Every finding on record at St Benedicts Health Center

Based on observation, record review, review of professional reference, and staff interviews, the facility failed to ensure residents received the necessary care and services to attain the highest degree of safety and comfort for 2 of 4 sampled residents (Resident #10 and #88) reviewed for positioning and/or pain. Failure to ensure staff provided proper positioning while eating and at rest placed Resident #88 at risk for aspiration, choking, and discomfort. Failure to ensure staff reported signs and symptoms of pain/discomfort to the nurse in a timely manner resulted in Resident #10 experiencing avoidable pain during cares. Findings include: Swigert's The Source for Dysphagia, 4th Edition, 2019, Pro-Ed, Inc., Texas, page 130 stated, . During oral intake of medicines, foods, and/or liquids, it is optimal for a patient to be seated at a 90 [degree] angle, whether in a bed or in a chair. the 90 angle is necessary before and during feeding. Being 90 allows the patient to control material in the oral cavity with a minimal impact of gravity. This position must be maintained during and following the meal. Repositioning is frequently required during the meal. Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 262, 625, and 639, stated, . Comfort is associated with compassionate care and many nursing interventions are carried out to provide comfort. For example . positioning . [is] often performed to increase a resident's comfort level. clients who are nonverbal (e.g., . people with cognitive impairment .) are at risk for undertreatment of pain. There are wide variations in nonverbal responses to pain. Facial expression is often the first indication of pain . Vocalizations such as sighing, moaning and groaning, crying, and screaming are sometimes associated with pain. The facility failed to provide requested policies related to positioning, pain management, and standards/quality of care. - Review of Resident #10's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and unable to answer questions related to pain. The staff identified the resident displayed nonverbal indicators of pain (e.g., crying, whining, moaning, groaning) on one to two days during the five-day lookback period. Physician's orders included the following:* Acetaminophen three times a day (TID) as needed (PRN), start date 01/02/23.* Acetaminophen scheduled twice a day (BID), start date 01/20/23.* Morphine oral solution every four hours as needed, start date 06/23/26. Review of Resident #10's Medication Administration Record (MAR), dated July 1-13, 2026, identified no PRN acetaminophen or PRN morphine administered and the resident refused the scheduled acetaminophen 12 of the 26 times. Resident #10's current care plan identified the following:* Problem . I have potential for anxiety . Approach . Nursing to assess for pain. * Problem . I have the potential for pain related to dorsalgia [back and spine pain], spinal stenosis [narrowing of the spinal canal space placing pressure on nerves], osteoarthritis [degenerative joint disease] to [both] knees, osteoporosis [weakened bone density]. I have dementia and failure to thrive which is end stage with less than 6 months of life expected, declines are expected in my condition. Goal . I will verbalize complaints or show lessened non verbal complaints of pain and pain will be lessened within 1 hour of receiving pain intervention . Approach . Meds [medications] as per provider order . Observe for nonverbal signs and symptoms of pain . Question resident verbally if having any complaints of pain . Report all complaints of pain to charge nurse . Observations on 07/14/26 of Resident #10 showed the following:* 7:30 a.m., Seated in a wheelchair at a table in the dining room, making vocal sounds/moaning, and refusing to wear oxygen and eat. A certified nurse aide (CNA) (#8) asked a staff member to take the resident to her room.* 7:43 a.m., Two CNAs (#9 and #10) attempted to transfer the resident from the wheelchair to the bed. The resident refused to let go of her blanket, continued with the vocal sounds/moaning, and refused the oxygen. The CNA (#9) summoned the nurse for direction. The nurse obtained the resident's oxygen saturation level, stated she would get her something for pain, and instructed the CNAs to let the resident stay in her wheelchair. Resident #10's MAR showed the nurse administered PRN morphine on 07/14/26 at 8:05 a.m. A progress note, dated 07/14/26 at 7:45 p.m., stated, Resident was moaning and groaning this morning. She was unable to say what was wrong, hitting out at staff when trying to reapply oxygen. Liquid morphine prn was given and effective. Staff able to lay resident down. The CNAs (#9 and #10) notified the nurse about Resident #10's behaviors and moaning, the nurse administered PRN morphine, and the resident was able to rest. Observations on 07/15/26 of Resident #10 showed the following:* 10:00 a.m., Lying in bed moaning, making vocal sounds, and periodically stating ohhhh.* 10:18 a.m., A CNA (#10) placed a shower chair in the resident's room as the resident continued to moan. * 10:20 a.m., Two CNAs (#10 and #11) entered the resident's room. Resident #10 displayed increased moaning and vocal sounds as the CNAs rolled the resident side to side, placed a transfer sling, and removed the resident's brief and pants. The resident made crying sounds and displayed facial grimacing. The CNA (#10) asked the resident if she needed something for pain and where it hurt. The resident failed to respond. During the mechanical lift transfer, the resident continued to moan, made vocal sounds, cried, and stated, oww. The CNA (#10) asked the resident a few more times where it hurt, and the resident failed to respond. The CNA (#10) pushed the resident in the shower chair to the bathing room.* 10:32 a.m., The resident displayed the same signs of pain/discomfort. The CNA (#10) again asked where it hurts, and resident failed to respond.* 10:35 a.m., The CNA (#10) requested a nurse come to the bathing room, and reported, She's in pain and crying. The CNA (#10) continued with the shower while the nurse obtained pain medication.* 11:53 a.m., Resident #10 rested comfortably in bed with no vocal sounds or nonverbal indications of discomfort/pain. Resident #10's MAR showed the nurse administered PRN morphine on 07/15/26 at 10:42 a.m. A progress note, dated 07/15/26 at 7:32 p.m., stated, . Res. [resident] had a shower today. Signs and symptoms of pain observed via moaning. PRN morphine given at that time. Upon follow up, res. was no longer moaning and it appeared effective. Resident #10 showed signs and symptoms of pain in the presence of two staff members for 24 minutes before the nurse administered morphine, resulting in avoidable pain. During an interview on 07/15/26 at 2:35 p.m., a management staff member (#13) stated the facility received the morphine order after the resident's last hospitalization to place the resident on more of a comfort care. - Review of Resident #88's medical record occurred on all days of survey. Diagnoses included Alzheimer disease, dementia, dysphagia (difficulty in swallowing), and abnormal posture. The care plan stated, . I have End of Life diagnoses . and identified the resident sits in a specialty wheelchair. A physician's order, dated 06/11/26, identified an IDDSI (International Dysphagia Diet Standardization Initiative) 6 diet (soft diet with bite sized pieces) and thin liquids. A quarterly MDS, dated [DATE], identified moderately impaired cognition and required supervision or touching assistance during eating. Review of Resident #88's progress notes showed the following:* 05/09/26 at 9:17 p.m. (Recorded as Late Entry on 05/18/2026 at 9:19 p.m.), Resident coughing when she was eating eggs at breakfast. Was able to eventually cough up pieces of scrambled eggs.* 05/12/26 at 4:26 p.m., Resident seen by SLP [Speech-Language Pathologist] today and recommends diet change to IDDSI 6/soft and bite size with nectar thick liquids.* 06/11/26 at 11:12 a.m., Resident seen by SLP today and recommended fluid upgrade from nectar to thin liquids.* 06/22/26 at 2:42 p.m., . No issues reported/observed on current diet textures. Will proceed with current plan of care, goal is to maintain weight however may anticipate changes r/t [related to] less than 6 month life expectancy dx [diagnosis]. Observations of Resident #88 identified the following:* 07/13/26 at 3:59 p.m., Seated in a wheelchair in her room with eyes closed, head leaned back, and her face tilted up towards the ceiling. * 07/14/26 at 7:16 a.m., Seated in the wheelchair in the dining room, eyes closed, head leaned back, and her face tilted up towards the ceiling. * 07/14/26 at 7:26 a.m., Seated in the wheelchair with eyes closed, head leaned back, and her face tilted up towards the ceiling. A CNA (#8) stated several times, [Resident's name]. Wake up. It's time to eat. Your breakfast is here. On a few occasions, the resident opened her eyes, moved her head forward with the CNAs assistance, took a few bites of food, and while chewing, leaned her head back again with her face tilted up towards the ceiling. Eventually, the CNA (#8) asked a staff member to remove the resident from the dining room and stated, She cannot stay awake to eat.* 07/14/26 at 7:47 a.m., Remains seated in the wheelchair in her room, eyes closed, head leaned back, and face tilted up towards the ceiling.* 07/14/26 at 8:26 a.m., The surveyor asked a management staff member (#13) to observe the resident's wheelchair positioning due to concerns about eating and overall comfort related to her head positioning. * 07/14/26 at 8:50 a.m., Remains seated as previously observed.* 07/14/26 at 9:23 a.m., Observation showed a head positioning device in the resident's wheelchair, the resident seated erect with a slight chin tuck, and her eyes closed. A progress note, dated 07/14/26 at 8:59 a.m., stated, Resident noted to have some neck and head hyperextension while in the w/c [wheelchair]. Restorative nurse added neck pillow for w/c positioning and order received for OT [occupational therapy] eval [evaluation] for w/c positioning. During an interview on 07/14/26 at 5:55 p.m., when asked if the head positioning device benefited Resident #88 while eating/feeding, a CNA (#15) stated, Oh yes! We [staff] were always having to reposition her all the time. Now she sits up better. On 07/15/26 at 7:17 a.m., when asked the same question, another CNA (#8) stated, Absolutely! It is working very well. During an interview on 07/15 26 at 1:56 p.m., a therapy staff member (#14) stated she expected residents to sit in a chair or a bed as close to 90 as possible and to use a neck pillow if needed for proper positioning. She also stated, any position other than close to 90 can cause issues with swallowing and eating. The facility failed to provide an OT evaluation for Resident #88 prior to the teams exit on 07/16/26 at approximately 12:15 p.m. The facility failed to ensure proper wheelchair positioning while eating and at rest which placed Resident #88 at risk for aspiration and pain/discomfort.

Based on observation, review of facility policy, review of resident meal tickets, and resident and staff interviews, the facility failed to ensure each resident received a palatable meal and considered the preferences of each resident and their right to make choices about their diet for 5 of 27 sampled residents (Resident #4, #8, #9, #14, and #27) and 4 supplemental residents (Resident #19, #26, #28, and #81). Failure to accommodate resident choices and preferences may result in dissatisfaction with eating meals, decreased quality of life, and/or weight loss.Findings include: Review of the facility policy Resident Dining Areas occurred on 07/16/26. This policy, dated July 2021, stated, Policy: St Benedict's Health Center supports residents to maintain their highest level of independence by encouraging them to eat in dining areas. Trays will be provided to residents related to their medical condition or personal preference/request. -During an interview on the morning of 07/13/26, Resident #8 stated she ordered a fried egg and Cream of Wheat cereal for breakfast. The resident received a scrambled egg and oatmeal. The resident stated on two previous days the meal orders were incorrect and she reported it. Resident #8 compared the meal ticket to what was delivered and stated, Several times it [meal ordered] is not correct. Observation showed the resident had a stack of menus/meal ticket papers at her bedside. -During an interview on 07/13/26 at 1:04 p.m., Resident #27 stated, Here [the facility] you get what you didn't order. They [kitchen staff] don't read what you have ordered. When I order soup, they bring me something different [a different soup] than what I ordered. -During an interview on 07/13/26 at 2:39 p.m., Resident #81 stated the food he received doesn't match the meal ticket, and staff never remember to put everything on the plate. The resident indicated the facility requested he eat out in the dining room, but he would rather eat in his room. The resident stated his meal ticket is auto-generated so he does not get options. The resident wished he had a choice on what he gets to eat. On 7/14/26 at 8:05 a.m., Resident #81 wheeled himself into the hallway to get this surveyor's attention. He voiced frustration/anger regarding the items missing from his breakfast tray and indicated this as a normal occurrence. Observation showed the following missing items: cinnamon, salt/pepper, scrambled egg, donut, and a second carton of 2% [percent] milk. Resident #81 indicated he did not want to eat the food items without the missing condiments. -During an interview 07/14/26 at 10:34 a.m., Resident #4 indicated she always eats in her room, and does not want to eat in the dining room. The resident stated, They ask me what I want to eat but I usually get something else, and not what I asked for. -Observation in the main dining room on 07/14/26 at 5:30 p.m. showed Resident #28 upset and conversing with an unidentified dietary staff member. The resident stated she ordered tomatoes and no lettuce for her hamburger but received lettuce and no tomato instead. Review of Resident #28's meal ticket showed lettuce entered instead of the tomato. At the same time, the resident's tablemate, (Resident #26), was also upset and conversing with the unidentified dietary staff member stating she did not receive the ranch dressing for a lettuce salad, the ice cream, or the lemon pudding, all of which she ordered. Resident #28 confirmed she heard Resident #26 order those three food items. Review of Resident #26's meal ticket showed ranch dressing, ice cream, and lemon pudding not listed. -Observation of the evening meal on 07/14/26 in the Emmaus dining room showed Resident #14 with his/her meal tray. The resident stated, I didn't get my soup, and it's on my list. An unidentified staff member stated she would get the soup from the kitchen. -Observation in the main dining room on 07/15/26 at 9:14 a.m. showed Resident #19 asked for the bacon she did not receive in a loud voice. Review of the resident's meal ticket showed bacon requested. At the surveyor's request, an unidentified dietary staff member reviewed the resident's meal ticket, requested bacon from the kitchen, and stated, This happens a lot. When asked to clarify the statement, the unidentified staff member indicated residents do not receive what they ordered. -Observation of the breakfast meal on 07/15/26 in the Emmaus dining room showed Resident #9 did not receive cooked cereal. The meal ticket stated oatmeal. A certified nurse aide (CNA) (#18) then requested the missing oatmeal from the kitchen. During an interview on the afternoon of 07/15/26, two dietary staff members (#4 and #5) stated residents are encouraged to come to the dining room to eat. One dietary staff member (#4) explained the process of obtaining each resident's order at the dining room table before the meal in the main dining room and identified residents who eat in their rooms automatically receive the first choice on the menu without a chance to choose.

Based on observations, a sample test tray, and resident interviews, the facility failed to serve food at palatable and appetizing temperatures for 6 of 27 sampled residents (Resident #4, #11, #14, #27, #97, and confidential resident A) and 4 supplemental residents (Resident #46, #55, #81, and #115). Failure to serve food at a temperature acceptable and palatable to residents places the residents at risk of decreased food intake and has the potential to result in weight loss and nutritional decline. Findings Include: During interviews, the residents reported the following: - Resident A, The food is sometimes cold, delays in receiving meals, and stated, it depends on how much help they have. - Resident #4, Eats in the room, waits for meal delivery, and the food is cold, every meal. - Resident #11, The food is mostly cold. - Resident #27, Food is cold when you get it in your room. Sometimes in the dining room it's really cold too, especially if you have soup. - Resident #55, It could be warmer when asked about the temperature of the soup. - Resident #81, The food is always cold because it is sitting out in the containers for a long time before the food is served. Sometimes the resident doesn't receive a breakfast tray until 8:00 a.m. after the tray has been sitting in the cart. The food is on heated plates, but they need to leave the cover on, and the eggs and hashbrown are cold. - Resident #97, Waits for assistance in the morning and this past Sunday (07/12/26) and staff didn't get him out of bed until 10:30 a.m. and his breakfast was cold. Observations showed the following: - 07/14/26 at 7:39 a.m., Resident #14 seated in the main dining room waiting for her breakfast tray. While waiting for the tray, she began to eat the remaining breakfast items from her husband's tray. At 8:18 a.m. (39 minutes later), a staff member delivered her breakfast tray and stated the tray was delivered to her room. The staff member prepped the resident's tray and failed to ask if she wanted any of the food items reheated. - 07/14/26 at 8:05 a.m., Resident #81 approached the surveyor and voiced frustration over missing items on his breakfast tray. Observation showed the following missing items: cinnamon, salt/pepper, scrambled egg, donut, and a second carton of 2% (percent) milk. Resident #81 indicated his food was cold because he didn't want to eat the food items delivered and there were missing condiments. - 07/14/26 at 5:00 p.m., A meal cart arrived in the Emmaus Place dining room in a metal, non-heated food cart. Staff opened the cart door, and observation showed meal plates on hot pellets covered with an insulted cover. At 5:23 p.m., a staff member placed Resident #46's meal plate on the table, removed the insulated cover, and the resident attempted to reach for the food on the plate. At 5:34 p.m., an unidentified certified nurse aide (CNA) arrived at the table and assisted the resident with the meal. Resident #46's meal sat uncovered approximately 11 minutes prior to being served. - 07/15/26 at 7:05 a.m., A meal cart arrived in the Emmaus Place dining room in a metal, non-heated food cart. The meal plates were on hot pellets covered with an insulated cover. At 7:40 a.m., a staff member placed Resident #115's meal tray on the table and removed the insulated cover from the plate. At 7:50 a.m., an unidentified staff member arrived at the table and assisted the resident with the meal. Resident #115's food sat in the metal cart for 35 minutes and uncovered an additional 10 minutes on the table. At 7:55 a.m., the surveyor obtained food temperatures from the last meal tray on the cart, and the temperatures showed oatmeal 120 degrees (degrees) Fahrenheit (F), hashbrowns 100 degrees F, sausage 100 degrees F, and eggs 99 degrees F. - 07/15/26 at 7:35 a.m., Resident #14's breakfast tray sat on the bedside table as two staff members provided morning cares. At 7:59 a.m. (24 minutes later), the staff members prepped the resident's tray and exited the room without asking the resident if she wanted any of the food items reheated. When asked questions pertaining to her meal, Resident #14 stated, I usually eat it [meal] cold. Delivery varies. Sometimes they bring it [tray] even earlier than they did today. On 07/15/26 at 11:10 a.m., the surveyor requested a meal test tray in the Emmaus place dining room. Observation showed the test tray and three other meal trays on top an open cart and the meal plates on hot pellets covered with an insulated cover. After the two residents trays were delivered, the surveyor brought the test tray to the conference room and immediately checked the food temperatures. At 11:24 a.m., the temperatures showed the frankfurter 117 degrees F, steamed broccoli 107 degrees F, and chicken dumpling soup 140 degrees F. The surveyors tasted the meal, and all confirmed the frankfurter and the broccoli tasted lukewarm. The facility failed to serve food at a temperature that is acceptable and palatable to residents.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to store and serve food in accordance with professional standards of food safety in 1 of 1 kitchen and 1 of 3 dining rooms (main dining room). Failure to properly store thawing meat products, clean fans in the walk-in cooler, change soiled gloves when handling ready-to-eat food, and to properly store scoops in ice buckets has the potential to cause cross-contamination and may result in a foodborne illness for residents.Findings include: Review of the 2022 Food and Drug Administration Food Code identified the following: * Chapter 3, Section 3-304.15 Gloves, Use Limitation, pages 61-62, stated, . (A) If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD. used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Annex 3, Section 3-304.15 Gloves, Use Limitation, page 372, stated, . Gloves used in touching ready-to-eat food are defined as a 'utensil' . * Chapter 3 Section 3-305.11 Food Storage, pages 63-64, stated, . Food shall be protected from contamination by storing the food: . 2) Where it is not exposed to . dust, or other contamination. * Annex 3, Section 3-302.11 Packaged and Unpackaged Food – Protection Separation, Packaging, and Segregation, page 366, stated, . With regard to the storage of different types of raw animal foods . it is the intent of this Code to require separation based on anticipated microbial load and raw animal food type (species). Separating different types of raw animal foods from one another during storage . will prevent cross-contamination from one to the other. * Annex 3, Section 3-304.11 Food Contact with Equipment and Utensils, page 370, stated, . Some pathogenic microorganisms survive outside the body for considerable periods of time. Food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to such contamination. The handles of utensils, even if manipulated with gloved hands, are particularly susceptible to contamination. Review of the 7th edition of ServSafe Manager, Section Five - The Flow of Food: Purchasing, Receiving, and Storage, page 5.15, stated, Storage Order. Store raw meat, poultry . in cooler in the following top to bottom order . whole cuts of beef . ground meat . whole and ground poultry. This order is based on the minimum internal cooking temperature of each food. Review of the facility policy titled Food Storage - Perishable occurred on 07/16/26. This undated policy stated, Policy: Sanitary procedures will be maintained in perishable food storage to keep foods safe . and to prevent contamination. 1. All storage that takes place in refrigerated and freezer areas will be maintained in a clean, sanitary condition. During the kitchen tour on 07/13/26 at 9:50 a.m. with two dietary staff members (#4 and #5), observation showed the following: * Three boxes of raw chicken thawing on a shelf above raw ground beef and beef steaks in the small walk-in cooler. Upon request, the staff member (#5) moved the boxes of chicken to the bottom shelf and the ground beef and beef steaks to the shelf above the chicken. Staff members (#4 and #5) confirmed raw chicken should not be stored above raw ground beef and beef steaks. * An accumulation of dust on a fan, including several areas with large clumps of dust, in the large walk-in cooler. Observation on 07/15/26 at 2:30 p.m. showed the large clumps of dust remained on the fan in the large walk-in cooler. - Observations on 07/14/26 at 7:02 a.m., 7:22 a.m., 5:02 p.m., and 5:19 p.m. and on 07/15/26 at 7:27 a.m. showed a container filled with ice on top of a rolling beverage cart in the main dining room. On each observation, unidentified staff members used bare hands to obtain the handle of the scoop laying on top the ice in the container. The staff returned the scoop to the bucket with the handle touching the ice. - Observation of the meal service tray line in the main kitchen showed the following: * 07/14/26 at 5:11 p.m., An unidentified dietary staff member placed a bun (a ready-to-eat food) with gloved hands onto a resident's meal plate. The staff member then opened a cart across the room, obtained food containers, closed the cart, and without changing gloves, began to place additional buns onto resident meal plates. * 07/15/26 between 7:10 a.m. and 7:25 a.m., An unidentified dietary staff member wore the same gloves throughout the following: Periodically placed bacon (a ready-to-eat food) onto resident meal plates after touching a computer screen and the handles of the meal tray delivery carts; placed toast (a ready-to-eat food) onto a meal plate after touching a computer screen; manipulated bacon to fit a plate, the bacon extended over the plate and touched the meal service cart; grasped potholders to place a container of food into the steam table, and touched the tops of muffins (a ready-to-eat food) and placed them onto meal plates. The dietary staff member failed to change gloves and/or use utensils when handling the ready-to-eat foods and ensure food touched only clean surfaces.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure staff provided adequate supervision to prevent accidents and/or injury for 1 of 1 sampled resident (Resident #79) with a risk and history of falls. Failure to ensure staff followed the care plan and provided adequate supervision placed the resident at risk for falls and/or injury. Findings include: Review of the facility's policy titled Integrated Fall Management occurred on 07/16/26. This undated policy stated, . 3. Residents at risk for falls have an individualized resident centered care plan developed. Care plan interventions are based on the findings of the fall risk assessment. Review of Resident # 79's medical record occurred on all days of survey. Diagnoses included a recent stroke affecting the left side, unsteadiness, and dementia. The current care plan, dated 05/08/26, stated, . Approach: Cannot be left alone in wheelchair in room. Observation on 07/14/26 at 11:02 a.m. showed Resident #79 unattended, seated in a wheelchair in his room, and positioned in front of the sink. Observation on 07/14/26 at 11:35 a.m. showed Resident #79 unattended, seated in a wheelchair, and the call light not within reach. The resident stated he needed staff assistance to apply his deodorant. Observation on 07/15/26 at 7:28 a.m. showed Resident #79 unattended and seated in his wheelchair in his room. During an interview on 07/15/26 at 1:48 p.m., an administrative staff member (#7) confirmed Resident #79 should not be left alone in his room while seated in his wheelchair.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of infection control and prevention for 2 of 13 sampled residents (Resident #9 and #88) observed during cares and in 1 of 1 laundry room observed. Failure to practice infection control standards related to glove and gown use during resident cares and in laundry services has the potential to spread infection throughout the facility.Findings include: Information found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, dated 02/27/24, stated, . When to change gloves and clean hands . If gloves become soiled with . body fluids after a task. Review of the facility policy titled Linen Handling occurred on 07/16/26. This policy, dated June 2017, stated, . To prevent the spread of infection . Clean linen is handled to prevent infection. Clean linen is separate from soiled linen. - Observation on 07/13/26 at 12:32 p.m. showed two certified nurse aides (CNAs) (#9 and #16) performed Resident #88's perineal care while in bed. One CNA (#9) used a soiled gloved hand to open a drawer of a nightstand to obtain a skin cream. The CNA (#9) failed to change gloves between the dirty and clean tasks. - Review of Resident #9's medical record occurred on all days of survey and identified a central venous catheter for dialysis, requiring Enhanced Barrier Precautions (measures to prevent the spread of multidrug-resistant organisms (MDROs) by the use of gowns and gloves during high-contact care for residents with indwelling medical devices). Observation on 07/14/26 at 12:42 p.m. showed two CNA's (#3 and #6) applied gowns and gloves and assisted Resident #9 with perineal cares in the bathroom. The CNA (#6) failed to tie the neck strings of the gown and the gown fell from the CNA's shoulders to the chest and elbow areas. - Observation of the laundry room occurred on 07/15/26 at 1:10 p.m. and showed a staff member (#17) transferred clean linen from a bin to a folding table and a pillowcase fell onto the floor. The staff member retrieved the pillowcase from the floor and placed it onto the folding table with the other clean items. During an interview on 07/15/26 at 1:28 p.m., a laundry supervisor (#18) stated she expected staff to rewash the pillowcase.

Based on review of facility reported incident (FRI) investigations, record review, review of facility policy, and staff interview, the facility failed to ensure residents remain free from abuse for 2 of 5 sampled residents (Resident #4 and #6) who were subjected to physical abuse by other residents. Failure to ensure processes were in place to meet the needs of residents such as adequate supervision and oversight and effective care plan interventions resulted in incidents of resident-to-resident abuse and placed all residents at risk for physical harm, pain, mental anguish, and emotional distress.Findings include: Review of the facility policy titled Abuse Prevention Plan occurred on 01/28/26. This policy, dated 2017, stated, . Resident to Resident Altercations: An incident involving a resident who willfully inflicts injury upon another resident. 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Definitions: 'Abuse': The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse . includes verbal abuse . hitting, slapping, kicking, pinching, biting . -Incident involving Resident #6 and #7 Review of the facility's FRI investigation, dated 11/14/25, stated, [Resident #6] was propelling himself down the hall in his wheelchair when his roommate [Resident #7] began kicking the back of his wheelchair. [Resident #6] turned around to see what was happening and [Resident #7] took a closed fist and hit him in the jaw on the right side of his face. Staff intervened and immediately separated the residents. Nursing did an exam with no noted injuries to [Resident #6]. [Resident #6] reports that he is not hurt and that he is ok. [Resident #6] was offered a room change to a different unit, and was in agreement. Call placed to the family and they agreed to the change. Room change took place at 11 am. The residents were immediately separated during this time and monitored by staff to prevent further interactions. Review of Resident #7's medical record occurred on 01/28/26. The care plan stated, I have potential for agitation. I have Dx [diagnosis] of Restlessness and Agitation. I am taking an anti-psychotic medication. I have had a physical altercation with resident [#6] due to being agitated . -Incidents involving Resident #3, #4, and #5 Review of the facility's FRI investigation, dated 11/21/25, stated, At approximately 1:30 PM on 11/21/25, [Resident #4] was seated at a table in the activity room during the scheduled folding activity. She was positioned directly across from [Resident #5]. [Resident #4] knocked several clothing items from the table onto the floor, which appeared to cause visible distress to [Resident #5]. As a response, [Resident #5] maneuvered her wheelchair to the opposite side of the table, positioning herself next to [Resident #4], and stated you should not be doing that. subsequently slapped [Resident#4] on her right cheek. Activity staff immediately intervened and separated both residents. The nurse promptly assessed [Resident #4], noting no physical injuries such as bruising, scratching, or bleeding [;] mild redness was observed on her right cheek. [Resident #4] denied any pain or distress and did not exhibit any signs of psychosocial anguish (e.g. crying, fearfulness, anxiousness, etc.). Review of the facility's FRI investigation, dated 01/09/26, stated, At approximately 4:20 PM on January 9, 2026, [Resident #4] was in her doorway singing. [Resident #5] told [Resident #4] to stop singing and shut up and go back into her room. Staff told [Resident #5] its OK for [Resident #4] to be in the hall/doorway and to just leave her be. Staff went to assist another resident [and] upon her return to the med cart, [Resident #3] was inside room [of Resident #4] pushing [Resident #4's] chair back. [Resident #3] had kicked [Resident #4's] leg and slapped at her hand. Then [Resident #4] slapped [Resident #3's] hand. Staff removed [Resident #3] from [Resident #4's] room and told her she can't be in there as it's not her room. Staff immediately intervene and separated all [three] residents. The nurse promptly assessed both [Resident #4] and [Resident #3] noting no physical injuries such as bruising, scratching, or bleeding. [Resident #3] and [Resident #4] denied any pain or distress and did not exhibit any signs of psychosocial anguish (i.e. crying, fearfulness, anxiousness, etc.). Review of Resident #3's medical record occurred on 01/28/26. The Minimum Data Set (MDS), dated [DATE], identified a BIMS of 11, indicating moderate cognitive impairment. A care plan problem, dated 01/12/26, stated, . I have [sic] an altercation in the past with resident [#5] and resident [#4] . Review of Resident #4's medical record occurred on 01/28/26. The Quarterly MDS, dated [DATE], identified a Brief Interview for Mental Status (BIMS) of 4, indicating severe cognitive impairment. A care plan problem, dated 11/21/25, stated, . I have had an altercation in the past with resident [#5] and resident [#3] . Review of Resident #5's medical record occurred on 01/28/26. The Quarterly MDS, dated [DATE], identified a BIMS of 10, indicating moderate cognitive impairment. A care plan problem, dated 11/21/25, stated, . I have had an altercation in the past with resident [#4] and resident [#3] . Review of Resident #3, #4, and #5's care plan contained identical problems and interventions related to resident-to-resident altercations as follows: *Observe for psychosocial and mental status changes. *Document and report as indicated. *Provide alternative methods of communications with family/visitors. *Provide in room activities of choice, as able. *Provide support and allow resident to express feelings, fears and concerns. The care plans lacked individualized interventions specific to each resident's needs. Another problem identified on Resident #3, #4, and #5's care plans stated, . I am a vulnerable adult and need assistance to remain safe within the community . If I become violent or physically aggressive, you shall implement interventions to minimize risk to myself and others. The care plan problem lacked further information as to what interventions staff should implement. The first incident involving Residents #4 and #5 occurred on 11/21/25, during which the facility failed to protect Resident #4 from abuse. A second altercation occurred on 01/09/26, and again the facility failed to protect Resident #4. A staff member reported hearing Resident #5 tell Resident #4 to stop singing and to shut up, but did not intervene until Resident #3 had already pushed Resident #4 into her room and kicked and slapped her. During an interview on 01/28/26 at 1:38 p.m., an administrative staff member (#1) stated the facility educated staff to keep the residents separated and monitor them and needed no further education on these incidents. Staff monitored the residents for at least seven days, with no further concerns identified, and closed out the incidents.

Based on observation, review of facility policy, and staff interviews the facility failed to follow standards of infection control and prevention for 3 of 22 sampled residents (Residents #16, #29 and #88) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), dressing changes, and hand hygiene, has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 04/24/25. This policy, revised April 2024, stated, . Enhanced Barrier Precautions (EBP) is a strategy in nursing homes to decrease transmission of . important multidrug-resistant organisms (MDROs). Additionally, residents at risk for MDROs, specifically those with an indwelling medical device . will be required to use EBP. (EBP) expands the use of Personal Protective Equipment (PPE) . refers to the use of gown and gloves during high-contact resident care activities . When to use: . All residents with any of the following: . Indwelling medical devices (e.g. central lines, urinary catheters .) . During high-contact resident care activities: . Indwelling medical device care or use: central line, urinary catheter . Gloves and gown prior to the high-contact care activity . Review of the facility policy titled Dressing Change occurred on 04/24/25. This policy, revised October 2015, stated, . Procedure: . 3. Set up clean field and place supplies on clean field. - Observation on 04/02/25 at 11:13 a.m. showed Resident #16 seated in a wheelchair in his/her room with a peripherally inserted central catheter (PICC) line to the right arm. A sign on the wall outside of the room indicated EBP. A staff nurse (#6) entered the room with two syringes and an intravenous (IV) medication bag, performed hand hygiene, gathered additional supplies, applied gloves, removed the PICC line dressing, removed gloves, performed hand hygiene, and applied a new dressing. The nurse (#6) flushed the PICC line and started the IV medication The staff nurse (#6) failed to wear a gown during the PICC line dressing change and administration of the IV medication. - Review of Resident #29's medical record occurred on all days of survey. The current care plan stated, . I have a foley catheter . Enhanced Barrier Precautions . Observation on 04/23/25 at 6:35 a.m. showed Resident #29 resting in bed. A sign on the wall outside of the room indicated EBP. A nurse (#5) entered the resident's room with a bag of dressing supplies from the medication cart. The nurse set the bag on the bedside table, performed hand hygiene, applied a gown and gloves, obtained supplies from the bag, and performed the dressing change to Resident #29's arm and lower legs. The nurse (#5) returned the bag of dressing supplies to the medication cart with other dressing supplies, emesis bags, and a catheter kit. The staff nurse (#5) failed to disinfect the bedside table before placing the bag of dressing supplies on it and failed to disinfect the bag prior to returning it to the medication cart with medical supplies. - Observation on 04/22/25 at 8:13 a.m. showed Resident #88 seated in a wheelchair. A nurse aide (NA) (#4) applied gloves, placed Resident #88's dentures in his/her mouth, removed her gloves, and without performing hand hygiene, wheeled the resident to the dining room for breakfast. The NA (#4) failed to perform hand hygiene after removing gloves and before exiting Resident #88's room. During an interview on 04/23/25 at 4:20 p.m., two administrative nurses (#1 and #2) confirmed they expected staff to perform hand hygiene after glove removal.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 19 sampled residents (Resident #45, and #56). 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 H - BLADDER AND BOWEL The Long-Term Care Facility RAI User's Manual, revised October 2023, page H-2, states, . Check next to each appliance that was used at any time in the past 7 days. H0100A, indwelling catheter . - Review of Resident #56's medical record occurred on all days of survey. The physician's orders dated 12/23/23, included Foley Catheter [indwelling catheter] to gravity drainage; . Review of the significant change in status assessment MDS, dated [DATE], Section H0100A, indwelling catheter, lacked documentation to indicate the presence of an indwelling catheter. During an interview on 03/19/24 at 12:55 p.m., a clinical manager (#1) confirmed Resident #56's MDS section H0100A lacked the documentation for the presence of an indwelling catheter. SECTION O - SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS The Long-Term Care Facility RAI User's Manual, revised October 2023, page O-7, states, . Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. - Review of Resident #45's medical record occurred on all days of survey. The current care plan identified, . I am at the end of my life/receiving hospice service related to Alzheimer's Disease. Review of the admission MDS, dated [DATE], Section O110K1, hospice, lacked the documentation to indicate the presence of hospice services. During an interview on 03/19/24 at 5:14 p.m., an administrative nurse (#2) confirmed Resident #45's MDS section O110K1 lacked the documentation for the presence of hospice services. 27221

Based on observation, record review, review of facility policy, resident interview, and staff interview, the facility failed to ensure activities of daily living (ADLs) were appropriately completed for 1 of 1 sampled resident (Resident #9) and 1 supplemental resident (Resident #296) observed with poor oral care and/or grooming. Failure to ensure residents are assisted to maintain oral hygiene and grooming may result in lack of personal hygiene and decreased self-esteem. Findings include: Review of the facility policy titled ORAL CARE occurred on 03/19/24. This policy, dated May 2000, stated, OBJECTIVE: 1. To keep the teeth, gums and mouth in good condition. 2. To clean and freshen mouth. Review of the facility policy titled SHAVING THE RESIDENT occurred on 03/19/24. This policy, dated January 2000, stated, . Shaving the Female Residents. 1. Observe for facial hair during bathing procedure & [and] PRN [as needed]. - Review of Resident #9's medical record occurred on all days of survey. The resident's care plan stated, . I require assist with dressing and personal hygiene . Resident to shave as needed . The record identified Resident #9 receives weekly baths/showers on Thursdays and has an electric shaver. Random observations on all days of survey showed Resident #9 seated in her room with visible facial hair on her chin. Review of Resident #9's progress notes, dated 03/14/24 to 03/18/24, identified: - 03/14/24 at 11:05 p.m. - Needed 2 person [usually 1 person] assist this shift. MD [medical doctor] informed. - 03/16/24 at 9:29 a.m. and 5:48 p.m. - . Noted confusion. resident noted productive cough and congestion . increased confusion . reminded verbally and with written signage to stay in room. - 03/18/24 at 2:31 p.m. resident continues with increased confusion. - Review of Resident #296's medical record occurred on all days of survey. Diagnoses included dislocation of a shoulder joint. The resident's care plan stated, . Resident requires set up assistance with oral Care [sic] . I require staff assist with dressing and personal hygiene . Resident to shave as needed . The record identified Resident #296 receives baths/showers twice a week on Mondays and Thursdays and has an electric shaver. Observation on 03/18/24 at 7:33 a.m. showed Resident #296 seated in a wheelchair in her room wearing a shoulder immobilizer sling to the right arm. While interviewing the resident she appeared to have dried saliva between her lips and debris noted in her teeth. When asked if she had brushed her teeth today, the resident stated, I have been here since Monday [since admission 7 days ago] and I have brushed my teeth once, and further stated, I don't have a toothbrush. Do they throw them [toothbrushes] away after using them once? Further observations of Resident #296 showed the following: * On 03/18/24 at 4:59 p.m., resident reported she still does not have a toothbrush in her room and staff had not offered assistance with oral cares. * On 03/19/24 at 8:37 a.m., visible facial hair on the resident's chin. When asked if the chin hair were a concern, the resident stated, I shave them when I am at home. I have a shaver in my bag and pointed across the room. The resident reported she is right hand dominant and is not very good with her left hand. Observation showed the resident with debris/food present in her teeth. * On the afternoon of 03/19/24, resident reported she still does not have a toothbrush in her room and staff had not offered assistance with oral cares. During an interview on 03/19/24 at 10:45 a.m. an administrative staff member (#4) stated shaving is completed with scheduled bathing, and due to transmission precautions, Residents #9 and #296 received bed baths. The facility failed to ensure Resident #9 and Resident #296 completed ADLs for teeth brushing and/or chin hair removal, and staff assisted as needed for proper grooming/appearance.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 4 of 14 sampled residents (Resident #7, #38, #45, and #54) and 1 supplemental resident (Resident #4) observed during personal cares. Failure to follow infection control practices during cares and/or related to hand hygiene/glove use has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled HAND HYGIENE occurred on 03/19/24. This policy, dated November 2017, stated, . If hands are not visibly soiled and/or the resident does not have infectious diarrhea, an alcohol based hand hygiene product may be used. If hands are visibly soiled . soap and water must be used for hand hygiene. - Observation on 03/17/24 at 11:17 a.m. showed a certified nurse aide (CNA) (#5) donned gloves, removed and bagged Resident #54's soiled pants, removed her soiled gloves, and then donned a new pair of gloves before performing other tasks. The CNA (#5) failed to perform hand hygiene after removing Resident #54's soiled clothing and prior to performing other tasks. - Observation on 03/17/24 at 2:43 p.m. showed two CNAs (#8 and #9) donned gloves and completed personal cares for Resident #45. After completion of cares, CNA (#9) held onto the tip of a straw and offered Resident #45 a drink of water. The CNA (#9) failed to remove her soiled gloves and perform hand hygiene after providing personal care and prior to offering her a drink of water. - Observation on 03/18/24 at 10:00 a.m. showed Resident #7 with a catheter in place. Two CNAs (#10 and #11) donned gloves and provided perineal care for Resident #7. The CNA (#10) cleansed the rectal area of stool, removed her soiled gloves, and washed her hands. The CNA (#11) placed a new brief on the resident, removed her gloves, performed hand hygiene, and covered the resident with a blanket. The CNAs (#10 and #11) failed to cleanse the front perineal area. - Observation on 03/18/24 at 11:17 a.m. showed a CNA (#3) donned gloves and provided perineal care for Resident #4. The CNA cleansed the rectal area of stool using a wet wipe and without removing the soiled gloves, applied a protective barrier ointment to the resident's bottom. The CNA (#3) failed to remove her soiled gloves and perform hand hygiene after cleaning the rectal area and prior to applying ointment. - Observation on 03/18/24 at 4:18 p.m. showed two CNAs (#6 and #7) donned gloves, transferred Resident #38 onto the bed, lowered the soiled shorts and brief, and provided perineal cares. The CNAs (#6 and #7) removed their gloves and completed the transfer. After providing personal cares for Resident #38, the CNA (#6) offered Resident #38 a drink of water before performing hand hygiene. The CNAs (#6 and #7) failed to perform hand hygiene after removing their visibly soiled gloves, after removing Resident #38's soiled clothing, and prior to performing other tasks. During an interview on 03/19/24 at 4.46 p.m., a managerial nurse (#12) confirmed she expects staff to perform complete perineal cares and to perform hand hygiene after removing soiled gloves and prior to completing other tasks. 27221 40488

Based on observation, record review, review of professional reference, and record and staff interview, the facility failed to follow professional standards of practice regarding physician's orders for 1 of 1 sampled resident (Resident #21) with an order for a pain ointment. Failure to carry out the physician's orders resulted in Resident #21 experiencing pain and discomfort. Findings include: Berman, Snyder, and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., Massachusetts, page 68, states, . Carrying Out a Physician's Order . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #21's medical record occurred on all days of the survey. The current physician's orders identified, . apply Voltaren gel [a pain medication] . topically, two times a day as scheduled to right trunk, back and lower legs for chronic pain . Observation of a medication pass on 04/24/23 at 3:34 p.m., showed a container of Voltaren gel sitting on Resident #21's bedside table. When asked if he received his early morning dose of Voltaren, Resident #21 stated, No . I am a little sore right now. When asked if Resident #21 had received his medication, a staff nurse (#4) reviewed the Medication Administration Record (MAR) and stated the MAR showed a nurse administered the Voltaren gel between 4:00 a.m. and 7:00 a.m. During an interview on 04/25/23 at 7:48 a.m., the staff nurse (#3) stated she forgot to apply Resident #21's pain medication between 4:00 a.m.- 7:00 a.m., left the Voltaren container on his bedside table, and documented in the MAR as if she had administered the medication. During an interview on 04/26/23 at 7:45 a.m., an administrative nurse (#2) indicated she expected nursing staff to administer medications as ordered by the physician.

Based on observation, facility policy review, and staff interview, the facility failed to ensure safe and secure storage of medications for 1 of 3 medication carts (Unit 2) observed during medication pass. Failure to store all medications securely may result in unauthorized access to medications. Findings include: Review of the facility policy titled Pharmacy Services occurred on 04/26/23. This policy, revised October 2022, stated, . During the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide . no medications are kept on top of the cart . the cart must be clearly visible to the personnel administering medications . all other sides must be inaccessible to residents or others passing by . Observation on 04/25/23 at 7:52 a.m., showed a staff nurse (#1) preparing the residents' medications in the hallway. The staff nurse (#1) left the medication cart unlocked and unattended in the hallway when she entered the dining room to deliver the medications. The nurse (#1) left eight medication cartridges, two unlabeled cups containing medications and one insulin pen on top of the cart. Observation showed the top drawer open and medications visible. A number of residents, staff members, and construction workers passed by the unlocked/unattended medication cart during the observation. During an interview on 04/25/23 at 8:03 a.m., the staff nurse (#1) confirmed she left the medication cart in the hallway unlocked and unattended. An administrative nurse (#2) indicated she expected the medication cart to be locked when not in clear view and/or within reach of the person administering medications.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to identify/treat a new pressure ulcer and failed to implement prevention measures for existing pressure ulcers for 1 of 2 sampled residents (Resident #22) with a new and/or existing pressure ulcer. Failure to identify and treat a new skin injury/pressure ulcer in a timely manner and failure to apply pressure-relieving devices as ordered may result in worsening of new/existing pressure ulcers and delayed healing. Findings include: Review of the facility policy titled Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This policy, dated 2018, stated, . Maintaining intact skin is integral to resident health and wellness. Those residents' who experience a break in skin integrity or wounds are provided care and services to heal the skin according to professional standards of care. Skin integrity is monitored and abnormal findings are documented: Skin is observed daily with cares. If any skin concerns are noted, they are reported to the licensed nurse. Weekly skin audits are performed by a licensed nurse. If a resident is admitted with impaired skin integrity or a new pressure injury or a lower extremity wound develops the licensed nurse implements the following items . Notify attending provider . Attending provider determines wound type and may provide additional orders. Review of Resident #22's medical record occurred on all days of survey and identified a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's orders dated 11/18/21 and 11/29/21 stated to keep a right heel protector in place at all times. Observations of Resident #22 on 11/30/21 showed the following: * 8:37 a.m., the resident lying in bed without a right heel protector in place. Two CNAs (certified nurse assistants) (#4 and #5) transferred the resident from the bed to a wheelchair without a right foot protector. * 8:53 a.m., the CNAs (#4 and #5) transferred the resident from the wheelchair into the shower chair without foot protection. The CNA (#4) removed the resident's left compression stocking and revealed a blackened circular area (approximately 1/4 inch in diameter) to the left side of the resident's foot near the fifth toe. * 12:37 p.m. and 2:44 p.m., the resident seated in a wheelchair and without a right heel protector. Resident #22's medical record lacked documentation of a skin injury/pressure ulcer on the left foot. During an interview and observation on 11/30/21 at 2:44 p.m., two managerial nurses (#1 and #3) assessed Resident #22's left foot, confirmed the blackened area, identified it as an ulcer, and acknowledged they were not aware of the skin injury to the left foot prior to this. When asked about the ordered right foot protection, Resident #22 stated the staff removed the boot from the room for laundering a while ago and it never came back. The facility failed to assess, monitor, treat, and notify the provider of a new skin injury/pressure ulcer to Resident #22's left foot and also failed to apply the right foot protector as ordered.

Based on observation, record review, review of facility agreement, and resident and staff interviews, the facility failed to provide care and services for the provision of hemodialysis consistent with professional standards of practice for 1 of 1 sampled resident (Resident #67) currently receiving [CONDITION(S)]. Failure to follow physicians' orders according to changes in [CONDITION(S)] treatment dates may result in staff failing to administer medications as ordered. Findings include: Review of the facility's [CONDITION(S)] Services Agreement occurred on 12/01/21. This policy, effective 03/01/17, stated, . Provide . medication administration . for each individual resident receiving out-patient [CONDITION(S)] treatment . Review of Resident #67's medical record occurred on all days of survey. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Special Instructions: given on non [CONDITION(S)] days in the AM . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/30/21 at 2:32 p.m. Resident #67 stated he receives [CONDITION(S)] treatments three times a week on Monday, Wednesday, and Friday, but last week's schedule changed due to the holiday. During an interview on 12/01/21 at 12:46 p.m., a managerial nurse (#1) stated, If a [CONDITION(S)] appointment changes then KDU [kidney [CONDITION(S)] unit] sends us a fax of the date changes and the nurse administers or holds medications and adjusts assessments. During an interview on 12/02/21 at 08:10 p.m., a managerial nurse (#1) confirmed staff failed to administered the medication on both non-[CONDITION(S)] days.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free of significant medication errors for 1 of 1 sampled resident (Resident #38) who experienced a significant medication error. Failure of staff to clarify the physician's orders and verify the medication received from pharmacy placed Resident #38 at risk for adverse drug effects. Findings Include: Review of the facility policy Medication Administration Tips occurred on 12/02/21. This policy, revised April 2018, stated, . Check label on MAR [medication administration record] against card or bottle. Review of the facility form [Facility name] Medication Pass Audit Tool occurred on 12/02/21. This form, revised January 2018, stated, . The nurse . verifies medication and strength with order as transcribed in eMAR [electronic medication administration record] 3 times . Follows the 6 rights of med [medication] administration . right med . right dose . Review of the facility policy Ordering and Receiving Controlled Medications occurred on 12/02/21. This policy, revised November 2017, stated, . Upon delivery of a controlled medication, the receiving nurse verifies the medication has a current order before signing the delivery record and accepting the medication. Review of Resident #38's medical record occurred all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's telephone order dated 11/12/21 stated, [MEDICATION(S)] [[MEDICATION(S)] concentrate - a liquid narcotic pain medication] 5 mg [milligrams] = 0.25 mg q [every] 2 hrs [hours] prn [as needed] for pain. Review of Resident #38's Individual Narcotic Record occurred on 12/02/21. This record, dated 11/12/21, showed the facility received [MEDICATION(S)] 100mg/5ml from the pharmacy. Directions for usage stated, Take 0.125ml (2.5mg) PO (orally) q 2 hrs prn severe pain. The facility failed to verify the medication dosage received from pharmacy matched the physician's order in the medical record, which may have resulted in Resident #38 receiving the wrong dose of medication 24 times. During an interview on 12/01/21 at 4:09 p.m., two administrative nurses (#1 and #2) stated the nurse who received the telephone order transcribed the order incorrectly, and entered the order into the eMAR incorrectly. The nurses (#1 and #2) acknowledged the facility staff failed to verify the medication received from the pharmacy matched the order that was in the medical record.

Based on information from the complainant, observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #3) received the services necessary to attain the highest degree of safety possible during medication administration and/or while drinking liquids in bed. Failure to ensure staff provided proper positioning and cueing when giving foods/liquids placed Resident #3 at risk for aspiration. Findings include: The complainant alleged the facility failed to recognize/appropriately respond to a resident's signs/symptoms of dysphagia/aspiration. Review of the facility policy titled Assisting the Resident with Dining occurred on 06/03/21. The policy, revised October 2018, stated, . Assure resident is positioned properly . monitor resident swallowing . Swigert's The Source for Dysphagia, 3rd ed., Pro-Ed, Inc., Texas, 2007, pages 9, 10, 125, and educational handouts, identified, . Signs and Symptoms of Dysphagia . coughing . during a meal . Some patients cough and choke when they aspirate . During the oral intake of . food and/or liquids, it is optimal for a patient to be seated at a 90-degree angle, whether in bed or in a chair. Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue . - Review of Resident #3's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders identified the following: * 05/20/21, Recommend . reg [regular] liquids via [with] covered cup. Speech [Speech Language Pathologist] to assess 4 visits in 6 weeks to assess diet & [and] adjust as appropriate. * 05/21/21, Change liquids to nectar thick no straw - open cup. The current care plan identified, . IDDSI [International Dysphagia Diet Standardization Initiative] 6/soft and bite size, nectar liquids per SLP 5/21 [05/21/21] . I am coughing on foods/fluids. 6/1/21 I was diagnosed with pneumonitis due to inhalation of food and vomit . Observation on 06/02/21 at 10:50 a.m., showed a certified nursing assistant (CNA) (#3) raised the head of Resident #3's bed to an approximate 30-degree angle and repositioned her head on the pillow. The CNA (#3) offered Resident #3 a spoonful of thickened water. During an interview on 06/02/21 at 11:30 a.m., a nurse (#4) stated, [Resident #3] had aspiration pneumonia and is on medications for it. Observations showed the following: * 06/02/21 at 2:29 p.m., a nurse (#4) raised the head of Resident #3's bed to an approximate 30-degree angle. Resident #3 laid in the bed leaning heavily to her left side. The nurse (#4) gave Resident #3 three half teaspoons of thickened water. * 06/03/21 at 7:38 a.m., a CNA (#5) raised the head of Resident #3's bed to an approximate 45-degree angle. Resident #3 laid in the bed leaning heavily to her left side. A nurse (#4) administered Resident #3's medications (liquid and crushed in puree) via teaspoon. The nurse (#4) gave Resident #3 five sips of thickened water via a glass. Resident #3 sputtered/spit water out of her mouth, and had water drooling down her chin. The nurse (#4) wiped the drool from the resident's face. Resident #3 exhibited an immediate weak cough and a delayed stronger cough. During an interview on 06/03/21 at 10:34 a.m., when asked questions regarding positioning Resident #3 prior to food/liquid intake, a therapist (#6) responded, Sitting upright, preferably not in their bed. Upright. When asked if staff should reposition Resident #3 to midline, the therapist (#6) stated, Yes, with her. When asked how staff should offer liquids to Resident #3, the therapist (#6) responded, [Another therapist] made a significant effort regarding getting her a cup. She was looking at some type of cup to regulate the amount of liquid that came out. The facility failed to ensure: * Staff positioned Resident #3's bed as close to 90 degrees as possible prior to food/liquid intake, * Staff repositioned Resident #3 to midline prior to food/liquid intake, * Staff recognized/responded to Resident #3's signs/symptoms of dysphagia/aspiration.

Based on information from the complainant, observation, record review, review of facility policy, and review of professional reference, the facility failed to offer fluids to 3 of 10 sampled residents (Resident #1, #2, and #8) observed during cares and/or requiring staff assistance for fluid intake. Failure to provide assistance with fluid intake may result in dehydration, constipation, and urinary tract infections (UTIs). Findings include: The complainant alleged the facility failed to offer residents liquids throughout the day. Review of the facility policy titled Hydration occurred on 06/03/21. This policy, revised February 2019, stated, . Fluids are offered to the resident during the night and before breakfast in the AM, in addition to the hydration passes during the day. Fluids . will be offered throughout the day. Swigert's The Source for Dysphagia, 3rd ed., Pro-Ed, Inc., Texas, 2007, page 137, identified, . One of the most difficult challenges when working with patients is getting them to take enough thickened liquids to meet their fluid needs. Observation on 06/02/21 at 10:10 a.m., showed no water/fluids available in Resident #1's room. - Review of Resident #2's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan identified, . I am at risk for dehydration . Fluids offered with meals, nutrition breaks and as desired in room . I am at risk for constipation . Encourage fluids with meal and hydration breaks as resident able . Observations showed the following: * 06/02/21 at 1:25 p.m., Two certified nurse assistants (CNA) (#1 and #2) assisted Resident #2 into the bathroom provided toileting cares, transferred Resident #2 back to bed, and exited the room. The CNAs (#1 and #2) failed to offer Resident #2 water prior to leaving the room. * 06/02/21 at 2:19 p.m., Resident #2 asleep in bed. A glass of water sat on the bedside table across the room and out of her reach. * 06/02/21 at 2:45 p.m., Two CNAs (#1 and #2) transferred Resident #2 into her wheelchair and failed to offer water prior to leaving the room. * 06/03/21 at 7:36 a.m., Resident #2 asleep in her bed. A glass of water located on the bedside table at the foot of her bed and out of her reach. - Review of Resident #8's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan identified, . I am at risk for dehydration related to dementia and diuretic use . fluids to be offered . with meals . nutrition breaks in room . I may have constipation . encourage fluids with meals and hydration breaks . Observations on 06/02/21 showed the following: * At 10:28 a.m., No water/fluids available in Resident #8's room. * At 11:02 a.m., Two CNAs (#7 and #8) entered Resident #8's room, assisted with cares, transferred Resident #8 to the wheelchair and exited the room. The CNAs (#7 and #8) failed to offer Resident #8 water/fluids prior to leaving the room. Facility staff failed to ensure Resident #1 and #8 had water in their room, place liquids within Resident #2's reach, and/or assist Resident #2 and #8 with liquid intake.

Based on observation, review of facility policy, review of Center for Disease Control Guidelines (CDC), and staff interview, the facility failed to follow infection control practices for 9 of 22 sampled residents (Residents #12, #22, #52, #37, #48, #60, #95, #106, and #107) and one supplemental resident (Resident #102). Failure to follow proper infection control practices regarding use of dedicated equipment in an isolation room (Resident #37), removal of a soiled mechanical lift sling (Resident #22), hand hygiene (Resident #37, #102, #106, and #107), cleaning of environmental surfaces (Resident #37 and #48), and cleaning of transfer equipment (Resident #12, #52, #60, and #95) has the potential to spread infection to other residents, personnel, and visitors. Findings include: DEDICATED EQUIPMENT IN ISOLATION ROOM Center for Disease Control guidelines for transmission-based precautions, found at http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html, stated, . providing patients who are on Transmission-Based Precautions with dedicated noncritical medical equipment (e.g. (for example), stethoscope, blood pressure cuff, electronic thermometer) has been beneficial for preventing transmission. - Observation on 02/25/20 at 4:27 p.m. showed a certified nursing assistant (CNA) (#2) donned a gown and gloves and entered Resident #37's (contact isolation) room. The CNA (#2) placed his/her personal gait belt on Resident #37's waist and assisted him/her to sit on the toilet. After completing perineal cares, the CNA (#2) transferred Resident #37 to the wheelchair, and removed his/her gown and gloves. Without performing hand hygiene, the CNA removed the gait belt from Resident #37, placed it back around his/her waist, and exited the room. The facility failed to ensure each resident in contact isolation had dedicated noncritical medical equipment. REMOVAL OF A SOILED SLING - Observation on 02/25/20 at 2:49 p.m. showed two CNAs (#11 and #12) transferred Resident #22 from the wheelchair to the bed with the full body mechanical lift. Observation showed Resident #22's pants and the lift sling soiled with urine and bowel movement. The CNAs performed perineal care and placed a clean brief and pants on the resident. The CNAs placed the soiled sling on Resident #22's wheelchair and moved it to the hallway. The CNAs (#11 and #12) failed to remove the soiled sling and send it to laundry and disinfect the wheelchair. HAND HYGIENE Review of the facility policy titled Hand Hygiene occurred on 02/27/20. This policy, dated (MONTH) (YEAR), stated, . Staff must perform hand hygiene (even if gloves are used) . After contact with blood, body fluids . after removing personal protective equipment (e.g., gloves .) . - Observation on 02/25/20 at 10:01 a.m. showed two CNAs (#3 and #4) donned gloves and provided bowel incontinence care for Resident #102 in bed. The CNA (#4) cleansed the rectal area, removed his/her gloves, assisted with the resident's clothing and the lift sling, applied the resident's shoes, positioned the wheelchair, and then performed hand hygiene. The CNA (#4) failed to perform hand hygiene after providing perineal care and prior to completing other tasks. - Observation on 02/25/20 at 10:21 a.m. showed two CNAs (#3 and #8) donned gloves and transferred Resident #106 from the wheelchair to the bed. The CNA (#3) provided bowel incontinence care and removed his/her gloves. Without performing hand hygiene the CNA (#3) applied a clean brief, adjusted the resident's clothing, placed the lift sling under the resident, hooked the sling to the lift, and assisted with Resident #106's transfer into the wheelchair. The CNA (#3) positioned the bedside table near the resident and gave him/her the call light. The CNA (#3) failed to perform hand hygiene after removing gloves and prior to completing other tasks. - Observation on 02/25/20 at 3:03 p.m. showed a CNA (#2) donned gloves and removed Resident #107's soiled incontinence product and then removed his/her gloves. The CNA (#2) donned new gloves, assisted Resident #107 to stand and provided perineal care. The CNA (#2) pulled Resident #107's pants up and assisted him/her in the wheelchair. The CNA (#2) then removed his/her gloves. The CNA (#2) failed to perform hand hygiene after removing gloves and prior to completing other tasks. - Observation on 02/25/20 at 4:27 p.m. showed a CNA (#2) donned a gown and gloves and entered Resident #37's contact isolation room. The CNA (#2) removed Resident #37's soiled incontinence product, performed perineal care and then removed his/her gloves. The CNA pulled up Resident #37's pants and transferred him/her to the wheelchair, removed his/her gown and without performing hand hygiene left the room. The CNA (#2) failed to perform hand hygiene after glove removal and before completing other tasks. DISINFECTION OF ENVIRONMENTAL SURFACES Review of the facility policy titled, Environmental Services - Cleaning occurred on 02/27/20. This policy, dated (MONTH) (YEAR), stated, . Special attention will be paid to cleaning of environmental surfaces in the isolation room, as these surfaces are frequent sources of person-to-person transmission of infection. Guidelines for Environmental Infection Control in Health-Care Facilities Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC) Updated: (MONTH) 2019, Page 83 stated, Associated equipment (e.g., parallel bars . Hoyer lifts, and wheelchairs) can also be potential reservoirs of microorganisms, depending on the materials used in these items. - Observation on all days of survey showed a porous, hard foam padding taped to the assist rails by the toilet and the water supply pipe on the back of the toilet in Resident #37's bathroom (shared with another resident). Observation showed gaps in the foam on the underside of the assist rail, exposing the adhesive surface of the tape and a space between the foam and assist rail. - Observation on 02/25/20 at 11:04 a.m., showed contact isolation supplies outside of Resident #37's room. An interview with a staff nurse (#10) confirmed contact precautions for gastrointestinal symptoms. During an interview on 02/27/20 at 9:30 a.m., an infection control nurse (#1) stated staff clean the foam/tape with a standard disinfectant and confirmed nursing staff is not trained to disinfect shared bathrooms between resident use. - Observation on all days of survey showed a porous, hard foam padding taped to the assist rails by the toilet in Resident #48's bathroom and the edges of the tape coming off the foam, exposing the adhesive surface. Review of Resident #48's medical record occurred on all days of survey. Nurses notes dated 02/25/20 at 9:43 a.m. stated, Resident had a loose stool this shift, placed res. (resident) on contact precautions. During an interview on 02/27/20 at 11:30 a.m., an administrative environmental staff member (#5) stated the facility planned to purchase another type of padding that is less porous. DISINFECTION OF MECHANICAL LIFTS - Observation on 02/24/20 at 4:04 p.m. showed two CNAs (#13 and #15) transferred Resident #60 after a check and change from the bed to the wheelchair using the full body mechanical lift. After the transfer, the CNA (#15) placed the lift in the hallway and failed to disinfect the mechanical lift. - Observation on 02/25/20 at 8:36 a.m. showed two CNAs (#13 and #16) transferred Resident #52 after a check and change from the bed to the wheelchair using the full body mechanical lift. After the transfer, the CNA (#13) brought the lift out to the hallway and failed to disinfect the mechanical lift. - Observation on 02/25/20 at 9:24 a.m. showed two CNAs (#6 and #7) transferred Resident #95 from the wheelchair to the bed using the sit to stand mechanical lift. After the transfer, the CNA (#6) placed the lift in the hallway and failed to disinfect the mechanical lift. - Observation on 02/25/20 at 9:47 a.m. showed two CNAs (#13 and #14) transferred Resident #12 after a check and change from the bed to the wheelchair using the full body mechanical lift. After the transfer, the CNA (#14) brought the lift out to the hallway and failed to disinfect the mechanical lift. During an interview on 02/27/20 at 9:26 a.m., an infection control nurse (#1) stated she expected staff to perform hand hygiene after glove removal, to disinfect the mechanical lifts after use, and take the soiled sling to laundry.

Based on record review, review of facility policy, information from the complainant, and staff interview, the facility failed to notify the physician for 1 of 3 sampled residents with a blood sugar below the ordered parameter readings (Resident #31). Failure to notify the physician of blood sugar results out of ordered parameters may result in complications to the resident and prevented the physician from evaluating/prescribing an appropriate treatment plan. Findings include: Review of the facility policy titled CHANGE IN RESIDENT STATUS occurred on 02/27/20. This policy, revised (MONTH) 2020, stated, . St Benedict's Health Center will notify medical provider, residents and families when there is a significant change in condition, incident or accident that occurs in the facility resulting in injury or a significant change in medications or treatments that occur in the facility . staff will notify emergency contact . Review of Resident #31's medical record occurred on (MONTH) 26 - 27. [DIAGNOSES REDACTED]. The current physician's orders stated, Check Blood Sugars BID (two times a day) and PRN (as needed) for s/s (signs/symptom) of [DIAGNOSES REDACTED] . Notify MD (medical doctor) if blood sugar less than 60 or greater than 400. The (MONTH) 2020 Medication Administration Record [REDACTED]. The medical record lacked evidence the facility notified Resident #31's physician of the blood sugar reading. During an interview on 02/27/20 at 3:05 p.m. an administrative nurse (#9) confirmed she would expect the nurse to notify the physician of any blood sugar results outside of the ordered parameters and document the notification.

Based on information received from the complainant, record review, review of facility policy, and staff interview, the facility failed to ensure the environment remained free of accident hazards for 1 of 1 sampled resident (Resident #5) who fell from a full body lift. Failure to ensure a safe environment resulted in Resident #5's six centimeter (cm) scalp laceration and fractures to her left lower leg (tibia and fibia) and right knee cap (patella). Findings included: Information submitted by the complainant identified the facility failed to transfer Resident #5 in a safe manner. Review of the "MECHANICAL FULL BODY LIFT" policy occurred on 04/13/15. The policy, dated February 2014, stated, ". . . One caregiver will primarily run the lift and the other will manage the resident in the sling. . . ." - Resident #5's medical record, reviewed 04/13/15, identified [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and total assistance required with transfers. The current care plan identified, ". . . Problem: Resident dependent upon staff for transfers . . . Approach: . . . Pt (Patient) to be hoyer lift for all transfers . . ." The progress notes identified the following: * 03/15/15 at 7:15 p.m., "Res (Resident) receive laceration to top of head during Hoyer transfer. CN (charge nurse) called to room to assess Res." * 03/15/15 at 7:50 p.m., "(Physician) called and informed of Res. condition. Orders received to transfer to (emergency room (ER)). . . ." * 03/15/15 at 8:02 p.m., "Res. transferred to (ER) per ambulance." The hospital report, dated 03/15/15, identified, ". . . woman that was being lifted with mechanical sling at care facility. Apparently there was a dysfunction and the patient fell and landed cutting her head. No LOC (loss of consciousness) reported. Pt has laceration on scalp. No other injuries reported. . . . no apparant distress . . . laceration . . . mid parietal scalp 5 cm . . . (extremeties) no evidence of injury . . . Reassessment: . . . Pt mental status stable, CT (computerized tomography) neg (negative) . . . Will return to NH (nursing home). . . ." The progress notes identified the following: * 03/15/15 at 10:00 p.m., "Res. returned from (ER). Res was put in bed. Res has 6 staples in head. . . ." * 03/16/15 at 7:58 a.m., "At 6 am with cares CNAs (certified nursing assistants) reported that res having significant pain s/s (signs/symptoms) with movement of LEs (lower extremeties) and had a small emesis of green bile, approx (approximately) 60 ml (milliliters). CN into assess and res had 3+ edema from shins to thighs bilat. (bilaterally). Bluish/purple bruising around knees bilat. Res would say ouch with even gentle physical manipulation of LEs. Res was saying, "please help me God" over and over and would not respond to CN questions. . . . CN gave resident prn (as needed) Morphine 30 mg (milligrams) . . . for pain which took approximately 20 minutes. CN assesses ER return orders from last evening and only CT of head was done. (Physician) called with orders to send back to ER for evaluation. . . . Res was transferred via ambulance to (ER) at 7:45 a.m. . . . res was diaphoretic upon transferring to ER stretcher. . . ." The hospital report, dated 03/16/15, identified, "Patient to ER via ambulance from (nursing home) as was noted have decreased level of consciousness and pain and swelling to her LE (lower extremeties). Small emesis this morning. Patient fell from a hoyer lift yesterday, and was seen in the ER. Initial CT of head was negative. Patient hypotensive on arrival. Nursing concerned for a possible femur fracture. . . . Clinical Impression: . . . s/p (status [REDACTED]. . . right patellar fracture . . ." The radiology reports, dated 03/16/15, identified, ". . . IMPRESSION: . . . (left) distal tibia and fibular fractures . . . (right) patellar fracture. . . ." During interview on 04/13/15 at 4:22 p.m., four managerial staff members (#1, #2, #3, and #4) provided additional information regarding the 03/15/15 incident. One staff member (#4) reported the two CNAs were transferring Resident #5 to bed when she fell out of the Hoyer lift. A second staff member (#1) described Resident #5 as having her "arms crossed and her legs straightened out." She reported one CNA used one hand to control the lift and the other to guide the resident. She also reported the second CNA stood on the "other side of the bed to receive the resident." The first staff member (#4) then described Resident #5 as falling "out (of the sling) head first." One CNA failed to run the lift and the other failed to managed the resident in the sling. Failure of facility staff to transfer Resident #5 per facility policy resulted in the resident falling from the lift and obtaining a scalp laceration and multiple leg fractures.

Based on record review, the facility failed to provide the necessary care and services to promote optimal well-being for 1 of 1 sampled resident (Resident #20) with unresolved pain and receiving Hospice services. Failure of the facility to develop an effective plan of care and ensure management of Resident #20's continuous pain resulted in the resident experiencing unresolved pain. Findings include: Review of Resident #20's medical record occurred on February 11-12, 2014 and identified an admission to Hospice services on 12/27/13 with a [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. Resident #20's significant change Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition, usually makes self understood, sometimes understands others, and no pain present during the look back period. Current pain medications included [MEDICATION NAME] Patch 5% (percent) and [MEDICATION NAME] 25 micrograms per hour (mcg/hr) (increased from 12.5 mcg/hr on 01/13/14). As needed (PRN) medications included [MEDICATION NAME] liquid 0.5 milliliters (ml) every 6 hours PRN for agitation, [MEDICATION NAME] 0.5 milligrams (mg) every 2 hours PRN for anxiety, [MEDICATION NAME] concentrate (used for moderate to severe pain) 5 mg every 1 hour PRN for pain or dyspnea, and Tylenol 650 mg every 8 hours PRN for pain or fever. Resident #20's current care plan stated, "Problem . . . Pain r/t (related to) chronic back pain, [MEDICAL CONDITION], RLS (restless leg syndrome), [MEDICAL CONDITION] reflux . . . Goal . . . Resident will verbalize complaints of pain and pain will be lessened within 1 hour of receiving pain med (medication) to an intensity of 2/10 . . . Approach . . . Meds as per PO (physician orders) . . . Observe for non-verbal signs and symptoms of pain . . . Question res (resident) verbally if having any complaints of pain . . . Report all complaints of pain to charge nurse . . ." Resident #20's medical record failed to include an individualized care plan revised and updated to reflect Resident #20's current status and addressing Resident #20's unique needs, including directives for managing pain. Review of Resident #20's pain assessments, dated 01/16/14, 01/23/14, and 02/06/14, identified non-verbal sound indicators of pain including calling out, moaning, crying, and anxiety. Review of Resident #20's PRN Medication Administration Record [REDACTED] * [MEDICATION NAME] administered thirty-seven times for moaning/crying/yelling. The facility failed to document the response or the facility documented Resident #20 continued to moan, was restless, yelling or less restless 12 times. * [MEDICATION NAME] administered twelve times for moaning/restless/yelling out. The facility documented the Resident as still yelling or moaning or as less yelling or moaning 6 times. * [MEDICATION NAME] administered nineteen times for moaning/anxiety/yelling out. The facility failed to document the response or the facility documented Resident #20 continued to moan or less moaning or crying out 12 times. The facility stopped administration of [MEDICATION NAME] on 01/27/14 and began the use of [MEDICATION NAME]. The MARs identified Resident #20 received PRN pain medications a total of sixty-nine times for the same nonverbal signs and symptoms of pain. The facility's failure to assess Resident #20's pain and develop a plan of care specific to the signs and symptoms the resident expresses for pain, develop interventions to consistently manage the pain, and evaluate the effectiveness of the interventions resulted in Resident #20 experiencing unresolved pain.

Based on record review, review of facility policy and procedures, review The Long-Term Care Resident Assessment (RAI) User's Manual (Version 3.0), review of information provided by the facility and the complainant, and staff interview, the facility failed to promptly implement interventions for 1 of 1 closed record (Resident #7) with a worsening pressure ulcer. Failure to promptly notify the physician and implement interventions to promote healing resulted in the resident's pressure ulcer rapidly deteriorating and requiring surgical intervention. Findings include: Review of the National Pressure Ulcer Advisory Panel document "Deep Tissue Injury," provided by the facility, occurred on 11/20/13. The undated document stated, ". . . deep tissue injury represents a dangerous lesion due to its potential for rapid deterioration. . . . a deep tissue injury may present as a serum blister or blood blister . . ." Review of the facility Clinical Practice Guide "Stage II Pressure Ulcer/Partial Thickness Wound" occurred on 11/20/13. The undated document stated, "Objective: To prevent wound deterioration, provide appropriate local management to optimize healing potential . . . Stage II: Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents as an abrasion, blister, or shallow crater. . . . Note: If wound deteriorates or fails to progress after one to two weeks of appropriate management, notify physician or wound care specialist . . ." Review of the facility Clinical Practice Guide "Full Thickness Wound / Stage III / Stage IV Pressure Ulcer" occurred on 11/20/13. The document stated, ". . . Stage III; Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. . . . Note; If wound contains slough or necrotic tissue that is firmly adherent to the wound bed, employ debridement method that is appropriate, considering the patient's overall condition . . . (See 'Addendum - Management of Necrotic (dead) Tissue'). . . Review of the facility Addendum "Management of Necrotic Tissue (dead tissue)" occurred on 11/20/13. The document stated, ". . . Ulcer Characteristics: Necrotic tissue may appear as moist, loose or firmly adherent yellow greenish, gray, black or brown slough, or as dry dark brown to black, leathery eschar that covers a portion of the wound or its entirety. Necrotic tissue harbors bacteria, supports bacterial growth and in most cases, should be removed in order for healing to progress . . ." The Long-Term Care Facility RAI User's Manual, May 2013, stated the following: * Pages M-16 - M-17 (Pressure Ulcers) 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. Eschar Tissue: 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 side/edges of the wound. . . ." Review of the facility procedure "Skin Integrity Team" occurred on 11/20/13. The procedure, revised December 2005, stated, "OBJECTIVE: . . . d. Changes in condition are recognized, evaluated, reported to practitioner, and addressed. . . . PROCEDURE: . . . 2. The skin Integrity Team documents in each record reviewed a. adequacy of healing/treatments b. Recommendations for treatment changes or plan of care revisions/additions. . . ." Review of the facility document "Pressure Ulcer/ Wound Record Completion Instructions" occurred on 11/20/13. The undated document stated, ". . . 2. Identify the wound type. a. For Pressure Ulcers, stage the wound . . .If the pressure (sic) deteriorates to higher stage, note the new stage and date in the appropriate box. . . ." - Review of Resident #7's closed medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #7 required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; was frequently incontinent of bowel and bladder; and had no current pressure ulcers. The MDS identified the resident at risk for pressure ulcers with the following interventions in place: pressure reducing devices in the chair and bed and a turning and repositioning program. An "Event Report," dated 06/13/13 at 6:45 a.m., identified a "blood blister" to the resident's coccyx with no dimensions recorded. The report identified staff notified the physician of the blister on 06/13/13 at 6:45 a.m. On 06/14/13 the Pressure Ulcer/ Wound record identified an open area to Resident #7's "coccyx/sacrum" measuring 0.5 centimeters (cm) by 0.2 cm with light sanguineous drainage and no odor. The wound sheet failed to identify the wound type or stage. The record indicated staff applied an Allevyn (a foam dressing) to the wound, but lacked evidence staff notified the physician of the change in the wound. A progress note, dated 06/19/13 at 11:51 a.m., stated, "Skin committee noted yesterday that (Resident #7) has blood blister to coccyx. Completed Nutritional Flow Sheet for Wound Healing. . . ." The Nutritional Flow Sheet for Wound Healing, dated 06/19/13 at 11:46 a.m. stated, "Current interventions are appropriate will not recommend MVI (multivitamin with iron) (with) minerals @ (at) this time d/t (due to) good meal intakes." The progress note and Nutritional Flow Sheet failed to identify the wound had opened and was no longer a blood blister and failed to show interventions to address the changes to the wound, which occurred four days before the skin committee met. A progress note, dated 06/22/13 at 1:26 p.m. stated, "Dressing changed to coccyx area, old dressing 3/4 saturated with serous drainage, wound is worsening with more area and more depth noted from previous, wound bed is white, surrounding tissue is red and intact . . ." The wound sheet showed the dimensions had markedly increased to 1.5 cm by 2.0 cm with a depth of 0.1 cm and "very odorous" with slough present. Although the pressure ulcer showed a significant change over an eight day period, the record lacked evidence staff notified the physician of the increased size, drainage, redness, and odor or considered alternative treatments. The record indicated the wound continued to increase in size. On 06/28/13, the wound sheet identified the dimensions as 2.2 cm by 2.2 cm with 50% slough and a "heavy" odor and "tender (with) manipulations" with "purple/black" surrounding tissue. The record lacked evidence staff notified the physician of the changes in the wound or considered alternative treatments. A progress note, dated 07/01/13 at 11:01 p.m., stated, "Dressing changed to coccyx. Wound bed noted to (sic) yellowish/green outside with purple, green, and brown middle. Moderate amount of brown drainage noted on old dressing." A fax communication to the physician, dated 07/01/13 (time not documented), described the wound and stated, "? (question) use of topical oint (ointment) & (and) would you be able to assess. Resident currently has Allevyn in place." A response from a Nurse Practitioner (GNP) on 07/02/13 (time not documented), stated, "1) Culture area 2) Bactoban to area tid (three times a day)." Wound records identified, on 07/05/13, the wound increased in size to 3 cm by 3.3 cm with a depth of 0.1 cm and was covered with 50% slough and 50% necrotic/eschar. The record lacked evidence staff notified the physician or NP of the increased size or necrotic eschar present on the wound. A progress note, dated 07/05/13 at 6:46 p.m., stated, "would (sic) culture report received; placed in res (resident's) chart." The record lacked evidence staff notified the physician or NP of the culture results. A progress note, dated 07/06/13 at 6:09 p.m., stated, "Lab report returned from (local lab), copy forwarded to infection control nurse, no new orders, observed." The record again failed to show staff notified the physician or NP of the results. The final culture report, dated 07/06/13 at 11:30 a.m. and faxed to the facility on [DATE] at 3:25 p.m., showed three organisms present: Staphylococcus aureus, [DIAGNOSES REDACTED] pneumoniae, and [MEDICATION NAME] cloacae. The report indicated all three organisms susceptible to the antibiotics [MEDICATION NAME] and Bactrim. The Nursing 2013 Drug Handbook, Lippincott, Williams, and Wilkins, Philadelphia, Pennsylvania, page 943, identified [MEDICATION NAME] as an antibacterial ointment indicated for traumatic [MEDICAL CONDITION] infected with Staphylococcus aureus, but did not indicate [MEDICATION NAME] effective for [DIAGNOSES REDACTED] pneumoniae and [MEDICATION NAME] cloacae. A progress note, dated 07/10/13 at 8:07 a.m. stated, "Skin committee noted area to buttocks is larger and wound was cultured. . . . Will fax MD (medical doctor) to recommend MVI with minerals and will start 4 oz (ounces) supplement bid (twice a day) per supplement s.o. (standing order)." Although the blister changed to an open wound on 06/14/13 and continued to deteriorate over the next three weeks, the skin committee failed to recognize the deterioration or implement aggressive interventions to address the changes in the wound until 22 days after the pressure ulcer developed. On 07/11/13 the wound sheets revealed further deterioration of the wound. The ulcer measured 3.8 cm by 3 cm with 1 cm depth with an odor and the wound covered with 20% slough and 80% eschar. The record showed the NP examined Resident #7 at the facility on 07/11/13 and wrote an order for [REDACTED]. . . reviewed culture report = will start bactrim ds . . . Nursing staff question if Kennedy terminal ulcer. . . ." The NP's review of the culture and initiation of the antibiotic occurred 5 days after the facility received the final culture report. The record lacked evidence staff informed the NP immediately of the culture results. The record failed to identify the skin committee considered a Kennedy ulcer or that the MD or NP diagnosed a Kennedy ulcer. The record showed on 07/12/13 the physician ordered hourly turning and repositioning for Resident #7. On 07/12/13 at 12:56 p.m. the NP ordered [MEDICATION NAME] (an enzymatic ointment to debride the wound) and to hold the [MEDICATION NAME] until PT completed wound care. A PT "Therapist Progress & Discharge Summary," dated 07/16/13, indicated the PT started therapy on 07/11/13 and ended on 07/16/13. The summary stated, "Current Level of Function; The patient exhibits sacral ulcer Stage 3 measuring 3 cm in width by 3.8 cm in length by 1.3 in depth and characterized by odor drainage tunneling (wound extending under the skin). . . . attempted debridement times 2. . . . Patient may not improve even with wound care. . . ." On 07/17/13 at 2:33 p.m. the NP wrote orders for nursing to perform the dressing changes daily applying [MEDICATION NAME] and an Allevyn dressing. On 07/19/13, the wound record identified the ulcer as 4.5 cm by 3.5 cm with a depth of 2.8 cm and covered with 25% slough and 75 % eschar, [DIAGNOSES REDACTED] (redness) of the surrounding tissue, and tunneling. Review of Resident #7's current care plan, dated 12/20/12, identified a problem: "At moderate risk for pressure sores. . . ." The care plan failed to identify Resident #7's current unstageable pressure ulcer. The record identified Resident #7 had a clinic appointment with the MD on 07/22/13. At that time the physician admitted the resident to a local hospital for treatment. A transfer sheet, dated 07/22/13 stated, " . . . Reason for Transfer: Admit from clinic for wound care . . . Skin Condition & Treatments: Stage 4 pressure ulcer bottom . . ." Information provided by the complainant identified the following: * A hospital history and physical, dated 07/22/13 stated, ". . . Plan: I am extremely concerned about the overall well-being of the patient and have made the decision to admit her as an inpatient and perform a debridement of the wound with bone and tissue cultures tomorrow in the operating room. I will also plan on placing a wound VAC (vacuum) if the wound is clean enough . . . I have started the patient on [MEDICATION NAME] (an antibiotic) and [MEDICATION NAME] (an antibiotic) for suspected multi-drug-resistant osteo[DIAGNOSES REDACTED] in the wound bed. . . ." * An operative report, dated 07/23/13, stated, "OPERATION PERFORMED: 1. Debridement of sacrococcygeal stage IV decubitus ulcer associated full thickness debridement of necrotic bone, muscle, subcutaneous fat and skin. . . . POSTOPERATIVE PLAN: Due to the depth of the patient's wound and my concern that she potentially would need a flap procedure and will potentially need further sequential operative debridement, I do think the (sic) that the level of ongoing care that her needs exceed the level of care available in our critical access hospital. I discussed with her daughter that I will be transferring her mother to (name of tertiary hospital) so that she could have ask (sic) access to plastic surgery services and ongoing inpatient wound care which she will likely need for several weeks. . . ." An interview with an administrative nurse (#1) occurred on 11/19/13 at 10:55 a.m. The nurse stated the facility did a root cause analysis regarding Resident #7's pressure ulcer and determined the ulcer may have been a deep tissue injury resulting from a fall on 05/21/13 when the resident fell in the shower. A fax to the physician, dated 05/21/13 at 2:00 p.m. stated, "witnessed fall in shower room, leaned to (sic) far forward, fell into CNA (Certified Nursing Assistant); no injuries noted." Record review identified staff monitored the resident daily following the fall until 05/28/13 and failed to identify any bruise or injury until 06/13/13 when staff identified the blood blister to the coccyx. A second interview with the administrative nurse (#1) occurred on 11/19/13 at 3:00 p.m. When asked, the nurse stated the skin committee meets weekly and discusses all residents with skin issues at that time. When requested, the nurse (#1) stated the committee does not keep notes from the meetings. An interview with two administrative nurses (#1 and #3) occurred on 11/20/13 at 7:30 a.m. The nurses stated staff usually continue treatment for two weeks before consulting the physician for a change in treatment. The nurses stated they did consider that Resident #7 may have had a Kennedy ulcer, but because she did not have weight loss or other conditions usually associated with that type of ulcer, they could not determine it was or was not a Kennedy ulcer. The facility's failure to promptly consult the physician and implement aggressive treatment/interventions for Resident #7's rapidly deteriorating coccyx ulcer resulted in the resident requiring hospitalization for surgical debridement and treatment for suspected osteo[DIAGNOSES REDACTED] which, according to the surgeon, would likely require addition surgical procedures.