Every finding on record at SMP Health - St Raphael

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 4 sampled residents (Resident #1) who exhibited and/or were subjected to physical abuse by and/or to other residents. Failure to prevent resident to resident physical abuse resulted in pushing, hitting, and kicking and placed all residents at risk for serious injury, pain, mental anguish, and emotional distress. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation and Misappropriation of Resident Property occurred on 07/07/26. This policy, dated January 2026, stated, . Verbal abuse is defined as any use of oral . communication . that willfully includes disparaging and derogatory terms to residents . within their hearing distance, regardless of their . ability to comprehend . Physical abuse includes, but is not limited to hitting, slapping, punching . Resident-to-Resident Abuse of Any Type . A resident-to-resident altercation should be reviewed as a potential situation of abuse . Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions in these situations . Review of Resident #1's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, dementia with agitation, depression, severe psychotic disorder with delusions, and wandering. The current care plan stated, . I have behaviors s/t [secondary to] dementia. I have a history of elopement attempts, agitation, restlessness, physical aggression, verbal aggression, and barricading. I wander and may enter my peers' room. I sometimes take items and refuse to let them go . Resident #1's progress notes identified the following:* 01/15/26 at 3:46 p.m., . Resident came up to another resident and placed her hands on his arm and was trying to move him or just hang on to him. The other resident then turned and pushed her away from him. She lost her footing and started to twist a little with her left knee/leg. In doing this she fell to the floor with partial assistance from a dietary staff that tried to keep her from falling and kept resident from hitting the floor as hard. She c/o [complained of] her left knee hurting but when asked again she said nothing hurt.* 01/26/26 at 9:40 p.m., . Resident was in the activity room . Another resident started wheeling into her. Staff in the room . stopped the other resident from running into her and as she was being pulled back, she pulled her left leg up and kicked this resident in the right leg.* 01/31/26 at 3:44 p.m., Resident wandering the dining room. Resident walked up to peer, scowled and flicked her in the forehead. Interaction was unprovoked as other resident was sitting quietly at the table. PRN [as needed] hydrocodone given to rule out pain . treat pain as able .* 03/13/26 at 5:44 p.m., . Another resident was standing by her. This resident hit the other resident in the face. * 04/03/26 at 6:53 p.m., . Resident was sitting at a table in the dining room close to another resident. She was seen reaching out and touching one of the toys the other resident had. The other resident swung and hit the resident on the right side of her head. Resident appears to be teary by this and upset.* 04/10/26 at 6:27 p.m., . Resident had walked up to a table and started to pull out a chair to sit down. Another resident at the table grabbed the chair away from her and pushed it in under the table. Resident started pointing a finger and 'scold' the other resident. The other resident picked up a paperback book and hit this resident in the hand, told her to 'Go Away' . No injuries noted .* 04/19/26 at 8:10 p.m., . Resident walked up to another table next to another resident. The other resident swung and hit this resident in the torso. This resident reciprocated and hit the other resident on top of the head.* 04/30/26 at 6:40 p.m., . Resident was walking in the hallway behind another resident. Resident grabbed the shirt collar of the other resident and pulled, choking the other resident.* 05/01/26 at 10:02 p.m., . 5/1/26 1820 [6:20 p.m.] . [Resident initials] was monitoring resident as she was being intrusive. She turned her attention to another resident, when she looked up [Resident #1] had ahold of the male resident. He grabbed her and pushed her against the wall. [Resident #1] slid down the wall landing on her buttocks with her back resting on the couch.* 05/10/26 at 5:29 p.m., . Resident was done with supper and was leaving the dining room. Came up behind another resident who was eating and punched him in the back of the head and called him a 'damn fool' . Resident . remained very angry. Resident that was punched had no injuries . During interviews on 07/07/26 at 12:45 p.m. and 4:30 p.m., two administrative staff members (#1 and #2) reported they talk about behaviors every morning with social services and the unit managers. They described Resident #1 as trying to annoy the other residents, but not intentionally hurt them. They indicated she can be nice one minute and acting out the next and doesn't target any one person. The facility failed to effectively manage Resident #1's behaviors which resulted in repeated episodes of resident-to-resident abuse.

Based on record review, review of facility policy, and staff interview, the facility failed to report incidents of abuse to the State Survey Agency (SSA) within the required time frames for 1 of 4 sampled residents (Resident #1) reviewed for resident-to-resident altercations. Failure to ensure potential abuse incidents of abuse are reported immediately to the SA, and no later than 2 hours after the allegation is made, may result in continued abuse, fear, anxiety, and psychosocial harm. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation and Misappropriation of Resident Property occurred on 07/07/26. This policy, dated January 2026, stated, . Reporting of all alleged violations to the . state agency . and to all other agencies . within specific time frames . Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Review of Resident #1's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, dementia with agitation, depression, severe psychotic disorder with delusions, and wandering. The current care plan stated, . I have behaviors s/t [secondary to] dementia. I have a history of elopement attempts, agitation, restlessness, physical aggression, verbal aggression, and barricading. I wander and may enter my peers' room. I sometimes take items and refuse to let them go . Resident #1's progress notes identified the following:* 01/15/26 at 3:46 p.m., . Resident came up to another resident and placed her hands on his arm and was trying to move him or just hang on to him. The other resident then turned and pushed her away from him. She lost her footing and started to twist a little with her left knee/leg. In doing this she fell to the floor with partial assistance from a dietary staff that tried to keep her from falling and kept resident from hitting the floor as hard. She c/o [complained of] her left knee hurting but when asked again she said nothing hurt.* 01/26/26 at 9:40 p.m., . Resident was in the activity room . Another resident started wheeling into her. Staff in the room . stopped the other resident from running into her and as she was being pulled back, she pulled her left leg up and kicked this resident in the right leg.* 01/31/26 at 3:44 p.m., Resident wandering the dining room. Resident walked up to peer, scowled and flicked her in the forehead. Interaction was unprovoked as other resident was sitting quietly at the table. PRN [as needed] hydrocodone given to rule out pain . treat pain as able .* 03/13/26 at 5:44 p.m., . Another resident was standing by her. This resident hit the other resident in the face. * 04/03/26 at 6:53 p.m., . Resident was sitting at a table in the dining room close to another resident. She was seen reaching out and touching one of the toys the other resident had. The other resident swung and hit the resident on the right side of her head. Resident appears to be teary by this and upset.* 04/10/26 at 6:27 p.m., . Resident had walked up to a table and started to pull out a chair to sit down. Another resident at the table grabbed the chair away from her and pushed it in under the table. Resident started pointing a finger and 'scold' the other resident. The other resident picked up a paperback book and hit this resident in the hand, told her to 'Go Away' . No injuries noted .* 04/19/26 at 8:10 p.m., . Resident walked up to another table next to another resident. The other resident swung and hit this resident in the torso. This resident reciprocated and hit the other resident on top of the head.* 04/30/26 at 6:40 p.m., . Resident was walking in the hallway behind another resident. Resident grabbed the shirt collar of the other resident and pulled, choking the other resident.* 05/01/26 at 10:02 p.m., . 5/1/26 1820 [6:20 p.m.] . [Resident initials] was monitoring resident as she was being intrusive. She turned her attention to another resident, when she looked up [Resident #1] had ahold of the male resident. He grabbed her and pushed her against the wall. [Resident #1] slid down the wall landing on her buttocks with her back resting on the couch.* 05/10/26 at 5:29 p.m., . Resident was done with supper and was leaving the dining room. Came up behind another resident who was eating and punched him in the back of the head and called him a 'damn fool' . Resident . remained very angry. Resident that was punched had no injuries . During interviews on 07/07/26 at 12:45 p.m. and 4:30 p.m., two administrative staff members (#1 and #2) reported they talk about behaviors every morning with social services and the unit managers and review the residents' behaviors, talk to staff, and review the camera footage. (Record review showed the review of camera footage occurred up to three days later in some instances.) The administrative staff members (#1 and #2) indicated they did not believe abuse occurred in the cases listed above once they finished reviewing the camera footage during each investigation. The facility failed to report the cases of potential resident-to-resident verbal and physical abuse listed above to the SSA within two hours.

Based on observation, review of temperature logs, review of professional reference, and staff interview, the facility failed to store food in accordance with professional standards for food service safety in 1 of 1 main kitchen and 6 of 7 food storage areas (Third Floor Kitchenette, First Floor Kitchenette, First Floor Sub-station, Special Care Unit, Sunshine Kitchenette, and Circle of Life Cottage Kitchenette). Failure to discard expired food, ensure required refrigerator temperatures, ensure functioning of temperature monitoring devices in refrigerator, ensure clean equipment, and ensure protection of dry food storage from leaking pipes has the potential to affect the quality and safety of food served to the residents. Findings include: Review of the Food and Drug Administration (FDA) Food Code 2022, Annex 3 - Public Health Reasons, states . Ready-to-Eat, Time/Temperature Control for Safety Food . Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microbes. ready-to-eat, time/temperature control for safety food . kept at 41 degrees Fahrenheit a total of 7 days. Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature . Time/temperature control for safety refrigerated foods must be consumed . or discarded by the expiration date .Manufacturer's use-by dates . Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) . If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind . Food Storage. FOOD shall be protected from contamination by storing . (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . FOOD may not be stored: . (G) Under leaking water lines . (I) Under other sources of contamination. Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food.Temperature Measuring Devices. A permanent temperature measuring device is required in any unit storing time/temperature control for safety food because of the potential growth of pathogenic microorganisms should the temperature of the unit exceed Code requirements. Observation with an administrative dietary staff member (#3) occurred on 09/24/25 at 11:15 a.m. and showed the following: Main Kitchen:* Walk-in cooler - a black substance on the grates of the fan and around the outside of the fan. * A black pipe on the ceiling in the dry storage room dripping liquid on the floor next to a rack of food. Third Floor Kitchenette: * Turkey sandwich dated 09/13/25 (expired 11 days prior)* Hard boiled eggs dated 09/12/25 (expired 12 days prior) * Sliced cheese dated 09/15/25 (expired 9 days prior) * Thickened water dated 08/25 and 09/15 (expired 30 days and 9 days prior) * Cheese slices in a plastic bag dated 08/26 (expired 29 days prior) * Shredded American cheese in a plastic bag dated 09/15/25 (expired 9 days prior) * Shredded cheese in a plastic bag dated 09/01/25 (expired 23 days prior) Special Care Unit Kitchenette: * Refrigerator- 52 degrees Fahrenheit * Review of the refrigerator log showed a temperature of 44 degrees Fahrenheit on the morning of 09/24/25 that morning. An unidentified kitchen staff member stated he had not been in the refrigerator recently. Circle of Life Cottage Kitchenette: * Cheese slices in a plastic bag dated 09/01/25 (expired 23 days prior) * Seven yogurt cups with an expiration date of 09/16/25 (expired 8 days prior) The administrative dietary staff member (#3) threw the expired food away. Sunshine Kitchenette: * A broken and unreadable refrigerator thermometer. Review of the refrigerator/freezer log showed staff failed to log temperatures since 08/16/25. * Silverware drawer with several crumbs scattered throughout the drawer. First Floor Kitchenette: * Microwave with pieces of cooked eggs on the inside and side wall. * Toaster with numerous scattered crumbs on the top First Floor Substation: * Microwave with food debris inside The administrative dietary staff member (#3) stated she expected staff to discard expired foods and stated their policy is to discard after five days.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 7 sampled residents (Resident #16 and #73) observed during cares. Failure to remove gloves and perform hand hygiene during wound care and perineal care has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Glove Usage occurred on 09/24/25. This policy, revised November 2018, stated, Purpose: To reduce the risk of exposure, prevent the spread of infection, identify situations where usage of gloves is appropriate and incorporating proper usage of gloves. Procedure: . 2. Once gloves are contaminated, they must be changed before touching clean items or proceeding to perform clean procedure. 7. Hand hygiene must be performed prior to gloving and after removing gloves. Review of the facility policy titled Hand Hygiene occurred on 09/24/25. This policy, revised September 2023, stated, Purpose: . Hand hygiene . an effective method for preventing the spread of pathogens, such as bacteria and viruses, which cause infections. Condition: Hands are visibly soiled with blood or other body fluids. After handling contaminated objects. Before and after handling clean or soiled dressing. -Observation on 09/23/25 at 9:39 a.m. showed the nurse (#1) performed a dressing change for Resident #73. The nurse applied personal protective equipment (PPE), a gown and gloves and entered the resident's room. The nurse removed a soiled abdominal (ABD) pad from the left hip of Resident #73. Without removing her gloves, the nurse (#1) cleaned the area with wound cleanser, placed a new ABD, and applied tape. The nurse (#1) then removed the gown and gloves and washed her hands. The nurse failed to remove gloves, perform hand hygiene, and apply new gloves prior to applying the clean dressing. -Observation on the afternoon of 9/23/2025 showed two certified nurse aides (CNAs #2 and #5) applied gowns and gloves and transferred Resident #16 from the wheelchair to the bed using the mechanical lift. The CNA (#2) wore gloves and completed Resident #16's perineal care after a soft bowel movement. With the same gloves, the CNA reached into a container of ointment and applied it to the resident's bottom, fastened the new brief, pulled up his pants, opened up a drawer to retrieve a bandana and placed it by the resident's mouth. The CNA (#2) removed her gown, and with same gloves still on plugged in a pump, tied a garbage bag, lowered the bed, turned the television on, took the pillowcase off the resident's neck pillow, tied a garbage bag, and then removed gloves and performed hand hygiene. The CNA (#2) failed to remove gloves and perform hand hygiene after perineal care and prior to doing other tasks in the resident's room. During an interview on the afternoon of 09/24/25, an administrative nurse (#4), confirmed staff should remove gloves and performed hand hygiene after removing a soiled dressing and after performing perineal cares.

Based on observation, record review, facility policy review, and staff interview, the facility failed to follow standards of infection control for 8 of 25 sampled residents (Resident #9, #28, #70, #79, #92, #96, #260, and #360) observed during cares. Failure to follow infection control practices during resident cares related to hand hygiene, glove use, and enhanced barrier precautions (EBP), has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 08/08/24. This policy, revised September 2023, stated, . Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of care. The use of gloves does not replace hand hygiene. Practice hand hygiene before donning and after doffing gloves. Review of the facility policy titled Skin and Wound Management Program occurred on 08/08/24. This policy, revised June 2024, stated, . Cleaning a Wound and Applying a Dressing . Carefully remove the soiled dressings. Place soiled dressings in the appropriate waste receptacle. Remove your gloves and dispose of them in an appropriate waste receptacle. Perform hand hygiene. Put on gloves . Apply any topical medications, foams, gels, and/or gauze to the wound . Gently place a layer of dry, . or other prescribed cover dressing . Apply tape . Remove and discard gloves. Perform hand hygiene. Review of the facility policy titled Enhanced Barrier Precautions occurred on 08/08/24. This policy, revised June 2024, stated, . Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities. Standing orders will be implemented for enhanced barrier precautions for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and /or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, . ) even if the resident is not known to be infected or colonized with a MDRO. make gowns and gloves available immediately in or outside of the resident's room. In general, gowns and gloves would not be required for resident care activities other than those listed below, . Device care or use: . feeding tube . Wound care: any skin opening requiring a dressing . 40489 HAND HYGIENE/GLOVE USE - Observation on 08/06/24 at 3:08 p.m. showed the CNA (#12) assisted Resident #9 who is on enhanced barrier precautions with transferring to the wheelchair from the bed. When completed CNA (#12) removed her gown, gloves and grabbed the resident's blanket and placed on resident's lap. The CNA (#12) pushed Resident #9 out of the room and failed to perform hand hygiene. - Observation on 08/06/24 at 1:12 p.m. showed two CNAs (#4 and #10) assisted Resident #70 with incontinent cares. The CNA (#4) removed her gloves and without performing hand hygiene exited the resident's room with the Hoyer lift. WOUND CARE - Observation on 08/06/24 at 3:24 p.m. showed the nurse (#3) removed the soiled dressing from Resident 260's foot, removed the soiled gloves, and without performing hand hygiene donned new gloves, applied a clean dressing to the wound, and wrapped the resident's foot with a protective dressing. - Observation on 08/06/24 at 3:24 p.m. showed the nurse (#13) removed the soiled dressing from Resident #360's right knee, cleansed the area with soap and water, and without removing the soiled gloves and performing hand hygiene, applied a clean dressing and a compression sleeve to the wound. - Observation on 08/07/24 at 1:55 p.m. showed the nurse (#7) removed Resident #92's wound dressing. Without removing the soiled gloves and performing hand hygiene, inserted a foam dressing into the wound, secured the outer dressing with tape, and then removed her gloves. During an interview on 08/08/24 at 10:55 a.m., an administrative nurse (#1) confirmed she expected staff to follow policy and procedures for hand hygiene and dressing changes. 46477 ENHANCED BARRIER PRECAUTIONS: - Review of Resident #28's medical record occurred on all days of survey. Physician's orders included a dressing change to a surgical wound twice daily. The care plan stated, Enhanced Barrier Precautions (EBP) related to Chronic Wounds (unhealed surgical wound) . Personal Protective Equipment (PPE) use during wound care . Observation on 08/06/24 at 10:27 a.m., showed a nurse (#14) removed a soiled dressing from Resident #28's wound, cleansed the wound, and applied a clean dressing. The nurse (#14) failed to apply a gown before providing wound care. - Observation on 08/07/24 at 1:30 p.m. showed a nurse (#9) applied gloves and entered Resident #79's room with medications. A sign on the resident door indicated EBP. The nurse administered the medications and water flushes through the resident's feeding tube. The nurse (#9) failed to wear the appropriate enhanced barrier precautions PPE. - Review of Resident #96's medical record occurred on all days of survey. Physician's orders included wound care to a right ankle pressure ulcer daily. The care plan stated, Enhanced Barrier Precautions (EBP) related to Chronic Wounds (pressure ulcer) and Indwelling Medical Device urinary catheter . Enhanced Barrier Precautions (EBP) should be used for the duration of the affected residents [sic] stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Observation on 08/06/24 at 9:33 a.m., showed a nurse (#14) performed a dressing change to Resident #96's wound. The nurse failed to wear the appropriate enhanced barrier precautions PPE. 46963

Based on record review and resident and staff interviews, the facility failed to follow the grievance process for 2 of 2 sampled residents (Resident #99 and #133) with concerns regarding treatment from staff during cares. Failure to act upon resident grievances is a violation of resident's rights and may result in resident dissatisfaction. Findings include: The facility failed to provide a policy. - During an interview on 08/05/24 at 1:25 p.m., Resident #133 stated on the night of admission, he/she pushed the call light multiple times. A certified nurse aide (CNA) (#5) came to the doorway and yelled, What the [explicit comment] do you want? This happened again the same night. The resident stated he/she did not want to deal with this CNA again, so he/she took himself/herself to the bathroom for the remainder of the night. When asked if the resident reported the incident to staff, Resident #133 replied, yes. - During an interview on 08/05/24 at 2:36 p.m., Resident #99 stated three weeks ago during the night shift, an unknown CNA came to the doorway and yelled, What do you want? The resident stated he/she felt disrespected. When asked if the resident reported the incident to staff, Resident #99 replied, yes. - During an interview on the afternoon of 08/08/24, administrative staff members (#1 and #2) stated all resident incidents are covered during the management stand up meetings and these incidents were delegated to the unit manager to further review. The staff members reported the staff involved received verbal coaching but failed to follow up with the residents. The facility failed to make a prompt effort to resolve Resident #99 and #133's grievances and keep both residents apprised of progress toward a resolution.

1. Based on observation, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 2 of 2 residents (Resident #22 and #149) observed for insulin preparation and administrations. Failure to prime insulin pens correctly may result in residents receiving an inaccurate dose. Findings include: Review of the facility policy titled Insulin Pen occurred on 08/08/24. This policy, revised July 2023, stated, . Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. screw the pen needle onto the insulin pen. Twist open and remove the outer cover from the pen needle. H. Prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. - Observation on 08/07/24 at 8:08 a.m. showed a nurse (#7) prepared Resident #22's insulin pen for administration. The nurse failed to remove the cover of the needle before priming the insulin pen. - Observation on 08/07/24 at 4:44 p.m. showed a nurse (#8) prepared Resident #149's insulin pen for administration. The nurse failed to remove the cover of the needle before priming the insulin pen. During an interview the morning of 08/08/24, an administrative staff member (#1) stated she expected staff to remove the cover of the needles when priming insulin pens. 46477 2. Based on observation, record review, policy review, and staff interview, the facility failed to transcribe a treatment order accurately for 1 of 1 sampled resident (Resident #133) observed during a dressing change. Failure to accurately transcribe orders may result in residents receiving the wrong treatment and potentially cause adverse effects. Findings include: Review of the facility policy titled Standing Orders occurred on 08/08/24. This policy, dated July 2021, stated, . 1. standing orders must be on PCC [Point click care] MAR [Medication Administration Record] to be implemented. 4. When implementing an order from the standing orders, the nurse will enter it into . MAR . TAR [Treatment Administration Record] accordingly. Observation on 08/06/24 at 10:20 a.m. showed a medication aide (#11) removed a soiled Interdry (antimicrobial dressing) from under Resident #133's abdominal folds and replaced with a clean Interdry after bathing. Review of Resident #133's medical record occurred on 08/07/24. The recorded failed to identify an order for Interdry and instructions for administration. During an interview on 08/08/24 at 11:00 a.m., an administrative staff member (#1) confirmed the record lack the required information.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of medications in 1 of 2 medication carts (Union Square) observed. Failure to store all medications securely may result in unauthorized access to medications. Findings include: Review of the facility policy titled Medication Cart occurred on 08/08/24. This policy, revised 2023, stated, . Medication cart will be locked when not within complete site of the nurse and/or med aid [medication aide] left unattended . Observation on 08/06/24 at 3:47 p.m. showed a staff nurse (#3) left the medication cart unlocked and unattended for 55 minutes. The medication cart remained by the nurses station unlocked and out of the nurses' view with staff members and residents present. During an interview on 08/08/24 at 10:55 a.m., an administrative nurse (#1) confirmed she expected staff to lock the medication cart when out of eyesight.

Based on information provided by the complainant, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to attain the highest practicable level of well-being and to prevent and/or manage pain for 1 of 1 sampled resident (Resident #1) who experienced a fall with major injury. Failure to identify circumstances when pain could be anticipated and recognize when the resident experienced pain resulted in Resident #1 experiencing uncontrollable pain related to his untreated hip fracture. Findings include: Information provided by the complainant indicated facility staff failed to identify and respond to changes in the physical status of a resident who experienced uncontrollable pain from a hip fracture sustained during a fall. The complainant also indicated Emergency Medical Services (EMS) staff administered Fentanyl (a medication given for severe pain) during the ambulance ride to the hospital in an effort to alleviate the resident's pain. Review of the facility policy titled Pain Management occurred on 02/16/24. This policy, revised December 2023, stated, . Nurses will assess the resident's pain level . Nurse will complete the following: . Pain assessment, identifying the . factors which increase or decrease pain, nonverbal signs that indicate possible pain, and effect of pain on ADL's. Review of Resident #1's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, vascular dementia, psychotic disorder with delusions, osteoarthritis, repeated falls, and history of left lower leg and right femur fractures. The care plan, dated 12/16/23, identified, . I transfer independently. I need supervision to get to desired locations. Assist me to the bathroom routinely. I take myself to the bathroom and am unable to remember to report having a BM [bowel movement] to staff. A progress note, dated 01/20/24 at 8:15 a.m., identified, . On coming nurse was walking onto the unit and resident was laying on the floor . Resident is unable to tell nursing staff what happened. Evaluation was completed and resident was assisted to feet . vitals were obtained . 0/10 pain [0 pain on 10 point scale], POA [Power of Attorney] was notified . and provider was faxed. The resident experienced a second fall later in the day on 01/20/24. A post-fall huddle tool, dated 01/20/24, identified the following: * Time of Fall 2:50 p.m. * 2:50 p.m., . laying on back . weakness - flu . bruise coccyx . on-call called - push fluids, monitor 4 [for] head injury, give prn [as needed] [medication] for pain for bruising . RLE [right lower extremity] pain . * 3:10 p.m., . Pain 6/10 . RLE WNL [within normal limits] Pain . A progress note pertaining to the second fall identified the following: * 01/20/24 at 4:32 p.m., . Date/Time of Fall . 1-20-24 1350 [1:50 p.m.] [The time entered contradicts the entry the nurse made on the post-fall huddle tool.] Heard a loud noise, Resident found laying [sic] on back with head against the doorframe . Resident has been restless since falling this morning, continues to have flu-like symptoms. Resident assisted up into wheelchair. Resident c/o [complained of] pain to right hip/pelvic area. On-Call provider notified by phone, due to resident hitting head, and being on anti-coagulants [blood thinners]. Provider also notified of increased weakness and pain related to fall. Provider instructed writer to administer PRN pain medication and monitor resident for s/s [signs/symptoms] of head injury. [POA]-Phone call . [Physician] Faxed . * 01/21/24 at 2:33 a.m., . bruising to tailbone area, pain in pelvic/hip area . yells when moved d/t [due to] pain in pelvic/hip area. Bruise noted to tailbone region. Gets very frustrated and angry when trying to help him when needing to change him . * 01/21/24 at 2:50 a.m., . frustrated and irritated when moved . * 01/21/24 at 5:26 a.m., . Staff saying when staff moves him from side to side, he yells out in pain, when he is laying still on his bed or when he moves himself, he denies having any pain. * 01/21/24 at 10:31 a.m., . C/o pain but unable to express where. Resident is still unable to stand without assistance of stand lift. Resident does become agitated and aggressive when staff is assisting. * 01/21/24 at 10:30 p.m., . c/o pain to right pelvic/hip region . continues to c/o of pain to right pelvic/hip region when moving, ROM [range of motion] is limited d/t the pain to the RLE. yells out and gets upset with staff when he is moved . * 01/22/24 at 5:19 a.m., . Reported from day [sic] staff, resident is agitated when being moved or assisted with cares. Resident is able to move RLE on own but ROM is limited when staff is helping him do this. Resident did not receive any pain medication PRN throughout the day. * 01/22/24 at 10:29 a.m., . (R) [right] hip pain and pelvic pain after fall. Pain has continued to worsen and unable to reposition due to pain. updated [Physician's Assistant] when she was here on rounds on 1/20/24 [This date was entered in error.] and she gave orders to transfer to emergency room via ambulance. * 01/22/24 at 10:59 a.m., . Reason for Transfer . increased pain, edema and bruising right hip after fall . * 01/22/24 at 2:17 p.m., . Resident presenting with uncontrollable pain with movement of LE [lower extremity]. Noted edema RLE from the hip to the knee. Resident unable to bear weight due to increased pain. 9/10 pain limited ROM on RLE, increased pain with movement of LLE [left lower extremity]. * 01/22/24 at 2:40 p.m., . Right hip fx [fracture], admitted to [Hospital] for pain control until resident can be transferred to [another Hospital] for surgical repair. Review of the eMAR [electronic medication administration record] showed Resident #1 received two doses of as-needed acetaminophen (a medication given for mild pain); the first dose on 01/20/24 at 3:21 p.m. and the second dose on 01/22/24 at 10:23 a.m. Follow-up documentation, dated 01/22/24 at 12:43 p.m., identified the as-needed acetaminophen was ineffective . Pain Scale was: 9 [on 10 point scale]. During an interview on 02/13/24 at 5:20 p.m., an administrative nurse (#1) acknowledged staff failed to identify/respond to Resident #1's verbal and nonverbal signs/symptoms of pain that were indicative of a possible hip fracture. The administrative nurse (#1) indicated staff felt these signs were related to his flu-like symptoms, weakened condition, and bruised tailbone. Resident #1 experienced uncontrollable pain when facility staff failed to: * Identify circumstances when pain could be anticipated: when Resident #1 was rolled side-to-side, repositioned, and/or bearing weight, * Recognize when Resident #1 experienced pain: when Resident #1 denied being in pain while lying still, but was frustrated, irritated, angry, agitated, aggressive and/or yelling out in pain while being moved, * Identify Resident #1's inability to perform ADLs: when Resident #1 showed limited ROM and his status changed from ambulating independently to requiring a stand-lift and/or being changed by staff, and * Follow-up with the on-call provider regarding Resident #1's verbal/nonverbal signs/symptoms of pain that were indicative of a possible hip fracture versus waiting for the nurse practitioner to make her scheduled rounds.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 4 of 17 sampled residents (Resident #12, #13, #15, and #42) observed during personal cares and/or insulin administration. Failure to practice infection control standards related to hand hygiene, glove use, and insulin administration has the potential to spread infection throughout the facility. Findings include: HAND HYGIENE Review of the facility policy titled Hand Hygiene occurred on 09/14/23. This policy, dated August 2022, stated, . Procedure: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of care. 6. Additional considerations: . b. The use of gloves does not replace hand hygiene. Practice hand hygiene before donning and after doffing gloves. hand hygiene should be performed for the following conditions . between resident contacts, After Handling contaminated objects, . Before applying and after removing personal protective equipment [PPE], including gloves . Before and after handling clean or soiled dressings, linens, Before and after resident care procedures . during resident cares, moving from a contaminated body site to a clean body site . After assistance with personal body functions (e.g., [example] elimination, hair grooming . - Observation on 09/12/23 at 11:00 a.m. showed a certified nurse aide (CNA) (#4) performed perineal cares on Resident #13. The CNA (#4) performed hand hygiene, donned gloves, closed the resident's privacy curtain, removed the resident's brief, and performed perineal cares. Without removing the gloves, the CNA (#4) opened the privacy curtain to obtain more supplies from the bathroom and continued to assist Resident #13. The CNA (#4) removed the gloves and exited the room without performing hand hygiene. - Observation on 09/12/23 at 4:41 p.m. showed two CNAs (#6 and #7) donned gloves to assist Resident #12 with incontinent cares. The CNA (#6) removed the soiled incontinent product, cleansed the perineal area, applied a skin protectant cream, and a clean brief. Without removing the gloves, the CNA (#6) assisted the resident out of the bed into the wheelchair utilizing the mechanical lift. With the same gloves on, the CNA (#6) combed the resident's hair, gave the resident her purse, repositioned the wheelchair, and made the bed. The CNA (#6) collected the garbage and dirty linen, and exited the resident's room without performing hand hygiene. While walking down the hallway removed her gloves and stopped at the soiled utility room door, utilized the keypad for entry, disposed of the linen and garbage, and performed hand hygiene. - Observation on 09/13/23 at 1:37 p.m. showed two CNAs (#7 and #8) donned gloves to assist Resident #12 with incontinent cares. The CNA (#7) removed the wet brief, cleansed the resident's perineal area, placed a medicated pad in the resident's perineal area, applied a new product, and doffed her gloves. Without performing hand hygiene, the CNA moved the resident's purse, collected the garbage, exited the resident's room, utilized the key pad for entry into the soiled utility room, disposed the garbage, and performed hand hygiene. - Observation on 09/12/23 at 5:01 p.m. showed two CNAs (#6 and #7) donned gloves to assist #15 with incontinent cares. The CNA (#7) removed the soiled incontinent product, cleansed the resident's perineal area and applied a new product. Both CNAs assisted the resident from the bed to the recliner utilizing the mechanical lift. The the CNA (#7) doffed her gloves, picked up the garbage bag, exited the resident's room, utilized the keypad for entry into the soiled utility room, disposed of the garbage bag, and performed hand hygiene. During an interview on 09/14/23 at 10:22 a.m., an administrative nurse (#1) stated she expected staff to remove gloves after perineal care, perform hand hygiene prior to performing other tasks and prior to exiting a resident's room. INSULIN ADMINISTRATION Review of the facility policy titled Insulin Pen occurred on 09/14/23. This policy, revised July 2023, stated, . Injecting the insulin: i. Cleanse the skin with an alcohol pad. k. Remove gloves and perform hand hygiene. Review of the facility policy titled Medication Administration occurred on 09/14/23. This policy, revised on July 2023, stated, . Procedure: . 4. Wash hands prior to administering medication per facility protocol and product . Eye medications are administered as ordered by the physician and in accordance with professional standards of practice . - Observation of medication administration on 09/13/23 at 8:26 a.m., showed a nurse (#2) wore gloves to prime an insulin pen and prepare medications for Resident #42. The nurse failed to change the gloves, perform hand hygiene, or cleanse the resident's skin with alcohol prior to administering the insulin. While wearing the same gloves the nurse (#2) administered two different eye drops, removed the gloves, and without performing hand hygiene exited the room. During an interview on 09/13/23 at 4:30 p.m., an administrative staff member (#1) stated, she expected staff to use proper hand hygiene and glove use during medication administration. 46964 47896 .

Based on observations, review of facility policy, and staff interview the facility failed to maintain a comfortable temperature level for 1 of 6 units (Valley View). Failure to maintain comfortable room temperature levels can result in resident discomfort. Findings include: Review of the facility policy titled Safe and Homelike Environment occurred on 09/14/23. This policy, revised May 2023, stated, . The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. Observation on 09/12/23 at 4:00 p.m. showed Resident #63 in the Valley View resident common area rubbing their shoulders and making complaints of being cold. An unidentified staff member retrieved a sweater for the resident. Observation on the morning of 09/13/23 showed Resident #60 in the Valley View resident common area leaning forward in their wheelchair. An unidentified staff member asked if the resident was cold, the resident shook their head yes. The unidentified staff member retrieved a warm blanket from the tub room for the resident. Observations of air temperatures taken in the Valley View common resident areas showed the following: *09/12/23 at 11:24 a.m., 66 degrees Fahrenheit (F). *09/12/23 at 5:15 p.m., 66.5 degrees F. *09/13/23 at 8:00 a.m., 66 degrees F. *09/13/23 at 4:52 p.m., 68 degrees F. *09/14/23 at 9:23 a.m., 67 degrees F. During an interview on 09/14/23 at 9:00 a.m., a maintenance staff member (#3) reported their expectation for the temperatures in the resident's room and in the resident common areas would be between 71 degrees Fahrenheit (F) and 81 degrees F. The facility failed to maintain a comfortable temperature on the Valley View common resident areas.

Based on record review, review of facility policies/procedures, review of the facility's investigation reports, review of quality assurance and process improvement (QAPI) audits, and staff interviews, the facility failed to ensure freedom from abuse/neglect for 1 of 1 sampled resident (Resident #1) with a facial injury sustained while residing in the facility. Failure to provide necessary services to protect residents from harm resulted in Resident #1 sustaining pain, facial bruising, and fear after being slapped by a staff member. Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation and Misappropriation of Resident Property occurred on 01/31/23. This policy, revised date 01/23/23, stated, . All residents at [name of facility] have a right to be free from abuse, neglect, misappropriation of property, and exploitation. No resident shall be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, . Physical abuse includes, but is not limited to hitting, slapping, . Review of Resident #1's medical record occurred on 01/31/23. The progress notes contained the following: * 01/19/23 at 7:15 a.m. During medication pass around 0530-0600 [5:30 a.m. - 6:00 a.m.] this nurse heard resident hollering in his room, get out and leave me alone. Upon entering res [resident] room, a CNA [certified nurse assistant] was noted to be kneeling down in front of resident trying to help him put his pants on. Resident was noted to be sitting in his wheelchair with his underwear at his knees and he was not wearing his oxygen at this time. The resident was hollering out that the CNA hit him across the face and knocked his glasses off. This nurse tried to reassure resident that the staff were only here to help him; in which the resident continued to holler out get him out of here! and he hit me, I want to call the cops, right now!. The CNA was then immediately sent out of the residents' room and told to not come back to his room again. Despite all this nurses' efforts, resident could not be calmed down therefore a different CNA was brought into the room to help deescalate the situation and finish getting the resident ready for the day. While in room with CNA, it was noted that resident had a new skin tear to the left ring finger and new bruising across the left side of face extending to left ear. Bruising to face was not noted to be there during medication pass the evening before. * 01/19/23 at 11:22 a.m. PT [physical therapy] Session - [name of resident] says he is not feeling well enough to do therapy this morning. He still has ringing in his ear since last night. Will check back again tomorrow. * 01/19/23 at 4:00 p.m. saw resident's call light on and went to answer it. When asked what he needed, he said he wanted to talk with someone about what happened during the night. The resident went on to ask this author who I was. I told him and he asked what authority I had. He said 'Someone came in telling me to do stuff, throwing his weight around- trying to be the boss, I told him to get out.' 'He hit me and knocked my glasses off.' 'Lucky they weren't broken.' This author asked him to describe who slapped him and he said 'I can't, what do you expect when someone hits you in the eye?' The resident said maybe he said something to make the staff mad, but he couldn't remember what. 'He hit me first, but I tried to hit him back.' . 'I don't want to be here tonight if that staff is here.'. * 01/19/23 at 4:30 p.m. Resident was self-propelling himself down the hallway and told staff he wanted to talk to someone in charge. He said, 'I am scared to go in my room because that man might come in, . * 01/19/23 at 5:03 p.m. skin assessment completed. Noted bruising to lt [left] side of face. bruising measures on lt cheek 1) 2.3 by 3.8 2) 2 by 5.5 3)1.4 by 5.5. 4) Bruising closer to nose next to number 1 measures 3.7 by 3. 5)on res lt ear 3.5 by 3 6) behind rt ear on head 2.9 by 1.4. [record failed to identify the measurement units] * 01/20/23 at 5:15 p.m. [name of nurse practitioner] called after her office visit with [name of resident] . She also reported the resident report of being slapped by a staff member and of being thrown around. * 01/21/23 at 7:39 a.m. Resident was calm and quiet the whole NOC. [night] He refused to sleep on his bed and opted to sleep on his recliner. Resident denies pain on the bruise on his left cheek and made a comment to this nurse Do you see what that guy did? He left quite a mark there. * 01/22/23 at 2:28 a.m. Resident has been in and out of nurses station agitated and looking for help. He states he needs someone to watch his back and requested staff check on him every hour. Staff agreed and this seems to have calmed him down. Resident rested in his bed the rest of the NOC. A skin assessment, completed 01/20/23, identified, .Skin Issue #4 Bruising . L [left] cheek, multiple bruises (handprint) . A provider visit note, dated 01/20/23, stated, . asked what happened to his face and why he has bruising and he states that 'the man working during the night slap [sic] me in the face so hard that it disturb [sic] my hearing for awhile'. administration and director or nursing aware of this incident. During an interview the morning of 01/31/23, an administrative team member (#1) stated staff informed her of the incident at approximately 9:00 a.m. the morning of 01/19/23, and the facility immediately initiated their investigation of the alleged abuse. Based on the following information, non-compliance at F600 is considered past non-compliance with a correction date of 01/26/23. The facility addressed the corrective action accomplished for the resident affected by the deficient practice as evidenced by the following facility actions: - 01/19/23 the facility staff completed the following: * At 7:35 a.m. the charge nurse documents in the progress notes: . Plan of Action: That particular staff member is to not enter residents' room at any given time. Reassurance will be given to resident when needed. Monitoring of resident will continue. * At 9:00 a.m. the Director of Nursing (DON) and charge nurse interview Resident #1. * At 9:30 a.m. the initial allegation of mistreatment, abuse, neglect, or theft facility reported incident reporting form completed and sent to the State Agency. * At 1:15 p.m. the Valley City Police Department (VCPD) informed of the allegation of abuse, and at 2:00 p.m. an officer from the VCPD along with the facility administrator interviewed Resident #1. * At 1:40 p.m. members of the management staff began interview with staff members. * At 5:05 p.m. members of the management staff interviewed the accused CNA. - 01/20/23 during the daily morning meeting via zoom, the leadership staff and risk management staff discussed the 01/19/23 incident and reviewed the abuse policy. * Members of the management staff continued with staff interviews. - 01/23/23 the management staff completed revisions to the policy titled, Abuse, Neglect, and Exploitation and Misappropriation of Resident Property. All staff required to review the revised policy, sign, and date upon completion of review. Review of staff education revealed staff signed and dated, acknowledging review of the policy. - 01/26/23 CNA education meetings held at 7:30 a.m., 2:00 p.m., and 3:30 p.m. to review topics of ADL (activities of daily living) charting and abuse. Review of staff education revealed staff signed the attendance rosters for each meeting. * Review of QAPI audits related to resident abuse showed a facility audit form titled QA Resident Abuse. The audit form contained the definitions of several types of resident abuse and interview questions specific to identification of signs of abuse, reporting, who to contact, etc. The facility completed one to five audits per day on the following dates, 01/19/23, 01/20/23, 01/23/23, 01/24/23, 01/25/23, 01/30/23 and is ongoing. 46259

Based on observation, review of facility policy, and staff interview, the facility failed to maintain food and dishware storage areas in a sanitary manner for 1 of 1 kitchen (main kitchen). Failure to store food and dishware in a sanitary environment has the potential to result in contamination of food and dishware and could result in a foodborne illness. Findings Include: Review of the policy, Purchasing, Receiving and Storage occurred on 07/21/22. This policy, revised May 2018, stated, Policy: Food will be properly stored to preserve . safety. The initial observation of the kitchen, with an administrative dietary staff member (#3) and a supervisory dietary staff member (#5), occurred on 07/18/22 at 10:50 a.m. Observation showed the following: - Walk in Cooler #1 - accumulation of thick, dark black dust/dirt on the fan and heavy accumulation of dust clumps on walls, ceiling, and light above the door.- Walk in Cooler #2 - accumulation of dark black dust/dirt on the fan and accumulation of dust clumps on the wall, ceiling, and light above the door. Observation of the kitchen, with an administrative dietary staff member (#3) and a supervisory dietary staff member (#5) occurred on 07/21/22 at 8:30 a.m. and showed the following:- Dishwashing Room (clean dish side) - accumulation of dust on the dishwashing machine, walls, and ceiling. Observation showed clean dishes stored in this area. - Walk in Cooler #1 - accumulation of thick, dark black dust/dirt on the fan and heavy accumulation of dust clumps on the walls, ceiling, and light above the door.- Walk in Cooler #2 - accumulation of dark black dust/dirt on the fan and accumulation of dust clumps on the wall, ceiling, and light above door. During an interview on 07/21/22 at 9:30 a.m., both dietary staff members (#3) and (#5) confirmed staff need to clean the dust from the walls, ceilings, and fans, and they had not included these areas on the cleaning schedule.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure dignity and provide privacy for 1 of 19 sampled residents (Resident #64) observed during personal cares. Failure to maintain a resident's privacy during cares is a violation of residents' rights and may decrease their quality of life. Findings include: Review of the facility policy titled Routine Cares occurred on 07/20/22. This policy, dated November 2020, stated, . Provide privacy with cares (close shade, pull privacy curtain, use towel/bath blanket to coverage.) . On 07/18/22 at 1:22 p.m. observation showed a certified nursing assistant (CNA) (#2) provided toileting cares for Resident #64 and failed to close the bedroom door, bathroom door, and window coverings prior to the cares. During an interview on 07/21/22 at 1:30 p.m., an administrative nurse (#1) confirmed staff failed to follow facility policy for privacy.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 1 of 32 sampled residents (Resident #132). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plan occurred on 07/21/22. This policy, revised May 2022, stated, Care plans will be developed and updated in PCC (electronic health record) for each resident on admission, quarterly and annually, as well as post hospital and if a significant change in the resident's status occurs. They also must be updated on a continual basis as resident's needs change to ensure that the care plan adequately reflects the resident's status at that point and time. Review of Resident #132's medical record occurred on all days of survey. The current care plan stated, TOILET USE: I am independent with toileting. DRESSING: I require assistance with set up with dressing. BED MOBILITY: I am independent with repositioning and turning in bed. PERSONAL HYGIENE/ORAL CARE: I require supervision and reminders to complete hygiene and oral care. A progress note, dated 06/28/22, stated, Resident requires extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Review of the resident's CNA charting showed staff provided extensive assistance for bed mobility, dressing, toileting, and personal hygiene throughout the period of June 21, 2022-July 20, 2022. During an interview on 07/21/22 at 1:38 p.m., an administrative nurse (#1) confirmed staff failed to revise Resident #132's care plan to reflect current care needs.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to ensure appropriate care and services for 1 of 6 sampled residents (Resident #71) with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policy Thickened Liquids occurred on 7/21/22. This policy, dated July 2022, stated, POLICY: Residents requiring thickened liquids per MD [medical doctor] order will be provided beverages of appropriate consistency to prevent aspiration . 7. All staff are responsible to assure beverages they serve residents for meals, snacks, or med passes are the ordered consistency. Review of Resident #71's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A speech assessment, dated 04/18/22, recommended liquids by spoon and one-to-one feeding supervision. A dietary assessment, dated 04/18/22, identified honey thick liquids given by spoon. A physician's order, dated 05/26/22, identified moderate thickened (honey) consistency fluids per dietary recommendations. Observation showed the following: * 07/19/22 at 8:25 a.m., a nurse (#7) identified Resident #71's medication administration (MAR) stated, . crush medications, mix in pudding, give nectar thick liquids, liquids to be given to him by spoon . The nurse crushed the medications and mixed them in pudding, poured a small cup of Med Pass 2.0 nectar consistency (a fortified nutritional vanilla shake), and gave it to Resident #71. The resident drank a small amount of the fluid from a nosey cup (not from a spoon) and the resident started to cough. * 07/19/22 at 8:40 AM an unidentified certified nursing assistant (CNA) assisted Resident #71 to drink using a nosey cup instead of a spoon and the resident coughed throughout the observation. When asked about Resident #71's diet for liquids, the CNA stated she thinks the resident is to receive nectar thick fluids as written on the CNA care sheets, but was unsure. * 07/19/22 at 10:02 a.m., a staff nurse (#7) obtained three more containers of nectar thick vanilla shakes from the kitchen and stated she will be using these for Resident #71. During an interview on 07/19/22 at 10:04 a.m., the nurse (#7) stated, I'm not sure what the fluid consistency is for Resident #71 . I assume it is what the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . and that is what I follow to give . During an interview on 07/19/22 at 11:15 a.m., a nurse manager (#8) stated Resident #71 is to follow a moderately thickened (honey) consistency fluid diet and staff should use a spoon to assist with fluids.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Sets (MDSs) for 4 of 9 sampled residents (Resident #44, #55, #67, and #100). 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 M: SKIN CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2019, page M-2 stated, M0100: Determination of Pressure Ulcer/Injury Risk. Coding Instructions . Check A if resident has a Stage 1 or greater pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/ device. Review descriptions of pressure ulcers/injuries. Page M-4 stated, M0210: Unhealed Pressure Ulcers/Injuries. Coding Instructions. Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days. Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Page M-7 stated, Steps for completing M0300A-G. Step 1: Determine Deepest Anatomical Stage. For each pressure ulcer, determine the deepest anatomical stage. Page M-8 stated, Step 2: Identify Unstageable Pressure Ulcers. 3. Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable. Page M-21 stated, DEFINITIONS SLOUGH TISSUE Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. - Review of Resident #44's medical record occurred on all days of survey. The Quarterly MDS, dated [DATE], identified three unstageable ulcers. A nursing skin assessment note, dated 01/19/21, stated, . Skin is hard and dry in appearance. Skin is white/yellow in color. - Review of Resident #55's medical record occurred on all days of survey. The Quarterly MDS, dated [DATE], identified two unstageable pressure ulcers coded under Section M. A nurse's note, dated 02/11/21, stated, . Pressure Ulcer Location: 1) L) [left] palm 2) R) [right] palm Stage: both are considered unstageable calouses [sic]. - Review of Resident #67's medical record occurred on all days of survey. The Quarterly MDS, dated [DATE], identified one unstageable ulcer. A nurse's note, dated 02/15/21, stated, Resident has a callus to the sole of his let 5th toe. - Review of Resident #100's medical record occurred on all days of survey. The Quarterly MDS, dated [DATE], identified one unstageable ulcer. A nursing skin note, dated 05/05/21, stated, . callus to left outer foot, hard in center and painful to touch, hard corn like callus to right inner foot. During an interview on 05/05/21 at 1:30 p.m., a MDS licensed nurse (#6) confirmed Residents #44, #55, #67, and #100 did not have pressure ulcers and facility staff coded Section M incorrectly.

Based on observation, record review, review of facility policy, resident interview, and staff interview, the facility failed to provide the necessary services to 2 of 29 sampled residents (Resident #47 and #51) who required staff assistance with Activities of Daily Living (ADL) for bathing. Failure to provide assistance with bathing as scheduled may result in poor personal hygiene and decreased self-esteem. Findings include: Review of the facility policy titled Standard of cares occurred on 05/06/21. This policy, revised November 2020, stated, Each of the following is part of the routine care provided by caregivers, unless otherwise directed. Resident will receive/be offered a bath/shower at least weekly. - Review of Resident #51's medical record occurred on all days of survey. The current care plan stated, It is important to me to make choices in regards to my preferences with activities and daily living. It is very important for me to have choices in regards to: . choosing my bathing needs . I have an ADL Self Care Performance Deficit r/t [related to] [CONDITION(S)] . BATHING: I require 1 staff participation with bathing. During an interview on the afternoon of 05/03/21, Resident #51 stated she didn't get a bath today (Monday) as the facility had no staff to do it. The resident stated she often does not get two baths per week as scheduled on Mondays and Fridays. Observation on 05/04/21 at 8:32 a.m. showed a bath aide/certified nurse aide (CNA) (#4) bringing Resident #51 to her room from the tub room. The CNA stated she made up Resident #51's bath today (Tuesday) as the bath aid needed to fill in on the floor yesterday. The CNA stated Resident #51 normally gets a bath every Monday and Friday. During an interview on 05/06/21 at 10:31 a.m., a nurse manager (#5) stated the facility scheduled all residents for twice weekly baths, unless a resident only wanted one. The manager confirmed Resident #51's scheduled bath days as Monday and Friday. She stated the facility tried to schedule two bath aides on Mondays, Wednesdays, and Fridays (noting the facility often pulled one aide to work on the floor) and one bath aide on Tuesdays and Thursdays. Review of Resident #51's bathing records for 13 weeks from 02/01/21 to 05/02/21 showed the resident received two baths per week on one occasion (March 21-27), otherwise she received one bath weekly with the exception of no bath during the week of February 28-March 6. - Review of Resident #47's medical record occurred on all days of survey. The current care plan stated, . I have an ADL Self Care Performance Deficit r/t Dementia, Impaired balance . BATHING: I require physical assist staff participation with bathing. During an interview on 05/03/21 at 1:24 p.m., Resident #47 stated it had been over a week since she had received a bath. The resident stated she has not been getting her bath twice a week as scheduled and sometimes it has been longer than a week. Observation on the morning of 05/05/21 showed an unidentified CNA attempting to start morning cares for Resident #47 when the resident told the CNA about her bath today. The CNA left the room to verify the bath and upon the CNA's return she confirmed Resident #47 was scheduled for a bath today. During an interview on 05/06/21 at 8:45 a.m., a CNA supervisor (#8) confirmed Resident #47 is scheduled for a bath twice a week, Sundays and Thursdays. Review of Resident #47's bathing records for 13 weeks from 02/01/21 to 05/05/21 showed the resident received one bath a week during that time, and identified Resident #47's last bath occurred on 04/18/21 and she did not have another bath until 05/05/21 (16 days).

Based on observation, record review, review of facility policy, and staff interview, the facility failed to implement pressure ulcer prevention measures for 1 of 4 sampled residents with pressure-relieving devices (Resident #55). Failure to provide pressure-relieving boots as ordered/care planned may result in the development of new pressure ulcers. Findings include: Review of the facility policy titled Skin Care occurred on 05/06/21. This policy, revised October 2019, stated, . Braden scale [a tool used to identify pressure ulcer risk] plan of action: LOW RISK (18-15) actions: . Assess the need for pressure relieving measures such as heel and elbow protectors . Care plan to identify interventions . Review of Resident #55's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician's orders included, Apply socks and heelbos [a type of padded heel protector] after applying daily moisturizers to bilat [bilateral] heels in the morning and up for the day. Remove at bedtime. Resident #55's care plan stated, . I have, potential/actual impairment to skin integrity r/t [related to] Hx [history of] of ulcers, impaired mobility, rejection of cares. Apply minerin [a moisturizer] bilateral feet/heels and cover with heelbos to protect from rubbing on wheelchair. A nurse's note, dated 02/12/21, stated, . Braden Evaluation . Result: At Risk . Score: 17.0 . Clinical Suggestions: . Heel/elbow pads or socks utilized. Observation on the mornings of 05/04/21 and 05/05/21 showed a certified nursing assistant (CNA) (#1) assisted Resident #55 with morning cares and transferred the resident to his wheelchair. The CNA failed to apply moisturizer/heelbos to Resident #55's feet. Observations throughout the survey showed Resident #55 did not wear heelbo heel protectors. During an interview on the morning of 05/06/21, a nurse manager (#2) verified Resident #55 did not have heelbo heel protectors on, and staff should be putting them on in the morning and removing them at night.

Based on record review, facility policy review, and staff interview, the facility failed to ensure orders for as needed (PRN) [CONDITION(S)] drugs were limited to 14 days for 1 of 1 sampled resident (Resident #76) receiving a PRN antipsychotic medication. Failure to ensure the physician renewed the PRN order after 14 days may result in the resident receiving an unnecessary medication. Findings include: Review of the facility's policy titled [CONDITION(S)] Drug Use occurred on 05/06/21. This policy, revised March 2020, stated, . PRN orders for [CONDITION(S)] drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Review of Resident #76's medical record occurred on 05/06/21. Diagnoses included dementia and anxiety. The physician's orders dated 02/17/21 included [MEDICATION(S)] (antipsychotic) five milligrams by mouth as needed for agitation, [CONDITION(S)], and aggression, one tablet PRN twice a day. The record lacked evidence the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication after14 days. During an interview on the morning of 05/06/21, an administrative nurse (#3) confirmed the provider had not reviewed the PRN medication since the initial order received on 02/17/21.

Based on record review, facility investigation, review of facility policy, and staff interview, the facility failed to immediately inform the physician and the resident's family/representative of a significant change in the resident's physical condition for 1 of 1 resident (Resident #1) with an injury of unknown origin. Failure to notify the physician of a significant change resulted in the resident experiencing pain and a delay in treatment of [REDACTED]. Findings include: Review of the facility policy, Physician Notification occurred on 10/26/20. This policy, dated September 2020, stated, Policy: Physicians will be notified in a timely manner regarding resident change in condition or an injury. Purpose: To insure (sic) that residents are assessed for changes or injuries that need to have Physician notification and interventions put into place. Procedure: 1. The nurse who first observes an injury or significant change in a resident's condition will be responsible to assess the resident and use their professional judgement to determine if the change in condition or injury requires the Physician to be contacted immediately. If the resident needs immediate attention, they will be sent over to the clinic or emergency room . (ex. (example) . accident with major injury . Review of Resident #1's medical record occurred on October 21-22, 2020. Resident #1's medical [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment, and total dependence on two or more staff members for bed mobility and transfers. Resident #1's current care plan identified the following: . I have Potential for Pain. *[MEDICAL CONDITION] and arthritis *Hx of compression fx's (fractures) to spine. monitor resident for c/o (complaint of) pain or discomfort. If pain noted or change noted notify MD (medical doctor) PRN (as needed) . I am at risk for falls r/t (related to) Unaware of safety needs. *I rarely make positional changes per self. I have an ADL (activities of daily living) Self Care Performance Deficit r/t Dementia. Transfer/Mobility: Hoyer Lift assist of two with all transfers. CRA (certified resident assistant (certified nursing assistant)) for all mobility. Bed Mobility: The resident requires extensive to total assist to turn and reposition. Needs assistance to make repositional (sic) changes . Skin: I require skin inspection Q (every) shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. Review of Resident #1's nurses notes identified the following: * 10/19/20 at 8:15 a.m. - Med-aid (medication assistant) asked this author (Nurse #9 (day shift nurse)) to come look at resident's left foot this morning. When author uncovered residents left foot, residents left foot was visibly longer than her right foot. Residents L) (left) foot was in the pressure relieving booty and pressed into the mattress. Color of Left foot was pale in color and dark in areas and cool to touch. Author palpated for pedal pulse on left foot and was absent. Resident did yell out in pain when author touched the top of her foot. Author did not move resident foot and something was visibly wrong. Then called nurse manager and DON (director of nursing) to assess. *10/19/20 at 8:26 a.m. - (Note written by night nurse #4) . Health status and vitals: Resident was more uncomfortable during the night, but discomfort did not seem to be originating from infection. Run (sic) from a deep tissue wound over the left outer malleolus. Entire red area was 8.5 cm (centimeter) X 1.5 cm. Skin over malleolus appeared thinner, with fluid present underneath, and very purple, blanched when pressure applied, but resident's pain response was very evident when palpated. Applied a loose [MEDICATION NAME] dressing over area. Family . updated: Aware. *10/19/20 at 8:39 am - (Note written by night nurse #4) Skin note. Observation: Resident has a large deep tissue injury over left outer malleolus of ankle. Area is red, but pressure is applied, painful with palpation. Area the time of observation was not open, but skin over area is fragile. Placed [MEDICATION NAME], and loose [MEDICATION NAME] drsg (dressing) to protect wound, so dressing should not stick to area if it did open. Sent note to skin nurse to observe on rounds. *10/19/20 at 9:14 a.m. - (Note written by night nurse #4) Spoke to daughter (name of daughter) and informed he (sic) that resident has a broken ankle. Drgr (daughter) asked how this happened and told her we had discovered this during the noc (night). Resident's dtgr was very aware how [MEDICAL CONDITION] and bone dimeiniearilization (sic) from non-use occurs. Informed her that resident would be sent to ER for evaluation. *10/19/20 at 10:44 a.m. - (Note written by nurse manager # 10) 8:30 a.m. CRA (certified resident assistant) was doing cares and noticed that residents L) foot was deformed, CRA went and got (Nurse #9) to observe and upon seeing foot (Nurse #9) had (Nurse #8) and this nurse (Nurse #10) come in to assess it. L) foot and ankle has severe deformity noted, appears to be fractured. Call placed to DON to come over to observe and assess while this nurse called (name of physician) for orders to send to (name of local hospital) ER (emergency room ) by ambulance . Nursing assessment: Resident screams out in pain with any movement or touching of ankle . No pedal pulses present, foot and toes were cold to touch and gray in appearance. Foot supported with soft boot while waiting for the ambulance to arrive. (Name of physician) informed of deformity, lack of pedal pulses, discoloration and pain when called. order received to send to ER by ambulance. Ambulance called for transfer to (name of hospital) ER . 8:50 am Ambulance here to get resident and upon getting resident ready for transfer onto gurney it was noted that R) leg had deformity as well. Ambulance crew and this nurse unsure if it was a femur injury or an injury to her R) knee. Large amount of bruising noted to the back of her R) knee that was deep purple in color. Resident in pain with any movement of this leg as well. Assisted ambulance crew with placing immobilizer/air splint on both legs and then carefully transferring her onto the gurney for transfer to ER. family informed by . night nurse prior to hospital transfer. *10/21/20 at 10:17 a.m. - Author called . (name of hospital) for an update on resident. (Name of hospital nurse) explained that the resident has a left tibia and fibia (sic) fracture and right femur fracture and is not a candidate for surgery so the bones have been set and splinted. Review of the facility investigation/interview with the night CRA (#6) identified the CRA (#6)thought Resident #1's foot 'looked bad' when she did her first rounds of the night and notified the nurse (#4) to come and check her foot. The CRA (#6) stated the nurse didn't come to the room until 1:00 or 2:00 a.m., and she told the nurse she thought it was broke. The CRA (#6) stated the nurse said it was a deep tissue injury, measured the area, and then left the room. The CRA (#6) stated the resident did not look in distress at that time. The CRA (#6) did rounds again at 4:30 a.m. and insisted the nurse (#4) come and look at the foot because it was bad and something needed to be done. The CRA (#6) said the nurse (#4) dressed the area and said she would contact the wound nurse. Review of the facility investigation/interview with the night nurse (#4) identified the nurse said that around 1-2 a.m. a CRA (#6) asked her to look at Resident #1's foot. The nurse (#4) said she thought the area was a deep tissue bruise because it was purple with fluid under it. When she looked at it again with the CRA (#6) around 5:00 a.m., she felt Resident #1's foot and the 'bones felt like there were misplaced' and she thought it was broken. The nurse said she did not want to overreact, so told the CRA she would notify the wound nurse. The nurse (#4) denied Resident #1 had any facial grimacing or indications of pain or discomfort, but later stated the resident had been more vocal this night than the past night. The nurse confirmed she did not call the nurse manager, director of nursing, or the physician about Resident #1's foot. During an interview on 10/22/20 at 8:00 a.m., an administrative nurse (#1) stated she was not satisfied with the nurse's (Nurse #4) assessment/actions regarding Resident #1's leg and placed her on suspension. During an interview on 10/26/20 at 11:00 a.m., the administrative nurse (#1) stated that after completion of the investigation, the facility terminated the nurse (#4) and confirmed the nurse should have notified the physician of Resident #1's injury. The facility staff failed to notify the physician and the resident's family/representative of Resident #1's suspected fracture, discomfort, bruise/tissue injury when assessed at 5:00 a.m. on 10/19/20. Failure to notify the physician immediately when a fracture was suspected resulted in the resident experiencing pain and a delay in treatment for [REDACTED].

Based on information from the complainant, record review, review of facility policies/procedures, review of the facility's investigation reports, and staff interviews, the facility failed to ensure residents have the right to remain free from possible physical abuse/neglect for 1 of 1 resident (Resident #1) with fractures of unknown source while residing in the facility. Failure to provide necessary services to protect residents from physical harm resulted in Resident #1 sustaining fractures from an unknown source to her right femur and left tibia/fibula. Findings include: Review of the facility policy, Abuse Policy occurred on 10/21/20. This policy, revised June 2020, stated, Purpose: All residents at Sheyenne Care Center have a right to be free from mistreatment, neglect . All staff will be educated as to specific types of abuse . Staff will also be educated as to their responsibility to report any and all suspected and observed incidents of abuse, neglect . All alleged violations involving mistreatment; neglect or abuse, including injuries of unknown source . will be reported immediately to the administrator and to other officials in accordance with State law . Appropriate corrective action will be taken if the alleged violation was (sic) been verified. Abuse or neglect means the non-accidental physical injury or condition, . or negligent treatment of [REDACTED]. I. Procedure/Intervention(s): . Education/Training 1. As a part of orientation, staff and volunteers will receive training . on Abuse/Neglect of residents along with definitions to assist them in recognizing Abuse and their responsibility. 2. Ongoing education on Abuse will be offered no less than yearly. Identification/Injuries of Unknown Origin: 1. Staff will report all resident injuries, of both known and unknown origin immediately to the Nurse Manager or Charge Nurse. The reported injuries are to include bruises, skin tears, fractures, and suspicious injuries. 2. The Nurse Manager or Charge Nurse will complete an Injury of Unknown Origin Investigation Form . assure the immediate safety and mental well being of the resident, investigate the extent of harm to the resident . 3. If the Nurse Manager or Charge Nurse's conclusion is that suspected or actual mistreatment, abuse or neglect has taken place, the NSA (nursing service administrator) or Administrator is contacted . 8. If it is an employee who is being suspected for abuse, the employee is informed and suspended while the NSA (nursing service administrator) or designee conducts investigation. The investigation will include interviews with the resident reported to have been abused: . anyone witnessing the abuse; the persons suspected of committing the abuse; or other pertinent persons. Review of the facility policy, Lifts and transfers occurred on 10/26/20. This policy, dated May 2020, stated, . Purpose: Residents will be moved and/or repositioned in a manner that will ensure resident comfort and reduce risk of injury to resident and/or staff. Procedure: Guidelines for moving, positioning, lifting and transferring residents: 1. Verify care plan and/or with nurse before attempting to move, lift or transfer resident. 2. Have second CNA (certified nursing assistant) assist if required. Mechanical Lifts: . 2. When a mechanical lift is determined as necessary it will be placed on resident's care plan by nurse . 3. Mechanical lift (Hoyer) requires two people to be present during all transfers. Review of the facility policy, Walking Rounds occurred on 10/26/20. This policy, dated July 2020, stated, Policy: CRA (certified resident assistant) will report to oncoming CRAs at the beginning and end of each shift any special information that occurred during their shift regarding resident. Procedure: CNA reporting to oncoming CNA is a simple transfer of information between certified nursing assistants at shift change. This will empower CNAs to not only complete tasks but to inform the next shift of care, issues, treatments or any special information that occurred during their shift to report to the CNA beginning the next shift. - Review of Resident #1's medical record occurred on October 21-22, 2020. Resident #1's medical [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment, extensive assistance required from one staff for dressing and toilet use, total dependence on two or more staff members for bed mobility and transfers, total dependence on one staff for personal hygiene, locomotion on/off the unit, and daily scheduled medications for pain. Resident #1's current care plan identified the following: - . I have Potential for Pain. *[MEDICAL CONDITION] and arthritis *Hx (history) of compression fx's (fractures) to spine. monitor resident for c/o (complaint of) pain or discomfort. If pain noted or change noted notify MD (medical doctor) PRN (as needed) . - . I am at risk for falls r/t (related to) Unaware of safety needs. *I rarely make positional changes per self. - . I have an ADL (activities of daily living) Self Care Performance Deficit r/t Dementia. Toilet Use: I require total assist of 1. I am checked and changed routinely. I currently have a Foley (urinary) catheter. Hoyer Lift assist of two with all transfers. The resident requires extensive to total assist to turn and reposition. Needs assistance to make repositional (sic) changes . reposition every 2-3 hours. - . I require skin inspection Q (every) shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. Review of Resident #1's nurse's notes identified the following: *10/18/20 at 2:24 p.m. - Res (resident) alert. Res not using call light at any time. Res yells out loudly and grinds teeth when staff try to repo (reposition), move, give meds, etc. Res rests well when in bed not moving. Res has contractures to arm and legs, knees are bent up to chest and arms are pulled up to chest. *10/19/20 at 8:15 a.m. - Med-aid (Medication Assistant (MA)) asked this author (Nurse #9) to come look at resident's left foot this morning. When author uncovered residents left foot, residents left foot was visibly longer than her right foot. Residents L) (left) foot was in the pressure relieving booty and pressed into the mattress. Color of Left foot was pale in color and dark in areas and cool to touch. Author palpated for pedal pulse on left foot and was absent. Resident did yell out in pain when author touched the top of her foot. Author did not move resident foot and something was visibly wrong. Then called nurse manager and DON (director of nursing) to assess. *10/19/20 at 8:26 a.m. - (Note written by night shift nurse #4) . Resident was more uncomfortable during the night, but discomfort did not seem to be originating from infection. Run (sic) from a deep tissue wound over the left outer malleolus. Entire red area was 8.5 cm (centimeter) X 1.5 cm. Skin over malleolus appeared thinner, with fluid present underneath, and very purple, blanched when pressure applied, but resident's pain response was very evident when palpated. Applied a loose [MEDICATION NAME] dressing over area. Family/POA (power of attorney) updated: Aware. *10/19/20 at 8:39 am - (note written by night shift nurse #4) Skin note. Observation: Resident has a large deep tissue injury over left outer malleolus of ankle. Area is red, but pressure is applied, painful with palpation. Area the time of observation was not open, but skin over area is fragile. Placed [MEDICATION NAME], and loose [MEDICATION NAME] drsg (dressing) to protect wound, so dressing should not stick to area if it did open. Sent note to skin nurse to observe on rounds. *10/19/20 at 9:14 a.m. - (note written by night shift nurse #4) Spoke to daughter (name of daughter) and informed he (sic) that resident has a broken ankle. Drgr (daughter) asked how this happened and told her we had discovered this during the noc (night). Resident's dtgr was very aware how [MEDICAL CONDITION] and bone dimeiniearilization (sic) from non-use occurs. Informed her that resident would be sent to ER (emergency room ) for evaluation. *10/19/20 at 10:44 a.m. - (Note written by day shift nurse #10) 8:30 a.m. CRA was doing cares and noticed that residents L) foot was deformed, CRA went and got (Nurse #9) to observe and upon seeing foot (Nurse #9) had (Nurse #8) and this nurse (Nurse #10) come in to assess it. L) foot and ankle has severe deformity noted, appears to be fractured. Call placed to DON to come over to observe and assess while this nurse called (name of physician) for orders to send to (name of local hospital) ER by ambulance . Nursing assessment: Resident screams out in pain with any movement or touching of ankle . No pedal pulses present, foot and toes were cold to touch and gray in appearance. foot (sic) supported with soft boot while waiting for the ambulance to arrive. (Name of physician) informed of deformity, lack of pedal pulses, discoloration and pain . order received to send to ER by ambulance. 8:50 am Ambulance here to get resident and upon getting resident ready for transfer onto gurney it was noted that R) leg had deformity as well. Ambulance crew and this nurse unsure if it was a femur injury or an injury to her R) knee. Large amount of bruising noted to the back of her R) knee that was deep purple in color. Resident in pain with any movement of this leg as well. Assisted ambulance crew with placing immobilizer/air splint on both legs and then carefully transferring her onto the gurney for transfer . family informed by . night nurse prior to hospital transfer. *10/21/20 at 10:17 a.m. - Author called . (name of hospital) for an update on resident. has a left tibia and fibia (sic) fracture and right femur fracture and is not a candidate for surgery so the bones have been set and splinted. An interview with an administrative nurse (#1) occurred on 10/22/20 at 8:00 a.m. The administrative nurse (#1) indicated she found out about the incident involving Resident #1 the morning of 10/19/20 and is starting day three of the investigation. The administrative nurse (#1) stated no staff members have reported and/or admitted knowledge regarding the cause of Resident #1's leg fractures. After staff interviews, the administrative nurse (#1) stated she narrowed the time frame of the incident to the afternoon/evening of 10/18/20. - The administrative nurse (#1) stated that during her interview with the CRA (#2) who transferred Resident #1 from the chair to the bed around 2:00 p.m. on 10/18/20, the CRA (#2) admitted transferring the resident without assistance, but denied anything happened during the transfer. The administrative nurse (#1) placed the CRA (#2) on suspension during the on-going investigation, but stated she felt the CRA (#2) was very honest and detailed with his/her story. - The administrative nurse (#1) stated she interviewed another CRA (#3) twice, because his/ her story did not match the information provided by other staff. The CRA (#3) transferred Resident #1 into her chair around 4:00 p.m. with the help of another CRA (#7) and proceeded to transfer her back to bed after the nurse (#5) told him/her not to get the resident up. The CRA (#3) admitted he/she noticed something was wrong with the resident's foot at 8:00 p.m. rounds but insisted nothing happened during the transfer. The CRA (#3) told her he/she took responsibility for not doing safety rounds (walking rounds) with the day shift CRA (#2) and not reporting to the nurse about Resident #1's foot. The administrative nurse (#1) said the CRA (#3) became very argumentative and defensive, wanted to blame others, and refused to answer questions during the second interview. The administrative nurse (#1) placed the CRA (#3) on suspension during the on-going investigation. - The administrative nurse (#1) stated the night shift CRA (#6) had reported his/her concerns regarding Resident #1's left ankle to the night nurse (#4). The night nurse (#4) assessed the resident's ankle as a deep tissue injury and did not notify the physician, as he/she thought it could wait until the morning. The administrative nurse (#1) indicated she was not satisfied with the nurse's assessment/actions of not reporting the injury. She placed the nurse (#4) on suspension during the on-going investigation. Additional information from the facility's investigative report identified the following: * The ER physician called the facility and described Resident #1 as having a right smashed distal femur and fracture to tibia, fibula of left leg and these types of injury (sic) are caused by great force. * A nurse (#5) and a MA (#13) described Resident #1 as resting comfortably in the commons area at 2:00 p.m. on 10/18/20 with no injuries observed. * The CRA (#7) who was identified as assisting CRA (#3) transfer Resident #1 in the Hoyer lift to the chair at 4:00 p.m. on 10/18/20 denied helping CRA (#3) with the transfer. * The nurse (#5) who was identified as instructing the CRA (#3) to transfer Resident #1 back to bed around 4:00 p.m. on 10/18/20 denied telling this to the CRA (3#). * When the administrative nurse (#1) alleged the CRA (#3) transferred the resident by herself, the CRA (#3) responded with an angry tone, 'If I did that, the lift would fly back and break both of her legs!' * The night shift (10/19/20) CRA (#6) stated he/she and the evening shift (10/18/20) CRA (#3) did verbal rounds at shift change and the CRA (#3) told her everyone is good. * The night shift CRA (#6) noticed something was wrong with Resident #1's foot when he/she checked her on first rounds of the night and reported it to the nurse (#4). The CRA (#6) stated the nurse (#4) didn't assess Resident #1's foot until 1:00 a.m.-2:00 a.m., at which time the nurse thought the resident had a deep tissue injury. At 4:30 a.m. rounds, the CRA (#6) insisted the nurse (#4) look at Resident #1's foot as it looked bad and you need to do something. The nurse dressed the ankle with gauze. * The night shift (10/19/20) nurse (#4) reported she thought Resident #1 had a deep tissue injury on her initial assessment. Later, after being asked by the CRA (#6) to look at Resident #1's foot again, the nurse (#4) stated that at her 5:00 a.m. assessment, the bones felt like they were displaced and she thought it was broke. The nurse (#4) initially denied Resident #1 showed any signs/symptoms of pain, but later described the resident as being more vocal. The nurse (#4) reported asking the wound nurse to assess Resident #1's leg, as she felt it was broken. The wound nurse (#17) denied being told the leg may be broken, so planned to look at the wound the next day. * A MA (#12) observed Resident #1's leg at 8:30 a.m. on 10/19/20 and described it as white/green in color and curved. She reported the night nurse (#4) described the leg as bruised, but not broke during rounds. The MA (#12) reported another nurse (#19) examined Resident #1's ankle and determined it was not broken, described the situation as a non-emergency, and stated she would deal with it after she finished passing medications. The MA (#12) reported the nurse (#19) told her she used to be a paramedic and therefore knew the leg was not broken. The nurse (#19) acknowledged briefly looking at Resident #1's leg and stated she would come back after passing medications to assess the leg. * A MA (#12) and a CRA (#14) stated a CRA (#3) told them he/she described (trying) to put (Resident #1's) foot back together, her bones. The facility failed to protect the resident from abuse, which resulted in a severe injury of unknown origin. The facility staff failed to immediately report changes in the resident's condition to the nurse, complete a prompt, thorough assessment of the resident to determine the extent of injury, treat pain experienced by the resident, and report these findings to the physician, family, and administrative staff. These events resulted in delay of investigation, notification, and treatment of [REDACTED].

Based on information provided by the complainant, record review, review of facility policy, and staff interview, the facility failed to provide the services necessary to prevent the development and promote healing of pressure ulcers for 1 of 1 sampled resident (Resident #6) and 2 residents discharged from the facility (Resident #7 and #8) identified as being at risk for skin breakdown/pressure ulcers. Failure to evaluate risk factors that may impact the development/healing of a pressure ulcer, implement, monitor, and modify interventions to reduce those risk factors, and/or consistently provide treatment to heal current pressure ulcers and/or prevent the development of new pressure ulcers resulted in Resident #8 developing an avoidable, facility-acquired pressure ulcer on his left heel and had the potential to result in other residents (including Resident #6 and #7) developing skin breakdown/pressure ulcers. Findings include: Information provided by the complainant indicated facility staff failed to consistently provide the services necessary to prevent/heal pressure ulcers. Review of the facility policy titled Skin Care occurred on 04/26/18. This policy, revised (MONTH) (YEAR), stated, . Nursing Skin Assessment will be completed on each resident upon admission, and for the following: 3 weeks . Braden . MODERATE RISK (13-14) actions . Monitor positioning . Assess the need for . heel . protectors . Care plan to identify interventions . Complete the following with the occurrence of a pressure . ulcer: (All stages) . Notify Dietary . Weekly skin assessment done by night nurse . - Review of Resident #8's medical record occurred on 04/26/18. Medical [DIAGNOSES REDACTED]. The record showed upon admit, Resident #8 had very limited range of motion (knee immobilizer), was non-weight bearing on his right leg, and had significant pain with movement. A Braden Scale for Predicting Pressure Sore Risk, dated 10/06/17, identified the following: * ACTIVITY - Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. * MOBILITY - Slightly Limited: Makes frequent though slight changes in body or extremity position independently. * FRICTION & SHEAR - No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up. * Total Score - 20 (19 or above = No Risk) An admission Weekly/Monthly Skin Assessment, dated 10/06/17, identified, . Calcaneus bone on R) (right) heel is swollen. No concerns were noted regarding Resident #8's left heel. The progress notes identified the following: * 10/07/17, . Had stated heels were painful keeping him from sleep. When CN (sic) was in room to obtain VS (vital signs) resident requested a pillow under ankles as he stated they were painful from pressure on mattress. * 10/09/17, . Resident needs extensive assist to move. All attempts to manage pain ice, medication every 4 hrs (hours) routinely, repositioning, did not alleviate resident's pain. A Braden Scale for Predicting Pressure Sore Risk, dated 10/13/17, identified the following: * ACTIVITY - Chairfast * MOBILITY - Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. * NUTRITION - Probably Inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding. * FRICTION & SHEAR - Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction. * Total Score - 13 (13-14 = Moderate Risk) The progress notes identified the following: * 10/13/17, Res (resident) is to have both legs up with no pressure on the heels. resident noted to have an Unstageable pressure ulcer to L) (left) heel. area is 1/2 inch in diameter and black/brown eschar is present. no drainage noted and is not open. spends most of time in bed or in recliner. heels currently being floated while in recliner and pressure relief boot to L) foot. PUSH (Pressure Ulcer Scale for Healing) tool started and will be done weekly, fax to MD (Medical Doctor), dietary notified . area left OTA (open to air) at this time and will provide pressure relief to L) heel at all times. No shoes to be worn at this time. will monitor area twice daily . Resident #8 developed an unstageable facility-acquired pressure ulcer six days after he first reported experiencing pain in his heels (caused by his heels resting directly on his mattress) and requested staff float his heels. The record showed nursing staff failed to initiate any interventions to alleviate pressure to Resident #8's heels while he was in bed and/or a recliner prior to the development of an unstageable pressure ulcer on his left heel. * 10/14/17, Lt (left) heel elevated on pillow (floating) . no compromise is noted at this time. * 10/16/17, Resident had kicked off pressure relieving device. Elevated foot on pillow with heal (sic) floating. Resident has not moved his leg from pillow. * 10/18/17, . Braden score is 13 and is a risk for pressure ulcers. Res does have an unstageable ulcer to left heel, area is left open to air at this time and floated as able to minimize pressure. Unstageable pressure ulcer to left heel measuring 1.4 cm (centimeters) by 1.4 cm. Offer [MEDICATION NAME] (protein drink) at brunch and dinner, offer 2% (percent) milk at brunch and dinner, Offer cottage cheese at brunch and dinner . A Weekly/Monthly Skin Assessment, dated 10/20/17 (two weeks after the admission assessment), identified, . Has [MEDICATION NAME] drsg (dressing) to heel. Does have pressure area to left heel. Pressure relieving boot in place . Staff failed to complete weekly skin assessments per facility policy. The progress notes identified the following: * 10/20/17, . Lt foot and leg remains on pillow with foot and heel free flowing (sic) no further deterioration in lt heel . (brand name) boots worn or heels floated at all times . * 10/23/17, . Lt foot and heel placed on pillow with heel free floating to prevent pressure . * 10/23/17, (Physician) was faxed about res stage 3 pressure ulcer to L) heel with serosanguinous drainage and yellow/white sloughing. Total PUSH score of 10. MD faxed back, 'Ok please schedule podiatry visit.' . * 10/26/17, Res has been discharge from facility today. Staff failed to update Resident #8's care plan. The care plan failed to identify the following interventions: * Monitor the unstageable left heel ulcer twice daily * Float heels * No shoes to be worn at this time * Pressure relief boot to left foot * Podiatry consult During an interview on 04/26/18 at 11:00 a.m., an administrative nurse (#1) confirmed Resident #8's comments regarding his heel pain and his request for staff to float his heels, should have prompted ulcer interventions. Resident #8 developed a stage 3 facility-acquired pressure ulcer, secondary to the facility failing to: * initiate interventions to alleviate pressure to his heels while he was in bed and/or a recliner, * complete weekly skin assessments per facility policy, * and update his care plan per facility policy. - Review of Resident #7's medical record occurred on 04/26/18. Medical [DIAGNOSES REDACTED]. During an interview on 04/26/18 at 11:00 a.m., an administrative nurse (#1) reported it is a standard of care for residents to be repositioned every two hours. If staff are required to reposition residents less than or greater than every two hours, staff are required to document whenever they reposition the residents. Resident #7's care plan, dated 09/25/17, identified, . Assist with repositioning at least q (every) 2 hours. The Repositioning Documentation, dated (MONTH) (YEAR), identified staff should have repositioned Resident #7 every two-to-three hours. The documentation showed staff failed to reposition him 20% of the time (48 of 235 occurances). Review of Resident #6's medical record occured on 4/26/18. Medical [DIAGNOSES REDACTED]. Resident #6 does not ambulate, and utilizes a hoyer lift for transfers, and needs assist with repositioning. Resident #6's care plan, dated 01/24/18, identified, . Stage 3 pressure ulcer and potential for further skin breakdown r/t (related to) immobility and moisture . resident needs to be turned and repositioned at least every 2 hours, more often as needed or requested . requires 1-2 assist with repositioning. The Repositioning Documentation, dated (MONTH) (YEAR), identified staff should have repositioned Resident #6 every two-to-three hours. The documentation showed staff failed to reposition her 8% of the time (29 of 360 occurrences) in (MONTH) (YEAR), 9% of the time (33 of 372 occurrences) in (MONTH) (YEAR), and 8% of the time (26 of 336 occurrences) in (MONTH) (YEAR).

Based on record review and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #9) identified with a burn received the care and services necessary to attain the highest degree of safety possible while drinking hot liquids. Failure to provide assistance with hot liquids at a safe temperature resulted in Resident #9 sustaining burns on his body and caused unnecessary discomfort and pain. Failure of the facility to implement a system to monitor the temperature of the hot water dispensing machines used by residents has the potential to result in additional burns to residents who drink hot liquids. Findings include: Review of Resident #9's medical record occurred on June 2-5, 2014. Medical [DIAGNOSES REDACTED]. At the time Resident #9 sustained a burn, the Minimum Data Set (MDS), dated [DATE], identified severely impaired vision, moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of nine, and requiring extensive assistance of one person with eating. Review of Resident #9's progress notes stated the following: *08/29/13 at 1:48 p.m. - ". . . friction-skin rub under L) (left) thigh Cause of skin condition: unknown . . . no bleeding noted, no drainage, 3 cm (centimeters) in length . . . applied Bacitracin . . ." *08/30/13 at 10:01 a.m. - ". . . Burn . . . Resident states that he spilled hot tea on himself a few days ago' . . . Wound is C-shaped. No drainage. Resident denies pain at rest but burn is tender to touch. Wound bed is bright red. Peeling skin noted at wound edges . . . Resident going to (name of the clinic) to be evaluated this afternoon" *09/06/13 at 11:23 - ". . . Burn . . . Resident spilled hot tea on himself on 08/28/13 . . . . Edges of burn are pink. Burn wound bed is yellow in color. Small amount of purulent drainage noted. No odor . . . Resident denies pain while at rest but dressing change procedure was painful . . . Silvadene cream (antibiotic ointment) applied. Wound covered . . . Resident given scheduled pain medications . . ." *09/13/13 at 2:39 p.m. - " . . . Periwound area slightly pink. Wound itself is yellow in color and scabbed over with no drainage noted. Res (resident) does continue to c/o (complain of) pain to this area . . ." *09/13/13 at 10:41 p.m. - " . . . Burn . . . periwound reddened, wound bed yellow with scant amount of drainage noted . . . Silvadene ointment applied, area covered . . . and wrapped . . ." *09/20/13 at 5:15 p.m. - ". . . Noted burn measures 1.1 by 3 is whitish color in center and slightly redish (sic) surrounding burn. Res continues to c/o discomfort with touch and dressing changed. No drainage noted . . ." *09/27/13 at 11:25 a.m. - ". . . Burn measures 3.2 cm x 0.8 cm. Small amount of yellow drainage present on old dressing. Resident does complain of a little tenderness during his treatment but states that it's not as painful anymore . . ." *10/04/13 at 4:00 p.m. - ". . . Noted area to back of lt thigh is 1.4 by 0.6 area is scabbed with a light color scab and res stated that it must be healed as he felt no pain to area . . ." *10/06/13 at 1:03 p.m. - ". . . Posterior upper (L) thigh, dark red discoloration to periwound, wound with scab intact, no drainage noted . . ." *10/11/13 at 4:48 p.m. - ". . . area is scabbed measuring 0.8 by 0.4. Noted scar tissue surrounding wound. Res denies pain . . ." *10/19/13 12:53 a.m. - ". . . (L) upper posterior thigh, area healed with a scar present. Area resolved, order received to continue Silvadene until f/u (follow up) appt (appointment) . . ." Resident #9's current care plan stated a problem: ". . . Hx (history) of burn to upper posterior L thigh . . ." and approaches: ". . . Allow resident to consume liquids per self . . . Identify food items using the clock method. . . ." Observation on 06/03/14 at 1:40 p.m. showed Resident #9 seated independently in the dining room for siesta snack. Interview of a dietary aide (#1) identified the resident sometimes asks for hot tea and receives the tea in an uncovered plastic coffee cup. Observation on 06/04/14 at 7:50 a.m. showed Resident #9 seated independently in the dining room for breakfast. A dietary aide (#2) obtained water from a dispenser on the coffee machine and served Resident #9 hot chocolate in an uncovered plastic coffee cup. Interview of the dietary aide (#2) identified she serves him hot chocolate the same way each day. This surveyor obtained a cup of water from the dispenser, immediately checked the temperature, and found the temperature measured 166.7 degrees Fahrenheit. During an interview on 06/04/14 at 8:45 a.m., an administrative dietary staff member (#3) stated she was aware of Resident #9's burn in October 2013 and that Resident #9 "falls asleep with cup in hand"; however, facility staff did not implement interventions to prevent further burns after the incident in October 2013. The facility staff did, however, implement the use of a cup cover on Resident #9's hot liquid cups as of 06/04/2014. During an interview on 06/04/14 at 8:55 a.m., an administrative dietary staff member (#4) stated she was unaware of Resident #9's burn. This staff member stated dietary staff had never completed monitoring of hot water temperatures from the coffee machines and could not identify a target temperature for hot water. During an interview on 06/04/14 at 3:15 p.m., a representative for the coffee machine company (#5) stated each machine is set at 180 degrees Fahrenheit. The representative (#5) also indicated he adjusted the hot water temp down to 155 degrees F. for all facility dispensers on 06/04/2014. Failure to implement a systemic process to monitor and check the temperature of the coffee/hot water dispensing machines continue to place Resident #9 and all residents independent who consumed hot liquids at risk of sustaining burns.

1. Based on record review, review of professional literature, review of facility policy, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #3), with a [DIAGNOSES REDACTED]. Findings include: Berman, Snyder, Kozier, Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 9th edition, Pearson Education, Inc., New Jersey, pages 1349-1350, stated,"Constipation may be defined as fewer than three bowel movements per week. This infers the passage of dry, hard stool or the passage of no stool. . . . Many causes and factors contribute to constipation. Among them are the following: Insufficient fiber intake, Insufficient fluid intake, Insufficient activity . . . Neurologic conditions, . . . stroke, or paralysis, Emotional disturbances such as depression . . . Medications such as opioids (for pain). . ." Review of the facility policy, titled "Bowel Program," occurred on 05/10/12. The policy, reviewed by the facility January 2008, stated: ". . . Purpose: Attempt to avoid constipation and the potential for a bowel obstruction. Procedure: . . . 4. The day nurse needs to check the BM (bowel movement) book before the end of her shift and leave a list of residents who have not had a BM in the last three days. These residents will be put on a list for the PM (evening) nurse to administer laxatives. 5. The night nurse is responsible to check if the resident has had results from the laxative, if not, she needs to give the resident a suppository. If still no results, consult Physician." Resident #3's medical record, reviewed May 7-10, 2012, identified [DIAGNOSES REDACTED]. The resident's annual Minimum Data Set (MDS), dated [DATE], identified extensive assistance of one person required for toilet use, constipation present, frequent severe pain present, and as needed pain medication provided. Upon request, the facility provided the most current bowel assessment, dated 06/15/10, which stated, ". . . Resident is currently continent of bowel . . ." The progress notes and faxed order requests identified the following: * 12/14/11 at 4:00 p.m., "Resident asked to speak to nurse. Resident related that she had been very constipated and had trouble with her BM today." * 12/22/11 at 9:20 p.m., ". . . had a small hard stool with rectal bleeding and with difficulty. . . . 11:00 p.m. . . . Resident continues to have problem (with) constipation. Hard stools - difficulty (with) evacuation and rectal bleeding. . . ." * 01/27/12 at 1:39 a.m., "I manually assisted resident for removal of large hard stool. She tolerated procedure well. . . ." * 02/07/12 at 8:06 a.m., ". . . stool palpable when supp (suppository) given . . ." * 02/27/12 at 7:30 a.m., ". . . lg (large) results . . ." * 03/07/12 at 9:00 p.m., "Resident on toilet and having difficulty passing BM. Large amount soft BM in rectum. Res. (resident) bearing down but unable to pass stool. . . . Large amount soft BM manually removed. . . . Res. stated 'yes' when nurse asked if she was more comfortable. . . ." * 03/14/12 at 10:51 a.m., "MDS Coordinator Note . . . continent of bowel. Res. does have frequent constipation. . . ." * 03/28/12 at 8:14 p.m., "Resident unable to have BM on the toilet. Stool in rectum upon digital exam. . . ." * 04/08/12 at 6:00 a.m., ". . . Supp at 4:00 and XL (extra large) results . . . " * 04/18/12, ". . . Res had been having increasing difficulties with constipation. . . ." The 12/01/11-05/09/12 Bowel Movement (BM) Record and Legend Report, as well as the 04/01/12-05/09/12 BM List showed the resident failed to have a bowel movement on the following days: * 12/06/11-12/13/11: 8 days * 12/24/11-12/30/11: 7 days * 01/06/12-01/13/12: 8 days * 01/16/12-01/19/12: 4 days * 01/28/12-01/31/12: 4 days * 02/02/12-02/06/12: 5 days * 02/08/12-02/21/12: 14 days * 02/28/12-03/06/12: 8 days * 03/09/12-03/12/12: 4 days * 04/13/12-04/17/12: 5 days * 04/19/12-04/22/12: 4 days (Upon request, the facility failed to provide the 12/01/11-03/31/12 BM List.) The physician's orders, dated 04/17/12, identified the following: * Order Date of 06/14/10: 5 milligrams (mg) [MEDICATION NAME] tablet as needed, 10 mg [MEDICATION NAME] rectal suppository as needed, 7 grams (gm)/118 ml Fleet enema as needed, and 30 ml Milk of Magnesia (MOM) as needed for constipation * Order Date of 12/15/11: 50 mg [MEDICATION NAME] as needed for pain (Adverse reactions of [MEDICATION NAME] include constipation.) * Order Date of 12/23/11: 100 mg [MEDICATION NAME] twice daily for constipation * Order Date of 03/22/12: 50 mg [MEDICATION NAME] daily * Order Date of 04/19/12: 8.5 gm [MEDICATION NAME] daily for constipation ([MEDICATION NAME] had been previously prescribed for 28 days starting 01/27/12) The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] * 12/06/11-12/13/11: [MEDICATION NAME] daily, [MEDICATION NAME] tablet 12/08/11, 12/11/11, 12/13/11, [MEDICATION NAME] suppository 12/12/11 * 12/24/11-12/30/11: [MEDICATION NAME] daily, [MEDICATION NAME] suppository 12/27/11 * 01/06/12-01/13/12: [MEDICATION NAME] daily, [MEDICATION NAME] suppository 01/09/12 * 01/16/12-01/19/12: [MEDICATION NAME] daily * 01/28/12-01/31/12: [MEDICATION NAME] daily, [MEDICATION NAME] daily, [MEDICATION NAME] tablet 01/30/12, 01/31/12 * 02/02/12-02/06/12: [MEDICATION NAME] daily, [MEDICATION NAME] daily, [MEDICATION NAME] tablet 02/06/12 * 02/08/12-02/21/12: [MEDICATION NAME] daily, [MEDICATION NAME] daily, [MEDICATION NAME] tablet 02/11/12, 02/17/12 * 02/28/12-03/06/12: [MEDICATION NAME] daily, [MEDICATION NAME] tablet 03/06/12, [MEDICATION NAME] suppository 03/02/12 * 04/13/12-04/17/12: [MEDICATION NAME] daily, [MEDICATION NAME] tablet 04/16/12, [MEDICATION NAME] suppository 04/17/12, MOM 04/15/12, 04/17/12 * 04/19/12-04/22/12: [MEDICATION NAME] daily, [MEDICATION NAME] tablet 04/22/12 The current Care Plan, identified, "Focus: I have a mild dehydration risk. I have difficulties with constipation. . . . Interventions: . . . Offer whole wheat bread with meals . . . Routine and prn (as needed) laxatives as ordered. . . ." During an interview on 05/10/12 at 9:20 a.m., a managerial dietary staff member (#14) indicated she was not notified of Resident #3's increasing difficulties with constipation which resulted in two manual extractions. The managerial dietary staff member (#14) further indicated she had made "no notations indicating the resident did not want dietary interventions." She verified the resident's current care plan failed to adequately address constipation as a focus area. When asked what types of interventions she typically initiates if/when a resident demonstrates difficulties with constipation, she stated, "Prune juice or prune whip, increased fluids, whole wheat bread, fresh fruit, and vegetables or salads." During an interview on 05/10/12 at 10:30 a.m., a managerial nursing staff member (#8) agreed the resident's current care plan failed to identify constipation as a focus area and failed to include dietary measures. The facility failed to notify the dietary department, and assess and implement effective approaches/interventions to Resident #3's plan of care following the above described episodes of fecal impaction. 2. Based on observation, record review, review of professional literature, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #2) demonstrating symptoms of dysphagia received the care and services necessary to attain the highest degree of safety possible while being fed in the dining room. Failure to provide the appropriate adaptive equipment has the potential to affect the resident's overall swallow safety, placing her at greater risk of aspiration and limiting her nutritional intake. Findings include: Nancy B. Swigert, The Source for Dysphagia: Third Edition, LinguiSystems, Inc, 2007, pages 9-15, stated, "Signs and Symptoms of Dysphagia: Drooling . . . Weight loss . . . Changes in diet . . . Neurological Causes (of dysphagia): Stroke . . ." Resident #2's medical record, reviewed May 7-10, 2012, identified [DIAGNOSES REDACTED]. The resident's annual MDS, dated [DATE], identified extensive assistance of one person required for eating. The current Care Plan, identified, "Focus: . . . I have chewing difficulties. I have a hx (history) of weight loss. I receive assistance with nutrition and use adaptive equipment. . . . Interventions: . . . Offer Regular diet with pureed consistency as per MD (medical doctor) ordered. Offer sippy cups and coated and thermo spoons w (with) /meals . . ." Observation on 05/08/12 at 11:15 a.m. showed a certified nursing assistant(CNA) (#9) feeding Resident #2. Resident #2 reached for her sipper cups (containing supplement, milk, prune juice, and water) between bites of pureed food. The CNA (#9) removed the sipper lids from the cups and offered fluids via cup-sip. Resident #2 began drooling with the increased volume of liquids. Observation on 05/09/12 at 8:45 a.m. showed a CNA (#9) feeding Resident #2. The CNA (#9) presented the resident's supplement in a small glass (without a sipper lid). Resident #2 demonstrated a slight amount of fluid loss at the corner of her mouth as she drank her supplement. The staff member failed to use the proper equipment and/or use the equipment appropriately when offering Resident #2 a beverage. During interviews on 05/09/12 at 9:30 a.m., a managerial nursing staff member (#8) agreed staff should have utilized adaptive equipment (sipper cup) while feeding the resident.

Based on record review, policy review, review of standards of practice, and staff interview, the facility failed to provide the necessary services to prevent pressure ulcers for 1 of 3 sampled residents (Resident #6) with current pressure sores. Failure of the facility to contact the physician for instructions regarding the use of the CAM (controlled ankle movement) boot resulted in Resident #6 developing facility-acquired, avoidable pressure sores. Findings include: The Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, April 2012, Page M-7 defines a Stage I pressure sore as reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device. Page M-22 defines an unstageable pressure sore as dead or devitalized tissue that is hard or soft in texture; usually black, brown or tan in color, and may appear scab like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. Review of the facility policy titled "Skin care policy - pressure area prevention/care" occurred 05/10/12. The policy, revised March of 2012, stated, "All residents will be assessed for their level of risk for developing pressure areas at admission, quarterly, significant change, and readmission. Efforts will be aimed at early intervention and prevention. Efforts will be made to ensure a resident who enters without a pressure area will not develop one unless the individual's clinical condition demonstrates that it is unavoidable. . ." - Review of Resident #6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The record also identified Stage II pressure ulcers to the right heel and the right ankle (onset date 01/31/12). Resident #6's current Minimum Data Set (MDS), dated [DATE], identified two Stage II pressure ulcers, one unstageable pressure ulcer, and extensive assistance from two people with bed mobility, transfer, and toileting. Resident #6's care plan, dated 02/07/12, identified the following: ". . . Problem: Pressure areas on (right) heel, (right) ankle dorsal surface, and returned from hospital (with) lateral aspect (right) ankle. Approaches . . . Float heels (and) keep all pressure off (right) lateral aspect of (right) ankle. . . Review of Resident #6's Progress Notes identified the following: *01/13/12 (11:23 p.m.) ". . . Resident was walking to the bathroom with assist of 2, walker and gait belt. Resident got to the doorway and was unable to go farther. She was lowered to the floor with help and landed on her right foot tucked underneath her. . . orders to transfer per ambulance to ER (emergency room ) for x-ray of foot." *01/23/12 (3:30 p.m.) ". . . Resident to see (Doctor) for follow-up x-ray. . . Returned with orders . . . remain NWB (non-weight bearing) times 5 weeks; re-check appt (appointment) in 5 weeks." *01/23/12 (5:03 p.m.) "Nurse from (health care facility) called to inform this nurse that residents x-ray did show a fracture to right ankle." *01/25/12 (6:45 a.m.) ". . . Cam Walker on R Lower Leg for Fx (fracture) Support " *01/26/12 (1:51 p.m.) ". . . Cam Walker Boot on R ankle" *01/28/12 (3:35 p.m.) ". . . NWB on Rt) foot. cont (continue) to have cam boot on. . ." *01/31/12 (10:46 a.m.) "Type of Skin Condition: Res (resident) c/o (complaint of) pain to rt (right) heel area. Cause of skin condition: from boot to stabilize fracture to rt foot. Location, size, drainage and shape/appearance of wound: Noted res area to heel is blackened 4 by 7.7 (centimeter) area. Skin is closed. stage 1 ulcer. No drainage noted. Also noted skin tear 3 cm (centimeters) to front of foot. area dressed and protective dressing placed over it. Interventions used to promote healing: dressing placed for protection and appt made at clinic for this afternoon. . ." *01/31/12 (10:30 p.m.) " . . . The skin tear on the dorsum of the right foot was dressed using [MEDICATION NAME] and wrapped with Kerlix to cushion the heel. Moderate amount of serosanguienous (sic) drainage through the Kerlix dressing that was removed. Skin tear is about 3 cm and the area is red and macerated. The right foot boot was removed @ (at) HS (hour sleep) and her right foot is floating off the pillow. . ." *01/31/12 (10:30 p.m.) ". . . Written orders from (name) from clinic appt. from today: Boot needs to come off @ HS. . . recheck in 2 weeks. . ." A physician progress notes [REDACTED]. . . she had fallen and had complaints of pain. . . She was placed on nonweightbearing. Two days later she was seen in the clinic. x-rays were repeated and she was found to have a lateral bimalleolar fracture. She was placed in a CAM Walker and again in a nonweightbearing status. Unfortunately, the CAM Walker was not removed for some time. Subsequently, the patient developed a pressure sore on her heel as well as an initial skin tear over the dorsum of her foot. . ." A consultant podiatrist note, dated 02/14/12, stated ". . . She has been nonweightbearing on the right side in a Cam boot. Unfortunately, at the (facility) they did not remove the CAM boot for a period of 1 week. It was left on at all times. She (Resident #6) developed a decubitus heel ulcer and an ulcer over the tibialis anterior tendon on the anterior aspect of her right ankle in addition to the ankle fracture. . . I did measure the anterior ulceration on the tibialis anterior component. This measured 4.5 cm x 2.5 cm, had a black stable eschar. The borders were jagged and actually some weeping was noted, a serous drainage. No malodor. A decubitus heel ulceration is on the posterior plantar aspect of the right heel, measure 6.5 cm x 3 cm . . . " Failure of the facility to contact the physician for instructions regarding the use of the CAM boot resulted in the resident acquiring avoidable pressure ulcers.