Every finding on record at St Rose Care Center

Based on staff interview, the facility failed to ensure 1 of 1 culinary services supervisor (#2) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure the facility had qualified dietary management to carry out the functions of food and nutrition services may result in foodborne illness to residents, staff, and visitors.Findings include:During an interview on the afternoon of 03/31/26, the culinary services supervisor (#2) stated she is currently enrolled in a certified dietary manager course but has not completed it.The facility failed to ensure the culinary services supervisor (#2) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on observation, review of facility policy, and staff interview, the facility failed to discard spoiled and expired food in 1 of 1 kitchen. Failure to discard spoiled and expired food may affect the quality of the food and may result in foodborne illness to residents, staff, and visitors.Findings include:Review of the facility policy titled Food Storage - Perishable occurred on 04/01/26. This policy, dated August 2019, stated, . Sanitary procedures will be maintained in perishable food storage to keep foods safe, wholesome and appetizing; and to prevent contamination.Observation of the main kitchen occurred on 03/30/26 at 11:05 a.m. and showed the following:* One unopened packaged head of lettuce with visible browning and moisture* One container of cottage cheese with an expiration date of 03/10/26* One snack Jello with an expiration date of 01/26/26* Butter scotch baking chips with an expiration date of May 2025During an interview on 03/30/26 at 11:30 a.m., the culinary services supervisor (#2) confirmed she expected staff to discard the expired and spoiled food items.

Based on observation, review of facility policy, and staff interview, the facility failed to implement standard infection control practices for 1 of 9 sampled residents (Resident #3) observed during cares and 1 of 1 laundry room observed. Failure to practice infection control standards related to hand hygiene, and handling/transporting of soiled linen has the potential to spread infection throughout the facility. Findings include: Review of facility policy titled Hand Hygiene occurred on 04/01/26. This policy, dated September 2023, stated, . Times to Perform Hand Hygiene are, but not limited to: . After contact with a resident's . body fluids or excretions . After removing gloves . Review of facility policy titled Linen and Laundry occurred on 04/01/26. This policy, dated 05/15/24, stated, .Clean linen must always be kept separate from contaminated linen. A functional barrier must separate soiled and clean area. - Observation on 03/30/26 at 1:59 p.m. showed Resident #3 in bed. Two certified nurse aides (CNA) (#3 and #4) applied gowns, gloves, and masks, and entered Resident #3's room. The CNA (#3) removed the resident's soiled brief, completed perineal care, and without removing the soiled gloves or completing hand hygiene, applied a clean brief and applied clean shorts to Resident #3. During an interview on 04/01/26 at 1:05 p.m., an administrative nurse (#1) confirmed she expected staff to remove gloves and perform hand hygiene after coming into contact with excretions/body fluids. - Observation of the laundry room on 04/01/26 at 9:42 a.m. showed an uncovered linen cart of clean linen next to the dryers. An unidentified staff member transported uncovered soiled linen past the clean linen and placed the soiled items in the washing machines. The laundry staff failed to ensure the clean linen remained covered while transporting/handling soiled linen in the same area. During an interview on 04/01/26 at 1:20 p.m., an administrative nurse (#1) acknowledged clean linen should be covered during the transport and handling of soiled linen in the same area.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents (Resident #2 and #13). 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:The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30-32, stated, . Section A1500: Preadmission Screening and Resident Review (PASRR) . Coding Instructions . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . and continue to A1510 . Coding instructions Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness .- Review of Resident #2's medical record occurred on all days of survey. Diagnoses included schizophrenia, generalized anxiety disorder, and bi-polar disorder. A PASRR Level II, dated 08/08/2025, identified a serious mental health illness and no services required. The annual MDS dated [DATE], showed the facility failed to code Section A1500 and A1510 for serious mental illness. - Review of Resident #13's medical record occurred on all days of survey. Diagnoses included anxiety disorder, mild intellectual disabilities, mixed obsessional thoughts and acts, and schizoaffective disorder. A comprehensive MDS, dated [DATE], showed the facility coded A1500 as yes and A1510A as yes indicating a serious mental illness. Notice of PASRR Level II Outcome, dated 09/12/25, stated, . this evaluation has determined that you have a PASRR condition . The facility should mark yes for question A1500 on the Minimum Data Set . The annual MDS, dated [DATE], showed the facility failed to code Section A1500 and A1510 for serious mental illness. During an interview in the afternoon on 04/01/26 an administrative staff nurse (#1) confirmed the facility failed to accurately code Resident #2's and #13's MDS.

Based on observation, record review, policy review, and staff interview, the facility failed to ensure compliance with provider orders for 1 of 1 sampled resident (Resident #33), observed with medications at the bedside. Failure to follow physician orders may result in medication errors and place the resident and/or others at risk for harm.Findings include: Review of the facility policy titled Self-Administration of Medications occurred on 04/01/26. This policy, dated 04/10/25, stated, . The nursing associates will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. If it is determined a resident cannot safely self-administer medications, the nursing associates will administer the medication. Review of Resident #33's medical record occurred on all days of survey. A Self-Administration of Medication assessment, dated 11/25/25, stated, . Does the resident want to self-administer medications . No. A physician's order, dated 11/25/24, stated, Medications: May give Whole, observe her take. Observation on 03/30/26 at 11:19 a.m. showed two medications in a medication cup on Resident #33's bedside table. The resident was unaware of what the medications were. During an interview on 04/01/26 at 1:14 p.m., an administrative nurse (#1) confirmed Resident #33 was assessed to not have medications left at bedside.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure accurate medication labeling to facilitate precautions and safe administration for 1 of 1 sampled resident (Resident #42) receiving intravenous (IV) medication. Failure to include the infusion rate and specific administration route on the medication label may result in inaccurate medication administration and placed the resident at risk for adverse outcomes. Findings include: Review of facility the policy titled Infusion Therapy Medication Administration occurred on 04/01/26. This undated policy stated, . Regulate flow of medication infusion as prescribed. Review of the pharmaceutical professional reference [NAME], Rocephin occurred 03/31/26. This reference stated, . Intravenous injection . For i.v. injection, Rocephin 1 g [gram] in 10 ml [milliliter], of sterile water for injections. The intravenous administration should be given over 2-4 minutes.Review of Resident #42's medical record occurred on all days of survey. A physician's order, dated 03/26/26, stated, Ceftriaxone [Rocephin] [antibiotic] recon soln [reconstituted solution]; 1 gram; . administer 2000mg via IV push once a day x [times] 13 doses. Add 19.2 mL [milliliters] SW [sterile water] diluent prior to administration. The medication label failed to include the administration route of IV push and the IV push rate.Observation on 03/30/2026 at 1:47 p.m. showed a nurse (#1) administered Ceftriaxone by IV push. When asked how long the medication is administered, the nurse (#1) stated, at least over five minutes.

Based on observation, review of facility policy and staff interview, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity and individuality for 1 of 1 sampled residents (Resident #22) who received insulin in a public area and in 1 of 1 activity room. Failure to administer insulin in a private area, to address the resident with their preferred name, and remove incontinence pads from chairs in the activity room, does not preserve the resident's personal dignity and has the potential to affect the resident's psychosocial well-being. Findings include: Review of the facility policy titled Resident Rights and Notifications of Resident Rights occurred on 03/20/25. This policy, revised 01/16/24, stated, Resident Rights include . Respect and Dignity . Privacy and Confidentiality . Review of the facility policy titled, Administering Medications occurred on 03/20/25. This policy, revised 2020, stated, . Do not administer . injections in public . - Observation on 03/18/25 at 3:39 p.m. showed a certified nurse aide (CNA) (#3) entered Resident #22's room. The CNA (#3) addressed the resident with the prefix Mister (Mr.). The resident stated, do not call me Mr. It's the name of a TV show and the resident stated some explicative words. The CNA (#3) continued to address the resident incorrectly. - Observation on 03/20/25 at 12:00 p.m. showed Resident #22 in the activity room in a wheelchair. A staff nurse (#1) pulled up the resident's shirt and administered insulin in the resident's abdomen. Witnesses to the event included four residents and three staff members. - Observation on all days of survey showed cloth waterproof incontinence protectors on 5 of 6 chairs in the activity room. The chairs are available for all residents and are publicly viewed by residents, staff, and family members. During an interview on the morning of 03/20/25, an administrative nurse (#2) explained the waterproof incontinence pads are supposed to be on two of the chairs and agreed this could be a dignity issue. During an interview on the afternoon of 03/20/25, an administrative nurse (#2) stated she expected staff to address residents by their individual preference, to respect the privacy of the Resident #22 by not administering insulin in the activity room in front of other residents.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure accurate medication labeling for 1 of 1 sampled resident (Resident #20) receiving medications through a gastrostomy tube (G-tube). Failure to ensure medication labels matched physician orders may result in administration via incorrect route. Findings include: Review of the facility policy titled Administering Medications occurred on 03/19/25. This policy, dated 2020, stated, . To ensure safe administration of resident's medication as indicated and ordered by the provider . To administer resident medications in a safe and accurate manner that will ensure the 6 rights of patient identification for administration . Administer medications following the 6 rights of medication administration: . Right Route . Review of Resident #20's medical record occurred on all days of survey. The medical record identified Resident #20 as NPO (nothing by mouth) and medications administered per a G-tube. Physician's orders for Tylenol, Baclofen (a muscle relaxer), Warfarin (a blood thinner), iron, vitamin D3, and sertraline (an antidepressant) identified administration via G tube; however, observation of medication pass on 03/19/25 at 12:34 p.m. showed the medication labels lacked specific instructions for administration via G tube. During an interview on 03/20/25 at 1:51 p.m., an administrative nurse (#2) confirmed the medication labels did not match the physician orders.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 5 sampled residents (Resident #28) and 1 supplemental resident (Resident #2) observed during cares. Failure to practice infection control standards related to hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 03/19/25. This policy, revised September 2023, stated, . All associates will be trained and competent . proper hand hygiene practices. Hand hygiene. After removing gloves. Before and after direct resident care . - Observation on 03/18/25 at 3:28 p.m. showed a certified nurse aide (CNA) (#3) assisted Resident #28 with perineal cares. The CNA (#3) applied gloves, performed perineal cares and without removing the gloves, the CNA brushed food crumbs from the bed linen, lifted the resident's legs on to the bed, and lowered the bed. The CNA (#3) failed to remove the soiled gloves and perform hand hygiene after performing perineal care. - Observation on 03/19/25 at 11:08 a.m. showed a nurse (#1) entered Resident #2's room. The nurse applied gloves, completed perineal cares, changed gloves, applied a clean brief, and pulled up the resident's pants. The nurse removed the gloves and assisted the resident into the wheelchair. The nurse (#1) failed to perform hand hygiene between and after removing gloves. During an interview on 03/20/25 at 1:37 p.m., an administrative nurse (#2) stated she expected staff to perform hand hygiene after removing gloves. 51999

Based on review of dietary department manager employment histories and staff interview, the facility failed to employ a full-time qualified dietary manager to carry out the functions of food and nutrition services. Failure to ensure qualified staff have the appropriate competencies and skill sets to carry out the functions of the food and nutrition services has the potential to result in foodborne illness and/or adverse consequences to residents, staff, and visitors. Findings include: During an interview on 02/20/24 at 11:45 a.m., a licensed registered dietician (LRD) (#2) stated she is employed at the facility on a part-time basis (approximately 16 hours per week), oversees the kitchen, food, and nutrition services, and the facility has not had a dietary manager for a while. Review of the dietary department manager employment histories identified the facility employed three individuals as DMs over the past year. The individuals failed to complete the required training and certification during their employment. The facility failed to ensure a full-time dietary manager with the necessary qualifications provided oversight of the dietary department.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident representative for 1 of 1 sampled resident (Resident #16) reviewed for elopement. Failure to notify the resident representative of the elopements does not allow the representative to be fully informed of the resident's current status. Findings include: Review of the facility policy titled Change in Condition occurred on 02/22/24. This undated policy stated, . When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is a need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident/resident representative. Review of Resident #16's medical record occurred all days of survey. The record identified the resident triggered the wanderguard system by exiting a facility door (elopement) seven times between November 2023-February 2024. The record lacked evidence the facility notified the resident representative on 11/27/23, 12/14/23, and 01/07/24. During an interview on 02/22/24 at 10:28 a.m., an administrative staff member (#1) confirmed staff failed to notify the representative following the three incidents.

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 3 sampled residents (Resident #12, #14 and #17) reviewed for antiplatelet (medicine that stops blood cells from sticking together and forming a blood clot) use. 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: The Long-Term Care Facility RAI User's Manual, revised October 2023, page N-8, states, . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period . - Review of Resident #12, #14, and #17's medical record occurred on all days of survey and showed the following: * Resident #12 - Aspirin (an antiplatelet) 81 mg (milligrams) once a morning ordered on 03/23/23. A quarterly MDS, dated [DATE], failed to identify the use of an antiplatelet under Section N. * Resident #14 - Aspirin 81 mg once a morning ordered on 01/10/24. A quarterly MDS, dated [DATE], failed to identify the use of an antiplatelet under Section N. * Resident #17 - Aspirin 81 mg once per day ordered on 06/23/23. A quarterly MDS, dated [DATE], failed to identify the use of an antiplatelet under Section N. During interviews on the morning of 02/22/24, an administrative staff member (#1) confirmed staff coded the MDS incorrectly. 46259

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide oral hygiene for 1 of 7 sampled residents (Resident #15) dependent on staff for assistance with oral cares. Failure to provide oral care for a dependent resident may result in poor hygiene, increased gum problems, decline in oral intake, and a decreased quality of life. Findings include: Review of the facility policy and procedure titled Activities of Daily Living (ADL) occurred on 02/22/24. This undated policy stated, . Care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . During an interview on 02/20/24 at 12:06 p.m., Resident #15 reported staff do not brush her dentures and observation showed a pink substance between the resident's bottom teeth. Review of Resident #15's medical record occurred on all days of survey. The current care plan stated, . I require assistance with dental care. I am missing teeth and wear dentures. Assist x1 [of one staff] with denture cleaning. During an interview on 02/22/24 at 9:22 a.m., Resident #15 confirmed staff did not brush her teeth all week. During an interview on 02/22/24 at 9:29 a.m., a CNA (#3) reported the resident usually does her own mouth care and did not assist the resident with oral cares the morning of 02/22/24. During an interview on 02/22/24 at 9:47 a.m., an administrative nurse (#1) stated she expects staff to brush resident's teeth and assist with oral cares.

Based on observation and staff interview, the facility failed to ensure a safe environment for 1 of 4 sampled residents (Resident #26) in the Peace Garden Suite. Failure to properly cover and maintain a floor heating vent placed residents in the Peace Garden Suite at risk of injury. Findings include: Observation of Resident #4's room on all days of survey identified an approximate four foot long front heater vent cover pulled off about 10-12 inches away from the heating system causing possible fall risk or resident injury. The heater coils inside the floor heater were easily assessable and hot to touch. The heater unit was located approximately four feet from the resident's bed and easily assessable to residents. Review of Resident #4's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease and delusions. The current care plan identified, . I will live in the secure dementia unit at this facility d/t [due to] my cognitive impairment and aimless wandering. high risk for falling due to unsteady balance . cognitive decline. Observation of the Peace Garden Suite on all days of survey identified residents wandering in and out of other resident rooms, and identified Resident #26 up in his room per self on at least one occasion. On 02/01/23 at 11:46 a.m., During observation of Resident #26's heater with the plant operations supervisor (#8) and two administrative staff members (#9 and #10), they agreed the inside coils of the heater were exposed and hot to touch which posed a risk of injury to all residents residing on the Peace Garden Suite. .

Based on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 1 of 1 ice machine observed used for needs of the facility. Failure to provide the required air gap for the ice machine has the potential to allow contamination of the machine in the event of a sewer back up. Findings include: Review of the 2018 North Dakota Plumbing Code, section 801.2 Air Gap or Air Break Required, stated, Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. Where a drainage air gap is required by this code, the minimum vertical distance as measured from the lowest point of the indirect waste pipe or the fixture outlet to the flood-level rim of the receptor shall be not less than 1 inch (25.4 mm). Section 801.3.3 Food-Handling Fixtures, stated, Food-preparation sinks, steam kettles, potato peelers, ice cream dipper wells, and similar equipment shall be indirectly connected to the drainage system by means of an air gap. Bins, sinks, and other equipment having drainage connections and used for the storage of unpackaged ice used for human ingestion, or used in direct contact with ready-to-eat food, shall be indirectly connected to the drainage system by means of an air gap. Each indirect waste pipe from food-handling fixtures or equipment shall be separately piped to the indirect waste receptor and shall not combine with other indirect waste pipes. The piping from the equipment to the receptor shall be not less than the drain on the unit and in no case less than 1/2 of an inch (15 mm). Observation on 02/01/23 at 8:32 a.m. showed the ice machine located centrally for use by all departments. The ice machine drainpipe lacked an air gap. During an interview on 02/01/23 at 8:32 p.m., the maintenance director (#1) confirmed the ice machine failed to have the required air gap.

Based on observation, record review, review of facility policy, and resident, family, and staff interview, the facility failed to provide reasonable accommodation of needs for 1 of 6 sampled residents (Resident #9) observed dependent on staff to place the call light in reach. Failure to place Resident #9's call light within reach may result in an ability to call for help, discomfort, incontinence and skin breakdown. Findings include: Review of the facility policy titled Call System occurred on 02/02/23. This policy, revised April 2011, stated, Purpose: . to allow all residents to signal for assistance . Review of Resident #9's medical record occurred on all days of survey. Diagnoses included cerebrovascular accident (CVA) with left sided hemiplegia. The annual Minimum Data Set (MDS), dated [DATE], identified extensive assist of two persons with bed mobility and totally dependent on two persons for transfers. Resident #9's current care plan stated, I have ADL (activities of daily living) self care deficit . please place the call light on the right side of my bed as I am not able to use it if it is on the left side of my bed . Observations of Resident #9 showed the following: * 01/30/23 at 2:32 p.m., lying in bed with the call light draped over the left side bedrail with the push button touching the floor and not within reach. Resident #9 stated he wanted staff help, but could not see or reach the call light. * 01/31/23 at 09:37 a.m., lying in bed with the call light on the left side bedrail and not within reach. * 01/31/23 at 3:40 p.m., lying in bed with the call light on the left side of the bed rail above the level of his head and the call light not within reach. * 02/01/23 at 8:35 a.m., lying in bed and stated he needed help but could not reach his call light. The call light was located on the left side of the bed above his head and out of sight and out of reach. During an interview on the morning of 02/01/23, a family member reported they have observed Resident #9's call light located on the left side of the bed and out of reach and stated, He yells out to staff when he cannot reach his call light. During an interview on 02/02/23 at 10:35 a.m., an administrative nurse (#11) stated it is a standard of care for all residents to have their call light within reach.

Based on review of Medicare Beneficiary Notices and staff interview, the facility failed to submit a demand bill request for 1 of 3 supplemental residents (Resident #5) reviewed for termination of Medicare Part A services. Failure to submit a demand bill request violated the resident's right to appeal the termination of Medicare Part A coverage. Findings Include: Review of Resident #5's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) identified a Medicare Part A discharge date of [DATE]. The resident checked Option 1 on the SNFABN, which identified a request for an appeal of the termination of skilled services (i.e., a demand bill). Resident #5's billing records failed to identify the facility submitted the claim for Medicare review. During an interview on 01/31/2023 at 4:25 p.m., a business office staff member (#3) identified the corporate office is responsible for submitting a demand bill to Medicare after receiving notice from the facility. The business office staff member (#3) confirmed the facility failed to inform the corporate office of a demand bill.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 09/20/21 Based on observation, record review, review of facility policy, and resident/staff interviews, the facility failed to provide individualized and meaningful activities for 2 of 4 sampled residents (Resident #4 and #136) dependent on staff for activities in the Peace Garden Suite. Failure to implement group and individual activities designed to meet the interests, and support the physical, mental, and psychosocial well-being of each resident, and failure to attempt to engage the resident may have a negative effect on their quality of life. Findings include: Review of the facility policy titled WELLNESS occurred on 02/02/23. This undated policy stated, . Policy: To involve each resident in an ongoing program of activities that is designed to appeal to his or her interests and needs and to enhance the resident's highest practical level of physical, mental, and psychosocial well-being. This will be reflected in the resident's individualized, person-centered care plan. Complete a comprehensive assessment with the resident and/or resident representative to understand the resident's individual preferences on activities as related to their quality of life. Each resident's activity program should be individualized meeting their interests and needs with the resident's desired outcome . Consider alternative approaches to activities for each resident . activities can occur at any time, not just during formal activities provided by activity staff. For residents with dementia, activities will be tailored to meet the needs of residents: who exhibit unusual amounts of energy, walking without purpose . - Review of Resident #4's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease. The current care plan stated, . I am dependent on staff to give me self directed activities related to inability to make needs known at times. I enjoy sorting nuts and bolts and looking at old tractor books. I enjoy talking about my cattle . Staff failed to offer these activities to Resident #4 during observations. Observations identified the following: 01/30/23 at 3:00 p.m., Resident wandering in the suite. Staff gave blocks to the resident for self -activity. Resident displayed no interest, and staff failed to provide encouragement to engage in the activity. 01/31/23 at 11:02 a.m., A wellness assistant (#6) in the Peace Garden suite to provide the 10:45 a.m. activity. The activity calendar stated Bible Stories. The wellness assistant gave Resident #4 a National Geographic magazine to look at, which the resident did not even open. Staff made no attempt to engage the resident in the scheduled activity. 02/01/23 from 10:31 a.m. to 1:56 p.m., The resident repeatedly stated comments of What can I do, can I help? I would like to have something to do. The resident frequently wandered the hallways and in and out of other residents' rooms. The certified nursing assistant (CNA) (#7) offered the resident activities he/she was not interested in, and made no attempt to engage the resident in the activity or visit with the resident. 02/01/23 at 10:50 a.m., A wellness assistant (#5) gave the resident a newspaper to read for the scheduled AM wellness activity. The February activity calendar identified Color or Draw. Staff failed to offer a coloring or drawing activity to the resident. 02/01/23 at 02:17 p.m., the wellness coordinator (#4) asked the CNA (#7) where the resident's tool kit was located. The CNA stated she did not know. During an interview on 02/01/23 at 4:34 p.m., The wellness coordinator (#4) stated the tractor book and the nuts and bolts kit has been missing since the resident entered the unit about a month ago. - Review of Resident #136's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease and anxiety. The current care plan identified, . I am dependent on staff for activities, as I need assistance to give me the supplies necessary to perform the tasks that I like to do. I like to watch Gunsmoke and old westerns . During an interview 02/01/23 at 4:56 p.m., The wellness coordinator (#4) stated she gave a note to the staff on the Peace Garden suite regarding activities for the resident. The note identified, . I was a very active farmer and I love to tinker with objects, tools, gadgets, etc. I would love to help you clean if you give me the broom or a rag to do some dusting, please keep me busy as much as possible. like to listen to music. On the TV I like to watch Gunsmoke and older westerns and basketball games. Observations identified the following: 01/30/23 at 2:42 p.m., The resident wandered throughout the suite. Staff failed to offer activities. 02/01/23 between 10:11 a.m. and 10:48 a.m The resident wandered throughout the suite, looking in cupboards, and wandered in and out of other residents' rooms. Staff failed to offer activities. 02/01/23 at 10:55 a.m., A wellness assistant (#5) in suite to complete morning wellness activity. The activity calendar stated, Color or Draw. The staff failed to offer the activity to the resident and failed to visit with the resident. 02/01/23 at 11:30 a.m., The resident in the kitchen area moving things around. A CNA (#7) instructed the resident to leave things alone. The CNA brought the resident some puzzles to work on but failed to engage the resident in the activity. During an interview on 02/01/23 at 4:34 p.m., a wellness assistant (#5) confirmed her documentation for Resident #4 and #136's daily participation on February 1, 2023 was as follows: * Religious activity documented for the prayer before meals which she had not observed but stated they are suppose to be doing it. * Physical exercise and games documented for walking with the resident. Observation showed Resident #4 and #136 ambulate independently. * Coffee/[NAME] Cart documented for the afternoon snack the residents received. The wellness assistant confirmed she did not observe this, and stated they are to be getting the snack. The facility failed to provide activities that meet the individual interests for Resident #4 and Resident #136 that supported their physical, mental, and psychosocial well-being, failed to attempt to complete the schedule wellness activity, and failed to attempt to engage Resident #4 and #136 in activities.

Based on observation, review of facility policy, and staff interview, the facility failed to provide the housekeeping and maintenance services necessary to maintain a comfortable/homelike environment for 3 of 3 resident areas (100 Unit, 200 Unit, and Peace Garden Suite/Memory Care Unit). Failure to remove soiled linens and eliminate urine odors does not provide a comfortable/homelike environment for the residents, visitors, and staff. Findings include: Review of the facility policy titled Environmental Services - Cleaning occurred on 09/20/21. This policy, revised August 2021, stated, . It is the policy of [facility name] communities that they be maintained in a clean and hygienic condition with written schedules of cleaning and decontamination . The Environmental Service supervisor (EVS) will be responsible for maintaining a schedule of cleaning tasks and the associates responsible for them. The EVS supervisor, or designee, will perform regular observations and audits of the EVS department cleaning procedures . Routine Cleaning: . Clean surfaces such as . window ledges . toilet seats, etc. according to the schedule established by the EVS. High touch areas include: Cubicle curtain . toilet . High touch areas are cleaned daily . Cleaning of walls . will be done when dust/soil is visible. Observations showed the following: * Urine odor in four resident rooms on the 100 Unit and Peace Garden Suite on all days of survey. * A resident bathroom in the Peace Garden Suite with dried feces underneath the toilet rim and/or splattered on the bottom of the wall and piping adjacent to the toilet. * A dirty wall to the left of a resident bathroom in the Peace Garden Suite and a privacy curtain stained with a black/brown substance on all days of survey. * 09/13/21 at approximately noon: two unmade resident beds on the 100 and 200 Units. One of the beds showed the mattress protector soiled with feces. * 09/14/21, an unmade resident bed in the Peace Garden Suite with urine-soaked bedding visible throughout the day. * 09/15/21 at 12:28 p.m., a resident lying on his/her bed in the Peace Garden Suite. No sheets/bedding or pillow case were on the bed or pillow. During an interview on 09/15/21 at 9:15 a.m., a housekeeping supervisor (#17) stated staff clean every day, every [resident] room, including those in the Peace Garden Suite. When asked the process for cleaning rooms with strong odors, the staff (#17) stated, We deep clean them. During an interview on 09/15/21 at 10:42 a.m., a certified nursing assistant (CNA) (#12) acknowledged she forgot to remove the soiled bedding in a resident room in the Peace Garden Suite.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 10/24/19. Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the resident's current status for 5 of 20 sampled residents (Resident #9, #13, #16, #17, #22). Failure to review/revise care plans to reflect each resident's current status limited the staffs' ability to communicate needs and ensure continuity of care for the residents. Findings include: Review of the facility's policy titled Comprehensive Assessments and Care Planning occurred on 09/20/21. This policy, dated 2017, stated, . in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs . A facility should use the results of the assessment to develop, review and revise the resident's person-centered comprehensive care plan. - Review of Resident #9's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Float heels when in bed. Every Shift . Resident #9's current care plan failed to address use of the offloading boots as ordered. - Review of Resident #13's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . per G-tube [a tube that is placed directly into the stomach] . The current care plan failed to reflect the risks/complications related to tube feeding (aspiration risk secondary to positioning). Review of Resident #13's progress notes, dated 07/01/21-09/11/21, identified the resident periodically refused medications, staff assistance, adaptive devices, and in-house/professional consultations/services. The progress notes identified occupational therapy (OT) discharged Resident #13 on 07/22/21 and physical therapy (PT) discharged him on 07/26/21 due to [his] refusal of services. The current care plan stated, . My therapy plan includes PT 3 days a week; OT 12 sessions . During an interview on 09/15/21 at 11:26 a.m., a therapy staff member (#15) confirmed, . [Resident #13] has refused therapy services from OT . [Resident #13] was discharged from OT in July. During an interview on 09/16/21 at 10:28 a.m., two administrative staff members (#2 and #7) confirmed Resident #13 periodically refused care, services, and consultations. The current care plan failed to address Resident #13's refusals of medications, staff assistance, adaptive devices, and in-house/professional consultations/services and failed to reflect the resident's current therapy status. Observations on 09/13/21 at 4:35 p.m., 09/15/21 at 9:47 a.m. and 10:36 a.m., and 09/16/21 at 9:36 a.m., showed Resident #13 with contractures to both hands and a urinal sitting on the bedside table. The progress notes, dated 07/01/21-09/11/21, identified Resident #13, at times, made inappropriate comments/displayed inappropriate behaviors when staff assisted him with urinal use, resulting in the resident refusing the assistance and/or the staff addressing the comments/behaviors, leaving the room, and reapproaching the resident at a later time. During an interview on 09/16/21 at 10:28 a.m., an administrative staff member (#2) indicated staff are instructed to assist Resident #13 with placement of the urinal and he is capable of placing his penis into the urinal. The staff member (#2) stated he often insists staff place his penis into the urinal and makes inappropriate comments and/or displays inappropriate behaviors. In these instances, staff are instructed to verbally address the comments/behaviors, and if the resident is noncompliant, leave the room and reapproach him at a later time. The current care plan failed to address the protocol for staff assistance/urinal use. - Review of Resident #16's medical record occurred on all days of survey. The care plan identified, . I do not like other residents in my room . I have a 'do not enter' sign across my door to keep other resident out of my room. Observation on all days of survey showed Resident #16's room door without a do not enter sign across the entry. During an interview at 09/16/21 at 9:06 a.m., a certified nursing assistant (CNA) (#10) reported the facility discontinued the sign. The facility failed to remove the do not enter sign from Resident #16's careplan. - Review of Resident #17's medical record occurred on all days of survey. The record identified a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan failed to identify signs/symptoms of blood clot formation and possible adverse reactions secondary to anticoagulant use. - Review of Resident #22's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations showed the following: * 09/13/21 at 12:20 p.m. and 09/15/21 at 12:30 p.m., a CNA (#1) fed Resident #22. * 09/14/21 at 12:35 p.m., two CNAs (#1 and #6) took turns feeding Resident #22. The current care plan failed to reflect Resident #22's total dependence on staff for meal intake and signs/symptoms of aspiration.

Based on record review, review of professional literature, review of facility standing orders, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #2), with a [DIAGNOSES REDACTED]. Findings include: Berman, Snyder, Kozier, Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 9th edition, Pearson Education, Inc., New Jersey, pages 1349-1350, stated,"Constipation . . . infers the passage of dry, hard stool or the passage of no stool. . . . Associated with constipation are difficult evacuation of stool and increased effort or straining of the voluntary muscles of defecation. The person may also have a feeling of incomplete stool evacuation after defecation. . . . Careful assessment of the person's habits is necessary . . . Many causes and factors contribute to constipation . . . Insufficient fiber intake, Insufficient fluid intake . . . Irregular defecation habits . . . Chronic use of laxatives or enemas . . . Emotional disturbances such as depression or mental conditions, Medications such as . . . antidepressants . . ." The facility failed to provide a copy of their policy on constipation upon request. The physician's standing orders form, dated 09/11/12, identified, "Constipation Prevention: 1. Implement dietary measures (extra fluids, fiber, prune juice), encourage 2000 ml (milliliters) fluid intake daily (unless contraindicated), 2. [MEDICATION NAME] sodium 100 mg (milligrams) 1-2 capsules PO (orally) BID (twice daily) PRN (as needed) . . ." Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairment and extensive assistance needed with toileting. Record review identified the facility failed to assess Resident #2's bowel patterns. The current care plan stated, ". . . Approach: . . . Medications as ordered. Sometimes she has loose stools and occasionally has had some difficulty with constipation. . . ." The care plan failed to identify any dietary interventions to prevent Resident #2 from experiencing constipation. The current physician's orders [REDACTED]. * 04/11/14, [MEDICATION NAME] (for depression) 5 mg daily. * 04/11/14, [MEDICATION NAME] (for depression) 25 mg at bedtime. * 04/11/14, [MEDICATION NAME] ([MEDICATION NAME]) (for diarrhea) two tablets after first loose stool, and then one tablet after each loose stool after that prn. * 05/04/14, Milk of Magnesia (MOM) (for constipation) 2,400 mg/10 ml twice daily prn. The physician's orders [REDACTED]. * 05/20/14, Use prn Suppository before using MOM for constipation. * 06/23/14, [MEDICATION NAME] suppository (for constipation) if no results on 5th day or unable to use other interventions. The progress notes and the Medication Administration Record [REDACTED] * 05/04/14 at 11:46 a.m., ". . . Requested small dose of MOM, states she is constipated, will monitor for results. . . . Bowel sounds diminished at this time. No tenderness or distending of abdomen. . . ." The record lacked a response/result from the MOM. * 05/05/14 at 1:49 p.m., ". . . Had large liquid incontinent stool after dinner meal, prn [MEDICATION NAME] given with no further stools noted . . ." * 05/15/14 at 2:13 p.m., "Resident c/o (complained of) . . . loose stools this am, Prn . . . [MEDICATION NAME] given with relief stated. No further loose stools." * 05/18/14 at 4:51 p.m., "This nurse was called into residents room this Am with Certified Nursing Assistant (CNA) stating resident was having difficulty having a BM (bowel movement). Resident was sitting on toilet when this nurse walked in, asked resident if she was able to go she stated, 'It just won't come out.' Did check and residents stool was hard and was able to assist resident with some bowel remove (sic) at that time. Resident stated she felt she needed to go more, gave resident PRN order for [MEDICATION NAME] 1 tab po to help. After some time resident had a couple loose stools . . ." The record lacked evidence nursing staff notified Resident #2's physician and the dietitian of the manual extraction. * 05/19/14 at 3:10 a.m., ". . . Had smears of BM on brief." * 05/20/14 at 2:08 p.m., ". . . Resident was seen by (NP) for routine rounds . . . Orders to use prn Suppository before using MOM in regards to constipation. . . ." * 05/22/14 at 9:04 p.m., "Resident c/o loose stools this evening . . . [MEDICATION NAME] given . . ." * 05/24/14 at 2:20 p.m., ". . . Resident had couple loose stools before dinner, prn [MEDICATION NAME] given. Resident refused dinner meal, 'I just don't feel good.'" * 05/28/14 at 2:57 p.m., "This nurse was called to residents room this AM stating she was having difficulty having bowel movement. CNA stated resident had same complaint earlier this AM. Did give resident prn Suppository at 11 a.m. . . . Checked on resident after dinner meal and she stated she so far just had small results. . . ." * 05/30/14 at 2:40 p.m., ". . . Resident had 2 loose stools this AM. . . ." * 05/31/14 at 2:07 p.m., ". . . states she 'doesn't feel well.' . . . Incontinent of large loose bm in bed this am, prn [MEDICATION NAME] given with relief. Refused breakfast meal and had bites at dinner time. . . ." * 06/12/14 at 11:50 a.m., "Incont (incontinent) loose stools." * 06/21/14 at 3:14 p.m., ". . . [MEDICATION NAME] given after dinner due to loose stools x 3, no further complaints." * 06/23/14 at 10:39 a.m., "She c/o (complained of) not being able to have a bowel movement. Rectal check done and there was a moderate amount of formed stool present in her rectum. [MEDICATION NAME] supp. (suppository) given. . . ." The record lacked a response/result from the [MEDICATION NAME] suppository. * 06/27/14 at 2:54 p.m., ". . . Did request [MEDICATION NAME] after breakfast meal due to large incontinent loose stool. Gave resident 2 [MEDICATION NAME] prn with no further complaints of loose stools," and at 10:26 p.m., "Resident has had no further c/o loose stools this shift. . . ." * 06/29/14 at 11:24 p.m., "Resident c/o of pressure at rectum and unable to defecate. On observation (sic) no stool present at rectum. Lower abdomen firm showing presence of stool. Digital exam performed with no evidence of stool present in rectum. Resident given a [MEDICATION NAME] suppository with Medium results. Stool was soft and formed. Resident was unable to push the stool from rectum and needed manual assist to remove the stool. Staff report that when resident receives MOM she gets diarrhea and then will request [MEDICATION NAME]. Will address with (nurse practitioner) on rounds 07/01/14." The record lacked evidence nursing staff notified Resident #2's physician and the dietitian in a timely manner of the second manual extraction. * 06/30/14 at 3:09 p.m., "Resident c/o having difficulty having a bm, is unable to push out stool and is tearful. Abdomen firm but denies pain, bowel sounds present. Rectal exam completed with small amount of soft stool noted. MOM given this am and now Resident having loose stools and requesting [MEDICATION NAME]. Refused dinner meal," and at 9:55 p.m., ". . . did have one continent loose bowel movement." * 07/01/14 at 11:55 a.m., ". . . Resident was seen by (nurse practioner) today on rounds. Staff concern about manual removal of stool due to resident being unable to evacuate. . . ." During an interview the morning of 08/13/14, an administrative staff member (#1) confirmed the facility failed to assess Resident #2's bowel patterns and failed to notify Resident #2's physician and the dietitian of the two manual extractions and of her distress over not being able to have a bowel movement. The facility failed to: * Assess Resident #2's bowel patterns. * Identify the causative factors contributing to Resident #2's diarrhea-like stools and/or constipation. * Correlate the relationship between Resident #2's alternating symptoms of diarrhea and constipation. * Implement dietary measures (ie: extra fluids, fiber, prune juice) as per the physician's standing orders. * Specify when staff were to administer Resident #2's prn medications (ie: second, third, or fourth day, if no results). This failure resulted in Resident #2 experiencing the manual removal of stool/fecal impaction on two occasions, physical discomfort, and emotional distress.