Every finding on record at St Gabriel's Community

Based on record review, review of facility policy, and family and staff interview, the facility failed to notify the resident representative for 1 of 1 closed resident (Resident #1) reviewed for wounds/pressure injuries. Failure to notify the resident representative about new wounds/pressure injuries, changes to existing wounds/pressure injuries, and new/changes in treatment orders for these injuries does not allow the resident representative to be informed and make decisions significant to the resident's health and care. Findings include:Review of the facility policy titled Prevention and Treatment of Skin Breakdown occurred on 02/12/26. This policy, dated 2018, stated, . Weekly skin audits are performed by a licensed nurse. If a . new pressure injury or lower extremity wound develops . Notify attending provider, resident and resident representative. Educate resident/resident representative on skin wound/pressure injury and care plan interventions. Notify the attending provider, resident/resident representative . if the pressure injury has not shown progress in 2 weeks and/or is deteriorating unexpectedly. Documentation reflects areas as addressed above.Review of Resident #1's medical record occurred on 02/12/26 and identified wounds to the buttocks and right back heel. A comprehensive Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive impairment. Progress notes identified the following wounds/pressure injuries: -Right medial buttock:*09/29/25, Redness and moisture associated skin damage (MASD). *11/05/25, New MASD with excoriation (raw irritated skin lesions).-Right back heel: *11/11/25, New suspected deep tissue injury (SDTI) with different shades of purple discoloration.*11/18/25, The SDTI now an unstageable pressure ulcer with mostly black eschar [dead skin tissue].*11/20/25, Provider orders for an urgent referral to podiatry. Resident #1's medical record lacked documentation the facility notified the resident's representative about the wounds/pressure ulcers to the right buttock and right back heel, treatments, and new orders.During an interview on 02/12/25 at 12:05 p.m., a family member stated they were not aware of the buttock wound and the facility did not notify them about the right back heel ulcer. During an interview on 02/12/25 at 4:09 p.m., a staff nurse (#2) confirmed the facility's policy is to notify resident families of new wounds, changes in existing wounds, and orders/treatments for these wounds.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 17 sampled residents (Residents #25). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: Review of Resident #25's medical record occurred on all days of survey and identified hospitalizations from 02/28/25 to 03/03/25 for a urinary tract infection and from 04/09/25 to 04/10/25 for hematuria (blood in the urine). Active diagnosis included malignant neoplasm of the bladder. Medications included Bactrim DS (an antibiotic) for seven days, initiated on 03/03/25. SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised October 2024, pages I-5 and I-8, stated, . Active Diagnoses in the Last 7 Days - Check all that apply . Coding Instructions. Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status . medical treatments, nursing monitoring . during the 7-day look-back period . Resident #25's significant change MDS, dated [DATE], and a quarterly MDS, dated [DATE], showed the facility failed to code the diagnosis of cancer at Section I0100. SECTION J: HEALTH CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2024, pages J-29 through J-30, stated, . J1550: Problem Conditions (cont.) . Steps for Assessment 1. Review the medical record, interview staff . for any indications that the resident had . internal bleeding during the 7-day look-back period. Coding Instructions. Check all that apply . J1550D, internal bleeding . Coding Tips . Internal bleeding . Clinical indicators include . hematuria . Resident #25's quarterly MDS, dated [DATE], showed the facility failed to code Section J1550D, internal bleeding. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2024, pages N-4 and N-6, stated, . N0415: HIGH-RISK DRUG CLASSES: Uses and Indication . Coding Instructions. Code all high-risk drug class medications . Column 1: Check if the resident is taking any medications by pharmacological classification during the 7-day observation period . Resident #25's quarterly MDS, dated [DATE], showed the facility failed to code Section N0415F, antibiotic. During an interview on 06/26/25 at 10:36 a.m., an MDS staff member (#7) confirmed staff failed to accurately code the MDS.

Based on observation, record review, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure staff followed professional standards of practice for 1 of 2 sampled residents (Resident #26) reviewed for insulin use and 1 of 6 sampled residents (Resident #41) observed during insulin preparation. Failure to follow physician's orders for out-of-range blood sugar levels and failure to properly prime insulin pens may result in residents receiving an inaccurate dose of insulin and/or result in adverse health events. Findings include: Review of the manufacturer's instructions for the Humalog [a type of insulin]Kwik Pen occurred on 06/26/25. These instructions, revised May 2025, stated, . Priming your pen . priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly . if you do not prime the pen before each injection, you may get too much or too little insulin . to prime your pen, turn the dose knob to select 2 units . hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top of the cartridge . continue holding your pen with needle pointing up . push the dose knob until it stops . you should see insulin at the tip of the needle . Review of the facility policy titled Diabetic Management occurred on 06/26/25. This policy, dated 2001, stated, . The care and services to manage diabetes mellitus is directed by the providers orders and relevant protocols and guidelines. - Review of Resident #26's medical record occurred on all days of survey. Diagnoses included diabetes mellitus. Physician's orders stated, Blood sugar checks TID [three times a day] Call PCP [primary care provider] if blood glucose is greater than 400 [milligrams per deciliter (mg/dl)] or less than 70 . Review of Resident #26's blood sugar levels from March 26, 2025 through June 24, 2025 identified the following: * 04/16/25 at 7:32 p.m., 455 mg/dl * 05/20/25 at 8:18 p.m., 454 mg/dl * 06/02/25 at 8:04 p.m., 484 mg/dl * 06/04/25 at 7:57 p.m., 459 mg/dl Resident #26's medical record lacked documentation staff notified the physician regarding the blood sugar levels over 400 mg/dl. - Observations on 06/24/25 at 12:10 p.m. and 5:03 p.m. showed a nurse (#5) primed Resident #41's insulin pen horizontally. During interviews on 06/26/25 at 11:49 a.m., and 12:28 p.m., administrative nurse (#1), stated she expected nursing staff to prime the insulin pen with the needle pointing up and notify the physician regarding out of range blood sugar levels.

Based on record review, policy and procedure review, and staff interview, the facility failed to ensure appropriate care and services for 1 of 1 sampled resident (Resident #117) reviewed for fecal impaction. Failure to follow bowel protocol interventions may have contributed to Resident #117's fecal impaction. Findings include: Review of the facility policy, Bowel Management Protocol, occurred on 06/25/25. This undated policy stated, Purpose: To ensure proper bowel function and management. Procedure: 1. Bowel management report will be pulled daily. Nurse will refer to bowel protocol if no bowel movement unless otherwise indicated. * Day 3 (greater than 48 hours since last BM [bowel movement]) - offer 4 ounces prune juice - if no results - Senna [medication for constipation] 2 tablets PO [per oral] per SHO [Standing House Orders] Utilize SHO for additional Bowel management options. * Day 4 (greater than 72 hours since last BM) - Bisacodyl Suppository [medication for constipation] 10 mg [milligrams] rectally per SHO. If no results - Complete Bowel Assessment and notify Provider of assessment findings that may indicate the need for further intervention. Day 5 (greater than 96 hours since last BM) Complete Bowel Assessment and contract Provider for further instructions. Review of the Standing House Orders for Symptom Management occurred on 06/25/25. This document, dated February 2025, stated, The following Standing House Orders for Symptom Management are to provide support and palliation to patients/residents . Bowel: Constipation (if no bowel movement in [greater than] 48 hours; Perform steps sequentially) * Consider rectal check to determine if impaction is present. * Encourage 2000 ml [milliliters] daily fluid intake . * Consult nutrition services for dietary recommendations. * Give Sennoside 8.6 mg 2 tablets by mouth daily PRN [as needed] . if no BM by day three, offer/give Bisacodyl suppository 10 mg: rectally . * Reattempt Senna or Bisacodyl if no results after 24 hours and notify provider. Review of Resident #117's medical record occurred on all days of survey. The care plan stated, Problem Start Date: 10/02/2024 I am at risk for constipation related to impaired mobility, variable meal intakes, . and hx [history] of constipation. Long Term Goal . I will have a BM [bowel movement] at least every 4 days . Approach Start Date: 10/02/24 Administer meds as ordered, observe for effectiveness and side effects . Follow facility bowel protocol . Monitor my bowel patterns and for s/s [signs/symptoms] of constipation . Review of nurse's notes identified the following: 06/04/25 at 2:30 p.m., CNA [certified nursing aide] reported at shift change that guest requested Prune juice earlier today. 06/05/25 10:51 a.m., Guest had an unresponsive episode in the dining room where he became pale and hypotensive. Three staff members attempted to wake him up and he opened his eyes, but he was not able to talk. EMS [emergency medical system] was called and they arrived several minutes later .Guest left with EMS .and guest was then taken to [name of hospital] . 06/05/25 at 4:51 p.m., Guest is being admitted . for UTI [urinary tract infection]/fecal impaction. 06/08/25 at 2:20 p.m., Guest returned . was recently admitted to [name of hospital] r/t UTI and fecal impaction, guest has been having bowel movements, last BM today, received orders for new laxatives . Review of the Physician's History and Physical, dated 06/05/25, stated, . CT [computed tomography] scan [abdominal imaging procedure] showing a large stool burden - continue aggressive bowel regimen and enema . He [resident] states he has been having more trouble with stooling lately . he was given an enema in the ED [emergency department] . Review of Resident #117's bowel movement log showed a medium bowel movement on 06/01/25 and no further bowel movement prior to Resident #117's hospitalization on 06/05/25. The medical record failed to show staff initiated the bowel protocol on 06/04/25 (Day 3 -greater than 48 hours since last bowel movement) and failed to show nursing staff administered Senna or implemented any of the other interventions in the SHO after the resident failed to have a bowel movement after requesting prune juice. During an interview on 06/25/25, an administrative nurse (#1) confirmed the medical record lacked evidence nursing staff implemented the bowel management protocol interventions.

Based on review of a facility reported incident (FRI) investigation, record review, review of facility policy, and staff interview, the facility failed to ensure adequate supervision and/or monitoring for 1 of 1 sampled resident (Resident #49) with an elopement. Failure to identify the resident's risk for elopement and implement, monitor, and modify individualized resident-centered interventions when necessary placed all residents at risk for elopement and injuries.Findings include:The facility reported incident investigation, dated 06/15/25, stated footage showed Resident #49 exited the front doors of the facility at 6:31 p.m. and at 6:40 p.m., resident is seen walking in parking lot using her 4WW [wheeled walker] going east towards [NAME] street . The investigation stated a bystander notified the facility by phone at 8:01 p.m. of Resident 49's elopement and whereabouts. Review of the facility policy titled Elopement occurred on 06/26/25. This policy, dated December 2024, stated, . Purpose . To maintain safety of residents who are at risk of wandering and/or active elopement. Policy: Associates will engage in interventions to prevent wandering and active elopement. The nurse or social services will evaluate each resident's potential for wandering upon admission and as needed.Review of Resident #49's medical record occurred on all days of survey and identified admission to the facility on [DATE]. Diagnosis included dementia. The care plan, dated 06/16/25, stated, . I may wander about in my environment I have been known to exit seek and have a history of elopement.Resident #49's progress notes included the following:* 05/21/25 at 9:25 p.m. Guest is noted to be confused- talking about going 'upstairs' to get her stuff; looking for 'the car' that they used in the party last night; looking for people that her husband brought with him to their house tonight. Guest was reminded that she is currently in the nursing home; agreed to stay and sleep here tonight .* 05/23/25 6:48 at a.m. Presented to nurses station w/ [with] her water cup and a water bottle in her night gown. Said dhe (sic) was looking for water and found it. She is now heading to Bowling, SD [South Dakota]. She says her car is out front and she plans on taking that. I asked her if she would like to get dressed before she left and she agreed to that. Was walked back to her room and was able to be redirected.* 05/23/25 at 2:34 p.m. completed 5 day assessment: triggered severe for cognition .* 05/24/25 at 9:44 p.m. was noted wandering the hall ways, getting inside 151 room.* 5/26/25 at 1:23 p.m. has been noted to be wandering into the therapy room when no staff are in there without her walker.*05/26/25 at 8:41 p.m. was seen wandering around and was seen sitting at room [ROOM NUMBER].* 05/27/25 at 7:19 a.m. was found wandering in the 100's hall this AM after report. Unit doors were closed for safety.* 05/27/25 at 9:56 p.m. was found at 1930 [7:30 p.m.] standing with her walker outside 157's room. Stated she didn't know where she was.* 05/30/25 at 9:08 p.m. Noted to be wandering a lot this evening on the hallways .* 05/31/25 at 12:03 p.m. was found wandering on a neighboring unit . before lunch. Guest was brought back and doors to . unit were shut.* 06/01/25 at 8:42 a.m. has been found wandering off unit, in halls in other guests rooms.* 06/01/25 at 11:50 a.m. found at the end of the 50's hall standing facing the door.* 06/07/25 at 4:25 p.m. has been wandering throughout . halls excessively this afternoon. Occasionally goes to unlocked double doors and looks out. Stated she is 'trying to see where my car is so I can go home' . Has looked into several guests rooms .* 06/14/25 at 9:48 p.m. restless tonight.* 06/15/2025 at 8:45 p.m. exited the building at 6:30 pm with 4WW. Facility staff alerted via a telephone by bystander sitting on her walker off campus. I told bystander to stay with guest until staff got there. Author arrived and found guest sitting on her walker with bystanders. She was communicating with them, but noted to be confused and stated she was in Wisconsin. She appeared calm and not in distressed but fatigued. Resident then transferred into the car without issue. Upon return to facility guest was assessed, she was given a snack and fluids. VS [vital signs] and skin assessed. HS [hour of sleep] cares were done and guest requested her CPAP [continuous positive airway pressure]. Order obtained for a wander guard and the wander guard was placed on her Rt [right] wrist.Resident 49's medical record showed an initial care conference on 06/03/25 but failed to address the wandering. During an interview on 06/26/25 at 11:12 a.m., an administrative staff member (#1) verified the facility lacked documentation of an assessment of Resident #49's elopement risk related to the resident's behaviors after admission. The facility failed to reevaluate Resident #49's elopement risk when she began exhibiting wandering behaviors, looking for her car, and wanting to leave the facility, The facility failed to recognize the behaviors as possible signs of elopement and implement individualized interventions to prevent an elopement.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 2 sampled residents (Resident #12 and #117) in Enhanced Barrier Precautions (EBP). Failure to practice infection control standards related to EBP has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 06/25/25. This policy, dated 04/01/24, stated, . Procedure: Enhanced Barrier Precautions expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated. It also refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multi-drug resistant organisms] to staff hands and clothing. Enhanced Barrier Precautions: Applies to: All residents with any of the following: . Chronic wounds . urinary catheters . PPE used for these situations: During high-contact resident care activities . Transferring . Changing briefs or assisting with toileting . Chronic wound care: any skin opening requiring a dressing . - Review of Resident #12's medical record occurred on all days of survey. The care plan stated, . I require Enhanced Barrier Precautions r/t [related to] presence of indwelling foley catheter . Observation on 06/24/25 at 8:38 a.m. showed a nurse (#5) and a certified nurse aide (CNA) (#6) wore appropriate PPE in Resident #12's room while performing wound cares in bed. After completing the wound cares, the CNA (#6) removed her gown and gloves, performed hand hygiene, and applied new gloves. Without wearing a gown, the CNA assisted the nurse to place a sling underneath the resident and utilized a full body ceiling lift to transfer the resident to a recliner. - Review of Resident #117's medical record occurred on all days of survey. The resident's care plan stated, Problem . I require Enhanced Barrier Precautions r/t presence of indwelling foley . Observation on 06/24/25 at 9:30 a.m. showed two CNAs (#3 and #4) entered Resident #117's room, applied gloves, and without donning a gown, assisted the resident to transfer from his bed to the wheelchair. The CNAs (#3 and #4) failed to apply gowns prior to the transfer. During an interview on 06/26/25 at 8:53 a.m., an administrative staff member (#2) stated she expected staff to wear gowns during high-contact resident cares/transfers for residents on EBP.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 6 of 15 sampled residents (Resident #15, #19, #30, #55, #59, and #65) observed during cares. Failure to practice infection control standards related to use of personal protective equipment (PPE) and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 06/12/24. This policy, dated June 2017, stated, . Hand hygiene simply means cleaning hands using either handwashing (washing hands with soap and water), or antiseptic hand rub (i.e. alcohol-based hand sanitizer, including foam or gel). Times to Perform Hand Hygiene are, but not limited to: . Before and after direct resident contact . Before and after entering isolation precaution setting . Before and after assisting a resident with personal cares . Before and after handling peripheral vascular catheters and other invasive devices . Before and after assisting a resident with toileting - wash hands with soap and water . after contact with a resident's mucous membranes and body fluids or excretions . After handling soiled or used linens, dressings, bedpans, catheters and urinals . After removing gloves or aprons . Review of the facility policy titled Enhanced Barrier Precautions occurred on 06/12/24. This policy, dated April 2024, stated, .Enhanced Barrier Precautions (EBP) expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated. Indwelling medical devices (e.g. central lines.) . - Observation on 06/11/24 at 7:59 a.m. showed Resident #55 lying in bed and a PPE cart located outside the room with an Enhanced Barrier Precautions sign on top of the cart. Two certified nurse aides (CNAs) (#5 and #6) donned gowns and gloves and entered the room. The CNA (#5) assisted the resident from the bed to the bathroom and onto the toilet. The CNA assisted the resident to remove her night clothes, removed her gloves, applied new gloves, and offered the resident a washcloth for morning cares. The CNA (#5) placed a paper towel on the floor, obtained a graduated container, emptied Resident #55's urine collection bag into the container, removed her gloves, applied new gloves, applied the resident's knee length socks, secured the urine collection bag to the resident's left leg, assisted the resident with her brief, pants, and shoes, removed her gloves, and applied new gloves. The CNA (#5) placed the resident's walker in front of the resident to stand, completed perineal cares, removed her gloves, applied new gloves, and assisted the resident to pull up her brief and pants. The CNA removed her gloves, applied new gloves, assisted the resident to the sink, handed her a toothbrush/toothpaste, and began combing the resident's hair. The CNA emptied the container of urine into the toilet, removed her gloves, obtained the resident's glasses from the nightstand, gave the glasses to the resident, applied new gloves, and assisted the resident out of the bathroom. The resident ambulated out of the room to the dining room, both CNAs performed hand hygiene and exited the room. The CNA (#5) failed to complete hand hygiene between glove changes, after handling the resident's urine collection bag and graduated container and before touching other surfaces. - Observation on 06/11/24 at 9:08 a.m., showed Resident #59 seated on the toilet. Two CNAs (#8 and #9) entered the room, performed hand hygiene and donned gloves. The CNA (#8) provided perineal care, removed her gloves, and without performing hand hygiene, applied new gloves and transferred Resident #59 to the wheelchair. The CNA (#8) failed to perform hand hygiene between glove changes when performing perineal care. - Observation on 06/11/24 at 9:17 a.m. showed the CNA (#7) donned gloves, assisted Resident #15 onto the toilet, completed perineal cares, removed her gloves, applied new gloves, discarded the wet brief into the garbage, removed her gloves, applied new gloves, assisted the resident with a clean brief and pulled up her pants. With the same gloves, CNA (#7) guided the resident into the recliner chair, placed the call light, applied the oxygen nasal cannula, turned on the oxygen concentrator machine, removed her gloves, hand sanitized, and exited the room. The CNA (#7) failed to complete hand hygiene between glove changes and when toileting a resident. - Observation on 06/11/24 at 12:53 p.m. showed Resident #19 seated in a wheelchair in his room and PPE cart located outside the room with an Enhanced Barrier Precautions sign on top of the cart. Two CNAs (#1 and #2) donned gowns and gloves, entered the room, and transferred Resident #19 from the wheelchair to the bed. The CNA (#2) emptied the contents of the resident's urine collection bag into a graduated container. Without removing the gloves or performing hand hygiene, the CNA (#2) adjusted the resident in bed and placed the call light. The CNAs (#1 and #2) removed their gowns and gloves, performed hand hygiene, and exited the room. The CNA (#2) failed to change gloves and perform hand hygiene after handling the resident's urine collection bag and graduated container and before touching other surfaces. - Observation on 06/11/24 at 1:28 p.m. showed Resident #30 seated in a wheelchair in his room and a PPE cart located outside the room with an Enhanced Barrier Precautions sign on top of the cart. The CNA (#7) donned a gown and gloves, entered the room, applied a gait belt, positioned the walker in front of the resident, and assisted Resident #30 into the bathroom. The CNA lowered the resident's pants and brief and assisted the resident to sit on the toilet. The CNA removed her gloves, applied a new pair of gloves, obtained a graduated container, emptied the resident's urine collection bag into the container, removed her gloves, applied new gloves, and prepared the resident's bed, lowered the covers and adjusted the pillow. The CNA removed her gown and gloves and exited the room to get a package of disposable wipes. The CNA (#7) returned with the package of wipes, failed to hand sanitize, donned a gown and gloves, and entered the resident room. While in the resident's bathroom, the CNA removed the resident's brief, removed her gloves, applied new gloves, assisted the resident with a clean brief, assisted the resident to stand, used the disposable wipes to cleanse the rectal area following a bowel movement, removed the gloves, applied new gloves, secured the brief, pulled the resident's pants up, and held onto the gait belt as the resident walked to the bed. The CNA removed the gloves, applied new gloves, covered the resident with the blanket, placed the TV control and bedside table next to the resident. The CNA removed the gloves, applied new gloves, discarded the urine contents into the toilet, removed the gloves, applied new gloves, removed the garbage bag from the bathroom, removed her PPE, hand sanitized, and exited the room. The CNA (#7) failed to complete hand hygiene between glove changes when toileting a resident, and exiting/returning to a resident room in EBP. During an interview on 06/12/24 at 12:40 p.m. an administrative nurse (#3) stated she expected staff to remove gloves and perform hand hygiene when moving from a dirty to clean task and when changing gloves. Observations on the mornings of 06/10/24 and 06/11/24 showed a PPE cart located outside of Resident #65's room with an Enhanced Barrier Precautions sign and a bottle of hand sanitizer on top of the cart and PPE (i.e., gowns and gloves) located within the drawers of the cart. Observation on 06/12/24 at 8:18 a.m. of an intravenous (IV) antibiotic administration through Resident #65's Peripherally Inserted Central Catheter (PICC) line showed a lack of a PPE cart outside of Resident #65's room. The staff nurse (#10) performed hand hygiene, donned gloves, administered IV antibiotic, removed the gloves, performed hand hygiene, and exited Resident #65's room. During an interview on the morning of 06/12/24, the staff nurse (#10) stated she hadn't worked this unit in a while and was unaware if Resident #65 was on any precautions. The staff nurse (#10) failed to don appropriate PPE when entering Resident #65's room according to the residents' EBP. During an interview on the morning of 06/12/24, an administrative nurse (#3) confirmed Resident #65 continued to be on EBP. 42397 46964

Based on record review, family interview, and staff interview, the facility failed to notify the physician of a resident's rejection of a prescribed medication for 1 of 1 sampled resident (Resident #2) with a pattern of refusing a medication. Failure to notify the physician of the rejection of Ativan (antianxiety medication) may have prevented the physician from altering the treatment/care provided to the resident. Findings include: Upon request for a policy, on 06/11/24 at 5:30 p.m., an administrative nurse (#4) stated the facility does not have a policy related to notification of the physician. During an interview on the afternoon of 06/10/24, a family member (#1) expressed concern staff failed to administer scheduled Ativan. The family member stated the staff asked Resident #2 if the resident wanted the morning dose of Ativan (May 18) and the resident said no. The family member stated Resident #2 can't make that decision as the resident doesn't know yes from no. Review of Resident #2's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified no speech, sometimes understood, understands others, severe cognitive impairment, and rejection of cares on one to three days of the look-back period. Diagnoses included aphasia (comprehension and communication disorder), anxiety disorder, dementia, and epilepsy (seizure disorder). A physician's order, dated 03/19/24, stated, lorazepam [Ativan] . 0.5mg [milligrams]; oral. Special Instructions: re [regarding]: anxiety, seizures . Four Times A Day [at] 07:00 AM, 01:00 PM, 07:00 PM, 01:00 AM. The Medication Administration Record (MAR) showed Resident #2 refused Ativan seven times: the 1:00 a.m. dose of Ativan on May 4, 9, 10, 16, 17, and 18, and the 7:00 a.m. dose on May 18. During an interview on 06/11/24 at 3:44 p.m., a supervisory nurse (#12) stated she would inform the doctor if a resident repeatedly refused a medication, but was unaware if staff notified the doctor of Resident #2's refusal of Ativan.

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 3 of 18 sampled residents (Resident #13, #55, and #62). 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 N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages N-6 to N-8 stated, . N0415: High-Risk Drug Classes: Use and Indication . Coding Instructions . N0415E1. Anticoagulant (e.g., [for example] warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period . N0415H1. Opioid: Check if an opioid medication was taken by the resident at any time during the 7-day look-back period . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., . clopidogrel) was taken by the resident at any time during the 7-day observation period. - Review of Resident #13's medical record occurred on all days of survey. A physician's order, dated 12/18/23, stated, Tramadol [opioid] 50 mg [milligram] tablet three times a day . re [regarding]: low back pain. The quarterly MDS, dated [DATE], showed staff failed to identify Resident #13 received an opioid. During an interview on 06/12/24 at 2:37 p.m., a nurse manager (#11) stated staff should have coded opioid on the MDS. - Review of Resident #55's medical record occurred on all days of survey. A physician's order, dated 12/31/23, indicated Eliquis (anticoagulant) 2.5 mg twice a day. The quarterly MDS, dated [DATE], showed staff coded N0415I1. Antiplatelet and failed to code N0415E1. Anticoagulant. During an interview on 06/11/24 at 5:15 p.m., an administrative nurse (#4) confirmed Section N of the quarterly MDS was coded incorrectly for Resident #55. SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS The Long-Term Care Facility RAI User's Manual, revised October 2023, page O-7, stated, . Hospice Care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. 28398 - Review of Resident #62's medical record occurred on all days of survey. A nurse's note, dated 03/05/24 at 4:54 p.m., stated, Received new order from [name of physician] today: Hospice consult placed and will schedule admission visit for tomorrow. The care plan, dated 03/06/24, stated, . Advance Care Planning: I am receiving Hospice services . The significant change MDS, dated [DATE], showed staff failed to identify Resident #62 received hospice care. During an interview on 06/12/24 at 12:08 p.m., a nurse manager (#11) stated staff missed coding hospice on the MDS.

Based on observation, record review, and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment for 1 of 5 sampled residents (Resident #18) on oxygen. Failure to clean a personal fan and the oxygen concentrator filter does not provide a safe and clean environment and has the potential to place the resident at risk for illness. Findings include: The facility failed to provide a policy/procedure for the cleaning of personal fans and changing/cleaning the oxygen concentrator filters. Observation on 07/10/23 at 03:08 p.m. showed Resident #18 lying in bed with oxygen administered by nasal cannula while a fan blew air toward the resident. Observation showed the fan cover/grate and fan blade covered in dust and debris. Observation on 7/12/23 at 10:08 a.m. showed Resident #18 lying in bed with oxygen administered by nasal cannula. Observation showed the oxygen concentrator filter covered in dust and debris. Review of Resident #18's medical record occurred on all days of the survey. Diagnoses included respiratory failure. During an interview on 07/13/23 at 11:38 a.m., an administrative staff member (#1) stated the expectation is for all staff to clean dirty equipment in residents' rooms.

Based on record review, review of the North Dakota Provider Manual Preadmission Screening and Resident Review (PASRR) and Level of Care Screening Procedures for Long Term Care Services, facility staff interview, and PASRR agency staff interview, the facility failed to complete a status change assessment for 1 of 2 sampled residents (Resident #2) reviewed for PASRR. Failure to complete a change in status assessment with a newly diagnosed mental illness and/or new or increased behaviors may result in the delivery of care and services inconsistent with the resident's needs. Findings include: The North Dakota PASRR Provider Manual, revised December 2020, page 13, states, . Change in Status Process: Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC [mental illness, intellectual disability, and conditions related to intellectual disability (referred to in regulatory language as related conditions or RC)] was not identified at the Level I screen process, and that condition later emerged or was discovered. If a resident experiences increased symptoms or behavioral problems related to MI, ID and/or RC. Review of Resident #2's medical record occurred on all days of survey and showed the following: * A PASRR Level I screen outcome, dated 01/25/22, stated, No Level II required. There is no evidence of a PASRR condition or an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. The Level 1 form included mental health diagnoses of suspected anxiety disorder and adjustment disorder with depressed mood; the medical conditions included underlying dementia with progression. * On 7/22/22, the resident started on Risperidone, which was discontinued on 08/26/22 when the provider prescribed Seroquel (both medications are antipsychotics). Resident #2's progress notes showed the following: * 07/22/2022 at 2:32 p.m., . [health care provider] was updated about guests [the resident's] increased anxiety at night time. Order: start trial of Risperidone. Take 0.125mg [milligrams] by mouth at bedtime. Dx [diagnosis] dementia with agitation. may need to increase if behaviors continue. * 08/19/2022 at 5:18 a.m., Guest is agitated, combative and hit the CNA [certified nurse aide] when doing cares. A Psychiatry consult, dated 02/20/23, listed diagnoses, in part, as recurrent major depression, generalized anxiety disorder, psychotic disorder with delusions due to known physiological condition, dementia with psychotic disturbance, and dementia with agitation. The medical record lacked evidence of an updated Level I PASRR screen with the new antipsychotic medications and diagnoses of major depression, generalized anxiety disorder, and psychotic disorder with delusions. During an interview on 07/13/23 at 11:45 a.m., an administrative staff member (#2) confirmed the facility failed to complete a change in status Level I screen for Resident #2 due to the belief the resident's psychotic disorder was related to her dementia. During an interview on 07/13/23 at 12:05 p.m., a North Dakota PASRR consultant agency staff member (#3) stated due to the resident's increased behaviors, consult with psychiatry services, and the addition of new medications, the facility should have submitted a Level 1 screen at that time as that was a status change. She stated, It is up to our clinician to decide on recommendations based on the change in behaviors and medications and on the dementia.

Based on record review, staff interview, and Preadmission Screening and Resident Review (PASRR) agency staff interview, the facility failed to complete a Level I PASRR for 1 of 2 sampled residents (Resident #60) reviewed for PASRR. Failure to complete the required Level I screen within 30 days as indicated increased the potential for not identifying/providing needed mental health services. Findings include: Review of the medical record for Resident #60 occurred on all days of survey. Diagnoses included unspecified intellectual disabilities, bipolar disorder, and unspecified dementia. A Level 1 PASRR screening, completed on 12/27/22, identified a Level I outcome rationale: 30 Day COVID-19 Categorical Approval- A 30 day or less stay in the NF [nursing facility] is authorized. Re-screening must occur by or before the 30 day if the individual is expected to remain in the NF beyond the authorization timeframe. The record lacked evidence of the re-screening in 30 days. The facility completed a Level of Care (LOC) screen on 01/23/23, however failed to complete a PASRR Level 1 re-screen at that time. During an interview on 07/13/23 at 11:45 a.m., an administrative staff member (#2) confirmed the facility failed to complete a Level I re-screen for Resident #60. During an interview on 07/13/23 at 12:05 p.m., a North Dakota PASRR consultant agency staff member (#3) stated re-screening meant the facility needed to submit a Level 1 screen and a LOC screen.

Based on observation, record review, review of professional reference, policy review, and staff interview, the facility failed to transcribe a medication order accurately and verify the correct medication during medication administration in accordance with professional standards for 1 of 5 residents (Resident #50) observed during med pass. Failure to accurately transcribe medication orders and ensure the pharmacy label matches the Medication Administration Record (MAR) when passing medications may result in residents receiving the wrong medication and cause adverse health effects. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 838, stated, . Administering Oral Medications . Compare the label of the medication container or unit-dose package against the order on the MAR or computer printout. The facility policy titled Administering Medications occurred on 07/12/23. This policy, dated 2020, stated, . The person preparing or administering the medication will contact the provider if there are questions or concerns regarding medication. With any irregularities, appropriate notifications will be completed for clarification. Observation on 07/12/23 at 8:00 a.m. during med pass showed a nurse (#4) administered two tablets from a pharmacy medication card labeled as Senna Plus (senna 8.6 milligrams [mg] [laxative]/docusate 50 mg [stool softener]) to Resident #50. Review of Resident #50's medical record occurred on 07/12/23. A physician's order, dated 04/07/22, stated, senna [OTC] [over-the-counter] tablet; 8.6 mg; amt [amount]: 2 tabs [tablets]; oral. Special Instructions: BID [twice a day] . During an interview on 07/12/23 at 10:18 a.m., a supervisory nurse (#5) verified the medication card's pharmacy label differed from the MAR. During an interview on 07/12/23 at 10:46 a.m., an administrative nurse (#1) provided a copy of a form labeled Physician Orders for Resident #50. The order, dated 04/07/22, stated, [increase] Senna S [Senna Plus] ii [2] po [orally] BID constipation. The nurse (#1) confirmed the transcriber failed to enter the Plus (S) part of the Senna Plus order. The facility failed to recognize the discrepancy between the physician's order and the MAR for over a year.

Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 6 of 18 sampled residents (Resident #10, #16, #22, #31, #48, and #121) and two supplemental residents (Resident #15 and #66) observed during cares. Failure to follow infection control practices has the potential for transmission of communicable diseases and infections to residents and staff. Findings include: PERSONAL PROTECTIVE EQUIPMENT (PPE) During the entrance conference, administrative staff provided a list of residents not vaccinated for COVID-19. Signage is placed on the room door and staff is required to wear face shields while in the resident's room. The list identified Residents #10, #15, and #66. Observations showed the following: * 03/28/22 at 2:21 p.m., an unidentified staff member entered Resident #10's room to retrieve the meal tray. The staff member failed to wear a face shield. * 03/28/22 at 2:25 p.m., two unidentified staff members exited Resident #66's room. The staff members failed to wear face shields. * 03/29/22 at 9:54 a.m., a staff member (#14) exited Resident #15's room. The staff member failed to wear a face shield. During an interview on 03/29/22 at 9:59 a.m., a medication aide (MA) (#13) confirmed all staff must wear face shields in unvaccinated resident rooms. During an interview on 03/31/22 at 9:00 a.m., an administrative nurse (#12) confirmed staff should wear face shields in unvaccinated resident rooms and the facility failed to provide a policy regarding PPE worn during the care of unvaccinated residents. HAND HYGIENE Review of the policy titled Hand Hygiene occurred on 03/29/22. This policy, dated June 2017, stated, . Times to perform Hand Hygiene . Before and after assisting a resident with personal cares . after removing gloves . Observations showed the following: * 03/29/22 at 9:46 a.m., a nurse (#6) and a MA (#7) donned (put on) gloves and transferred Resident #22 to the bed. The nurse (#6) provided perineal cares, removed her gloves, and donned a new pair of gloves and failed to perform hand hygiene before providing additional cares. * 03/29/22 at 10:50 a.m., a certified nursing assistant (CNA) (#9) assisted Resident #16 to the bathroom and performed perineal care after the resident had a smear of stool. The CNA (#9) removed her gloves, failed to perform hand hygiene and assisted the resident to the bed. The CNA folded two blankets and placed them on a chair, positioned the wheelchair, moved the phone, removed the gait belt and adjusted the oxygen cord. The CNA (#9) failed to perform hand hygiene after removing gloves and before completing other tasks. * 03/29/22 at 11:55 a.m., two CNAs (#9 and #10) assisted Resident #48 into the bathroom. One CNA (#9) performed perineal care and returned the resident to the toilet while waiting for the nurse. The CNA (#9) removed her gloves, and without performing hand hygiene, moved the wheelchair and applied the leg rests. After the nurse arrived the CNA (#9) transferred the resident into the wheelchair, applied foam booties, and adjusted the leg rests. The CNA (#9) failed to perform hand hygiene after removing gloves and before completing other tasks. * 03/30/22 at 11:37 a.m., two CNAs (#4 and #5) donned gloves and transferred Resident #31 to the bed. One CNA (#4) provided perineal cares, removed her gloves, donned a new pair of gloves and failed to perform hand hygiene before providing additional cares. During an interview on 03/31/22 at 9:54 a.m., an administrative nurse (#1) confirmed she expected staff to perform hand hygiene after resident cares and removing gloves. PERINEAL CARES Review of the facility policy titled Perineal Care (Female) occurred on 03/31/22. This policy, dated March 2020, stated, . Position guest for pericare. Wash area with wash cloth with cleanser below umbilicus to pubic mound, abdominal folds, and inner thigh on one side. Turn wash cloth and repeat other side . With clean portion of the washcloth, clean the buttocks, back of thighs . Take fresh wash cloth with cleanser and clean anal area . Observation on 03/29/22 at 9:13 a.m. showed two CNAs (#2 and #3) donned gloves and assisted Resident #121 to stand utilizing a gait belt. One CNA (#3) provided perineal care and the other CNA (#2) held onto the resident. The CNA (#3) failed to clean the perineal area with a fresh wipe or with a clean area of a folded wipe. During an interview on 03/31/22 at 10:00 a.m., an administrative nurse (#1) agreed staff should use a fresh wipe or a clean area of a folded wipe when performing perineal cares. DRESSING CHANGES Review of the policy titled Dressing Change occurred on 03/31/22. This policy, dated March 2020, stated, . clean surface . Set up clean field . Observations on 03/30/22 showed the following: * At 10:40 a.m., two nurses (#8 and #11) performed a dressing change to Resident #48's heel. One nurse (#8) applied gloves and placed the box of supplies (packaged gauze, tape, saline solution and tube of medicated ointment) on the floor. As the nurse used the supplies, he took them out of the box and placed them directly on the floor. The nurse failed to provide a clean surface/barrier for the supplies prior to wound care. * At 11:37 a.m., a nurse (#6) entered Resident #31's room, applied gloves, and placed the supplies (packaged gauze/dressing, tape, cleansing solution and medicated ointment containers) on the bed and/or soaker pad Resident #31 was lying on. The nurse failed to place the dressing change supplies on a clean surface/barrier prior to attending to wound care. During an interview on 03/31/22 at 9:54 a.m., an administrative nurse (#1) confirmed she expected staff to use a towel or chux (disposable pad) as a barrier on the floor when doing a dressing change.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure appropriate care and services for 1 of 4 sampled residents (Resident #14) with orders for compression stockings. Failure to follow physician's orders for application and accurately document the application of compression stockings may result in worsening [CONDITION(S)] and complications for the resident. Findings include: Review of the facility policy titled Compression Stockings Application occurred on 03/31/22. This policy, dated March 2020, stated, . Apply stockings as ordered. The most appropriate time is prior to rising. Remove stockings as ordered at bed time unless contraindicated and inspect condition of skin. Review of Resident #14's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 06/01/18, stated, tensos [tensoshape/compression stockings] to bilateral LE [lower extremities] on in AM off in PM. The care plan stated, I wear Tenso [tensos] stocking in the AM, and remove at HS [evening cares], please help to don [apply] and doff [remove] my Tenso. Observations of Resident #14 showed the following: * 03/29/22 at 5:13 p.m., resident seated in a wheelchair at the dining room table, no tenso stockings on. * 03/30/22 at 10:12 a.m., resident seated in a recliner, transferred to a wheelchair by a certified nursing assistant (CNA) (#3), no tenso stockings on. * 03/30/22 at 3:11 p.m., resident seated in a recliner, no tenso stockings on. Review of Resident #14's treatment administration record (TAR) showed nurses initialed the TAR to indicate staff applied tenso stockings on 03/29/22 and 03/30/22. During an interview on 03/30/22 at 4:20 p.m., a licensed nurse (#8) stated the CNAs apply/remove the tenso stockings and verbally report to the nurse for documentation in the TAR. The nurse stated based on documentation staff applied the tenso stockings the morning of 03/30/22. The nurse observed Resident #14 and verified staff failed to apply the tenso stockings as documented.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 04/17/19. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide care for 9 of 19 sampled residents (Resident #3, #4,#17, #31, #35, #36, #40, #57, and #60) in a manner that maintained/enhanced each residents' dignity and individuality. Failure to provide meal assistance, remove transfer belt, and grooming in a dignified manner did not promote the residents' dignity and/or enhance their quality of life. Findings include: Review of the facility policy titled Feeding the Guest occurred on 02/04/21. This policy, revised April 2010, stated, . When feeding guest, sit when possible. Position yourself appropriately next to guest . Review of the facility policy titled Routine Hair Care occurred on 02/04/21. This policy, revised April 2010, stated, . Guest's hair is to be groomed during morning and evening cares, and throughout day as needed . Meal Assistance - Review of Resident #3's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified extensive assistance from one staff member required for eating. The current care plan identified, . I will be offered puree textures and thin liquids. Staff will assist me with feeding and provide direct supervision and encouragement/cueing for meals. Observations showed the following: * 02/01/21 at 12:44 p.m., Resident #3 sat at an assisted table with a certified nursing assistant (CNA) (#3) seated next to him. The CNA (#3) provided tray set-up which showed mashed potatoes and pureed chicken, carrots, and peaches presented on the same plate; with the food items spreading across the plate, blending along the edges. The CNA (#3) used a spoon to scrape residue from Resident #3 lips/chin. * 02/02/21 at 12:29 p.m., Resident #3 sat at an assisted table with a CNA (#4) seated next to him. The CNA (#4) provided tray set-up which showed mashed potatoes and pureed chicken, beets, and blondie bar presented on the same plate; with the food items spreading across the plate, blending along the edges, and the beets drizzled over the mashed potatoes and chicken. The CNA (#4) used a spoon to scrape residue from Resident #3 lips/chin. * 02/03/21 at 12:52 p.m., Resident #17 sat at an assisted table with a CNA (#4) seated next to her. The CNA (#4) was looking at her cell phone while holding it close to her lap. When she noticed she was being observed, she placed it under her leg. * 02/03/21 at approximately 01:00 p.m., Resident #3 sat at an assisted table with a CNA (#4) seated next to him. The CNA (#4) provided tray set-up which showed mashed potatoes with gravy, pureed chicken, applesauce, and pineapple dessert presented in separate bowls. At 1:11 p.m., observation showed CNA (#4) transferring the remaining pureed food onto a plate, pouring gravy over every thing on the plate, and reheating the food in a microwave (even the pureed applesauce and pineapple desert). * 02/03/21 at 1:20 p.m., Resident #4, #35, #36, and #60 sat at individual tables with unkempt hair. - Review of Resident #40's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified supervision required for eating. The current care plan identified, . I am at nutrition risk d/t (due to) .[MEDICAL CONDITION](reflux) . dysphagia . Please make sure I am sitting straight up to table for all meals, not angled . I will be provided with indirect supervision at meals. I will receive assistance with eating/drinking when needed. Observations showed the following: * 02/01/21 at 12:33 p.m., Resident #40 sat at an independent table with a CNA (#5) standing on his left side, feeding him a few bites of roast beef. * 02/02/21 at 3:49 p.m., With the head of the bed raised to an approximate 45-degree angle, the CNA (#6) gave Resident #40 a drink of water. Gait Belts - Review of Resident #31's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified extensive assistance from one staff member required for transfers. The current care plan identified, . I will be encouraged to call for assistance with transfers. Observation on 02/02/21 at 10:35 a.m. showed Resident #31 sitting in her wheelchair with a gait belt around her waist. - Review of Resident #57's medical record occurred on all days of survey. The significant change MDS, dated [DATE], identified extensive assistance from one staff member required for transfers. The current care plan identified, . I require Ax1 (assist of one) with 4WW (four-wheeled walker) for all in room transfers and walking. Observation on 02/02/21 at 1:43 p.m. showed Resident #57 sitting in her recliner, dozing, with a gait belt around her waist. During an interview on 01/04/21 at 5:00 p.m., two administrative staff members (#1 and #2) acknowledged, in the examples listed above, facility staff failed to provide assistance/cares in a manner that promoted the residents' dignity and/or enhance their quality of life.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure accurate labeling and storage of medications for 4 of 36 residents (Resident #9, #16, #21, and #26) and 2 of 3 medication storage areas (Grand Pacific and Prince) observed during medication storage review. Failure to correctly label, store, and dispose of medications may increase the risk of residents receiving an inaccurate dose of medication and/or reduced medication efficacy. Findings include: Review of the facility policy titled Medication Storage in the Facility, Storage of Medications occurred on [DATE]. This policy dated, [DATE], stated, . H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory . Review of the facility policy titled Medication Ordering and Receiving From Pharmacy occurred on [DATE]. This policy dated, [DATE], stated, . E. Improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy . - Observation of the(NAME)Neighborhood medication room occurred on the afternoon of [DATE] and identified one bottle of Diabetic [MEDICATION NAME] (cough syrup), expired [DATE], a bottle of Calcium 600+ Vitamin D, expired ,[DATE] (2007), and Lubricating Jelly packets, expired [DATE]. - Observation of the Grand Pacific Neighborhood Ebox (emergency medication) occurred on [DATE] at 5:10 p.m. and identified packaged medications with two expiration dates on the label. [MEDICATION NAME] (muscle relaxant) 5 milligram (mg), expired [DATE] with manufacture expiration date [DATE], and [MEDICATION NAME] (antibiotic) 500 mg, expired [DATE] with manufacture date [DATE]. - Observation on the afternoon of [DATE] showed the following: * Resident #9's medication cabinet [MEDICATION NAME] (treats allergy syptoms) 25mg med pack with an experation date of [DATE] and 3 unidentified white tablets, not in a container. * Resident #16's medication cabinet [MEDICATION NAME] (laxative) 5 mg med pack with an expiration date of [DATE]. * Resident #21's medication cabinet Visionart Eye Vitamin bottle expired [DATE]. * Resident #26's medication cabinet Metopropol [MEDICATION NAME] (treats high blood pressure) 25mg med pack with an expiration date of [DATE], Potassium Chloride (treats or prevents low blood potassium) 20 milliequivalent (meq) med pack expired [DATE], and Artificial Tears bottle expired ,[DATE] During an interview on [DATE] at 09:50 a.m., an administrative staff (#1 and #2) agreed medication labels should contain the correct expiration date.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 2 observations of insulin administration (Resident #34). Failure to administer rapid-acting insulin within 5-10 minutes of a meal may result in a hypoglycemic (low blood sugar). Findings include: Review of the facility polity titled Insulin Administration occurred on 02/04/21. This policy, revised October 2010, stated, . 2. The four types of insulin and their characteristics are: Type - Rapid-acting Onset 10-15 minutes . Prescribing information for [MEDICATION NAME] insulin, found at www.novo-pi.com/[MEDICATION NAME]., stated, . [MEDICATION NAME]® is rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus . Inject subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm. -Observation on 02/03/21 at 5:02 p.m., showed an unidentified nurse administered six units of [MEDICATION NAME]to Resident #34. The nurse failed to offer juice or snack to Resident #34. At 5:42, a certified nurse assistant (CNA) (#9) brought the resident to the dining room. Observation showed Resident #34 did not receive his/her tray until 5:44 p.m., 42 minutes after receiving [MEDICATION NAME]. During an interview on 02/04/21 at 5:30 p.m., an administrative nurse (#2) agreed staff are to ensure residents receive food in a timely manner after fast acting insulin administration.

Based on record review, review of the facility's policy, and staff interview, the facility failed to ensure a regimen free of unnecessary medications for 1 of 1 sampled resident (Resident #3) who received an antibiotic. Failure to discontinue the antibiotic or include documentation regarding the clinical justification for continued use of the antibiotic placed Resident #3 at risk of experiencing adverse effects related to its continued use. Findings include: Review of the facility policy titled Accepting Orders for Antibiotics occurred on 02/04/21. This policy, dated June 2017, stated, . It is the policy of (Facility) to use antibiotics appropriately to promote safe and effective quality of care to the residents. Clinician is asked to order appropriate tests (UA/UC (urine analysis/urine culture) .) to determine proper [DIAGNOSES REDACTED]. If clinician orders a UA/UC, antibiotics are not encouraged until the final culture comes back with sensitivity to the correct antibiotic. Once the final culture . (is) returned, the nurse will call the physician with the results to verify if they want to continue with initial antibiotic ordered, or if they would like a change. Review of Resident #3's medical record occurred on all days of survey and identified a [DIAGNOSES REDACTED]. The current care plan, identified; I have an acute UTI and am at risk for complications, I am receiving an antibiotic which is a high-risk medication, Administer my medications as ordered, monitor for effectiveness/side effects . Monitor for changes in my urinary status and for resolution of my UTI (i.e. dysuria, change in urinary output or character of urine, etc.), Monitor me for s/s of urine retention, perform bladder scans PRN (as needed), Monitor vital signs per protocol, Update my provider as needed with changes in my health status. A provider progress note, dated 01/29/21, identified, . (Resident #3's) urine is certainly cloudy. Urine sample was done by straight catheterization. To avoid worsening of his behaviors, we empirically started him on [MEDICATION NAME] (an antibiotic) for a few days. Awaiting his urine culture. Once in, will make appropriate changes to his regimen as needed. The Medication Administration Record [REDACTED]. The progress notes identified the following: * 01/29/21 at 6:45 a.m., Nurse and CNA assisted with getting a stright (sic) cath (catheter) urine sample for possible UTI. (Resident #3) tolerated procedure with minimal discomfort and at 10:58 a.m., (Physician) saw (Resident #3) and had new order: [MEDICATION NAME] 250 mg (milligrams) po (by mouth) BID (twice daily) x (times) 5 days. Ok to give via [DEVICE] (tube that passes through the abdominal wall into the stomach). Re (regarding): UTI complicated. * 01/30/21 at 2:37 a.m., (Resident #3) [MEDICATION NAME] shift for UTI, no adverse affects (sic) noted. (Resident #3) tolerating the extra fluids. Guest resting quietly, no combative behaviors. The urine culture microbiology report, dated 01/31/21 at 8:46 a.m., identified . No growth at 48 hours. The progress notes further identified: * 02/01/21 at 8:00 a.m., . Nursing noted (Resident #3) currently has a UTI and is being treated with antibiotics. Labs were done are (sic) Friday and came back good. * 02/01/21 at 8:48 p.m., . no worsening of UTI symptoms, no adverse effect to abx (antibiotic) therapy noted at this time. * 02/02/21 at 1:00 p.m., No outstanding behaviors notes this AM shift. No S/S (signs/symptoms) of UTI noted. The facility failed to discontinue the antibiotic after being informed there was no laboratory evidence Resident #3 had a UTI. During an interview on 02/04/21 at 5:00 p.m., two administrative staff members (#1 and #2) acknowledged the facility/provider failed to discontinue the antibiotic after being notified there was no laboratory evidence Resident #3 had a UTI and acknowledged Resident #3's medical record failed to include documentation regarding the clinical justification for continued use of the antibiotic.

Based on observation and staff interview, the facility failed to ensure staff were able to locate and operate the suction machine upon request for 1 of 3 units (Grand Pacific Neighborhood). Failure to ensure staff can operate the suction machine in case of an emergency situation placed residents at risk for choking and aspiration. Findings include: During an interview on the afternoon of 02/03/21, a licensed nurse (#7) stated, The suction machine is stored somewhere on Grand Pacific Neighborhood. The nurse (#7) was unsure of its location or how to operate it, and reported she had never used the suction machine or received training on its use. During an interview on 02/04/21 at 5:00 p.m., two administrative staff members (#1 and #2) acknowledged, in the example listed above, facility staff should be able to locate and operate the suction machine.

Based on record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #17) who required total assistance with transfers. Failure to safely utilize a ceiling lift requiring a sling/harness during transfer resulted in a fall and a fracture (diagnosed 9 days later) for Resident #17 and placed all residents requiring sling/harness transfer at risk for falls and injury. Findings include: Review of the facility policy titled Vulnerable Adult/Abuse Prevention/Elder Justice Act occurred on 05/31/18. This policy, dated (MONTH) (YEAR), stated, . Investigation of Incidents and Allegations 1. All accidents and incidents as well as allegations of abuse, neglect, and/or financial exploitation will be investigated by the Director of Guest Services, Director of Nursing, or appropriate designees. 2. Measures to be placed to identify the source of the alleged abuse and prevent future incidents. Review of Resident #17 medical record occurred on all days of survey. The progress notes contained the following: * 02/05/18 at 7:26 p.m. This nurse was assisting CNA (certified nurse assistant) with transferring guest using ceiling lift from w/c (wheelchair) to bed when guest fell from sling onto R (right) side onto floor. Guest did hit head. Guest was at about transfer level for bed when, what looks to have happened, is sling was not completely secured and slipped, causing guest to fall. Guest did have c/o head pain, . some soreness to R arm. Guest's foley catheter was also pulled out during fall. * 02/05/18 at 11:17 p.m. Guest did have c/o (complaint of) pain to R arm of 5/10 (pain scale at 5 with 10 being the worst) and PRN (as needed) tylenol was given with effective results. Guest does say that it is still sore if he moves it. * 02/08/18 at 10:33 a.m. Guest complains of right shoulder soreness . Guest mentioned maybe wanting to schedule an x-ray if it does not get better. * 02/09/18 at 11:48 a.m. Fax sent to (name of physician) requesting orders for PT (physical therapy) to evaluate and treat in regards to right shoulder pain/discomfort. * 02/11/18 at 5:21 p.m. Guest complaining of right shoulder pain at 5/10. States that he thinks he is going to need more than work with PT to make it better. Guest was administered PRN tylenol. Guest decided to have dinner in room instead of dining room. * 02/12/18 at 11:03 p.m. Guest received new order to have R shoulder x ray at (name of medical center) this week for R shoulder pain. *02/13/18 at 2:00 p.m. Guest returned from (clinic name), Shoulder X-ray done today. *02/14/18 at 9:30 a.m. Received xray report from (clinic name) guest does have nondisplaced fracture noted to right scapula (shoulder blade). During an interview on 05/31/18 at 2:00 p.m., an administrative team member (#1) stated the facility implemented corrective action and follow up after the fall. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility addressed the corrective action accomplished for the resident affected by the deficient practice by: * Interviews with the staff who provided the transfer assistance, dated 02/05/18, which stated, - Conversation took place with (staff name) and she stated that she transferred guest from wheelchair to bed and the sling hook was in place but came unhooked when guest was near the bed. The nurse tried to push guest towards the bed and he landed on the bed but slid off the edge landing on his right shoulder. They then assessed guest and lifted him with the assist of two. - Conversation took place with (staff name) as she was the second person in the room at the time of the transfer. The CNA stated that she was transferring guest with nurse and he didn't slip out of the sling immediately during the transfer but when guest was close to the bed. The right strap of sling had slipped and guest was slowly lowered to the floor. (staff name) stated that the nurse had tried to push guest onto the bed. * The facility completed a Nursing staff inservice on Ceiling Lift Education on 02/06/18. * Progress notes, dated 02/06/18 at 12:13 p.m., stated, IDT (interdisciplinary team) met regarding incident of guest sliding out ceiling lift sling. Will request therapy screen for most appropriate sling and will request maintenance staff inspect ceiling lift. * On 02/07/18 at 8:03 a.m. a Skilled Occupational Therapist completed a screen and determined the size X Large sling was appropriate for guest and in good repair. * On 02/09/18 a Skilled Physical Therapist completed an evaluation to assess pain and function following a right scapular fracture. * On 02/22/18 an inspection of the ceiling lift system, hoist and rail systems was completed by a certified company with no recommendations or concerns noted. The survey team determined a deficient practice existed on 02/05/18. The facility implemented corrective action on 02/05/18 and completed nursing staff education on 02/06/18. A certified company completed a ceiling lift system inspection on 02/22/18. Refer to F609

ANTICOAGULANT THERAPY 1. Based on record review, information received from the complainant, review of facility policy, review of professional reference, and staff interview, the facility failed to provide necessary care and services regarding medication management as identified in 1 of 1 closed record reviewed (Resident #14) who received anticoagulant therapy (blood thinners). Failure to promptly recognize excessive bruising as a complication of anticoagulation medication resulted in the continued administration of anticoagulants. This resulted in a hypertherapeutic (above the therapeutic level) international normalized ratio (INR, a test used to determine the clotting ability of blood) and a critically low hemoglobin which was severe enough to warrant a blood transfusion. Findings include: Information received from the complainant identified concerns with anticoagulation therapy management and treatment. Review of the facility policy titled "Administration of Anticoagulant Medications" occurred on 05/15/14. This undated policy stated, ". . . Monitor for s/s (signs and symptoms) of hypertherapeutic anticoagulation levels such as excessive bruising . . . Report any abnormal findings to provider. . . ." Review of the facility policy titled "Skin Risk Assessment" occurred on 05/15/14. This policy, revised March 2011, stated, ". . . Physician will be notified of changes in skin integrity, orders noted, care plan will be updated. . . ." The Nursing 2013 Drug Handbook, 33rd edition, Lippincott, Williams & Wilkins, Philadelphia, pages 1407-1410, stated, ". . . [MEDICATION NAME] (an anticoagulant) . . . Adverse Reactions . . . Hematologic: hemorrhage . . . Overdose S&S (signs and symptoms) . . . excessive bruising . . ." Pages 491-493 stated, ". . . [MEDICATION NAME] (an anticoagulant) . . . Adverse Reactions . . . Hematologic . . . hemorrhage, ecchymoses (escape of blood into the tissues) . . . Effects on Lab Test Results . . . May decrease hemoglobin level. . . . Use cautiously in elderly patients . . . Instruct patient and family to watch for signs of bleeding or abnormal bruising and to notify prescriber immediately if any occur . . ." Review of Resident #14's medical record occurred on May 13-15, 2014. [DIAGNOSES REDACTED]. The resident's care plan, with a start date of 06/04/13, stated, ". . . Guest is at increased risk for bruising related to anticoagulant use . . . Administer meds (medications) as ordered, monitor for side effects. . . . Monitor for new bruising or changes in bruises . . ." Resident #14's medications included: *[MEDICATION NAME] (an anticoagulant) 10 milligrams (mg) once a day (QD) at 5:00 p.m. on Sunday and Wednesday and 7.5 mg QD at 5:00 p.m. on the other five days (initiated 12/06/13) *[MEDICATION NAME] (an anticoagulant) 60 mg every 12 hours at 8:00 a.m. and 8:00 p.m. until INR is therapeutic (2-2.5 seconds) (initiated 11/02/13) *[MEDICATION NAME] sulfate (iron) 325 mg twice per day An "Event Report," dated/timed 12/14/13 at 2:27 p.m., stated, ". . . Bruise noted to right abdomen . . . 21 x 23 cm (centimeters) in diameter . . ." The Event Report identified staff left a note for the healthcare provider (HCP) regarding the bruise. The Event Report indicated that staff did not notify Resident #15's family. Refer to F157. Nurses' notes stated the following: *12/15/13 at 8:16 p.m.: ". . . guest has A huge bruise to her right side and it is black and blue and swollen and appears awful. No open skin to the area. Guest has some discomfort from it. Guest given H.SW. (bedtime) (sic) medications and Levenox (sic) injection. . . ." *12/16/13 at 2:35 p.m.: ". . . PT/INR ([MEDICATION NAME] time/international normalized ratio, a test used to determine the clotting {coagulation} ability of blood) drawn at this time. . . ." *12/16/13 at 3:03 p.m.: ". . . Call placed to (HCP) at this time re: (regarding) new bruise. Will await return call. . . ." *12/16/13 at 4:15 p.m.: ". . . Call placed to on call physician . . . and message left re: [MEDICATION NAME]. Will await orders. . . ." *12/16/13 at 4:47 p.m.: ". . . Call returned from (on call physician) at this time. Informed MD (medical doctor) that [MEDICATION NAME] was given this evening. Orders received for [MEDICATION NAME] to be held tonight and tomorrow morning and to recheck PT/INR in the morning. We are to inform (primary physician) of results and obtain orders. . . ." *12/16/13 at 5:45 p.m.: ". . . Guest's daughter here to visit her mother and stated her mother was not acting like herself and did not eat supper. I told her that she has A huge bruise on her right side and blood work is being done to see if her blood is too thin . . ." *12/18/13 at 11:22 a.m.: ". . . Guest has a large bruise to her right abdomen relating to being supratherapuetic (sic) with her INR at this time. INR remains to be at 4.59 at this time. Will continue to monitor the bruise. . . ." *12/18/13 at 9:06 p.m.: ". . . Guest did not open her eyes for me when I went into her room this evening and was unresponsive to her name. . . ." *12/19/13 at 10:00 a.m.: ". . . Family aware of occasional periods of unresponsiveness. Did fax (HCP) an update on decreased LOC (level of consciousness) at times and at other times guest very alert. Guest also has a bruise on Right abdomen that measures 21 x 23 cm. . . ." *12/24/13 at 9:00 a.m.: ". . . Call received from (lab). Guest has a critical Hgb (hemoglobin) level of 6.6. Team lead did contact dr (doctor) on call and family. . . ." *12/24/13 at 9:47 a.m.: ". . . called and spoke with (on call doctor) and he is agreeable for guest to come to ER (emergency room ) for blood if the family wishes to do so. . . . Their wishes are to keep her comfortable and to not transfer her in at this time. . . ." *12/30/13 at 11:38 a.m.: ". . . Guest's family had requested a care conference, Family wants to know what had happened recently with her [MEDICATION NAME], as they are concerned about how fast it happened. . . . Family would also like to know what her current hemoglobin is and if is (sic) has remained low or dropped, they will pursue a blood transfusion, as they had declined this in the past. . . ." *12/30/13 at 1:21 p.m.: ". . . Order received for STAT (immediate) CBC (complete blood count) regarding HGB. . . ." *12/30/13 at 3:04 p.m.: ". . . Guest's hemoglobin is 9.9. There is no need to send guest in for a blood transfusion. . . ." Laboratory reports showed the following: *12/16/13: INR 4.58 seconds (high value) *12/17/13: INR 4.59 seconds (high value) *12/20/13: INR 2.44 seconds (within therapeutic range) *12/24/13: Hgb 6.6 gm/dL (grams per deciliter) (critically low value), red blood cells (RBC) 2.12 (therapeutic range 4.1-5.3) (low value) *12/30/13: Hgb 9.9 gm/dL (low value), RBC 3.13 (low value) *01/07/13: Hgb 8.3 gm/dL (low value) A HCP note, dated 12/30/13, stated, ". . . We saw the patient for consultation and evaluation of . . . [MEDICAL CONDITION] . . . Severity: 12-24-13 CBC . . . HGB 6.6 (normal 12.0-16.0 gm/dL) Critical Low Final . . . 12-30-13 . . . HGB 9.9 . . . Associated Symptoms: . . . weakness; general malaise . . ." Resident #15's Medication Administration Record [REDACTED]. Resident #15 received [MEDICATION NAME] at 5:00 p.m. on 12/14/13, 12/15/13, and 12/16/13. Although staff noted significant bruising to Resident #15's right abdomen on 12/14/13 at 2:27 p.m., they continued to administer anticoagulant medications through the evening of 12/16/13 and failed to recognize the resident's bruising as a possible complication of anticoagulation therapy. BOWEL MANAGEMENT 2. Based on record review, review of facility policy and procedure, and staff interview, the facility failed to provide necessary care and services to maintain the highest physical, mental, and psychosocial well-being regarding bowel function for 1 of 1 sampled resident requiring manual extraction of stool (Resident #6). Failure to follow the facility's bowel protocol and failure to monitor and assess Resident #6's bowel function resulted in episodes of constipation and required manual extraction of stool. Findings include: Review of the facility's "Bowel Protocol" occurred on 05/15/14. This protocol, included in the facility's "Standing Orders," revised January 2014, stated "Bowel Protocol: Day 2: Give Prune Juice 8 oz (ounces) OR Milk of Magnesia 30 mL (milliliters) P.O. (by mouth) . . . OR [MEDICATION NAME] 17 gm (grams) in 8 oz of juice or water x (times) 1 dose. Day 3: Administer Ducolax (sic) suppository per rectum and give prune juice 8 oz. OR Fleets enema . . . May repeat [MEDICATION NAME] 17 gm in 8 oz of juice or water daily x 1 dose. Day 4: If no results from the above options; contact physician for further orders *Assess the guest for discomfort, bloating, vomiting, leakage.*" Review of Resident #6's medical record occurred on May 12-15, 2014. The facility admitted the resident in April 2012. Current [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified he understood others and made himself understood, was cognitively intact, walked in the corridor one to two times with assistance of one person during the seven day assessment period, required extensive assistance of one person for walking in room and toileting, had an indwelling urinary catheter, and was frequently incontinent of his bowels. The quarterly and annual MDSs, dated 09/29/13 and 06/29/13, identified the resident required extensive assistance of one person to walk in room and for toilet use. Resident #6's current care plan identified facility staff should assist the resident to the toilet every two hours. Current physician orders regarding bowel management, included the following, and the date ordered: *[MEDICATION NAME] (stool softener) 100 milligrams (mg), two times each day (bid), 04/04/12 *Fleet enema, once daily (qd), as needed (prn), 04/06/14 *[MEDICATION NAME] (laxative) 30 milliliters (ml), bid, 06/05/12 *Milk of magnesia (laxative) 30 ml, qd, prn, 04/10/12 *[MEDICATION NAME] (laxative) 17 grams, qd, prn, 04/06/12 *Senna-S (stool softener-laxative combination) 8.6-50 mg, 1 tablet, bid, 05/02/14 Resident #6's Nurse's Notes identified the following: *06/15/13, 9:21 a.m. - "Prune juice given per guest request for constipation. He also took [MEDICATION NAME] 15 ml as ordered." *06/16/13, 9:12 a.m. - "Prune juice and milk of magnesia 30 ml given this AM. Guest is on Day #4 with no BM (bowel movement)." The medical record failed to identify the facility staff contacted the physician on Day 4 as per facility protocol. *07/27/13 - manual extraction of stool by facility staff. *01/02/14, 2:16 p.m. - "Guest c/o (complained of) constipation, given [MEDICATION NAME], MOM (milk of magnesia) and warm prune juice at 9:00 a.m., no results yet. . . ." (Resident #6's BM records identify a BM on 01/04/14.) *02/08/14, 5:00 p.m. - "Guest is on day 3 without BM. Guest refuses prune juice and [MEDICATION NAME] at this time. States 'I will take it in the morning because I do not want to get up in the middle of the night.'. . ." (Resident #6's BM records identify a BM on 02/10/14.) The facility failed to notify the physician. *04/10/14, 5:11 p.m. - "Note left for (physician) to D/C (discontinue) [MEDICATION NAME] and trial [MEDICATION NAME] QAM (every morning). Will await for orders." *05/02/14, 1:41 p.m. - ". . . Guest stated he was having a hard time having a BM (bowel movement). . . . rectum was bleeding and guest had a very hard piece of stool. I did apply some lubricant around rectum. . . . I did receive order for Senna s 1 tab (tablet) po (by mouth) bid for constipation. . . ." Resident #6's BM records and medication administration records (MAR) identified the following: *07/02/14, MAR - fleets enema *07/27/13, 10:09 a.m. - manual removal of stool; MAR - fleets enema *08/28/13 - large BM. No BM since 08/18/13 (10 days). The facility failed to notify the physician per protocol. *10/31/13 - BM (no BM until 11/05/13) *11/13/13 - soft BM (no BM until 11/18/13) *02/05/14 to 02/10/14 - no BMs, refused prune juice and [MEDICATION NAME] on 02/08/14. Accepted [MEDICATION NAME] on 02/10/14. *03/12/14 -03/18/14 - no BMs, no interventions identified *03/20/14 - 03/25/14 - no BMs, no interventions identified *04/02/14 to 04/10/14 (no BM); MAR - 04/10/14 - fleets enema, no previous interventions Resident #6's BM record showed multiple three and four day periods without a BM. Neither the MAR indicated [REDACTED]. Resident #6's medical record shows the resident reported bowel problems to the facility staff and Nurse's Notes failed to follow-up on those reports. The facility staff failed to offer interventions identified in the Bowel Protocol and failed to contact the physician on Day 4 per facility protocol. Failure to consistently monitor, assess, offer, and provide bowel management interventions for Resident #6 resulted in repetitive constipation and required manual extraction. POSITIONING 3. Based on observation, record review, review of facility policy and procedure, and staff interview, the facility failed to provide the necessary care and services regarding prevention of aspiration for 1 of 1 sampled resident receiving tube feedings (Resident #3). Failure to ensure the head of Resident #3's bed remained elevated at least 30 degrees may have contributed to the resident's moist, non-productive cough and placed the resident at risk of aspiration, development of respiratory illness, and declining health status. Findings include: Review of the facility procedure, "Trouble Shooting For Gastrostomy Tube," occurred on 05/15/14. This procedure, dated March 2011, stated "OBJECTIVE: Maintain patent G (Gastrostomy) - tube . . . 8. Prevention of Aspiration: Keep head of bed elevated. . . ." Review of Resident #3's medical record occurred on May 12-15, 2014. Current [DIAGNOSES REDACTED]. Physician orders included gastrostomy tube feedings over 14 hours. Resident #3's significant change Minimum Data Set (MDS), dated [DATE], identified he required extensive assistance of two or more persons for bed mobility. Resident #3's "MDS Assessment" note, dated 04/07/14 at 3:38 p.m., stated ". . . Guest receives feedings via PEG (percutaneous endoscopic gastrostomy) tube daily. . . . Lung sounds are coarse and diminished in the bases. . . . HOB (Head of bed) elevated at all times related to PEG tube feedings and water flushes. Moist non productive cough noted. . . . Guest is a total assist for transfers and all ADL's (activities of daily living). . . . Within the last two months, guest has had projectile emesis times one. > (greater than) 60 mL (milliliters) residuals have been noted within the last two months. . . . Continue to keep HOB elevated 30 degrees with feedings. . . ." Resident #3's current care plan, edited on 01/08/14, stated "Problem, Guest is at a nutritional & (and) dehydration risk due to dx (diagnosis) of significant dysphagia, dependent upon PEG tube feedings to meet nutrition and hydration needs . . . Approach . . . Keep HOB > 30 degrees during feedings. . . ." Observation, on 05/14/14 at 8:05 a.m., showed Resident #3 laying in bed on his left side with the HOB elevated approximately 30 degrees and the tube feeding running. Two certified nursing assistants (CNAs) (#3) and (#22) lowered the HOB, turned the resident supine (laying on back), provided perineal care, and changed his gown. The CNAs (#3) and (#22) used a lift pad to move Resident #3 to the head of the bed and left the room. Resident #3 remained supine with the HOB at approximately 10 degrees and the tube feeding running. On 05/14/14 at 8:20 a.m., Resident #3 remained positioned as identified following the previous episode of care. A supervisory nurse (#12) entered Resident #3's room on request of the surveyor. This staff member (#12) reported the resident's HOB should be higher and elevated the HOB to approximately 30 degrees. During interview at this time, the supervisory nurse (#12) reported the facility had not provided facility staff with a guide or direction regarding how to gauge or judge 30 degrees elevation of the HOB. Observation, on 05/15/14 at 8:05 a.m., showed Resident #3 supine in bed with the tube feeding running. The HOB was elevated approximately 30 degrees. Resident #3 was positioned towards the foot of the bed with his head elevated approximately 10 degrees. The resident's respirations demonstrated a gurgling sound. A licensed nurse (#8) entered the room to administer medications and a supervisory nurse (#12) entered the room on request of the surveyor. The supervisory nurse identified Resident #3 may require "suctioning." The licensed nurse (#8) and the supervisory nurse (#12) lowered the HOB, moved Resident #3 to the HOB, and elevated the HOB. Resident #3's breathing no longer demonstrated the gurgling sound. The supervisory nurse (#12) used a toothette to cleanse the resident's mouth and the licensed nurse (#8) disconnected the feeding tube. The licensed nurse (#8) also administered an ordered "as needed" nebulizer treatment. The supervisory nurse (#12) confirmed Resident #3's HOB was not high enough during the observations on 05/14/14 and 05/15/14 and corrected the resident's positioning at the time of the observations. The supervisory nurse (#12) reported the facility did not have guidelines for gauging the level of the HOB. Resident #3's gurgling respirations resolved with repositioning on 05/15/14. Failure to properly position Resident #3 during tube feedings per facility procedure placed him at risk of aspiration. The resident's history of emesis placed him at risk of aspiration. The facility staff identified Resident #3's cough as moist, non-productive. Failure to ensure proper positioning may have contributed to Resident #3's moist, non-productive cough.

Based on observation, information from the complainant, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to provide the necessary treatment and services to promote healing and prevent the development of pressure ulcers for 1 of 9 sampled residents (Resident #3) who required extensive assistance with bed mobility and 1 of 1 closed records reviewed with a pressure ulcer. (Resident #14). Failure to ensure Resident #14 received appropriate incontinence cares, timely implementation of dietary interventions, and the application of treatments as ordered resulted in the deterioration of a facility-acquired pressure ulcer. Failure to provide appropriate wheelchair positioning and frequent repositioning placed Resident #3 at risk of developing pressure ulcers. Findings include: Information received from the complainant identified concerns with improper/infrequent incontinence cares and lack of frequent repositioning. - Review of Resident #14's medical record occurred on May 13-15, 2014. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS), dated [DATE], identified short and long term memory problems, moderately impaired daily decision-making skills, extensive assistance from two or more people for bed mobility and personal hygiene, and always incontinent of bowel and bladder. Resident #14's care plan identified the following: *A Foley catheter initiated 03/18/14 related to a Stage III pressure ulcer on her coccyx *A two hour repositioning schedule initiated 12/27/13 due to a coccyx pressure ulcer; on 03/21/14, an every one hour side to side repositioning schedule was initiated *On 03/24/14, the care plan was edited to include "up in wheelchair for meals only" *An air mattress and pressure reduction wheelchair cushion initiated 12/27/13 *An every two hour check and change toileting schedule which also included checking on rounds at night, initiated 08/15/13 A nurse's note stated the following: *12/27/13 at 9:02 a.m.: ". . . Guest presented this morning with stage 2 pressure ulcer to L) (left) side of coccyx measuring 1.5 cm (centimeters) x 1 cm. . . . Side-to-side repositioning Q (every) 2 hrs (hours) implemented. Fax sent to physician for treatment orders. . . ." *12/28/13 at 6:22 a.m.: ". . . Guest continues with stage 2 pressure ulcer to coccyx. . . . [MEDICATION NAME] (a type of dressing) in place. . . ." *12/31/13 at 8:07 p.m.: ". . . [MEDICATION NAME] in place on L side of coccyx . . ." *01/01/14 at 1:26 p.m.: ". . . Open area to coccyx noted. . . . Fax sent to (provider name) for mepiplex (sic) . . ." A provider order, dated 01/02/14, identified an order for [REDACTED]. An "Event Report," dated 12/27/13 at 9:02 a.m., identified: ". . . Pressure Ulcer - Location and Size . . . 1.5 x 1 x 0.1 (cm) . . . Notifications Attending (physician) faxed: No . . . Physician Notified: No . . ." When asked to provide a copy of the fax notifying the physician of the new pressure ulcer, the facility provided no further evidence. See F157. A Healthcare Provider (HCP) Progress Note, dated 12/30/13, stated, ". . . Pressure sore . . . coccyx . . . [MEDICATION NAME] border present upon exam. Spoke with unit manager who stated the [MEDICATION NAME] had initially been placed last week Friday. At this time this does appear to be a (sic) appropriate measure. . . ." The record lacked evidence of provider notification of the pressure ulcer prior to 12/30/13 and also lacked evidence of orders for treatment until 01/02/14. Wound measurement documentation showed the following deterioration of Resident #14's pressure ulcer: *01/02/14: ". . . Stage 2 to coccyx measures 1.2 x 0.6 cm . . ." *02/06/14: ". . . Stage 2 to coccyx measures 1.8 x 0.6 x 0.1 cm . . ." *02/15/14: ". . . Guest's wound presents with bright red blood in scant amount noted on dressing. . . . Wound does appear larger in diameter. . . ." *02/20/14: ". . . Stage 2 to coccyx measures 2.5 x 1.5 x 0.1 cm . . ." *02/21/14: ". . . Guest continues to be turned every two hours and her coccyx is still open and does not look like it is healing . . ." *02/27/14: ". . . Stage 2 to coccyx measures 3.5 x 2.2 x 0.1 cm . . . Notified FNP (family nurse practitioner) of wound description and the frequent bowel and bladder incontinence . . ." *02/27/14: ". . . Orders received . . . Culture coccyx wound for C & S (culture and sensitivity) . . ." *03/01/14: ". . . Results from wound culture reported . . . Orders receieved (sic) to begin Cephalaxin (sic) (an antibiotic) 500 mg (milligrams) for 10 days. . . ." *03/01/14: ". . . Wound appears larger in diameter and is black in color with yellow slough surrounding. . . . Extreme foul odor coming from wound. . . ." *03/02/14: ". . . Wound continues to have an extreme foul odor. Tissue is black in color and looks necrotic. Guest did verbalize pain when changing her patch. . . ." *03/06/14: ". . . Guest's coccyx remains open with foul odor coming from it. Area remains unchanged and continues to be deeper. . . ." *03/06/14: ". . . Unstageable pressure ulcer measures 3.8 x 2.5 x 0.1 cm . . . Guest reports having pain to area and odor is present. . . ." *03/11/14: ". . . Coccyx wound remains open and appears deeper with 100% yellow slough noted. . . . Extreme foul smelling odor present. . . ." *03/20/14: ". . . Area to coccyx is now a stage 3 pressure area as the wound bed is partially visible. The wound measures 4.2 x 3 x 0.6 cm . . . Upon removal of dressing a foul odor was noted. . . ." *03/21/14: ". . . Guest's coccyx wound remains to worsen (sic) measuring 2 cm in depth. Area is packed with gauze and Dakin's solution . . . Area has an extreme foul odor present. . . ." *03/24/14: ". . . The wound was debrided at the appointment and a depth of 2.7 cm was obtained. . . . Wound continues to have strong odor. . . ." *03/25/14: ". . . She does state her butt hurts when doing the dressing change. [MEDICATION NAME] (a narcotic pain reliever) is given before dressing changes. Coccyx wound appears deeper in size than yesterday and is beginning to tunnel. . . ." *03/25/14: ". . . Guest repositioned into chair and guest exhibiting signs of extreme pain. Guest holding her breath and would not eat, clenching onto care partner's hands. When asked if her butt hurt her reply was 'yes'. Guest also tried (to transfer) into wheelchair and exhibited extreme pain. Guest was placed back into bed on side and when asked if she felt better she said 'yes.' . . . Scheduled Hydro ([MEDICATION NAME]) given and guest is now eating comfortably. . . ." *03/26/14: ". . . wound assessed and measures 3.5 x 4.2 x 2.9 cm . . . Guest grimaced and cried during the dressing change so will change dressings to wet to dry instead of the Dakins solution per (HCP). . . . Guest has foley catheter that is patent due to incontinence. Guest does continue to be incontinent of bowel and guest is changed frequently due to close proximity of wound and rectum. Repositioning is done every hour from side to side for comfort. Family has choosen (sic) to get referral for hospice. . . ." *04/02/14: ". . . Unstageable wound to coccyx measures 2.6 x 4 x approx. (approximately) 4 cm in depth. . . . Guest medicated prior to dressing change and facial expressions indicated pain during dressing change. Exact depth not obtained due to increased pain. . . ." An HCP note, dated 02/17/14, stated, ". . . Encounter Reason/Date . . . coccyx wound . . . 02/17/14 - 7:00AM . . . Physical Exam . . . Skin: . . . Pt (patient) noted to have a significantly wet brief - very strong odor - urinary incontinence, no dressing on. . . . Assessment/Plan . . . 1. Pressure sore - coccyx appears worse however if not kept clean and dry this will worsen. Also if dressing is not on as ordered would will worsen as well . . . Instructions to nursing home - . . . 1. Continue [MEDICATION NAME] to coccyx ulcer and continue [MEDICATION NAME] border and change q 3 days. 2. Check/change brief Q 2 hours . . . 4. Dietician to add argininade (sic) or some equivalent to help with wound healing . . ." The HCP order, dated 02/17/14, stated "Q 2 hours check and change. Special instructions: Assure this is being completed q 2 hours." (The care plan identified an every two hour check and change toileting schedule was already implemented 08/15/13.) Review of Resident #14's "Vitals Report" (used by staff to document dates/times they check and change residents) showed staff failed to check and change Resident #14's brief as ordered. The day of the HCP's visit (02/17/14), staff documented two entries, one on 02/17/14 at 12:55 a.m. which showed a large amount of incontinent urine, and one entry at 10:39 a.m., which showed a small bowel movement. The record lacked evidence staff checked and/or changed Resident #14 from 12:55 a.m. until the HCP assessed the resident at 7:00 a.m. The Vitals Report from 12/01/13 until 03/18/14 (the day staff placed a foley catheter due to Resident #14's incontinence) lacked evidence staff checked and/or changed Resident #14's brief every two hours as ordered/care planned. During this time period, staff documented checking/changing Resident #14 only one time in 24 hours on 22 days, twice in 24 hours on 32 days, and zero times on 5 days. Failure to accurately document does not allow supervisory staff to ensure Resident #14 is checked and/or changed every two hours to keep her as clean and dry as possible in an attempt to prevent Resident #14's coccyx ulcer from deteriorating. During an interview on the morning of 05/15/14, a supervisory nurse (#18) stated staff are encouraged to document each time they check/change a resident; however, staff might not document anything if the resident was dry. The nurse stated the floor nurses talk to certified nursing assistants (CNAs) and are "out on the floor" to ensure residents are checked and changed as care planned. She also stated Resident #14 was incontinent "all the time." The nurse agreed the toileting records were incomplete. The supervisory nurse (#18) was also asked about dietary interventions for Resident #14's coccyx ulcer. The nurse stated the dietician initiated Plus 2 and magic cups in February. Prior to this, Resident #14 received Ensure [MEDICATION NAME] three times per day. Resident #14 received this "shortly after admit" for "weight gain and nutrition." A dietary progress note, dated 02/19/14, stated, ". . . recommend 8 oz (ounces) of plus 2 protein supplement w/ (with) HS (bedtime) snack and magic cups BID and p.r.n. (as needed) as tolerated re: poor po (oral) intake, wt. loss, and wound healing. Will continue to monitor and provide different nutritional interventions as needed. . . ." Although staff first noted the coccyx ulcer on 12/27/13, the record lacked evidence of dietary notification of the ulcer until 02/17/14 (nearly two months later). The record identified no new dietary interventions until the initiation of Plus 2 and Magic Cups on 02/19/14. Failure to promptly notify the dietary department to evaluate existing interventions and implement new interventions contributed to poor nutritional status which may impede healing and lead to deterioration of existing pressure ulcers. The care plan identified a two hour repositioning schedule initiated on 12/27/13 and a one hour repositioning schedule initiated 03/21/14. The complainant identified concerns with a lack of frequent repositioning. When asked for evidence that staff repositioned Resident #14 according to the care plan/schedule, the facility identified they do not keep repositioning logs, and provided no further information. Failure to ensure prompt evaluation and implementation of dietary interventions, failure to ensure dressings were applied as ordered, failure to ensure frequent repositioning, and failure to ensure Resident #14 remained as clean and dry as possible contributed to the deterioration of her facility-acquired coccyx pressure ulcer and resulted in avoidable pain. - Review of "Prevention of Pressure Ulcers: Quick Reference Guide", National Pressure Ulcer Advisory Panel, Washington, D.C., 2009, occurred on 05/15/14. This guide, page 18, states "Repositioning the Seated Individual . . . 4.2 Place the feet of the individual on a foot stool or foot rest when the feet do not reach the floor. . . . 4.3 Limit the time an individual spends seated in a chair without pressure relief. . . . Repositioning Documentation, 5. Record repositioning regimes, specifying frequency and position adopted . . ." Review of the facility procedure, "Turning Rounds" occurred on 05/15/14. This undated procedure stated "Purpose: 1. To cleanse, refresh and reposition bedfast and wheelchair-bound residents on a regular basis. 2. To stimulate circulation. 3. To inspect resident's body. . . . PROCEDURE: . . . 4. Offload for at least a minute or reposition resident in new desired position." During the entrance conference, on 05/12/14 at approximately 8:30 a.m. and throughout the survey, the survey team requested that the facility staff contact the survey team members for all resident cares. Review of Resident #3's medical record occurred on May 12-15, 2014. The facility admitted the resident in January 2011. Current [DIAGNOSES REDACTED]. The resident's significant change MDS, dated [DATE], identified the resident rarely or never made himself understood and sometimes understood others, required extensive assistance of two or more persons for bed mobility and transfers, was always incontinent of bowel and bladder, and was at risk for development of pressure sores. Resident #3's Braden Scale for predicting pressure sore risk, dated 04/08/14, identified a score of "10." (A score of "12" or less is considered "high" risk.) Resident #3's "Tissue Tolerance" note, dated 04/05/14 at 3:13 a.m., stated "Guest had small red area to sacrum. No additional changes in color to other bony prominences. After off-loading time, area reduced to being pink in color. Every 2 hour side to side repositioning would continue to be appropriate." Resident #3's "MDS Assessment" note, dated 04/07/14, stated ". . . Braden score is 10. Will continue to reposition guest every 2 hours/PRN (as needed) . . ." The resident's current care plan identified repositioning every two hours. Observation on May 12-14, 2014 showed Resident #3 seated in a wheelchair. The wheelchair's left foot rest did not remain in the upright position to support the left foot. The left calf support did not fully support the leg. This resulted in the left leg sliding to the middle and off the left leg rest. The weight of the left leg pulled the right leg off the right leg rest. This resulted in both legs positioned in a dependent position. The unsupported lower extremities increased the shear force and potential for tissue damage and pressure sores on Resident #3's buttocks. Observation on 05/13/14 at 11:25 a.m. showed certified nursing assistants (CNAs) (#4) and (#7) completed cares for Resident #3 and transferring the resident from his bed to a wheelchair. Random observation until 5:25 p.m. (six hours) showed the resident seated in his wheelchair. Observations at 1:55 p.m. and 3:50 p.m. showed Resident #3 seated in his room in a wheelchair with his head down, left arm hanging down off the side of the wheelchair in an unsupported position, and his feet to the left in the unsupported position as previously described. Observation failed to show Resident #3 repositioned or transferred from the wheelchair during this six hour period. During interview, on 05/15/14 at 10:00 a.m., a supervisory nursing staff member (#12) provided a form initialed by facility staff. This form signified the staff members followed the resident's plan of care for the day, evening, and night shifts, including repositioning him every two hours. The facility lacked documentation identifying what time facility staff repositioned Resident #3 or how the staff repositioned Resident #3. During interview, on 05/15/14 at 4:00 p.m., an administrative staff member (#1) and an administrative nurse (#2) reported a CNA did reposition Resident #3 in the afternoon on 05/13/14 using the overhead lift during a check of the resident's brief. These staff members reported they did not know if the CNA positioned Resident #3 on the bed or only lifted the resident with the lift sling or if more than one staff member provided the care. The facility lacked documentation of this reported repositioning. Failure to provide appropriate foot positioning increased shear force on Resident #3's buttocks and placed him at increased risk of developing pressure sores. Failure to reposition Resident #3 every two hours placed him at increased risk of developing pressure sores. Failure to document the reported repositioning limited the facility's ability to determine the effectiveness of the positioning program. Use of the overhead lift and sling to lift the resident to check for a soiled brief is not adequate pressure relief. Momentary pressure relief followed by return to the same position is not beneficial for a resident at risk of developing pressure sores.