identified the resident's history of trauma, and/or potential triggers which may cause re-traumatization. During an interview on 06/21/23 at 10:21 a.m. an administrative staff member (#5) confirmed the facility failed to address Resident #26's PTSD and/or trauma diagnosis and potential triggers.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 2 medication carts (Friendship Unit) observed during medication storage review. Failure to correctly label an insulin pen increases the risk of the wrong resident receiving the insulin. Finding include: Review of the facility policy titled Insulin Pen occurred on 06/22/23. This policy, dated February 2018, stated, . Insulin pens must be clearly labeled with the resident name. Observation of the medication cart on the Friendship Unit with staff nurse (#7) occurred on 06/21/23 at 4:36 p.m., and showed the following insulin pen for Resident #18: * Basaglar Kwik pen [a long acting insulin], displayed a label with only the first name visible. During an interview on 06/21/23 at 5:50 p.m., two administrative nurses (#4 and #6) confirmed the insulin pen failed to contain the full name of Resident #18.

Based on review of Medicare Part A letters/notices and staff interview, the facility failed to ensure the completion of the Centers for Medicare/Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form CMS-10055 for 1 of 2 residents (Resident #78) discharged from Medicare Part A services who remained in the facility. Failure to ensure the resident and/or resident representative received all available options for care and the option to appeal the termination of coverage has the potential to hinder the residents' right to an expedited review of a service termination. Findings include: Review of the Medicare Part A letters/notices for Resident #78 occurred the afternoon of 06/21/23 and identified the facility provided the SNFABN form to Resident #78's representative on 03/21/23. The facility failed to obtain documentation of the resident's wishes for continued services and/or the option to appeal the termination of Medicare Part A coverage prior to termination of Medicare Part A coverage on 03/25/23. During an interview on 06/21/23 at 3:05 p.m., a business office staff member (#1) confirmed staff failed to obtain the resident/resident representative option on the SNFABN form for Resident #78.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide care for 5 of 23 sampled residents (Resident #12, #35, #38, #57, and #60) and 3 supplemental residents (Resident #44, #55, and #72) in a manner and environment that maintained, enhanced, and respected each resident's dignity and individuality. Failure of staff to announce themselves/wait for permission prior to entering residents' rooms and failure to assist with set up of adaptive equipment as care planned does not preserve the residents' personal dignity or enhance their quality of life and places them at risk of embarrassment and/or emotional harm. Findings include: Review of the policy titled, Routine Cares occurred on 03/17/22. This policy, revised September 2019, stated, . Dignity and Privacy . Knock and identify yourself upon entering the apartment. Give resident time to respond. KNOCKING/ENTERING ROOMS Observations showed the following: * 03/14/22 at 3:23 p.m., a staff nurse (#12) entered Resident #44's room, and administered the resident's medications. The nurse (#12) failed to knock and/or announce herself before entering the resident's room. * 03/14/22 at 3:27 p.m., a certified nursing assistant (CNA) (#13) knocked as she entered Resident #60's room. The CNA (#13) failed to announce herself before entering the resident's room. * 03/14/22 at 3:47 p.m., a CNA (#13) knocked as she entered Resident #35's room. The CNA (#13) failed to announce herself before entering the resident's room. * 03/15/22 at 08:34 a.m., a staff nurse (#28) entered Resident #38's room, and provided the resident's wound cares. The nurse (#28) failed to knock and/or announce herself before entering the resident's room. * 03/15/22 at 08:40 a.m., a staff nurse (#28) entered Resident #72's closed bathroom door while the CNA (#30) provided perineal cares. The nurse (#28) failed to knock and/or announce herself before entering the resident's bathroom. * 03/15/22 at 8:57 a.m., while interviewing Resident #12 in his room with the door closed, an unidentified staff member knocked on the room door, opened the door, and stated, Are you ready to get ready for the day? The staff member failed to announce herself and wait for permission before entering the resident's room. * 03/15/22 at 09:19 a.m., while observing cares on Resident #55 in her room with the door closed, a CNA (#29) entered the room without knocking and/or introducing himself. During an interview on 03/17/22 at 11:35 a.m., an administrative nurse (#1) reported she expects staff to knock on the resident's door and wait for a response before entering. ADAPTIVE EQUIPMENT REQUIRED FOR MEALS - Observations in the dining room showed the following: * 03/14/22 at 4:20 p.m., an unidentified staff member placed a dinner plate with a plate guard on the left side of the plate, utensils, and three built-up foam handles on the table by Resident #57 without providing set-up assistance. Observation showed food fell on the table and the resident's lap as he attempted to scoop the food. * 03/15/22 at 10:15 a.m., an unidentified staff member placed a breakfast plate with a plate guard positioned at the top of the plate, utensils, and three built-up foam handles on the table by Resident #57 without providing set-up assistance. Observation showed food fell on the table and the resident's lap as he attempted to scoop the food. * 03/15/22 at 4:23 p.m., an unidentified staff member placed a dinner plate with a plate guard positioned at the top of the plate, utensils, and three built-up foam handles on the table by Resident #57 without providing set-up assistance. Observation showed the resident ate pieces of chicken with his fingers and food fell on the table and the resident's lap as he attempted eat the food. Review of Resident #57's medical record occurred on all days of survey and included a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan stated, . adaptive equipment: built up foam handled utensils and plate guard to aid in feeding . I am able to feed myself after set up assistance . The Resident's meal card stated, . red foam handles to utensils . plate guard . - Observation in the dining room showed the following: * 03/15/22 at 4:15 p.m., an unidentified staff member delivered a dinner plate with a plate guard positioned at the top of the plate to Resident #38, and walked away. The resident asked an unidentified dietary aide to turn her plate/plate guard to the left so she could scoop her food. Review of Resident #38's medical record occurred on all days of survey and included a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan stated, . Adaptive equipment: left side plate guard, long built up handles for silverware . I am able to eat independently after set up . The meal card label states, . left side plate guard . During an interview on 03/16/22 at 10:33 a.m., a dietary manager (#31) reported she expects staff to follow the resident's required adaptive equipment and set up needs per meal card and careplan.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 03/13/20. Based on observation, record review, review of the manufacturer's instruction manual, and resident/staff interviews, the facility failed to provide adequate assistance for 4 of 7 sampled residents (Resident #3, #35, #61, and #377) observed during a sit-to-stand mechanical lift transfer. Failure to ensure proper use of the stand lift caused Resident #3 pain/discomfort and placed Resident #35, #61, and #377 at risk for pain and/or injury. Findings include: Review of the [brand name] Sit-to-Stand Lift manufacturer's instruction manual occurred on 03/17/22. The manual identified, . Caution . Before the product is used, adequately qualified nursing staff must assess the physical and mental condition of the patient/resident. Caution . The patient/resident must have sufficient core stability (capability of sitting autonomously [independently] on the edge of the bed is an indicator for a sufficient core stability). Furthermore, he/she must be able to bear his/her body weight with one leg. Review of the facility policy titled Mechanical Lifts occurred on 3/17/22. This policy, dated July 2018, stated, Resident's at St. [NAME] will be transferred in the safest, easiest manner possible that promotes independence. A standing lift is available for resident that require more than one person to assist with a transfer and is used for residents capable of bearing weight. 3. A standing lift transfer may be done with only one caregiver present unless otherwise care planned. - Review of Resident #3's medical record occurred on all days of survey and included a diagnoses of anxiety, [CONDITION(S)], and polyneuropathy. The current care plan stated, . I require assist of one utilizing a standing lift for transfers with a large sling . Observations showed the following: * On 03/15/22 at 12:25 p.m., a CNA (#13) transferred Resident #3 onto the toilet and later into her wheelchair utilizing a sit-to-stand lift. During the transfer, Resident #3 did not bear weight and hung from the harness in a semi-seated position. As the harness straps pulled upward into Resident #3's axillae, her shoulders raised to ear level and her elbows extended horizontally or higher. As the CNA (#13) lowered Resident #3 into her wheelchair, she asked, Are you okay? Resident #3 responded, I have a sore shoulder. * On 03/15/22 at 3:16 p.m., a CNA (#13) transferred Resident #3 onto the toilet and later into her wheelchair utilizing a sit-to-stand lift. During the transfer, Resident #3 did not bear weight and hung from the harness in a semi-seated position. As the harness straps pulled upward into Resident #3's axillae, her shoulders raised to ear level and her elbows extended horizontally. * 03/15/22 at 3:50 p.m., a CNA (#16) transferred Resident #3 into her wheelchair utilizing a sit-to-stand lift. During the transfer, Resident #3 did not bear her weight and hung from the harness in a semi-seated position. As the harness straps pulled upward into Resident #3's axillae, her shoulders raised to ear level and her elbows extended horizontally or higher. Resident #3 grunted as she lowered into the wheelchair. - Review of Resident #35's medical record occurred on all days of survey and included a diagnoses of anxiety, ataxia [movement disorder], [CONDITION(S)], and chronic pain. The current care plan stated, . I require 1 staff assistance with transfers . Observation on 03/15/22 at 10:32 a.m., showed a CNA (#17) transferred Resident #35 onto the toilet utilizing a sit-to-stand lift. Resident #35 did not bear weight. While in the harness, she bent at the waist with her toes braced against the foot plate and knees locked. As the harness straps pulled upward into Resident #35's axillae, her shoulders raised. During an interview on 03/17/22 at 11:35 a.m., an administrative nurse (#1) reported she expects people who are using a stand lift to bear their weight. She added, We usually have physical therapy evaluate them. - Review of Resident #61's medical record occurred on all days of survey and included diagnoses of history of stroke, bilateral leg weakness, and chronic pain. The current care plan stated, . Transfer: I require 1 staff assistance with transfers . I require Mechanical aid standing lift for transfers . During an observation on 03/15/22 at 10:15 a.m., A CNA (#32) transferred Resident (#61) in a sit-to-stand lift from the wheelchair to the bathroom to perform toileting cares. The CNA fastened the transfer sling around the resident and to the lift, but failed to apply the lower leg strap behind the resident's calf. During the transfer, Resident #61's legs slipped forward and to the side and her upper body becaame loose in the sling. The CNA continued to transfer the resident to the toilet. The CNA (#32) stated she was in a hurry and needed to get the resident to an appointment. - Review of Resident #377's medical record occurred on all days of survey. The care plan stated, . TRANSFER: I require 1 staff assistance with transfers. I require Mechanical Aid standing lift for transfers. During an observation on 3/15/22 at 9:12 a.m., a certified nursing assistant (CNA) (#24) transferred Resident #377 from the commode with a stand lift. While in a standing position the CNA (#24) adjusted the resident's clothing and Resident #377 stated her arms were getting tired and she was ready to sit down. The CNA (#24) moved the lift toward the wheelchair, which then rolled away. The CNA (#24) backed up the lift, re-positioned the wheelchair, and only locked the left brake. As the CNA (#24) positioned the lift one of the legs became tangled with the overbed table. The CNA (#24) positioned the lift in front of the wheelchair and lowered the resident into the wheelchair. Because the CNA (#24) failed to lock the right brake on the wheelchair, it swung to the right and hit the wall when the CNA (#24) lowered the resident. During an interview on 03/17/22 at 11:00 a.m. two administrative nurses (#1 and #10), when asked if they expected the wheelchair brakes to be locked, responded yes.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 03/13/20. Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow infection control practices for 5 of 23 sampled residents (Resident #3, #8, #10, #33, and #65) and 1 supplemental resident (#32) observed during cares. Failure to follow standard infection control practices has the potential for transmission of communicable diseases and infections to residents and staff. Findings include: PROTECTIVE PERSONAL EQUIPMENT Review of the policy titled Novel Coronavirus Prevention and Response occurred on 03/17/22. This policy, dated 04/12/21, stated, . Make PPE [personal protective equipment], including facemask, eye protection, gowns, and gloves, available immediately outside of the resident's room . Review of CDC (Centers for Disease Control and Prevention) guidance found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html, updated August 13, 2021, stated, Reusable eye protection should [sic] cleaned and disinfected after each patient encounter. Ensure appropriate cleaning and disinfection after each use if reusable face shields or goggles are used. During an interview on 03/14/22 at 1:55 p.m., a nurse manager (#2) confirmed staff must wear face shields in unvaccinated resident's rooms, which are identified by Face Shield Required signage on the residents' doors. Review of the resident COVID-19 Vaccine and Declinations list identified Residents #8, #10, #32, #33, and #65 as unvaccinated. Observations showed the following: * 03/14/22 at 3:32 p.m. a clear tote with lid on a table outside of Resident #10 and #32's room used for both residents. The tote contained face shields and a container of disinfectant wipes. * 03/14/22 at 3:35 p.m., the absence of a PPE cart immediately outside Resident #65's room. Observation showed the nearest PPE tote approximately 75 feet from the resident's room. * 03/16/22 at 2:56 p.m. showed a shared PPE cart approximately 25 feet from Resident #8's room and approximately 50 feet from Resident #33's room. Observations showed the staff failed to follow standard infection control practices during the following times: * 03/14/22 at 12:18 p.m., a therapist (#22) reassessed Resident #33 without a face shield in place. * 03/14/22 at 3:42 p.m., two CNAs (#7 and #14) exited Resident #10's room without face shields in place. * 03/15/22 at 9:11 a.m., a CNA (#17) dressed Resident #33 and then exited the room without a face shield in place. * 03/15/22 at 9:34 a.m., a CNA (#5) and a nurse (#6) exited Resident #65's room and failed to clean and disinfect their face shields. Both staff entered other resident's rooms. * 03/15/22 at 9:50 a.m., two CNAs (#8 and #9) exited Resident #32's room and failed to clean and disinfect their face shields. The CNA (#8) continued down the hall and interacted with staff and the CNA (#9) entered another resident's room. * 03/15/22 at 9:52 a.m., a CNA (#5) exited Resident #65's room and failed to clean and disinfect the face shield. * 03/15/22 at 10:03 a.m., two CNAs (#4 and #5) and a nurse (#6) exited Resident #10's room and failed to clean and disinfect their face shields. The CNA (#4) assisted another resident in the hallway, the CNA (#5) and nurse (#6) entered other resident's rooms. * 03/15/22 at 10:05 a.m., a CNA (#21) sat next Resident #8 and assisted her as she ate brunch in the lounge. The CNA (#21) failed to wear a face shield. During an interview on 03/16/22 at 2:56 p.m., a nurse (#3) confirmed the facility did not follow the facility policy, failed to place a PPE cart immediately outside of unvaccinated residents' rooms, and failed to clean and disinfect face shields between use with residents. PERINEAL CARES Berman, Snyder, and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., Massachusetts, pages 743-744, stated, . Clean the labia majora and perineum from front to back, from pubis to the rectum . Observations showed the following: * 03/15/22 at 10:37 a.m., a CNA (#23) donned gloves, assisted Resident #8 to stand utilizing a sit-to-stand lift, and then provided perineal cares. The CNA (#23) failed to clean the perineal area from front to back. * 03/15/22 at 3:16 p.m., a CNA (#13) donned gloves, raised Resident #3 in a sit-to-stand lift, and then provided perineal cares. Resident #3 knees were bent in a semi-seated position in the lift, and the CNA (#13) failed to clean the front perineal area. During an interview on 03/16/22 at 2:56 p.m., an infection control nurse (#3) agreed staff should thoroughly clean the perineal area and must clean front to back when performing perineal cares to prevent urinary tract infections.

Based on observation, record review, review of professional reference, resident and staff interview, the facility failed to honor resident choices for 1 of 1 sampled resident (Resident #65) who felt she was not allowed to leave her room. Failure to honor Resident #65's choice related to time out of her room does not respect her autonomy or right to determine what is significant to her life. Findings include: A Guide to Your Rights as a Resident of a Nursing Facility In North Dakota, from the Long Term Care Ombudsman, updated 08/01/2019, page 12, stated, You can make choices about how you want to live your life that are significant to you. This includes deciding how you want to spend your time, what you would like your daily schedule and routine to be . During an interview on 03/14/22 at 3:06 p.m. Resident #65 identified she does not get to choose how to spend the day. During a care observation on 03/15/22 at 3:58 p.m. Resident #65 again stated she does not have a choice to leave her room. Resident #65's care plan stated, . My family and I choose that I be up for specific activities that may result in being up in my w/c [wheelchair] for prolonged periods of time. I need staff reminders and assist to act [activities] . Goal I will participate in bingo . Interventions . Act of interest include: Special events, Bingo, Reminisce. Observation showed the facility held Bingo and special music during the survey and Resident #65 did not attend these activities. Resident #65's activity report for March 2022 showed facility staff offered activities four of 16 days. During an interview on 03/17/22 at 11:02 a.m., two administrative staff members (#1 and #10) felt activities staff invited the resident to activities, but Resident #65 refused to attend and stated they could provide information to show refusals. Staff failed to provide this information.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the physician of a change in condition for 2 of 2 sampled residents (Resident #35 and #60) who experienced high blood sugars. Failure to notify the physician of blood sugar results above the ordered parameters may result in complications to the resident and prevent the physician from evaluating/prescribing an appropriate treatment plan. Findings include: Review of the facility policy titled Diabetic Protocol occurred on 03/17/22. This policy, revised February 2019, stated, . All residents with Diabetes will be monitored and treated as ordered by the physician/NP [nurse practitioner]/PA [physician's assistant]. Follow diabetic protocol if there are not specific orders. Treating Hyperglycemic episodes . If blood sugar is greater than 400 call the Dr. [doctor]/practitioner unless orders indicate different level for notification. - Review of Resident #35's medical record occurred on March 13-17, 2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders also identified, Accu-checks [blood sugar checks]three times a day. Review of the January-March 2022 blood sugar log showed the following results: * 03/09/22, 435 milligrams per deciliter (mg/dL) * 03/11/22, 459 mg/dL Review of the medical record showed the facility failed to notify Resident #35's physician of the high blood sugar readings. - Review of Resident #60's medical record occurred on March 13-17, 2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders also identified, Accu-checks three times a day every Tue [Tuesday] Sat [Saturday] . Review of the January-March 2022 blood sugar log showed the following results: * 01/01/22 405 mg/dL * 01/25/22 415 mg/dL and 446 mg/dL * 02/01/22 448 mg/dL * 02/22/22 450 mg/dL and 401 mg/dL Review of the medical record showed the facility failed to notify Resident #60's physician of the high blood sugar readings. During an interview on 03/16/22 at 4:00 p.m., an administrative nurse (#1) confirmed facility staff failed to notify the physicians of Resident #35 and #60's high blood sugar readings.

Based on observation, record review, and staff interview, the facility failed to provide care and services to ensure proper skin care for 1 of 1 sampled resident (Resident #10) with a skin condition (rash). Failure to complete skin assessments and notify the provider of worsening skin conditions may cause continued pain, worsening skin conditions, and delay changes in treatment. Findings include: Review of Resident #10's medical record occurred all days of survey. A physician order, dated 02/08/22, stated, [MEDICATION(S)] Ointment [a barrier cream] 0.44-20.6 % (Menthol-[MEDICATION(S)]) Apply to Groin/penis topically two times a day for Excoriation After cleansing and patting dry apply [MEDICATION(S)] BID [twice a day] and with brief changes till clear then go back to tena with zinc tx [treatment]. ok to use Aquaphor also. AND Apply to Groin/penis topically as needed for excoriation With brief changes. The care plan stated, . I have potential for pain related to: Impaired mobility, inability to communicate needs . Intervention . Monitor/record/report to Nurse any s/sx [signs/symptoms] of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); . I have an alteration in my skin integrity of . excoriation [a stripping or removal of skin] to bilateral groin and underside of penis . I am at risk for alterations in my skin integrity related to: disease process, Impaired Mobility, Incontinence . nonverbal. Interventions . Skin assessment as scheduled, update provider if indicated; Administer treatments as ordered and monitor for effectiveness. Observation on 03/15/22 at 10:06 a.m. showed three certified nurse aides (CNAs) (#4, #5, and #9) assisted Resident #10 with morning cares. The CNAs opened the resident's brief and turned him to his side. Observation showed a red, excoriated rash on the resident's buttocks which extended down his thighs. As the CNA (#5) cleansed and dried the area, two dry [CONDITION(S)] fell off. The CNA (#5) failed to apply [MEDICATION(S)] to the resident's buttocks/thighs. The CNAs (#4, #5, and #9) returned the resident to his back and two CNAs (#4 and #9) cleansed the groin and genitalia. As they patted the area dry, bloody areas appeared on the resident's skin. The CNA (#9) applied [MEDICATION(S)] to the resident's groin and genitalia area. The nurse (#6) entered, provided care, and examined the placement of the [MEDICATION(S)] and added more to the pubic area. Observation showed the location of Resident #10's rash matched the location where the brief encountered his skin. Facility staff completed weekly skin assessments for Resident #10 from 11/18/21 through 02/07/22. A nursing skin assessment note, dated 02/07/22 identified the following . Bilateral groin areas are excoriated and underside of penis is excoriated. Current Skin Interventions in Place: Note placed on PAC [practitioner communication] folder updating regarding skin on groin and penis. Skin was lotioned [sic]. Plan: Continue with current plan of care This assessment failed to identify Resident #10's rash on his buttocks and thighs. The medical record lacked another skin assessment after 02/07/22. During an interview on 03/17/22 at 11:02 a.m., with administrative staff members (#1 and #10), staff member (#1) stated she talked with the nurse who completed the skin assessment on 02/07/22 and communicated with the practitioner and the nurse felt the rash had improved. Facility staff failed to notify Resident #10's provider when the rash/excoriation worsened and spread to his buttocks and thighs and failed to complete skin assessments after 02/07/22.

Based on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to provide care and services to control pain for 3 of 23 sampled residents (Residents #12, #31 and #40). Failure to offer pharmacological and/or non-pharmacological pain interventions may result in unresolved/increased pain and decreased quality of life for all residents. Findings include: Review of the facility policy titled Pain Management occurred on 03/17/22. This policy, dated December 2015, stated, . Pain in residents will be assessed and treated promptly and consistently to help assure the highest level of pain relief possible. Assess for possible non-pharmacological parameters which may include: Behavioral . Physical Agents (application of heat or cold), Massage, Exercise, Repositioning, Distraction Techniques. Assess for possible pharmacological interventions; administer medication as ordered. Enter pain problem and interventions on care plan. Reassess resident as necessary. - Review of Resident #40's medical record occurred all days of survey. The record identified the resident experienced an unwitnessed fall on 03/13/22 at 5:10 a.m., which resulted in a right hip/pelvis injury. Physician's orders included [MEDICATION(S)] oral solution 4 mg [milligrams] every one hour prn [as needed]. Resident #40's care plan stated, Focus . pain . Interventions: Provide me with medications/treatments as ordered. Anticipate my need for pain relief . Evaluate the effectiveness of pain interventions . Review of Resident #40's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 03/15/22 at 5:05 p.m. through 5:37 p.m. showed two CNAs (#18 and #19) provided care to Resident #40. Before turning the resident, a CNA (#19) told the resident it would hurt. The CNAs (#18 and #19) rolled the resident from side to side three times and each time the resident grimaced and yelled. During an interview on 03/17/21 at 11:02 a.m., two administrative staff members (#1 and #10) agreed the goal is to keep Resident #40 as comfortable as possible, and if able, give pain medication before a care task that may increase the resident's pain. - Review of Resident #31's medical record occurred on all days of survey and identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan stated, . Provide me with medications/treatments as ordered. Encourage me to try different pain-relieving methods i.e. positioning, relaxation therapy, bathing, heat and cold application. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease [sic] ROM [range of motion], withdrawal or resistance to care. During an interview on 03/15/22 at 8:55 a.m., Resident #31 stated she has pain in her back, so bad that when I'm standing at my sink, I have to sit down to finish brushing my teeth. Resident #31 explained she took [MEDICATION(S)] at home four times a day. Resident #31 stated she no longer gets pain medication as her nurse practitioner discontinued the [MEDICATION(S)]. During an interview with Resident #31 on 03/17/22 at 8:30 a.m., Resident #31 stated, not right now, when asked if she has pain. If Resident #31 reports pain, they ask if I want Tylenol, but I can't have that. Resident #31 responded no when asked if staff offer other interventions. A physician's order, dated 01/17/22, stated, Pain level: assess pain level BID [twice a day] and follow up as necessary, every day and evening shift for pain level. Review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record lacked evidence staff offered non-pharmacological interventions for pain. Resident #31's current orders failed to include a scheduled or PRN medication for pain, and the medical record failed to show staff implemented interventions as care planned for pain. In an interview on 03/17/22 at 11:00 a.m., two administrative nurses (#1 and #10) identified their expectation is that staff would document interventions offered for pain in the progress notes. - Review of Resident #12's medical record occurred on all days of survey and identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's orders showed the resident received scheduled Tylenol, PRN (as needed) Tylenol, and an analgesic rub for pain. The current care plan stated, . Encourage me to try different pain relieving methods i.e. positioning, relaxation, therapy, bathing, heat and cold application. Evaluate the effectiveness of pain interventions PRN. Resident #12's medical record lacked evidence staff implemented non-pharmacological pain interventions as care planned.

Based on observation and staff interview, the facility failed to discard expired suction equipment/supplies in 2 of 2 medical equipment storage areas (North and South). Failure to discard expired suction machine supplies may result in reduced efficacy if/when a resident requires suctioning. Findings include: Observation of the North and South medical equipment storage areas occurred on [DATE] at 3:45 p.m. with a licensed staff member (#32). Observations identified the following: South Medication Storage Room: * Two ConMed 66-inch suction tubing expired [DATE] and February 2021. * Three sterile water containers expired [DATE], [DATE], and February 2021 North Medication Storage Room: * Two ConMed 66- inch suction tubing expired [DATE] and [DATE] * One sterile water container expired [DATE] During the observation, the licensed staff member (#32) agreed the expired items needed to be discarded and expected all equipment to be up to date.

Based on observation, record review, review of maintenance records, and staff interview, the facility failed to provide housekeeping/maintenance services necessary to maintain a safe, clean, and comfortable environment in 2 of 3 units (Residents #12, #29, #69 and #276's rooms) and in 1 of 1 dining room. Failure to maintain a safe, clean, and comfortable living environment placed the residents at increased risk for illness. Findings include: Random observations on March 14-15, 2022, showed dust/grime in the following resident rooms: * Resident #12, on the ceiling vent cover, the air flow deflector attached to the vent, and the ceiling above the vent. * Resident #29, on an upper wall/beam vent cover and the wall surrounding the vent. * Resident #69, on the ceiling above a vent. * Resident #276, on an upper wall/beam vent cover and top of the adjacent sprinkler head. * Main dining room, on most of the upper wall/beam vent covers. Resident #12, #29, #69, and #276's diagnoses included asthma (a lung disorder that causes shortness of breath, wheezing and cough), acute and chronic respiratory failure (poor exchange of oxygen and carbon [MEDICATION(S)] by the respiratory system) with [CONDITION(S)] (low oxygen levels in the blood), chronic obstructive pulmonary disorder ([CONDITION(S)]) (constricted airways in the lungs causing difficulty in breathing), and dependence on supplemental oxygen. During an interview on 03/17/22 at 10:28 a.m., a maintenance supervisor (#27) stated the vents in the facility are blown out every 30 days around the third week of the month. Review of the vent maintenance/cleaning records indicated the vents in Resident #12's room were blown out on 01/07/22 and Resident #29, #69 and #276's rooms and the main dining room were blown out on 01/11/22 (approximately 60 days ago). During an interview on 03/17/22 at 11:56 a.m., the maintenance supervisor (#27) agreed the vents in the resident rooms and the main dining room needed washing.