Every finding on record at The Meadows on University

Based on review of resident council meeting minutes, review of facility policy, confidential resident, family, and staff interviews, the facility failed to ensure sufficient nursing staff and related services are available to meet the residents' need for 4 of 18 sampled residents (Resident E, J, N, and P), and 12 supplemental residents (Resident A, B, C, D, F, G, H, I, K, L, M, and O) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for all residents. Findings Include: Review of facility policy titled Call lights: Accessibility and Timely Response occurred on 06/10/26. This policy, dated 06/15/25, stated, . All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate person should be notified. Review of resident council meeting minutes dated 12/15/25, 02/23/26, 03/20/26, and 04/17/26, identified residents reported long call light response times, unanswered call lights after 6:00 p.m., staff turning off call lights, and staff failing to return after acknowledging resident requests. Confidential interviews conducted June 7-8, 2026 identified the following: * 06/07/26 in the afternoon Resident E stated it can take an hour for someone to answer my call light. * 06/07/26 at 11:29 a.m. Resident F stated at times she waits one hour for her call light to be answered. During an interview on 06/07/26 at 11:38 a.m., a certified nurse aide (CNA) (#12) stated there were currently six CNAs working the day shift and reported seven CNAs were scheduled; however, one had called in sick. During an interview on 06/07/26 at 11:41 a.m., a nurse (#7) stated, I am the only nurse in the building, but there's another nurse coming at noon. When asked if it was normal staffing for one nurse in the building until noon, the nurse stated, There's supposed to be three nurses in the building, I am the only nurse for long term care and there is another nurse on South rehab. The nurse (#7) stated there are two nurses scheduled for long term care. * 06/07/26 at 11:55 a.m. Resident A stated the average call light wait time is 30 to 45 minutes, usually in the evenings. * 06/07/26 at 12:00 p.m. Resident G stated, between 6:00 p.m. and 7:30 p.m., it often takes one to two hours for staff to answer the call light. * 06/07/26 at 12:04 p.m. Resident H stated it occasionally takes one and a half hours for staff to answer the call light. especially between 2:00 p.m. and 3:00 p.m.* 06/07/26 at 12:15 p.m. Resident D stated the call light wait times can be anywhere from an hour to two hours usually late in the evenings and on weekends. * 06/07/26 at 12:20 p.m. Resident I stated it takes an average of one and a half hours for staff to answer the call light at times. * 06/07/26 at 12:34 p.m. Resident K stated call lights are ridiculous, and it takes staff 45 minutes to one hour to answer the call light just to get water and stated last week he/she put the call light on for another resident and the call light was not answered until one hour and 35 minutes later. *06/07/26 at 2:31 p.m. Resident L stated it often takes 45 minutes to one hour for staff to answer the call light and stated two nights ago there were only three CNAs and two nurses for the whole building. * 06/07/26 at 2:42 p.m. Resident P stated the average call light wait time is 15 to 30 minutes. * 06/07/26 at 3:00 p.m. Resident B stated the average call light wait time is 30 to 45 minutes, mainly on the weekends and evenings. * 06/07/26 at 3:47 p.m. Resident C stated call light wait times can range 30 minutes to one hour. * 06/08/26 at 8:00 a.m. Resident J stated my call light last night was on from 9:30 p.m. to midnight. I really struggled; I could not get anyone in to help me. * 06/08/26 at 9:06 a.m. Resident O stated the staff say they are short staffed and it often takes 45 minutes for staff to answer the call light.* 06/08/26 at 9:45 a.m. a family member AA stated it can take up to 35 minutes for staff to answer the call light and assist the resident.* 06/08/26 at 4:20 p.m. Resident N stated most of the time and it takes them 45 to 60 minutes to answer the call light. * 06/08/26 at 4:30 p.m. Resident M stated call light wait times are sometimes 30 to 45 minutes. During an interview on 06/10/26 at 1:40 p.m., an administrative nurse (#1) stated he/she expected staff to answer call lights as soon as possible and no longer that 15 minutes.

Based on record review, review of facility policy, and resident and staff interviews, the facility failed to provide the necessary services for 4 of 18 sampled residents (Resident #1, #10, #30, and #55) who required assistance with bathing. Failure to provide bathing as scheduled may result in poor personal hygiene and decreased self-esteem. Findings include: Review of facility policy titled Activities of Daily Living occurred on 06/10/26. This policy, dated May 2025, stated, . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. - Review of Resident #1's medical record occurred on all days of survey. The current care plan stated, has impaired physical functioning r/t [related to] fatigue and weakness . Shower/bathe . A [assist] [of] 1 . During an interview on 06/08/26 at 4:20 p.m., Resident #1 stated he/she requested two showers a week, but usually only receives one a week. Review of Resident #1's bathing/shower record identified showers scheduled twice weekly on Wednesdays and Sundays. The bathing record, dated May 13 - June 7, 2026, showed the resident received a shower on four of nine scheduled bath days, refused once, and not applicable twice. The record failed to show whether staff offered an alternate time or day for the refused baths and explain not applicable. - Review of Resident #10's medical record occurred on all days of survey. The current care plan stated, . has impaired physical functioning . Shower/Bathing: A x 1 . Review of Resident #10's bathing record identified bathing scheduled twice weekly on Monday and Saturday. The bathing record, dated May 12 - June 8, 2026, showed the resident received a bath on two of eight scheduled bath days and refused six times. The record failed to show whether staff offered an alternate time or day for the refused baths. - Review of Resident #30's medical record occurred on all days of survey and identified a hospitalization from May 21-29, 2026. The current care plan stated, . has impaired physical functioning . Shower/Bathing: A x 1 . Resident #30's medical record identified bathing scheduled twice a week on Wednesday and Sunday. The record lacked documentation of a bath/shower or refusal on three of three scheduled bath days. Review of Resident #55's medical record occurred on all days of survey. The current care plan stated, . has impaired physical functioning . Personal Hygiene: A [assist] x 1 . has ADL [activities of daily living] Self-care deficit as evidence by . paraplegia, muscle weakness . Review of The Resident #55's bathing record identified bathing scheduled twice a week on Thursday and Sundays. Review of the bathing record, dated April 12 to May 31, 2026, showed the resident received baths on eight of 15 scheduled bath days. The record lacked documentation for seven of the scheduled bath days. During an interview on 06/10/26 at 1:10 p.m., an administrative staff member (#1) stated she expected residents bathed according to their schedule and if they refuse, to notify the nurse and document in the resident's record.

Based on observation and staff interview, the facility failed to provide adequate housekeeping services to prevent accidents on 1 of 4 days of survey (06/07/26). Failure to clean standing water from the floor placed residents, staff, and visitors at risk of falls and injury.Findings include: -Observation on 06/07/26 at 11:05 a.m. showed a trail of water on the floor extending down the central hallway. Observation of staff and residents walking in hallway. The water remained on the floor until 11:48 a.m. (43 minutes). -Observation on 06/07/26 at 11:30 a.m. showed water dripped from the ceiling air-conditioning unit into a bucket near the Dakota Dining Room. Observation showed a puddle of water surrounding the bucket and extended under and into the doorway threshold of the Dakota Dining Room. Staff propped a wet floor sign against the wall. Observation of staff and residents walking in hallway. The water remained on the floor until 1:10 p.m. (One hour and 40 minutes) -Observation on 06/07/26 at 2:28 p.m. showed water continued to drip into a bucket from the ceiling air-conditioning unit near the Dakota Dining Room. Facility staff placed a yellow caution sign over the puddle of water on the floor. At 3:05 p.m., observation revealed the puddle of water had increased in size and extended over a larger area of the floor than previously observed. During an interview on 06/09/26 at 3:20 p.m., the maintenance supervisor (#9) stated all staff are expected to monitor for water on the floor and other potential safety hazards and to clean them up promptly to prevent accidents and maintain a safe environment.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure food items were stored and monitored in a safe manner in 1 of 1 kitchen and 1 of 1 kitchenette observed. Failure to properly store, label, date, monitor, and discard food items may result in the consumption of unsafe food and place residents at risk for foodborne illness.Findings include:Review of facility policy titled, Monitoring of Cooler/Freezer Temperatures occurred on 06/10/26. This policy, dated 06/05/25, stated, . Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date . discarded . Review of facility policy titled, Foods Brought by Family/Visitors occurred on 06/10/26. This undated policy stated, . Food brought . will be labeled and stored in a manner that is clearly distinguishable . Containers will be labeled with the resident's name, the item and the 'use by' date. The food service staff will discard perishable foods on or before the 'use by' or three (3) days from opening date. will discard any foods . show obvious signs of potential foodborne danger ( . mold growth . ).Observation on 06/07/26 at 11:10 a.m., showed a container of green beans dated 05/05/26 located in the walk-in refrigerator. On 06/08/26 at 10:00 a.m. showed a bottle of V8 juice undated, unlabeled, and exhibited visible mold growth inside the bottle, and an unlabeled and undated Subway sandwich located in the kitchenette at the south nursing station.The facility failed to maintain sanitary food storage practices and ensure food items were properly dated, labeled, monitored, and discarded when no longer safe for consumption.During an interview on 06/08/26 at 10:20 a.m., the dietary manager (#3) confirmed staff should monitor refrigerators to ensure expired, unlabeled, and unidentified food items are discarded.

Based on observation, review of facility policies, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 7 sampled residents (Resident #2 and #7) observed during cares, 1 of 5 residents observed during medication pass (Resident #19), and one laundry room. Failure to follow infection control standards related to hand hygiene, glove use, medication administration, the use of personal protective equipment (PPE) and enhanced barrier precautions (EBP), and storage of soiled/clean items within the laundry room has the potential to spread infection throughout the facility. Findings Include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 06/09/26. This policy, dated 04/11/25, stated, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: . indwelling medical devices (. indwelling catheters, feeding tubes .) . Make gowns and gloves available immediately near or outside of the resident's room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include: . Transferring . changing briefs or assisting with toileting . Review of facility policy titled Hand Hygiene occurred on 06/10/26. This policy, dated 04/10/25, stated, . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of facility policy titled Laundry occurred on 06/10/26. This policy, dated 06/05/25, stated, . laundry area will provide. PPE. Soiled laundry shall be kept separate from clean laundry at all times. -Observation on 06/07/26 at 4:46 p.m. showed Resident #2's door with an EBP sign. A certified nurse aide (CNA) (#2) entered the room, applied gloves, and completed perineal cares. The CNA removed the soiled gloves, and without performing hand hygiene, applied new gloves, assisted the resident to a sitting position and transferred the resident with a stand lift. The CNA (#2) failed to apply a gown prior to completing perineal cares and failed to perform hand hygiene after removing the soiled gloves. -Observation on 06/08/26 at 9:15 a.m. showed a nurse (#10) assisted Resident #7 with toileting and performed perineal care. Without removing the soiled gloves, the nurse reached into her pocket and used the walkie talkie to call for assistance. The nurse removed the soiled gloves and without performing hand hygiene, moved the resident's wheelchair and removed the resident's pants and shoes. The nurse performed hand hygiene and left the room as CNA (#11) completed perineal care and assisted the resident into the wheelchair. The CNA (#11) removed the soiled gloves and without performing hand hygiene, assisted the resident to the sink. The staff failed to remove gloves and complete hand hygiene before performing other tasks. During an interview on 06/10/2026 at 1:20 p.m., an administrative nurse (#1) stated she expected staff to wear a gown and gloves when completing high contact care for residents in EBP and perform hand hygiene after removing gloves. -Observation on 06/08/26 at 7:45 a.m. showed the following in the laundry room: *The soiled laundry area contained gloves, but no additional PPE supplies. Lift slings and repositioning devices stored on top of the washing machine. *The clean laundry area contained a covered container of soiled kitchen towels. The facility failed to ensure separation of clean and soiled items, protect resident care equipment from potential contamination, and provide PPE for staff handling contaminated laundry. -Observation on 06/09/26 at 8:24 a.m., showed a medication aide (MA) (#6) prepared an inhaler medication, entered Resident #19's room, and without performing hand hygiene, administered the inhaler. The MA (#6) failed to perform hand hygiene upon entering the resident room and prior to administering the resident's inhaler.

Based on observation, review of facility policy, and staff interviews, the facility failed to provide care in a manner which maintained or enhanced resident dignity for 3 of 18 sampled residents (Resident #3, #7 and #12). Failure to knock on residents' doors/announce themselves prior to entering in a private area does not respect the resident's personal dignity and has the potential to affect the resident's psychosocial well-being.Findings include: Review of the policy titled Resident Rights occurred on 06/10/26. This policy, dated May 2025, stated, . The resident has a right to personal privacy . - Observation on 06/07/26 at 4:40 p.m. showed a nurse (#15) entered Resident #3 and #12's room and failed to knock or announce himself/herself. - Observation on 06/07/26 at 4:50 p.m. showed a nurse (#15) assisted Resident #3 with cares. A certified nurse aide (CNA) (#12) entered the resident's room and failed to knock or announce himself/herself. - Observation on 06/07/26 at 4:59 p.m. showed a CNA (#12) and a nurse (#15) assisted Resident #12 with cares. A staff member (#1) entered the resident's room and failed to knock or announce himself/herself. During an interview on 06/10/26 at 1:40 p.m., an administrative staff member (#1) stated she expected all staff to knock on resident doors and announce themselves prior to entering.

Based on observation, review of facility policy, and resident and staff interviews, the facility failed to ensure safe and secure storage of medications for 2 of 2 sampled residents (Resident #24 and Resident #66) and supplemental resident (Resident #49) with medications left at the bedside. Failure to securely store medications may lead to medications errors, unauthorized access, and/or resident harm. Findings include: Review of the facility policy titled Medication Storage occurred on 06/11/26. This policy, dated June 2025, stated, . All drugs . will be stored in locked compartments (i.e., medication carts . medication rooms) . -Observation on 06/07/26 at 11:55 a.m., showed a bottle of generic acid reducer on Resident #49's bedside table. -Observation on the afternoon 06/07/26 showed a container of Hempvana ultra strength topical pain relief gel for arthritis on Resident #24's bedside. When asked about the gel the resident stated, I use it on my legs, I need it on my back but can't reach it. -Observation on 06/07/26 at 3:19 p.m. showed a box of Topcare stomach relief tablets on Resident #66's bedside table. When asked about the medication the resident stated, I take that for my stomach. During an interview on 06/10/26 at 1:10 p.m., an administrative staff member (#1) stated it is an expectation that medications are not left in resident rooms, unless they have been assessed and deemed safe to keep the medications at bedside.

Based on observation, review of facility policy, and review of manufacturer's instructions, the facility failed to ensure a medication error rate of less than five percent for 2 of 25 medications observed during medication administration. Two medication errors occurred during staff administration of 25 medications, which resulted in an eight percent error rate. Failure to follow facility policy and pharmacy instructions may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health. Findings include:Review of facility policy titled Insulin Pen occurred on 06/10/26. This policy, dated 06/05/25, states, . Prime the insulin pen . With the needle pointing up, push the plunger, watch to see that at least one drop of insulin appears on the tip of the needle.Review of manufacturer instructions for Advair Diskus (dry powder inhaler), occurred on 06/10/26. These instructions, revised March 2026, states, . ADVAIR DISKUS can cause serious side effects, including . fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using ADVAIR DISKUS to help reduce your chance of getting thrush.- Observation on 06/07/26 at 4:34 p.m., a nurse (#7) prepared an insulin pen. The nurse dialed 2 units of insulin, then held the insulin pen horizontally (needle to the side). The nurse failed to prime the insulin pen pointing upward.- Observation on 06/09/26 at 8:24 a.m., a Medication Aide (MA) (#6) administered Fluticasone-Salmeterol Inhalation Aerosol (Advair) to a resident. Review of the pharmacy label stated, . Rinse mouth after each use. The MA failed to instruct the resident to rinse their mouth after administering each inhaler.

Based on observations, record review, review of facility policy, and staff interview, the facility failed to provide care and services for 1 of 1 supplemental resident (Resident #57) observed with a wound dressing. Failure to follow physician's orders regarding dressing changes may result in delayed treatment, infection, and increased wound complications. Findings include:Review of the facility policy titled Clean Dressing Change occurred on 06/10/26. This policy, dated May 2025, stated, . It is the policy of this facility to provide wound care in a manner to decrease potential for infection . Physician's orders will specify type of dressing change and frequency of changes. Assure dressing is labeled with initials and date.Review of Resident #57's medical record occurred on June 7, 9 and 10, 2026. A physician's order dated 06/02/26 stated, Skin tear to right lower extremity. Cleanse area, pat dry, keep steri strips intact. Cover with 4x4 gauze and secure with tape QD [every day] and prn [as needed].Observation on 06/07/26 at 4:30 p.m. showed an occlusive dressing to Resident #57's right lower calf dated 06/03/26 . Observation on 06/09/26 at 5:00 p.m. showed an undated, uninitialed white dressing (not gauze) to Resident #57's right lower calf. Observation on 06/10/26 at 10:50 a.m. showed an undated and uninitialed occulsive dressing to Resident #57's right lower calf. Review of Resident #57's treatment administration record from 06/02/26 through 06/10/26 lacked documentation facility staff changed the resident's dressing on June 2, 3, and 5, 2026 (3 of the 9 days). During an interview on 06/10/26 at 1:40 p.m. an administrative staff member (#1) stated she expected staff to follow physician orders for the type of wound dressing and the frequency of changes.

Based on record review and resident and staff interviews, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 18 sampled residents (Resident #1 and #30). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 06/10/26. This policy, dated May 2025, stated, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team . - Review of Resident #1's medical records occurred on all days of survey. A progress note dated 5/26/26, stated, . The resident informed this writer that, moving forward, he only wishes to see his sister in open areas of the building. and the resident has expressed that no further information is to be shared with her.Resident #1's care plan failed to include choices related to his sister's involvement with his care. - Review of Resident #30's medical record occurred on all days of survey. The care plan stated, . has potential for complications/injury r/t [related to] smokes cigarettes. During an interview on 06/08/26, at 11:15 a.m., an administrative nurse (#1) confirmed Resident #30 is not a smoker. During an interview on 06/09/26, at 3:40 p.m., Resident #30 stated he/she does not smoke. The staff failed to review and revise Resident #30's care plan to reflect his/her current smoking status.

Based on observation, review of facility policy, and resident and staff interviews, the facility failed to provide housekeeping services to maintain a safe, clean, comfortable and homelike environment for 4 of 4 days of survey. Failure to ensure the resident environment and equipment are kept clean and sanitary does not promote a homelike living environment or enhance the residents' quality of life. Findings include: Review of the facility policy titled Safe and Homelike Environment occurred on 06/10/26. This policy, dated May 2025, stated, . In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. - Observation on all days of survey showed large amounts of food debris on Resident #3's wheelchair and stains on the padded footrests. During an interview on 06/10/26 at 1:40 p.m. an administrative staff member (#1) stated she expected staff to clean wheelchairs, including footrests. Observations on 06/07/26 showed the following; * At 11:12 a.m., a water trail from the central hallway bathing room down the entire length of the hallway and around to the next hallway. In addition, two alcohol wipe wrappers, food debris, a single piece of paper and straw wrappers on the floor outside of room [ROOM NUMBER]. * At 11:30 a.m., an empty chip bag on a side table, a straw on the floor, and a used blanket on a couch in the common area adjacent to the Dakota Dining Room. * At 12:17 p.m., a sticky substance on the floor and on the countertop in Resident D's room and the room appeared disorganized and cluttered. * At 12:00 p.m., multiple areas of crumbs, a foil candy wrapper, and debris on the hallway floor by room [ROOM NUMBER] and a large area of dried brown substance splattered on the floor near the central supply room door. * At 2:05 p.m., a candy wrapper and multiple areas of crumbs along the hallway floor outside rooms [ROOM NUMBERS]. Observations on 06/09/26 showed the following; * At 10:41 a.m., the grates of a black pedestal fan coated with dust and clumps of dust blowing toward Resident #45's bed. When asked if staff clean the fan, the resident stated, No. * At 11:57 a.m., the grates and blades of a white table fan coated with dust located on a bedside table in Resident #17's room. During an interview on 06/09/26 at 2:00 p.m., administrative nurse (#1) stated he/she expected the housekeeping staff to clean the fans when needed. During an interview on 06/09/26 at 3:20 p.m., the maintenance supervisor (#9) stated all staff are expected to monitor their work areas and ensure environmental concerns are promptly addressed to maintain a clean and sanitary environment. - Observation on 06/10/26 at 10:55 a.m. showed large amounts of scrambled eggs, toast, and other food particles under two tables in the main dining room. The noon meal is scheduled from 11:00 a.m. to 1:00 p.m. and the dietary staff had started serving the noon meal.

Based on review of Medicare Part A letters/notices, review of facility policy, and staff interview, the facility failed to ensure the resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 2 of 3 residents (Resident #43 and #81) reviewed for termination of Medicare Part A services. Failure to ensure the completion of the SNFABN limited the resident/representative's ability to exercise their rights regarding Medicare Part A services.Findings include:Review of facility policy titled Advance Beneficiary Notices occurred on 06/10/26. This policy, dated 06/25/25, stated, . The facility shall inform Medicare beneficiaries of his or her potential liability for payment. the form shall comply with related instructions and regulations regarding the use of the form. The notice shall . obtain beneficiary or representative signature.- Review of Medicare Part A beneficiary notices identified Resident #43 discharged from Medicare Part A on 05/20/26. The SNFABN failed to identify if the resident/resident's representative chose to continue services, discontinue services, or request a demand bill.- Review of Medicare Part A beneficiary notices identified Resident #81 discharged from Medicare Part A on 01/23/26. The SNFABN failed to identify the estimated cost of services, if the resident/resident's representative chose to continue services, discontinue services, or request a demand bill and lacked a signature from the beneficiary or the representative.During an interview on 06/09/26 at 2:22 p.m., an administrative nurse (#1) confirmed the SNFABN's for Residents #43 and #81 were incomplete.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure posting of resident census on 3 of 4 days of survey (June 7, 2026 - June 9, 2026). Failure to post the resident census may impede the facility's ability to evaluate staffing levels in relation to the number of residents residing in the facility.Findings include:Review of the facility policy titled Nurse Staffing Posting Information occurred on 06/10/26. This policy, dated 05/16/26, stated, . The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: . Facilities current resident census .- Observation on June 7-9, 2026, identified the facility failed to include the resident census number on the nurse staffing information.During an interview on 06/09/26 at 3:30 p.m., an administrative staff member (#1) stated she expected the human resource staff to complete and post a daily census/staffing report.

Based on record review, review of facility policy, and staff interview, the facility failed to develop a baseline care plan to reflect the needs for 1 of 1 sampled resident (Resident #1) identified as a new admission. Failure to develop and implement a baseline care plan may result in inconsistent and unsafe care for all newly admitted residents. Findings include:Review of the facility policy titled Baseline Care Plan occurred on 12/30/25. This policy, dated 05/05/25, stated, . The baseline care plan will . be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident .Review of Resident #1's medical record occurred on all days of survey and identified an admission date of 12/10/25. The comprehensive assessment, dated 12/12/25, stated, . Transfer - assist x1 (assist of one) . Eating - independently . Toileting - assist x1 .The resident's base line care plan, dated 12/10/25, identified no interventions for specific needs such as transfers, eating, and toilet use. During an interview on 12/31/25 at 10:35 a.m., an administrative staff member (#1) confirmed staff failed to develop a baseline care plan for Resident #1.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #1) on contact precautions. Failure to practice infection control standards related to contact precautions and hand hygiene for staff and residents has the potential to spread infection throughout the facility.Findings include:Review of the facility policy titled Management of C. [Clostridioides] Difficile Infection [a contagious bacterial infection] occurred on 12/04/25. This policy, revised 04/10/25, stated, . All staff are to wear gloves and a gown upon entry into the resident's room and while providing care . Hand hygiene shall be performed by handwashing with soap and water . Encourage/assist residents to wash hands frequently.Review of the facility policy titled Hand Hygiene occurred on 12/04/25. This policy, revised 04/10/25, stated, . If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. For conditions involving a resident, or the resident's environment, who is isolated for Clostridioides difficile [C. diff]. hand washing with soap and water is required.Review of Resident #1's medical record occurred on 12/04/25 and included a diagnosis of enterocolitis due to clostridium difficile. The current care plan stated, [Resident #1] has potential for complications r/t [related to] C-Difficile . isolation as ordered by physician or following CDC [Centers for Disease Control and Prevention] guidelines . [Resident #1] is on contact/enteric precautions r/t C. diff. Ensure strict adherence to hand hygiene protocols before and after patient contact . Use appropriate PPE [personal protective equipment] . as per isolation guidelines.Observation on 12/04/25 at 9:22 a.m. showed a CNA (#2) enter Resident #1's room, applied gloves and without applying a gown, pivot transferred the resident from bed. Using a walker, Resident #1 ambulated to the bathroom and the CNA assisted her onto the toilet. Resident #1 independently completed toileting cares. The CNA transferred the resident off the toilet, and without performing hand hygiene, the CNA (#2) and resident exited the bathroom. The CNA assisted the resident to a wheelchair and the table in the room, placed a meal tray on the table, removed the soiled gloves, used hand sanitizer, and exited Resident #1's room. The CNA (#2) failed to apply a gown. wash hands with soap and water and encourage Resident #1 to perform hand hygiene.During an interview on 12/04/25 at 3:35 p.m., an administrative nurse (#1) stated she expected staff to follow contact-based precautions and perform hand hygiene as specified in facility policies.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 1 of 1 sampled resident (Resident #47) with weight loss. Failure to monitor/document intakes accurately and provide encouragement and assistance with meals and supplements resulted in a significant weight loss. Findings include: Review of the facility policy titled Weight Assessment and Intervention occurred on 04/09/25. This policy, dated September 2008, stated, . The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. 3. The Dietitian will review the weight record weekly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. Provider will be updated with significant weight changes. Analysis . 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: . b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake . Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences b. Nutrition and hydration needs of the resident c. Functional factors that may inhibit independent eating . f. Medications that may interfere with appetite, chewing, swallowing, or digestion . g. The use of supplementation . - Review of Resident #47's medical record occurred on all days of survey. Diagnoses included diabetes and malnutrition. Physician's orders identified Mounjaro (a medication to lower blood sugar that may also cause weight loss) weekly on Fridays, Boost (liquid supplement) three times (TID) (8:00 a.m., 2:00 p.m., and 8:00 p.m.) and as needed (PRN) for malnutrition, and a regular diet, easy to chew texture, thin consistency. The current care plan stated, . I have impaired physical functioning . Eating: supervision for meals . Potential for or presence of altered nutrition needs altered ability to feed self . requires mechanically altered diet, impaired cognition . Diet and food texture provided as ordered . Encourage food and fluid intake . Record % [percent] of meals consumed . An addition to the care plan on 03/06/25 stated, I have weight loss r/t [related to] loss of appetite, eating < [less than] 50% of meals, potential medication side effects, disinterest in food/meals . Dietitian consult for caloric, hydration and nutritional intake needs, with recommendations for increased caloric needs . Offer high calorie/nutrient dense supplements as ordered by physician/dietitian . Weekly weights as ordered by physician . A review of Resident #47's weight record identified the following: *12/27/24 (admission) 188 pounds *01/26/25 173 pounds (7% weight loss in one month) *03/23/25 169 pounds (10% weight loss in three months) *04/06/25 150 pounds (11% weight loss in two weeks and a 20% weight loss since admission) Observation of Resident #47 occurred on 04/07/25 and showed the following: *9:00 a.m., staff assisted Resident #47 with the morning meal in the dining room. The resident refused the meal and drank half a glass of juice. The meal intake record identified the resident consumed 25-50% of the morning meal which differed from the observation. *10:30 a.m., a medication aide (MA) (#12) brought the scheduled 8:00 a.m. Boost to the resident's room, placed it on the overbed table, and failed to provide assistance/encouragement to drink it. *11:55 a.m., a full glass of Boost remained on the resident's overbed table. *12:20 p.m., the MA (#12) confirmed the Boost on the overbed table as the 8:00 a.m. supplement. Review of the medication administration record (MAR) identified the resident consumed 25% of the 8:00 a.m. Boost which differed from the observation of a full glass of Boost . An unidentified certified nurse aide (CNA) confirmed Resident #47 refused lunch, and two glasses of juice were noted on the overbed table. *3:45 p.m., a full glass and one half glass of juice, and a full glass of the 8:00 a.m. Boost remained on the overbed table in the same position as earlier. *5:00 p.m., a staff member took Resident #47 to the dining room. A full glass and another half glass of juice and the full glass of Boost remained in in the same position as earlier on the resident's overbed table. *5:05 p.m., Resident #47 seated alone at the dining room table. The paper menu in front of the resident stated, doesn't want to eat. The resident's meal included a scoop of ham salad, creamed carrots, glass of juice, and two gelatin cups. Staff failed to offer assistance or alternative menu items to Resident #47 during the meal. *5:40 p.m., an unidentified dietary staff member cleared the table, and stated Resident #47 was done eating. The resident ate one spoonful of ham salad, no carrots, one spoonful of gelatin, and drank the juice. Review of Resident #47's meal intake identified the resident consumed 51-75% of evening meal which differed from the observation. Observation of Resident #47 on 04/08/25 showed the following: *8:52 a.m., Resident #47 sat alone at the dining room table with a glass of juice three-fourths full. An unidentified dietary aide stated, [Resident name] refused his meal and did not eat. *11:55 a.m., the resident sat in a wheelchair in his room. A nurse (#5) called a CNA on the walkie talkie and asked if the resident ate. The CNA responded, He refused, we asked him a couple of times. Another CNA in the hall said, He never eats. Observation showed two boxes of Boost (one opened and full and the other unopened), and a full glass of juice on the resident's overbed table. Review of the MAR identified the resident consumed 50% of the 8:00 a.m. Boost supplement which differed from the observation. *5:19 p.m., Resident #47 rested in bed. When asked if he was going to eat the resident replied No. Two boxes of Boost and a glass of juice remained on the bedside table as in prior observations. Review of the resident's meal intake identified staff documented 25-50% of the supper meal consumed; however, Resident #47 refused his meal. Review of the MAR identified the resident consumed 25% of the 2:00 p.m. Boost which differed from the observation. The MAR showed Resident #47 did not receive any PRN Boost on all days of survey. The Weekly Skin and Nutrition IDT [interdisciplinary team] Review, dated 03/27/25, identified a significant weight change of 10%. This assessment stated, Not eating well. Main intakes are supplements. Weight is stable over the past month. No new weight over the past week. Averaging 25-50% at meals . Diet: Regular . Supplements: Boost TID . Assistance/independence at meals: 1:1 [one to one] . Plan: Follow intakes and weight. No new weight this week. Will continue POC [plan of care]. Continue with Boost TID. Okay to drink supplement at meals if intakes poor. A nutrition/weight progress note on 04/03/2025 stated, Skin/Weight team met today to discuss resident. Resident continues to refuse food and prefers boost shakes, will continue to monitor per policy. Provider and resident updated. Resident #47's medical record lacked a dietitian's evaluation for the significant weight loss and current interventions or additional interventions to prevent further weight loss. The care plan failed to reflect the change to 1:1 assistance at meals as defined by the IDT. During an interview on 04/09/25 at 10:30 a.m., an administrative nurse (#1) stated she expected staff to accurately document meal intakes and observe and document percentage of supplements taken.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 8 sampled residents (Resident #2, #6, #8, #36, and #50) and one supplemental resident (Resident #15) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), perineal care, dressing changes, and hand hygiene, has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 04/09/25. This undated policy stated, . EBPs employ targeted gown and glove use during high contact care activities . Examples of high-contact care activities requiring the use of gown and glove for EBP include . urinary catheter . wound care (any opening requiring a dressing). Review of the facility policy titled Dressings, Dry/Clean occurred on 04/09/25. This undated policy stated, . Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. Review of the facility policy titled Handwashing/Hand Hygiene occurred on 04/09/25. This undated policy stated, . Use an alcohol-based hand rub or . soap and water for the following situations: . after contact with resident's intact skin; j. After contact with blood or body fluids; k. After handling used dressings . After removing gloves . Findings include: ENHANCED BARRIER PRECAUTIONS - Review of Resident #50's medical record occurred on all days of survey. The current care plan stated, enhanced barrier precautions r/t [related to] an indwelling medical device catheter. A physician's order, dated 04/01/25, stated, CATHETER CARE: flush Foley catheter with 30mL [milliliters] NS [normal saline] every day shift for blockage/obstruction . Observation on 04/06/25 at 2:07 p.m. showed a red dot sticker on Resident #50's door frame indicating EBP and a supply container in the room containing personal protective equipment (PPE) including gowns and gloves. A nurse (#11) performed hand hygiene, applied gloves, and flushed Resident #50's foley catheter with normal saline. The nurse failed to apply a gown. - Review of Resident #8's medical record occurred on all days of survey. The current care plan stated, enhanced barrier precautions . A physician's order, dated 04/03/25, stated, L [left] heel unstageable pressure ulcer . change dressing every day shift . Observation on 04/06/25 at 2:18 p.m. showed a red dot sticker on Resident #8's door frame indicating EBP and a supply container in the room containing PPE including gowns and gloves. A nurse (#11) performed hand hygiene, applied gloves, removed Resident's #8's left heel dressing, and discarded the dressing. Without removing the contaminated gloves, the nurse exited the room and obtained supplies from the top of the treatment cart located outside the resident's door. The nurse (#11) removed his/her gloves, performed hand hygiene, and completed the dressing change. The nurse failed to remove gloves and perform hand hygiene after removing the left heel dressing and failed to wear a gown during the dressing change. - Review of Resident #36's medical record occurred on all days of survey. The current care plan stated, [Name of Resident #36] is on enhanced barrier precautions per physician orders r/t [related to] an indwelling medical device - foley catheter. A physician's order, dated 12/21/24, stated, Change suprapubic catheter dressing daily . Observation on 04/08/25 at 8:31 a.m. showed a red dot sticker on Resident #36's door frame indicating EBP and a supply container in the room containing PPE including gowns and gloves. A nurse (#5) performed hand hygiene, gloved, and changed Resident #36's suprapubic catheter dressing. The old dressing had a scant amount of light colored drainage. The nurse failed to apply a gown to change the suprapubic catheter dressing. HAND HYGIENE - Observation on 04/07/25 at 9:24 a.m. showed two certified nurse aides (CNAs) (#6 and #8) applied gloves and a gown to assist Resident #15 with morning cares. The CNA (#8) completed frontal perineal care, removed his/her gloves, applied clean gloves, assisted the resident to use the mechanical lift, and placed the resident onto the toilet. The CNA (#8) performed perineal cares after Resident #15 had a bowel movement, removed his/her gloves, applied new gloves, adjusted the resident's clothing, applied foot pedals to the wheelchair, and combed the resident's hair. The CNA (#8) failed to perform hand hygiene after removing gloves and after performing perineal care. 31725 - Review of Resident #2's medical record occurred on all days of survey. A red dot sticker on the Resident's door frame indicated EBP. The current care plan stated, . [Resident name] is on enhanced barrier precautions per physician orders r/t [related to] an indwelling medical device . catheter . [NAME] [apply] gown and gloves during high-contact resident care activities . Observation on 04/06/25 at 1:46 p.m. showed a nurse (#13) entered Resident #2's room. The nurse, without performing hand hygiene, applied gloves, removed a band aid soiled with blood from the resident's toe, and with the same gloves, obtained a new band aid from her uniform pocket, and applied it to the open wound. The nurse (#13) failed to perform hand hygiene before applying gloves, obtained a clean band aid from her pocket with soiled gloves, and failed to remove the soiled gloves, perform hand hygiene, and apply clean gloves before applying a clean band aid to Resident #2's toe wound. The nurse (#13) also failed to apply required PPE (gown) before providing wound cares. Observation on 04/06/25 at 1:55 p.m. showed two CNAs (#10 and #14) performed hand hygiene and applied a gown and gloves. The CNAs turned Resident #2 onto his/her side and removed the resident's brief. The CNA (#10) performed perineal care, and without changing gloves or performing hand hygiene, opened the resident's top nightstand drawer, obtained a tube of barrier cream, applied it to resident's buttocks over an open area of the skin, and placed it back in the resident's nightstand drawer. The CNA (#10) removed the soiled gloves, and without performing hand hygiene, applied new gloves and bagged linen from the resident's bed. The CNA (#10) failed to change gloves and complete hand hygiene between tasks and after completing personal resident care. - Observation on 04/07/27 at 3:37 p.m. showed a CNA (#20) assisted two other CNAs (#9 and #18) transfer Resident #6 from a wheelchair into bed and perform incontinence and perineal cares. After cares, the CNA (#20) removed her gloves, and without performing hand hygiene, obtained the resident's water mug, attempted to open the mug cover, and touched the resident's personal water pitcher. The CNA (#20) confirmed she failed to perform hand hygiene after removing her gloves and prior to performing other tasks. During interviews on 04/08/25 at 1:08 p.m. and 04/09/25 at 11:25 a.m., an administrative nurse (#1) stated she expected staff to wear a gown when flushing a foley catheter and doing a dressing change, and perform hand hygiene after removing gloves and prior to performing other tasks. 45873 40488 PERINEAL CARES Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 744, stated, . Retracting the foreskin is necessary to remove the smegma (thick, cheesy secretion) that collects under the foreskin and facilitates bacterial growth . Hold the shaft of the penis . securely in one hand. Clean the tip of the penis at the urethral meatus in a circular motion from the center outward and wash down the shaft . This follows the principle of cleaning from the least contamination to that of the greatest. Observations on 04/07/25 of Resident #6 showed the following: * 10:15 a.m., a CNA (#6) provided perineal cares for the resident while in bed. The CNA used a washcloth to cleanse the penis shaft and moved up to the penis tip. The CNA (#6) failed to retract the foreskin. * 2:45 p.m., a CNA (#18) performed perineal cares for the resident while in bed. The CNA (#18) failed to retract the foreskin. * 3:07 p.m., while performing straight catheterization preparation, a nurse (#19) retracted the foreskin, exposing a large amount of smegma. During an interview on 04/08/25 at 1:08 p.m., an administrative nurse (#1) stated she expected staff to follow appropriate infection control practices during male perineal cares.

Based on observation, review of professional reference, and staff interview, the facility failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen. Failure to ensure dishware is stored in a clean area and failure to ensure the floors and warewashing machine are free from food/dust debris has the potential for contamination of food and may result in a foodborne illness to residents, visitors, and staff. Findings include: The 2022 Food and Drug Administration (FDA) Food Code, reviewed 01/08/25, Chapter 4-6, pages 20-21, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, stated, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Observations on 04/09/25 at 10:30 a.m. showed the following in the main kitchen: * Loose debris and dust accumulated on the top of the mechanical warewashing machine. * Visible dry particles and debris on a tray of uncovered bowls located in a high traffic area of the kitchen. * Visible dry food/debris on the bottom of a cart used to store clean dishware. * An accumulation of food/dirt debris on the floor between the table legs of a stainless-steel counter and the wall in the dishwashing room. During an interview on 04/09/25 at 10:30 a.m., a dietary staff member (#3) confirmed the kitchen environment and floors should remain clean.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 6 of 15 sampled residents (Resident #2, #6, #16, #36, #43, and #47) dependent on staff assistance for personal hygiene and dining. Failure to assist residents who cannot perform personal hygiene, position self, or open items at meals may result in poor hygiene, skin issues, weight issues, and decreased self-esteem. Findings include: Review of the facility policy titled Fingernails/Toenails, Care of occurred on 04/09/25. This policy, dated 2018, stated, . The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting occurred on 04/09/25. This policy, dated 2021, stated, . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, . including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, nail care and oral care) . Dining (meals and snacks) . - Review of Resident #2's medical record occurred on all days of survey. The current care plan identified, . has ADL self-care deficit as evidenced by decreased mobility related to paraplegia . Observation on 04/06/25 at 1:46 p.m. showed Resident #2 had long, thick, yellow toenails. The resident stated, I need someone else to cut them [toenails], it's been a while since they have been done. - Review of Resident #6's medical record occurred on all days of survey. The care plan identified dependent on staff for personal hygiene. Observation on 04/07/25 at 10:15 a.m. showed Resident #6's toenails on both feet approximately one-fourth inch in length. During an interview on 04/07/24 at 2:36 p.m., Resident #6 stated facility staff clip his/her toenails occasionally. During an interview on 04/08/25 at 1:34 p.m., an administrative staff member (#16) agreed Resident #6's toenails needed trimming. - Review of Resident #16's medical record occurred on all days of survey. A Minimum Data Set (MDS), dated [DATE], identified moderate assistance required for personal hygiene. Observation on 04/06/25 at 2:25 p.m. showed Resident #16's fingernails extended beyond her fingertips. The resident stated, The nurse was going to cut them today but hasn't yet. They cut them about every two to three weeks. Observation on 04/07/25 at 3:27 p.m. showed Resident #16's fingernails remained untrimmed and dirty under the nails. - Review of Resident #36's medical record occurred on all days of survey. Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following a stroke affecting the right dominant side. A quarterly MDS, dated [DATE], identified Resident #36 required ADL setup assistance for eating and dependent on staff for oral cares and personal hygiene. The current care plan stated, . should be upright in wheelchair for all meals to decrease risk for aspiration/choking. should receive consistent oral cares. I have physical functioning deficit . Personal hygiene: mod [moderate] A [assistance] . Eating: set up A, sitting up in w/c [wheelchair] during meals. Review of Resident #36's oral hygiene charting, dated March 9 - April 7, 2025 (30 days), identified staff provided oral cares one time a day for 12 days, two times a day for 12 days, and three times a day for six days. Observations of Resident #36 showed the following: * 04/07/25 at 8:49 a.m., seated in a wheelchair in his room and leaning to the left. A dietary staff member (#3) delivered the resident's breakfast tray and sat the tray on the bedside table in front of the resident but to his right side. The resident could not reach the items on the tray due to his inability to use his right arm and hand. * 04/07/25 at 12:06 p.m., seated in a wheelchair in his room and leaning to the left side with his left arm pressed against the wheelchair armrest. The resident stated an aide washed his face, but did not brush his teeth this morning. The resident stated staff do not help him brush his teeth with any regularity and have not yet today. Observation showed small yellow particles below his right eye and a brown dried substance on the corner of the left side of his mouth and down his chin. A sign above the bed stated, PLEASE!! complete oral care (brush teeth) after every meal, morning, and night. Thank you! At 12:08 p.m., a certified nurse aide (CNA) (#4) arrived with the resident's lunch tray, placed it on the bedside table, and removed the breakfast tray. The CNA failed to assist Resident #36 with hand hygiene or setup the resident's lunch tray. With his left hand, the resident tried to move the tray closer to him and attempted to open the milk carton. Observation showed his fingernails dirty with brown debris underneath them. The resident was able to get his right thumb into the top of the milk carton but failed to open it. The resident stated staff open the milk carton about half the time. The resident opened the milk carton about 20 minutes later by sticking his second and third fingers inside the milk carton. At 1:42 p.m., Resident #36 agreed to call for assistance when, after five minutes, he failed to remove a plastic cover from a dish of fruit. * 04/08/25 at 8:31 a.m., a nurse (#5) and a CNA (#6) repositioned Resident #36 in bed. The CNA raised the resident's head of the bed to 45-60 degrees, set up his breakfast tray, and opened the milk and yogurt cartons. The resident had difficulty reaching the items on his meal tray. At 09:02 a.m., the resident had not started to eat and stated, It would be good to sit up a little higher but he didn't want to call staff. An unidentified CNA arrived to assist the resident with cares, but the resident stated he would like to eat first. The unidentified CNA exited the room and failed to assist the resident with positioning and set up with his meal. At 9:14 a.m. (43 minutes after receiving the meal tray) this surveyor requested assistance for the resident and a CNA (#6) called for another staff member to assist her to position the resident. - Review of Resident #43's medical record occurred on all days of survey. The current care plan stated, I have physical functioning deficit . Personal Hygiene: A x 1 [assistance of one staff] . An activities' note, dated 02/26/2025 at 10:30 a.m., stated, 1:1 [one to one] pamper and polish. Observation on 04/07/25 at 8:39 a.m. showed Resident #43's fingernails with dark colored debris under the end of the nails and at least half of the purple nail polish worn off the resident's left hand and no polish on the right hand. During an interview on 04/09/25 at 8:57 a.m., a CNA (#7) stated the CNAs provide resident cares and baths. The bath includes looking at their nails and clipping them as needed. - Review of Resident #47's medical record occurred on all day of survey. The current care plan stated, . I have impaired physical functioning related to: . L [left] sided weakness, impaired cognition . Observations for Resident #47 showed: * 04/06/25 at 4:30 p.m., teeth with a yellow-brown looking substance and white crust on the corners of mouth and fingernails on both hands long with a dark substance underneath the nail bed. An unlabeled basin containing a toothbrush was observed by the sink, and the other resident in the room identified the basin as mine. * 04/09/25 at 8:18 a.m., two CNA's (#8 and #9) assisted the resident with morning cares. The CNA (#9) assisted the resident to sink, could not locate a basin or toothbrush, and took a basin and toothbrush out of the roommates drawer with the roommates name written on the basin. The surveyor asked the CNA to identify the name on the basin. CNA (#9) stated, oh my mistake, and obtained a new basin and toothbrush for Resident #47. *04/09/25 at 10:50 a.m., observed an unlabeled basin containing a toothbrush on the sink in Resident #47's room. The CNA (#9) failed to label the basin. During interviews on 04/09/25 at 10:30 a.m. and 12:05 p.m., an administrative nurse (#1) stated she expected the CNAs to assist dependent residents with all ADLs. 28398 40488

Based on observation, review of facility policy, and resident and staff interviews, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity and individuality for 1 of 15 sampled residents (Resident #6). Failure to honor the resident's request during cares and ensure staff speak respectfully does not promote the resident's self-esteem, preserve the resident's personal dignity, and may affect the resident's psychosocial well-being. Findings include: Review of the facility policy titled Quality of Life - Dignity occurred on 04/09/25. This policy, dated 2018, stated, . Residents shall be treated with dignity and respect at all times. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self -worth. Staff shall speak respectfully to residents at all times . Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed . Review of Resident #6's medical record occurred on all days of survey. A care plan intervention, dated 03/11/24, stated, . Bladder scan every shift and PRN [as needed] per [Resident's name] request. An annual Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Observation on 04/07/25 at 2:45 p.m. showed two certified nurse aides (CNAs) (#18 and #20) and a nurse (#21) transferred Resident #6 from a wheelchair into bed in preparation for a bladder scan and toileting cares. The resident requested to have the bladder scan before the start of toileting cares. The three staff members failed to honor the resident's request and continued rolling the resident from side to side and placed a new brief. While rolling the resident to the side, one CNA (#20) stated, I am going to build muscles in my [slang word for breasts]. During an interview on 04/08/25 at 1:08 p.m., an administrative nurse (#1) stated she expected staff to honor Resident #6's bladder scan request and the CNA's statement during cares was unacceptable. During an interview on 04/08/25 at 3:39 p.m., Resident #6 confirmed hearing the comment made by the CNA (#20) and stated, I didn't think it was professional.

Based on record review, review of professional reference, review of manufacturer's guidelines, and staff interview, the facility failed to ensure appropriate infection control standards during insulin administration for 1 of 1 sampled resident (Resident #2) reviewed for insulin use. Failure to ensure residents do not share insulin pens may result in the spread of bloodborne pathogens. During the on-site revisit survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on 11/16/22 at 4:16 p.m. The IJ situation resulted from record review of Resident #2, who used insulin pens and was noted to have used another resident's insulin pen. This finding placed residents in immediate danger due to incorrect insulin pen use and the potential for the spread of bloodborne pathogens between residents. * 11/16/22 at 6:30 p.m. - The survey team notified the administrator and director of nursing of the IJ situation and requested they develop a plan for removal of the immediate jeopardy. * 11/17/22 at 8:53 a.m. - The facility submitted a written immediate action plan. * 11/17/22 at 10:31 a.m. - The survey team reviewed and accepted the facility's written plan of correction for the IJ situation. * 11/17/22 at 11:58 a.m. - The survey team removed and reduced the IJ situation from a scope/severity of J to a scope and severity of G. * 11/17/22 at 3:41 p.m. - The State Survey Agency (SSA) notified the regional office of the immediate jeopardy removal. Findings include: Review of the manufacturer's guidelines for the NovoLog FlexPen (a fast-acting insulin), found at https://www.novo-pi.com/novolog.pdf, stated, . WARNINGS AND PRECAUTIONS . NOVOLOG(R) FlexPen(R), NOVOLOG(R) FlexTouch(R), PenFill(R) cartridge, and PenFill(R) cartridge devices should never be shared between patients, even if the needle is changed. Sharing poses a risk for transmission of blood-borne pathogens. Berman, Snyder, and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., New Jersey, page 835-836, stated, . Certain aspects of medication administration are important for the nurse to check each time a medication is administered. These are referred to as the rights. Right Medication . The medication given was the medication ordered . Right Client . Medication is given to the intended client . Review of Resident #2's medical record occurred on 11/16/22. Diagnoses included Type II diabetes mellitus. An assessment for self-administration of medications (SAM), dated 10/12/22, identified Resident #2 as safe to self-administer insulin. Resident #2's nurses' notes identified the following: *11/01/22 at 2:34 p.m.: . Writer went to room [ROOM NUMBER] [Resident #2's room] because there was some arguing going on between this room and room [ROOM NUMBER]. Writer was told that Nurse gave him the wrong pen, but he still needed another pen to complete his full insulin dose. Nurse stated that incorrect pen was contained in the same bag/location of correct pens for this resident. This writer was notified by resident that he was provided another residents' insulin pen. Resident states that he was given 4 empty pens by overnight nurse and that he took 60 units out of another residents' pen. The medication was the same medication he takes. *11/03/22 at 12:51 p.m.: . Reason for alert charting: effects from another resident's pen Interventions: monitoring Resident Reaction to Interventions/Response to treatment: res [resident] doing well Pain Management: no c/o [complaints of] pain Improvement/Decline: res is stable . *11/4/22 at 7:51 p.m.: . Reason for alert charting: Medication error Interventions: triple check that it is the right med [medication] and the right resident Resident Reaction to Interventions/Response to treatment: No concerns from resident noted Pain Management: No complaint of pain or discomfort. Improvement/Decline: No decline noted. Resident is the same as before. The record lacked evidence of further action taken by facility staff (notification of the resident's doctor and representative, investigation of the potential bloodborne pathogen exposure etc.) During an interview on the afternoon of 11/16/22, a managerial nurse (#1) identified staff notified Resident #2's doctor, but the doctor did not order anything further, and the staff did not complete a bloodborne pathogen exposure investigation.

Based on resident interview, record review, review of facility policy, and staff interview, the facility failed to provide effective pain management for 1 of 1 sampled resident (Resident #1) with unavailable pain medications. Failure to ensure the availability of pain medication resulted in Resident #1 experiencing increased, unresolved pain. Findings include: Review of the facility policy titled Administering Pain Medications occurred on 11/17/22. This policy, dated 2018, stated, . Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Conduct an abbreviated pain evaluation if there has been no change of condition since the previous assessment. The assessment may consist of at least the following components: a. Whether pain has improved or worsened since the last assessment; b. The general condition of the resident . 6. Administer pain medications as ordered. Review of Resident #1's medical record occurred on 11/16/22. Diagnoses included chronic pain and diabetic neuropathy (nerve damage). Current medications included Gabapentin (an anticonvulsant sometimes used to treat nerve pain) 200 milligrams (mg) two times a day (BID) and tramadol (a narcotic pain reliever) 50 mg BID. Resident #1's current care plain stated, . I am at risk for pain r/t [related to] debility, lymphedema [swelling in the body tissues], L [left] shoulder pain, neuropathy, anasarca [generalized swelling] . Administer analgesia medication as ordered . Review of Resident #1's nurses' notes identified the following: *11/13/22 at 7:52 p.m.: . Resident is alert and oriented x4 and able to make needs known. Resident is in a much better mood and rated shoulder pain 5/10; all pain meds [medications] administered as ordered. *11/14/22 at 8:14 p.m.: . Resident Reported 6/10 shoulder pain; pain meds administered as ordered. *11/15/22 at 9:31 p.m.: . Resident C/O [complained of] shoulder pain but couldn't administered tramadol due to the outage; was held per provider orders this evening. Review of Resident #1's pain scale ratings (1-10) identified a pain score of 7 on 11/15/22 at 8:40 p.m., and a pain score of 8 on 11/16/22 at 11:40 a.m. An interview with Resident #1 occurred on 11/16/22 at 11:05 a.m. The resident stated she had not received her tramadol since yesterday morning (11/15/22). She was supposed to have it on the evening of 11/15/22 and the morning of 11/16/22. She identified the evening nurse (on 11/15/22) told her she did not have a tramadol available for Resident #1 because they (the medication) did not get ordered. Resident #1 stated she had not received Gabapentin yet either, because she likes to take Gabapentin and tramadol together. Resident #1 stated, I know they'll say I 'refused' the Gabapentin, but I'm not. I just like to take both of them at the same time. She further stated, I've been so angry all day. You can tell when the pills are running low. If I forget to order my pills, they say I have dementia. But they [the staff] forget and it's ok. When asked if she was in pain, Resident #1 replied, Oh, yeah! I was in such pain at therapy [that morning]. It was just torture but I went ahead and did them [her exercises] anyway. She identified she was unable to complete one of her exercises due to her pain. An occupational therapy note, dated 11/16/22, stated, . Pre-Tx [pretreatment] . Pain Intensity = 9/10; Frequency = Constant; Location: L shoulder; Pain limits the following functional activities: ADL's [activities of daily living] and transfers; What relieves pain? = Prescribed Medications, Heat; . Post-Tx [posttreatment] Pain Intensity = 8/10; Frequency = Constant; Location: L shoulder . During an interview on the afternoon of 11/16/22, an occupational therapy staff member (#3) stated Resident #1 complained of pain during therapy that morning. During an interview on 11/16/22 at 11:50 a.m., a staff nurse (#2) stated she had to call the doctor and have a tramadol dose released from the Cubex (an automated medication dispensing system), so she [Resident #1] has just gotten it and her Gabapentin now. The nurse identified the tramadol did not get reordered soon enough by facility staff. Failure to ensure the availability of Resident #1's scheduled pain medication resulted in the resident experiencing increased, unresolved pain and decreased participation in therapy.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 02/25/21 Based on review of facility policy, record review, and staff interview, the facility failed to ensure acceptable parameters of nutritional status for 1 of 1 sampled resident (Resident #34) with severe weight loss. Failure to adequately monitor and evaluate weights, implement recommended dietician recommendations, assess the effectiveness of current interventions, re-evaluate the need for updated or additional interventions, and physician notification of weight loss resulted in continued, severe weight loss. Findings include: Review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol occurred on 04/21/22. This policy, dated Qtr [quarter] 3, 2021, stated, . The physician and staff will monitor nutritional status, an individual's response to interventions . When medical conditions or medication-related adverse consequences are causing or contributing to altered nutritional status, the physician and staff will collaborate in adjusting interventions, taking into account the status of those causes and the resident/patient's responses, goals, wishes, prognosis, and complications . Review of Resident #34's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), dated [DATE], identified severe weight loss. Review of Resident #34's physician's orders identified, . Regular diet . Med Plus 2.0 [nutritional supplement] two times a day . Weight 3x [times] / [per] week - Monday/Wednesday/Friday every day shift . The record identified the following weights obtained from admission on 11/24/21 to 03/09/22: * 11/24/21 116 lbs. (pounds) * 11/29/21 116 lbs. * 12/06/21 116 lbs. * 12/09/21 114 lbs. * 01/10/22 110 lbs. * 01/28/22 94 lbs. (14.5% decrease in 30 days represents a severe weight loss) * 02/15/22 90 lbs. (22.4% decrease in 180 days represents a severe weight loss) * 03/01/22 94 lbs. * 03/02/22 93.6 lbs. * 03/04/22 93 lbs. * 03/07/22 91.2 lbs. * 03/09/22 91.4 lbs. The facility failed to weigh Resident #34 as ordered on six occasions 12/13/21, 12/20/21, 12/27/21, 12/31/21, 02/25/22, and 02/28/22. Review of Resident #34's nursing progress note, dated 02/17/22, stated, Orders placed for Med Pass [nutritional supplement] BID [twice a day]. Pt. [patient's] son, [name], notified of weight loss and supplement added. Will monitor weight closely at this time. Review of Resident #34's dietician's notes showed the following: * 02/17/21 Nutritional review given underweight status and weight loss. PO [by mouth] intakes variable. Overall suboptimal intakes. Will add MedPass BID given high kcal [kilocalorie] content. * 02/25/21 Nutritional review given weight loss. Resident very underweight. Current BMI [body mass index] of 15.9 [percent]. Med Pass not accepted well. Does like Liquacel [protein supplement], would recommend 1 ounce daily. Would also trial Magic Cup [nutritional supplement] for more caloric supplement. Will continue to monitor. If intakes remain poor and weight not increasing would recommend enteral nutrition if appropriate. The facility failed to implement the dietician's recommendations of Liquacel, Magic Cup, or enteral nutrition. Resident #34's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] ., but failed to evaluate the resident's response to interventions and failed to address the 24.8 pound severe weight loss. During an interview on 04/20/22 at 2:30 p.m., a supervisory nurse (#8) confirmed the dietician and nursing staff failed to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 04/21/22 at 12:48 p.m., the administrative staff (#1 and #3) confirmed the physician and staff failed to adequately monitor Resident #34's nutritional status and severe weight loss. Failure to consistently obtain weights as ordered, monitor and notify physician and dietician of weight loss identified, ensure implementation of nutritional recommendations, evaluate interventions for effectiveness, and promptly communicate weight changes to the physician and nursing staff resulted in Resident #34's continued, severe weight loss.

Based on review of facility policy, review of the facility's investigation report, and staff and resident interviews, the facility failed to provide an environment free of verbal abuse for 1 of 1 resident (Resident #11) with an allegation of mistreatment by staff. Failure to ensure residents are free from verbal abuse, which includes disparaging and derogatory terms, and the disregard for resident personal possessions and privacy resulted in psychosocial harm. Findings include: Review of the facility policy titled Abuse Prevention Program occurred on 04/21/22. This undated policy stated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse . During an interview on 04/18/22 at 2:45 p.m., when asked about abuse and neglect, Resident #11 reported an incident that occurred with a registered nurse (RN) (#14) a week ago Saturday. Resident #11 stated the nurse brought his medications into his room along with several other medication cups containing pills and an insulin pen. The resident asked the nurse who the other medication and insulin were for, and the nurse said they were for other residents and then left the resident's room. Resident #11 stated after about ten minutes the nurse returned to his room, looked on top and inside the drawer of the resident's nightstand, and then left the room. After another 5-10 minutes the nurse returned to the resident's room and accused the resident of hiding the other resident's medications and insulin pen. Resident #11 stated the nurse opened his nightstand drawer and started going through the resident's wallet. The resident stated he told the nurse he did not have permission to be going through his personal belongings. The resident said the nurse stated, You're an [expletive] idiot and I'm on a drug seize and no one can tell me to get out of this room. The resident stated the nurse continued searching his room, looking in the resident's closet and other drawers. The resident told the nurse to leave and stop looking through his personal belongings and that he did not have the medications or insulin pen. Resident #11 said the nurse (#14) stated, Where did you put them? You are an [expletive] loser. The resident stated a certified nurse aide (CNA) (#15) entered the resident's room and attempted to get the nurse out of his room and the nurse kept saying, I'm on a drug seize and I'm not leaving this room. The resident reported after a short time the nurse and CNA left his room. The resident stated later he put his call light on to ask when he would get his lunch tray and the nurse (#14) answered his call light. When the resident asked the nurse his question the nurse stated, By the looks of you, you don't need any [expletive] food. The resident stated he spoke with the head nurse and the administrator on the following Monday regarding the situation. Information from the facility's investigative report, dated 04/15/22, identified the following: * During the administrative nurse's phone interview on 04/12/22 with the RN (#14) Employee was very aggressive with communication, raised voiced . continued to be aggressive with communication . During the interview the nurse (#14) acknowledged he did pre-dish 4 resident medications and carried them into other residents rooms and misplaced these. The nurse acknowledged he made an error yet continued to place the entire blame on the resident. During an interview on 04/20/22 at 10:38 a.m., an administrative nurse (#1) stated she was first notified of the situation on Monday 04/11/22 when Resident #11 requested to speak with her and the administrator. The administrative nurse stated she immediately started an investigation and notified the North Dakota Department of Health (NDDOH). The administrative nurse confirmed the incident happened on Saturday 04/09/22 and the RN (#14) worked in the facility the next day 04/10/22. The administrative nurse confirmed she terminated the RN's (#14) employment on 4/12/22 when she conducted a phone interview with the RN. During an interview on 04/20/22 at 11:00 a.m., the administrative nurse (#1) verified she had not educated all staff on abuse prevention stating, Starting 04/11/22, I just grabbed whoever I could and spoke to them about abuse. Review of a facility in-service attendance form showed the administrative nurse (#1) had provided education titled Mandatory Reporting/Handling Concerning Situation to eight staff members on 04/11/22 - 04/15/22. During an interview on 04/20/22 at 6:32 p.m., a CNA (#15) stated she became aware of the incident described above when she answered the phone at the facility on 04/09/22 and the caller, Resident (#11) demanding to get the administrator's phone number. The CNA stated she went to the resident's room and heard the nurse (#14) screaming and yelling at the resident that he was not leaving his room and was on a drug seize. I attempted to get him to leave the resident's room and apologized to the resident, other residents and visitors in the facility that had witnessed or overheard the incident. The CNA stated, (RN's name) was out of his mind accusing the resident of hiding the other medications. The CNA stated she had heard the nurse (#14) on the phone reporting the incident to the on call manager, so she felt the incident was already reported. When asked who the CNA would report potential abuse to she stated, The admission's lady is who we are to report it to. The CNA verified she had received abuse training but could not recall when the date of the last training. During an interview on 04/21/22 at 8:13 a.m., an administrative nurse (#1) stated the missing medications and insulin were found in another resident's room. During an interview on 04/21/22 at 8:33 a.m., an administrative nurse (#1) verified the nurse (#14) had received abuse education upon hire 02/17/21 and had not received any further education on abuse. During an interview on 04/22/22 at 10:38 a.m., an administrative nurse (#1) stated it is inappropriate and unacceptable for staff to use disparaging and derogatory terms to the residents. The facility failed to protect the resident from abuse and the staff failed to immediately report the abuse to the administrative staff.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 1 of 2 sampled residents with a tube feeding (Resident #20). Failure to provide adequate calories/nutrition via gastrostomy tube (G-tube) and/or ensure sufficient oral intake resulted in Resident #20 experiencing severe weight loss (greater than 7.5 % in 3 months). Findings include: Review of the facility policy titled Enteral Nutrition occurred on 02/25/21. This policy, dated 2018, stated, . Adequate nutritional support through enteral feeding will be provided to residents as ordered. Review of Resident #20's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nutritional assessment, dated 01/14/21, stated, . Nutritional review given weight loss and new pressure ulcer to ankle. Intermittent g-tube feedings continue x 16 hrs [hours] per day. Tolerating. Enteral feedings currently meeting [about] 40% of nutritional needs. Given weight loss and decrease in PO [oral] will increase enteral feedings to the following: [MEDICATION(S)] [an enteral feeding solution] 1.2 [calorie] 65 ml/hr [milliliters per hour] x 16 hr. This will meet [about] 70% of nutritional needs. A nutritional assessment, dated 02/22/21, stated, . Nutritional review given weight loss and new pressure ulcer to ankle. Intermittent g-tube feedings continue x 16 hrs per day. Tolerating. Enteral feedings currently meeting [about] 70% of nutritional needs. Given weight loss and decrease in PO will increase enteral feedings to the following: [MEDICATION(S)] 1.2 95 ml/hr x 16 hr. This will meet [about] 70% of nutritional needs. Physician's orders identified [MEDICATION(S)] 1.2 calorie at 40 ml/hr for 16 hours (a total of 640 ml), starting at 6:00 p.m. and ending at 10:00 a.m. the next day. The physician's order began on 12/10/20 and ended on 01/21/21. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Beginning on 01/21/21, the physician increased Resident #20's feeding to 65 ml/hr for 16 hours (a total of 1040 ml) until 02/23/21. The MAR for January and February 2021 identified Resident #20 received less than 1040 ml of feeding on 22 occasions during that time period. Beginning on the evening of 02/23/21, the physician ordered [MEDICATION(S)] 1.2 at 95 ml/hr for 16 hours (a total of 1520 ml). Resident #20's weights (ordered weekly) showed the following: 11/18/20 237.0 pounds (Lbs) 12/12/20 236.6 Lbs 01/04/21 225.0 Lbs 01/13/21 217.0 Lbs (a 19.6 weight loss in one month [8%, i.e. severe]) 01/14/21 214.6 Lbs 01/18/21 212.4 Lbs 01/25/21 216.8 Lbs 02/01/21 213.4 Lbs 02/08/21 211.4 Lbs 02/15/21 210.1 Lbs 02/22/21 209.2 Lbs *The weights identified a 27.8 pound weight loss over three months (11%, i.e. severe weight loss). The record failed to identify weights from 12/12/20 until 01/04/21 (three weeks), and Resident experienced an 11 pound weight loss during that time. Meal intake records for February 1-24, 2021 showed Resident #20 consumed 25% or less at 61 of 70 meals documented. Meal intake records for January 2021 showed Resident #20 consumed 25% or less at 58 of 92 meals documented. Meal intake records for December 2020 showed Resident #20 consumed 25% or less at 34 of 87 meals documented. Observation on 02/23/21 at 7:40 a.m. showed Resident #20 in his room, assisted with morning cares per two certified nursing assistants, and his tube feeding turned off. A nurse (#8) stated she shut the feeding off about 10 minutes prior for morning cares. At 08:22 a.m., staff assisted Resident #20 to eat breakfast in the dining room. Observation showed Resident #20 refused all food and fluids. At 8:26 a.m., staff brought Resident #20 to the hallway, and the nurse restarted the feeding at 65 ml/hour. At approximately 10:30 a.m., the nurse shut the feeding off, and noted the total volume to be 945 ml. Review of the MAR for 02/23/21 showed staff charted a volume of 950 ml. Observation on 02/24/21 from 7:50 a.m. until approximately 8:30 a.m. showed Resident #20 in his wheelchair with his feeding pump turned off. At 10:00 a.m., a nurse (#6) shut the feeding pump off for the day and charted a total volume of 1883 ml of feeding. Further inspection of the feeding pump identified a rate of 95 ml/hr and 1883 ml of total fluid given, with 500 ml of water flush (i.e., 1383 ml of feeding). During an interview, a charge nurse (#13) confirmed the total volume of feeding was 1383 ml, and not 1883 ml as the nurse (#6) had charted. Failure to ensure Resident #20 receives the full volume of enteral feeding and accurately chart intakes of enteral feedings misrepresents Resident #20's actual intakes and may delay implementation of additional interventions to prevent weight loss. Failure to provide adequate calories/nutrition via G-tube and/or ensure sufficient oral intake resulted in Resident #20 experiencing severe, avoidable weight loss (greater than 7.5 % in 3 months).

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/28/18. Based on observation, record review, review of facility policy, and family and staff interview, the facility failed to provide appropriate treatment and services to prevent the development and/or deterioration of pressure ulcers for 3 of 5 sampled residents (Resident #17, #30 and #31) with pressure ulcers. Failure to consistently implement interventions, ensure adequate monitoring/assessment, and complete wound care as ordered resulted in the deterioration of Resident #30's pressure ulcer, and delayed treatment/deterioration of pressure ulcers for Resident #17 and #31. Findings include: Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol occurred on 05/16/19. This undated policy stated, . In addition, the nurse shall describe and document/report the following, as applicable: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . The physician may guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Review of the facility policy titled Repositioning occurred on 05/16/19. This undated policy stated, . The purpose of this procedure is to provide guidelines . to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. - Review of Resident #30's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified no rejection of cares, extensive assistance from two or more people for bed mobility and two Stage IV pressure ulcers. Resident #30's current care plan stated, . Focus . I have potential for altered nutrition and weight changes r/t (related to) diuretic in use, presence of wounds . Interventions . Provide Regular diet with enhanced foods, double portions of protein and honey thick liquids as ordered . Provide supplements as ordered for wound healing. Focus . At risk for complications due to musculoskeletal problems r/t MS ([MEDICAL CONDITION]) . Interventions . Assist with bed mobilty . Focus . Resident has pressure ulcer(s) to right ischium related to: hx (history) of pressure sores, decreased mobility, MS, cardiac, and tendency to stay in one position per preference, resident chooses to set up longer in w/c (wheelchair) against the order to sit up only for 30 minutes for meals . Encourage and assist as needed to turn and reposition; use assistive devices as needed . Encourage resident to follow the limit time up in w/c and provide education about risk and benefit of following order or not following order. Pressure reducing surface on bed/wheelchair: Clinitron bed (sand bed) in use since (MONTH) 8th, 18 (2018) . Repositioning during ADLs (activities of daily living) . Resident has pressure ulcer(s) to left ischium related to: hx of pressure sores, decreased mobility, and tendency to stay in one position per preference, resident chooses to set up longer in w/c against the order to sit up only for 30 minutes for meals . Interventions . Adding yogurt to meal trays to try to improve intakes . Nurses' notes and wound assessments stated the following: *01/09/19 at 3:04 p.m.: . Pt. (patient) returned from appointment at (wound clinic). Left and Right Ischial ulcer: fill with Mesalt (a type of gauze dressing that uses a wicking action to cleanse draining wounds) and cover with [MEDICATION NAME] (a bordered foam dressing designed to minimize trauma to the wound and surrounding skin at removal) - change daily and PRN (as needed). Use barrier spray to peri (around) wound skin. Continue with activity orders - up for meals only (60 minutes only) and turn every 2 hours. *01/11/19 at 10:12 a.m.: . The unstageable pressure sore to the right ischium measures 2.0 x 2.0 x 0.3 cm (centimeters) (length x width x depth). The wound bed is 100% granulation tissue. No undermining/tunneling noted. The unstageable pressure sore to the left ischium measures 1.2 x 1.2 x 0.2 cm. The wound bed is 100% granulation tissue. No undermining/tunneling noted. Preventative measures in place include the use of the clinitron bed, keeping skin clean and dry, keep ischium wound sites off pressure, pressure reduction cushion in w/c (wheelchair), turning and repositioning regularly, assistance with meals, daily nutritional supplements, daily skin audit, and weekly skin assessment by nurse. *02/19/19: L ischium 1 cm x 0.8 cm x 0.8 cm, wound bed red and 100% granulation tissue, no undermining/tunneling noted, small amount serosanguinous drainage; R ischium 1.7 cm x 1.7 cm x 1.1 cm, wound bed red and 100% granulation tissue, tunneling at 7 o'clock, 2.2 cm, small amount serosanguinous drainage *03/07/19 (admission assessment post hospitalization ): L ischium 0.5 cm x 0.8 cm x 0.3 cm, no tunneling documented; R ischium 1 cm x 2 cm x 1.2 cm, no tunneling documented *03/13/19: L ischium 1.5 cm x 0.6 cm x 0.4 cm, no undermining/tunneling noted, small amount serosanguinous drainage; R ischium 1.2 cm x 2 cm x 1 cm, tunneling at 7 o'clock, 2.5 cm and 10 o'clock, 3.2 cm, small amount of sanguinous drainage *04/18/19: L ischium 0.5 cm x 1.5 cm x 0.8 cm, small amount of purulent drainage, periwound macerated; R ischium 1.2 cm x 1.2 cm x 0.8 cm, tunneling at 10 o'clock, 3 cm, moderate amount of serous drainage, periwound macerated *04/30/19: L ischium 1 cm x 1.5 cm x 1 cm, indicated wound was assessed at clinic on this day; R ischium 2 cm, 1.9 cm x 2 cm, indicated wound was assessed at clinic on this day *05/01/19 at 1:39 p.m.: . met for skin and wt (weight) review. Wound is stable, and treatment changed yesterday at wound clinic. Will offer Greek yogurt at meals. *05/15/19: L ischium 2.5 cm x 1.3 cc (sic) x 0.8 cm; R ischium 4 cm x 2.8 cm x 6.5 cm deep *The record identified staff failed to take measurements from 04/30/19 until 05/15/19 (15 days later). The wound clinic progress note stated the following: *04/30/19: . Patient was last seen by myself on 03/26/19. Last visit, Bilateral ischial ulcers were filled with mesalt ribbon, followed by [MEDICATION NAME] border foam dressings. Today, right ischial ulcer was not adequately packed, causing some peri wound skin maceration. Gauze and tape was also utilized by SNF (skilled nursing facility), not [MEDICATION NAME] borders as ordered. Assessment: . Decubitus ulcer of left ischium, stage 3 . Decubitus ulcer of right ischium, stage 3 . Plan: . Mesalt ribbon (fill wounds lightly but adequately) bilaterally, to cover with large [MEDICATION NAME] borders, use NO TAPE, [MEDICATION NAME] only. Change dressings daily and PRN. Wounds will not heal if not adequately packed - I wrote to SNF . Must use barrier spray to bilateral ischial wound with each dressing change to protect peri wound skin - I wrote to SNF . Continue with orders also given to turn patient every 2 hours when in bed, and for him to be up for meals only, for no longer than 60 minutes each time. Resident #30's treatment administration record (TAR) identified twice daily dressing changes (not daily as indicated by the wound clinic), and identified packing to the right ischial ulcer (not bilaterally as indicated by the wound clinic). During an interview on the afternoon of 05/14/19, a nurse (#19) stated Resident #30's skin has really improved since we stopped using tape, and she thought the wounds were healing. During an interview on the morning of 05/16/19, a nurse (#20) stated, Not yet, when asked if staff were packing Resident #30's left ischial ulcer. She further stated, I have a feeling we're going to need to start (packing the wound), and it's starting to get a little deeper. The nurse identified staff measure pressure ulcers weekly. Observation of the dressing changes on the morning of 05/16/19 showed the nurse failed to pack the left ischial wound. The nurse packed the right ischial wound and stated, It tunnels back. After completing the dressing change, the nurse stated to the CNA, We should leave him like that (on his left side) for awhile, get him off that right side. The nurse asked the resident, who agreed. Observations on 05/13/19 at 11:38 a.m., 12:28 p.m., 2:09 p.m., 2:50 p.m., 3:42 p.m., 4:47 p.m., 5:50 p.m., and 6:31 p.m. showed Resident #30 lying supine in bed with a pillow under his left hip (placing pressure on his right ischial ulcer for nearly seven hours). Observations on 05/14/19 at 7:51 a.m., 8:42 a.m., 9:08 a.m., 9:55 a.m., 10:39 a.m., 11:17 a.m., and 12:48 p.m. showed Resident #30 supine in bed (five hours). Certified nursing assistant (CNA) charting identified Resident #30 was up in his wheelchair for 45 minutes, charted at 10:41 a.m.; however, observations during this time showed the resident remained in bed. Observations on 05/15/19 at 8:47 a.m., 9:55 a.m., 10:37 a.m., 11:03 a.m., 11:41 a.m., 12:14 p.m., and 1:19 p.m. showed Resident #30 supine in bed (four and a half hours). Resident #30's medical record failed to identify repositioning records and/or refusals to be repositioned. Observations of the following meals showed staff failed to provide double servings of protein and/or yogurt as indicated in his care plan: *Noon meal on 05/13/19 (no double protein or yogurt) *Breakfast meal on 05/14/19 (no double protein or yogurt) *Noon meal on 05/14/19 (no double protein) The facility failed to consistently implement dietary inventions, reposition Resident #30 every two hours, and complete wound care as ordered by the wound clinic. These failures resulted in increased size/tunneling of Resident #30's ischial ulcers and subjected Resident #30 to the need for continued treatments of the open wounds. - Review of Resident #31's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. * 04/18/19 at 11:00 p.m. to 11:26 p.m.: . resident left dorsal foot area has open area, due to [MEDICAL CONDITION], skin cleaned and dressing applied . measurement on left dorsal foot 2 x 1.5 cm . resident left foot has pitted [MEDICAL CONDITION] +2, wear ACE wrap in AM and off at HS (hour of sleep) . has some redness around the wound . will continue to monitor. * 04/24/19 at 5:43 p.m.: . called physician to notify of ulceration and request new treatment. Cleanse ulceration to L (left) dorsal foot with NS (normal saline) once daily. Apply [MEDICATION NAME] to slough and cover with a dry gauze dressing daily. Review of the Weekly Pressure/Non-Pressure Wound Assessment form occurred on 05/16/19. This form dated 04/24/19 showed the following: * Number of stage 3 pressure ulcers: 1 * Most severe type of tissue: slough * Ulcer/wound measurements: Site: L dorsal foot, Length 4.9 cm, Width 5.0 cm, Depth 0.0, Stage III * Notes: Facility Acquired Stage 3 pressure ulcer to dorsal L foot. Nurse states resident ulcer presented as a ripple in the skin. Noted after ace bandage was removed. Ulcer is larger than initial presentation. Wound bed with large amount of purulent drainage. Periwound reddened. Resident denies pain to area. Ace bandage removed. MD (physician) updated of change in wound and new treatment ordered. Dietician also notified. The medical record lacked evidence of wound care or monitoring from 04/19/19 to 04/24/19 which resulted in worsening and delayed treatment for [REDACTED]. During an interview the morning of 05/16/19, an administrative nurse (#7) confirmed the medical record lacked documentation of wound monitoring/treatment and acknowledged Resident #31's wound deteriorated prior to physician notification. - Review of Resident #17's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Physician orders included weekly skin assessment and treatment for [REDACTED]. Observation of Resident #17's right foot showed reddened areas with dark spots in the middle of four of his toes. Observation on 05/15/19 and 05/16/19 showed Resident #17's right foot and toes up against the foot board of his bed. During an interview on 05/15/19 at 1:40 p.m. Resident #17's wife stated she asked staff approximately a month ago about the toes. She voiced concern because he had lost one toe on his left foot due to an ulcer not healing. Staff told her the resident had to wait to see the podiatrist. The medical record failed to show facility staff completed skin assessments related to Resident #17's toes or implemented interventions to prevent ulcers to his toes. During an interview on 5/16/19 an administrative nurse (#1) confirmed the medical record lacked documentation and interventions, and/or treatment of [REDACTED].

Based on record review, the facility failed to ensure appropriate treatment and services to treat a urinary tract infection [MEDICAL CONDITION] for 1 of 4 sampled residents (Resident #30) with an indwelling urinary catheter. Failure to adequately monitor and promptly treat Resident #30's UTI resulted in an admission to the hospital for [MEDICAL CONDITION] work up, including continuous bladder irrigation (CBI) and treatment with intravenous (IV) antibiotics. Findings include: Review of Resident #30's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Nurses' notes identified the following: *02/22/19 at 10:48 p.m.: . New order from (nurse practitioner) on call for (primary medical doctor) ordered a UA/UC (urinalysis/urine culture) for blood in urine and low grade temp (temperature) of 99.9 this shift. Foley changed. Foley was clogged with dried blood and urine was bright red. New foley inserted and N[NAME] (night) nurse was updated and will collect UA/UC. *02/23/19 at 2:29 a.m.: . Resident noted to have cherry red returns from catheter bag. This writer adjusted tubing and noted the urinary returns lighten up to pink. last shift had replaced catheter and noted hematuria. *02/23/19 at 4:30 a.m.: . Resident noted to have cherry colored urine in foley bag. Specimen was sent to lab. Last nurse had noted clots after removing old catheter. *02/24/19 at 12:16 a.m.: . Urine in Foley bag continues to be reddish colored. No clots noted. *02/24/19 at 10:29 p.m.: . Resident continues to have reddish brown urine. *02/25/19 at 12:12 a.m.: . Urine in Foley bag less red tonight. *02/25/19 at 3:30 p.m.: . resident continues to have blood in urine and (physician's assistant) called and update order to do CBC (complete blood count) and BMP (basic metabolic panel) note sent ton (sic) the lab. *03/02/19 at 9:32 p.m.: . Tylenol Tablet 325 mg (milligrams) Give 2 tablet by mouth every 4 hours as needed for pain/fever . Per request back et leg pain rated 6/10. *03/03/19 at 2:15 p.m.: . Noted urine remains red in Foley collection bag. Writer called (physician's assistant) at this time et (and) above information given. Orders received for CBC with diff (differential) et BMP tomorrow a.m. (gross hematuria). Lab request faxed to (name of lab) . *03/03/19 at 2:36 p.m.: . resident foley catheter was change (sic) due to it (sic) urine leakage, urine was bloody, will continue to monitor . *03/03/19 at 7:15 p.m.: . Urine continues to be bloody red in color in Foley collection bag. Writer called (physician's assistant) at this time et updated, requested resident be seen in (hospital name) ER (emergency room ). Order received to transfer resident . Ambulance took resident at 8 p.m. *03/03/19 at 11:38 p.m.: . admitted to hospital . *03/07/19 at 6:04 p.m.: . readmitted today via stretcher from (hospital name) following hospitalization [MEDICAL CONDITION]. Antibiotics are complete. The record lacked evidence of monitoring/assessment/communication regarding Resident #30's condition after the provider ordered labs on 02/25/19 until staff contacted him again on 03/03/19 (six days later, and nine days after staff first noted blood in Resident #30's urine). Resident #30's lab results showed staff collected a UA/UC on 02/23/19 at 4:20 a.m., with results faxed to the facility on [DATE] at 5:10 a.m. UA results showed: *Urine clarity as cloudy (reference range: clear) *Leukocyte Esterase (an enzyme found in white blood cells which can indicate infection) as large (reference range: negative) *Elevated white blood cells (WBC) (can indicate infection) at >= 50 (reference range: negative, 0-2, 3-5) *Elevated red blood cells (RBC) (can indicate infection, bleeding, or trauma) at >=50 (reference range: negative, 0-2) *Elevated bacteria at Moderate (31-50) (reference range: negative, rare (0-5), or few (6-30)) The preliminary UC results, faxed to the facility on [DATE] at 1:40 p.m., showed the presence of [DIAGNOSES REDACTED] pneumoniae at 30,000 CFU/ml (colony-forming units per milliliter, less than 10,000 CFU/ml is considered normal) The final UC with sensitivity results, faxed to facility on 02/25/19 at 1:40 p.m., showed: *30,000 CFU/ml [DIAGNOSES REDACTED] pneumoniae * <10,000 CFU/ml Mixed Microflora *With susceptibility (i.e., would inhibit the growth of the bacteria) to the following antibiotics: [MEDICATION NAME]/clavulanate, [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]/[MEDICATION NAME] The CBC, collected on 02/26/19 at 6:19 a.m. with results faxed to the facility on [DATE] at 9:09 a.m., showed the following results: *Elevated WBC at 12.1 (reference range 4-11) *Low RBC (can indicate blood loss) at 4.03 (reference range 4.4-5.8) *Low Hemoglobin (HGB) (can indicate blood loss) at 11 (reference range 13.5-17.5) *Low Hematocrit (HCT) (can indicate blood loss) at 34.2 (reference range 40-50) The above lab reports were signed off on 03/04/19 (the day after Resident #30 was admitted to the hospital). The record lacked evidence staff reviewed the labs prior to this day or communicated results to Resident #30's provider. The hospital progress notes identified the following: *03/04/19 at 1:25 a.m. (admission note): . REASON FOR ADMISSION: hematuria (blood in the urine), lactic acidosis (a buildup of [MEDICATION NAME] in the bloodstream) . sent from NH (nursing home) due to hematuria which has been present for the past 1 day. workup in ER shows elevated WBC and lactic acid. hgb (hemoglobin) is down from oct (October) (YEAR). Pt is admitted for further workup [MEDICAL CONDITION]. Last Vitals: . BP (blood pressure) 86/49 . Recent Results (from the past 24 hour(s)) . WBC 18.7 (increased from 12.1 on 02/26/19) . RBC 3.83 (decreased from 4.03 on 02/26/19) . HGB 10.2 (decreased from 11 on 02/26/19) . HCT 32.3 (decreased from 34.2 on 02/26/19) . Assessment/Plan . Hematuria - urology consult .[MEDICAL CONDITION] .[MEDICAL CONDITION] protocol monitor lactic acid, continue [MEDICATION NAME] ([MEDICATION NAME]) until cultures available . *03/04/19 at 8:16 a.m. (urologist note): . Impression: hematuria . Most likely hemorrhagic [MEDICATION NAME] . Plan: . When he is discharged we will set up cysto (cystoscope) as out pt . *03/04/19 at 10:58 a.m. (hospitalist note): . The patient's catheter has been leaking this morning and he has dark red hematuria. Per nursing, patient was oriented to person but currently is orientated x 0. Unable to perform ROS (review of systems): mental status change . Assessment/Plan: Principal Problem:[MEDICAL CONDITION] . Elevated WBC 18.7, Lactic acid 2.4, [MEDICAL CONDITION] 92/58. UA showed elevated WBC >182 indicating likely UTI. Patient continues to be hypotensive with min (minimum) BP 71/45. Typically BP has been 90s/50-60s. [MEDICATION NAME] is low 2.1 replacement may help BP. Plan . [MEDICATION NAME], IV [MEDICATION NAME] x1, IVF (IV fluids) . Hematuria . Plan . Catherer (sic) has been replaced, Urology consulted, continue antibx (antibiotics) to treat UTI, IVF . *03/06/19 at 10:49 a.m. (hospitalist progress note): . admitted for Heavy hematuria + elevated wbc's, urology did see him for foley placement and heavy hematuria, currently he is getting CBI (continuous bladder irrigation), received IV [MEDICATION NAME] one dose on 03/04/19 to help his [MEDICAL CONDITION] + [MEDICATION NAME] (low [MEDICATION NAME]). Assessment/Plan . Principal problem: 1) Acute complicated UTI . Stable, improving .[MEDICAL CONDITION]: Clinically undetermined if he was [MEDICAL CONDITION] or not - resolved . [MEDICAL CONDITION] on admission time was not due [MEDICAL CONDITION], it was due to a lack of po (oral) intake + [MEDICATION NAME]: resolved post IV [MEDICATION NAME] and IV fluids, b/p continues to be stable . Confusion on 03/03/19 due to UTI c/w (consistent with) Toxi(c) metabolic [MEDICAL CONDITION] (an acute mental status change often caused by electrolyte imbalance or infection): resolved - he is back to his baseline . Gross heavy hematuria . outpatient follow up with cystoscope with Urology . *03/06/19 at 11:46 a.m. (infectious disease consult): . was admitted with heavy hematuria status [REDACTED]. On admission the urine culture is now growing [DIAGNOSES REDACTED] pneumonia and [MEDICATION NAME] species. Initially he had a very elevated white blood cell count and altered mental status but now seems to be returning back to his baseline, still on CBI but urine has cleared completely, and leukocytosis (elevated WBC) has resolved. He has received a total of 3 days of high-dose [MEDICATION NAME] ([MEDICATION NAME]). Discharge instructions, dated 03/07/19, identified a follow up urology appointment scheduled for 03/18/19. Review of Resident #30's medical record identified the resident did not go to this appointment. When asked for information regarding the above, the facility provided no additional information. The facility failed to provide appropriate monitoring and assessment of Resident #30's condition, failed to promptly monitor lab results and recognize abnormal values, and failed to communicate adequately with the provider which resulted in a deterioration in Resident #30's condition, delayed treatment for [REDACTED]. The facility also failed to provide follow up care after this hospitalization . See F658.

Based on information provided by the complainants, observation, record review, review of professional reference, and resident/staff interviews, the facility failed to provide the necessary care/services to treat 1 of 10 sampled residents (Resident #10) with skin breakdown and pain/discomfort. Failure to monitor Resident #10's skin condition and provide physician-prescribed interventions in a timely manner contributed to her existing skin breakdown and resulted in her experiencing avoidable pain/discomfort. Findings include: Information provided by the complainants indicated facility staff failed to identify possible risk factors contributing to residents' skin conditions and failed to provide the care/services necessary to prevent further skin breakdown. The complainants reported having been contacted by residents who were frustrated waiting for staff to respond to their call lights and/or who experienced pain/discomfort secondary to skin breakdown/being soiled. The facility failed to provide a copy of their policy addressing skin conditions/pressure ulcers upon request. Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., New Jersey, pages 828 and 862, states, . Many medications increase (skin) sensitivity . [MEDICAL CONDITION] drugs [MEDICAL CONDITION] . Several factor increase the risk for the development of pressure ulcers: immobility and inactivity, inadequate nutrition, fecal and urinary incontinence . and certain chronic medical conditions. Nursing interventions to prevent the formation of pressure ulcers include conducting ongoing assessment of risk factors and skin status, providing skin care to maintain skin integrity, ensuring adequate nutrition and hydration . providing supportive devices . - Review of Resident #10's medical record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. * 11/26/18, [MEDICATION NAME] (an over-the-counter skin protectant ointment) - Apply TID (three times daily) to affected gluteal, perineal, and vulvar areas. * 12/03/18, [MEDICATION NAME] 0.2% - [MEDICATION NAME] 2% in Lipovan Rectal Cream (a prescribed cream applied to relieve pain) . Apply to rectum topically BID (twice daily). Donut cushion to minimize perineal discomfort with sitting. * Undated, Monitor skin for breakdown . Q (every) shift. * Undated, Must complete all documentation for skin alterations on Saturday . A Braden Scale (a skin assessment), dated 11/19/18 (the evening of Resident #10's admission to the facility), identified, . Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals . Chairfast: Ability to walk severely limited . Cannot bear own weight and/or must be assisted into chair or wheelchair. Slightly Limited (Mobility): Makes frequent though slight changes in body or extremity position independently. Adequate (Nutrition): Eats over half of most meals. Eats a total of 4 servings of protein . Occasionally will refuse a meal, but will take a supplement when offered . No Apparent Problem (Friction/Shear): Moves in bed and in chair independently and has sufficient muscle strength to lift up. It is unclear how staff determined Resident #10's skin was usually dry, her linens only required changing at routine intervals, she ate greater than 50% of most meals, ate 4 servings of protein daily, and/or occasionally refused meals. The current care plan identified the following: * . Focus: Resident is at risk for falls/injuries . Interventions: . Encourage resident to request assist whenever needed. * . Focus: Skin integrity impaired: redness to perineum area secondary to diarrhea r/t (related/to) [MEDICAL CONDITION] . Interventions: Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. Monitor for s/s (signs/symptoms) of infection . Notify MD (medical doctor) as needed. The care plan failed to reflect Resident #10's need for a physician-prescribed barrier cream and/or pressure relieving device. The progress notes identified the following: * 11/19/18, . Patient was admitted from (hospital) with a [DIAGNOSES REDACTED]. Patient has redness in groin areas and sacrum. * 11/20/18, . She uses call light for needs . * 11/22/18, . Patient is incontinent of B/B (bowel/bladder) . Assist of one for bed mobility and transfers. Patient stays in her room most of the time. * 11/25/18, Weekly skin assessment done, noted redness to her bottom and continuing with feces d/t (due/to) her illness. cleansed the area and treatment done as directed. * 11/26/18, Patient returned from (cancer center) with new orders to discontinue ammonium [MEDICATION NAME]. Start [MEDICATION NAME] to apply to gluteal/perianal and the vulvar areas three times a day. monitor skin for breakdown every shift. * 11/27/18, . Her coccyx area is excoriated from frequent diarrhea. Lac-Hydrine cream is burning her, so it will be d/c (discontinued) and [MEDICATION NAME] started. * 11/28/18, . Receiving [MEDICAL CONDITION] therapy and continuous chemo infusion for [MEDICAL CONDITION]. * 11/29/18, . Incontinent of B/B (bowel/bladder) maximum assist with all cares. Extensive assist with transfers and bed mobility. Pain management effective with Tylenol as when needed. * 11/30/18, . She is checked et (and) changed/repositioned on a routine basis. * 12/02/18, . She is routinely checked at night. Is able to direct own cares and does ask for assistance appropriately as needed. Assist with toileting needs. Assist with transfers, pt. did remain in room . resident is thin and skin intact with redness to the perirectal area do (sic) to stool, treatments and incontinences (sic) treatment to area bid and prn (as needed). * 12/03/18, Pt . is slightly confused/forgetful at times. Assist with toileting needs, is incontinent at times. Transfers with assist. Pt. does remain in room . Extensive assist with toileting needs. Patient is HOH (hard of hearing) but can make needs known. patient ask (sic) for assistance appropriately. * 12/04/18, . makes needs known to staffs (sic). Extensive assist with care and toileting needs. No new open areas noted in the button (sic) and the perineal area. Pt. does remain in room . Pain management was effective with Tylenol when needed. In the (care) conference more attention to be paid to patient care and diet. No new skin areas of concern noted by this writer after lasted (sic) treatment was done at HS (hour of sleep) this shift. Though patient is noted to have more than 3-4 bathroom trips during one shift. One assist using her walker for toileting. During an interview on 12/05/18 at 5:05 p.m., Resident #10 (identified by the facility as interviewable) stated, Last night, I sat all night in a dirty diaper. The call light was unplugged. That's a long time . all night. That's a long time to have a dirty diaper. No one was in here at all last night. Resident #10 also reported a staff member working the evening/night shift had directed her to put the cream on herself. Observation showed Resident #10 lying in bed on a pressure-guard mattress, with her wheelchair next to the bed, a square (versus donut-shaped) pressure-relief cushion in place. During an interview on 12/06/18 at 7:50 a.m., Resident #10 pointed to her call light and stated, I rang the bell here. I finally got up and went in there (bathroom). I rang the bell in there. Took them forever. About twenty-five minutes, I was sitting there this morning. She then repeated her concern regarding the evening/night shift staff member who directed her to put the cream on herself. Observation showed Resident #10 lying in bed, squirming from side to side. When asked if she required assistance, she pointed towards her buttocks and stated, It itches. Then it hurts. It's irritated. It hurts so bad! A different med (medication) is coming from Pharmacy today. During an interview on 12/06/18 at 10:50 a.m., Resident #10 shifted her weight as she laid on the bed and stated, My butt is so sore! The girls are getting so disgusted checking my diaper. I hate to do it (points towards call light). During an interview on 12/06/18 at 10:55 a.m., when asked questions pertaining to Resident #10's toileting needs, a CNA (#4) stated Resident #10 puts on (her) call light. If we're helping someone else, she will self-transfer to (the) bathroom. When we provide toilet cares, (we) gently wipe (the) little sore on her buttocks. Just redness to her buttocks, but very painful! Put a little ointment on the rash. The CNA then showed the surveyor the tube of Peri-Guard ointment located in Resident #10's dresser drawer. The CNA (#4) also reported offering to assist Resident #10 to the bathroom if needed. Observation showed no personal cares or assistance to the bathroom from 7:50 a.m. and 10:55 a.m. When asked questions pertaining to the progress notes referencing changing and/or routinely repositioning Resident #10, the CNA (#4) reported staff chart at the end of their shift. She confirmed staff are not required to chart after each interaction. Observation on 12/06/18 at 12:48 p.m., showed a CNA (#4) assisted Resident #10 into the bathroom and provided toileting cares. Resident #10's coccyx appeared darkened, and her perineal/rectal area appeared reddened/raw-looking. Resident #10 voiced discomfort when the CNA (#4) applied Peri-Guard ointment to the reddened area. During an interview on 12/06/18 at 1:30 p.m., when asked questions pertaining to Resident #10's prescribed skin cream, an administrative nurse (#1) reported the facility received the physician's orders [REDACTED]. The nurse (#1) explained the pharmacy did not have that particular cream in stock and therefore contacted a second pharmacy to see if they had it in their inventory. The administrative nurse (#1) reported the Pharmacy delivered the cream on 12/05/18. Review of the Medication Administration Record [REDACTED]. When asked questions regarding the discrepancy, the administrative nurse (#1) stated, It (Lipovan rectal cream) may have hit the building late in the day. It should have been here (12/03/18). Staff should have called (her physician) that evening, and checked into another medication until it came in. During an interview on 12/06/18 at 3:40 p.m., an administrative nurse (#1) reported the facility currently does not have a policy regarding skin issues/pressure ulcers. The administrative nurse (#1) then stated he would expect nursing staff to complete the Braden Scale upon admission, weekly for three weeks, and every three months thereafter. After identifying Resident #10 as having [MEDICAL CONDITION] and skin breakdown, the facility failed to: * Develop a policy outlining staff expectations for providing skin care, * Identify the risk factors impacting Resident #10's ability to heal, including her need for high calorie foods/supplementation, prompt transfer/toileting assistance following each episode of incontinence, and a physician-prescribed barrier cream/pressure relieving device, * Accurately document Resident #10's baseline risk factors for developing a facility-acquired pressure ulcer, * Continue to monitor Resident #10's skin until they were able to determine no concerns existed for the development of a facility-acquired pressure ulcer, * Care plan Resident #10's need for a physician-prescribed barrier cream and specific pressure relieving device, and/or * Provide the care/services necessary to prevent further skin breakdown and/or avoidable pain/discomfort; including scheduled and/or prompt transfer/toileting assistance, Lipovan rectal cream, donut cushion, etc. See F565 and F692.

Based on observation, record review, review of facility policy, and staff interviews, the facility failed to provide adequate supervision and assistive devices for 2 of 5 sampled residents (Resident #1 and #5) who experienced falls in the facility. Failure to utilize the Broda chair resulted in Resident #1's having an avoidable fall, and resulted in her hematoma, mild swelling, bleeding, superficial cut, and bruising to her face. Failure to ensure staff utilized a Hoyer (full body) lift placed Resident #5 at risk of falling and resulted in the cut to his leg. Findings include: Review of the facility policy titled "Falls Practice Guide Flowchart" occurred on 09/16/14. This policy, dated 2011, stated, ". . . Assess . . . Develop/revise initial or interdisciplinary care plan as applicable . . . initiate/update patient information worksheet, kardex, task list . . . Staff education . . ." - Review of Resident #1's medical record occurred on September 16-17, 2014. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognitive skills, extensive assistance of two or more people required for bed mobility and transfers (due to being unsteady, only able to stabilize with staff assistance when transferring surface-to-surface). The "Fall" Care Area Assessment (CAA), dated 07/22/14, identified, ". . . Physical Performance Limitations: difficulty maintaining sitting balance . . . impaired balance during transitions. . . . Risk Factors: . . . cognitive impairment . . . dementia . . . loss of arm or leg movement (following CVA) . . ." The care plan, dated 07/15/14, identified, "Focus: ADL Self care deficit as evidenced by weakness related to physical limitations . . . Interventions: . . . Assist to bathe/shower as needed, Assist with . . . eating as needed . . . Encourage and/or assist to reposition frequently, Transfer with mechanical lift with 2 assist." The progress note identified the following: * 07/18/14 at 4:42 p.m., ". . . Pt (patient) . . . sitting in broda chair. . . ." * 08/06/14 at 11:36 a.m., ". . . Staff notified me that pt just fell out of her w/c (wheelchair). I went to see the pt right away and see pt lying on the floor facing down. She has a golf ball size hematoma in the middle of her forehead. She also has mild swelling and bleeding in the upper lip, and 1 cm (centimeter) long superficial cut in the nose, between her eyebrows. . . . Pt reports having pain in the forehead at this time. She is alert, oriented to self and family members. She doesn't remember the incident and why she fell . Staff states pt was placed in a different w/c today and not her usual one, and the new one is easy for her to get out as she doesn't want to sit in the w/c. . . ." * 08/06/14 at 4:16 p.m. (Nursing staff documented additional information regarding Resident #1's earlier fall.), "Patient was assisted in to her wheelchair by Nursing Assistant. Nursing Assistant locked the breaks on the wheelchair. . . . Approximately 20 minutes later, at 11 a.m. patient was found on the floor. She was laying on her stomach, face down in front of her wheelchair. Blood was observed by Patient's head near her face. . . . . NP (nurse practioner) notified and assessed the patient. Blood determined to be coming from the Patient's upper lip on the inside. Resident was assisted in to bed with a mechanical lift and 2 staff. ROM (range of motion) done to upper and lower extremities in bed without difficulty. Patient observed to have a hematoma in the middle of her forehead. Hematoma the size of a small egg (approximately). Due to fall being unwitnessed Neuro checks started. . . . Patient was cleaned up and Ice pack applied to Hematoma. . . ." * 08/06/14 at 11:13 p.m., ". . . bruises on face from falls. . . c/o (complained of) pain in mouth due to falls. . . ." The physician's orders identified the following: * 08/06/14, "Ice Pack to forehead area for swelling hematoma secondary to fall. Applied Q 2 (hours) while awake - 20 min (minutes) every time." * 08/06/14, "Hold Coumadin due to bruises on face." The fall incident report, dated 08/06/14, identified, ". . . Patient was placed in her own personal wheelchair and not the Broda chair assigned to her. Personal wheelchair placed in patient's bathroom. In the bath tub in her room. A note was placed on the wheelchair not to use it and to use the Broda chair." The progress notes identified the following: * 08/07/14 at 12:31 p.m., ". . . Pt fell yesterday from sitting in the w/c. . . . Pt has new bruises in her face, under and upper eye orbital area. Bruises showed up today from fall yesterday. . . . pain secondary to hematoma forehead . . . swelling has reduced significantly. cont. with ice pack to the area q (every) 2 hr (hours) while awake to the area as well as face/ye (sic) area if pt allows. start Tylenol 650 mg (milligrams) BID (twice daily) for 3 days . . . We also talked about the fact the pt is on Coumadin . . ." * 08/07/14 at 11:35 p.m., ". . . Neuro-checks wnl (within normal limits) and patient when asked about pain pointed to areas around eyes. Site a little swollen. Ice pack used every 2 hours on fore head as ordered and prn (as needed). Tylenol given x 1 with some relief noted. . . ." The care plan, dated 08/07/14, identified, "Focus: ADL Self care deficit as evidenced by weakness related to physical limitations . . . Interventions: . . . BRODA chair for locomotion." The facility failed to care plan for the Broda chair prior to Resident #1's fall. The progress notes identified the following: * 08/08/14 at 8:27 a.m., ". . . Pt fell 2 days ago from sitting in the w/c. Her hematoma in the forehead stays stable, smaller in size and less swelling. . . . When assessing today pt states she has pain a little pain in the right shoulders but able to move arms and shoulder at her base line with no problems. Her bruises in her face, under and upper eye orbital are (sic) present and slightly edematous under the eyes. . . ." * 08/12/14 at 8:48 a.m., ". . . Pt fell last week while sitting in the w/c. . . . Her hematoma in the forehead is getting smaller. She cont to have bruises present in facial area. some of it is fading. . . . pain secondary to hematoma forehead . . . swelling in forehead cont to reduce significantly. . . . cont (continues) Tylenol 650 mg BID and q 6 hrs prn for now . . ." * 08/13/14 at 1:13 p.m., "pt is an assist of two with transferring and bed mobility. pt is dependent on staff for eating. . . . ice applied x 3 to head. . . ." The physician's order, dated 09/02/14, identified, "DC ice pack to forehead." During the initial tour on 09/16/14 at 11:30 a.m., Resident #1 was observed from the doorway to her room as she lay in the dark in bed. The resident showed bruising to her forehead/face. During an interview on 09/16/14 at 4:00 p.m., three administrative staff members (#1, #2, and #3) reported "Resident #1's family brought her personal wheelchair (even though she utilized a Broda chair at the facility). (Resident #1's) Broda (chair) was in the hallway outside her room. The CNA monitoring her hall (walked past the Broda chair, entered her room, and) put her into the wheelchair." The three administrative staff members (#1, #2, and #3) further reported the facility failed to care plan for the Broda chair prior to Resident #1's fall, and placed the wheelchair "in storage (the bathroom)" after the fall. They stated, "(Resident #1) was so weak, (she was) not able to hold herself up. They (therapy staff) tried a wheelchair, but she wouldn't/couldn't hold herself up, too weak, so she used a Broda. She was in a Broda chair on admit (admission to the facility). She was always in a Broda chair. She had no muscle strength, very, very weak." The administrative staff member (#1) added, "I thought everyone knew. I don't remember a time she didn't have a Broda chair. From the first day of therapy, they knew it wasn't feasible for her not to be in a Broda." The daily work assignment sheets, dated 07/17/14 - 08/06/14, identified the CNA who transferred Resident #1 into the wheelchair (versus Broda chair) worked on the South Unit (where Resident #1's room was located) on 11 of the 21 days prior to the fall. The administrative staff member (#1) provided additional information to the state survey and certification agency. She stated, ". . . We were being asked by (Resident #1's) family to strongly encourage her to sit up in a chair instead of lying in bed all day. According to (Resident #1's son), the Broda chair was in her room shortly after (Resident #1) was admitted to the facility. The Broda chair was being used as an alternative place for (Resident #1) to sit in order to help encourage her to get out of bed after she was witnessed slumped forward in her regular wheelchair . . . Nursing staff members stated that she appeared more comfortable in the Broda chair and was more willing to sit up if it was being used." The facility failed to ensure staff utilized the Broda chair with Resident #1, thereby reducing her risk of falls. The medical record contained documentation to indicate Resident #1 was unsteady and had difficulty maintaining sitting balance. Information provided on 09/23/14, indicated the Broda chair was utilized after staff witnessed Resident #1 slumped forward in the regular wheelchair, and described Resident #1 as "appearing more comfortable in the Broda chair and more willing to sit up if it was being used." Staff interviews confirmed Resident #1 utilized a Broda chair since admission due to her having "no muscle strength" and being "unable to hold herself up." Documentation further showed the CNA who transferred Resident #1 into the wheelchair had worked on the unit 11 of 21 days prior to the fall and therefore would have seen Resident #1 in the Broda chair on previous occasions. It is unclear why the facility removed the regular wheelchair if they felt the it's continued use was safe for Resident #1. - Review of Resident #5's medical record occurred on September 16-17, 2014. [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], identified severely impaired cognitive skills, extensive assistance of two or more people required for transfers (due to being unsteady, only able to stabilize with staff assistance when transferring surface-to-surface), and two falls with injury. Resident #5's care plan stated, "Focus: At risk for falls . . . history of falls. . . Interventions: . . . Utilize hoyer lift for transfers to and from shower chair . . ." The progress note identified the following: * 01/20/14, "CNA (certified nurse assistant) approached nurse stating pt (patient) was on the floor in the shower room. CNA states her and one other CNA were transferring him to his w/c (wheelchair) after his shower and pt would not hold himself up and they had to lower him to the floor. Pt was wearing his shoes. A 1 in (inch) cut is noted on his lower left leg. . . . Pt did not hit his head. ROM (range of motion) WNL (within normal limits). Pt assisted in to w/c via hoyer lift. . . . Will continue to monitor." * 01/21/14 at 11:07 p.m., "New order . . . Steristrips and tegaderm to LLE (left lower extremity) skin tear change Q (every) 7 days and PRN (as needed) until resolved." * 02/07/14 at 1:15 a.m., "skin check done no skin issues noted . . ." The incident report, dated 01/20/14, identified, ". . . Brief description of incident: CNA approached nurse stating pt was on the floor in the shower room. CNA states her and one other CNA were transferring him to his w/c after his shower and pt would not hold himself up and they had to lower him to the floor. . . . Type of injuries: Cut to LLE . . . Immediate action taken by center: Checked CP (care plan) (and) task list/kardex on transfer status of pt. Pt to be a hoyer lift for shower chair transfers (and) a standing lift for all other transfers. . . . Will obtain treatment orders for pt's LLE cut. CP updated on presence of cut/open area. . . ." During an interview on 09/16/14 at 4:00 p.m., two administrative staff members (#1 and #2) reported the two CNAs providing cares failed to follow Resident #5's care plan (using a Hoyer lift for transfer from the shower chair). Instead, they attempted to stand-pivot Resident #5 into his wheelchair. The two administrative staff members (#1 and #2) confirmed they expect CNAs to read the care plan prior to providing cares to a resident. The facility failed to utilize the Hoyer lift to transfer Resident #5 to/from the shower chair resulted in an injury to his leg.

Based on record review, review of facility policy, review of professional reference, information submitted by the complainant, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 2 of 3 closed records (Resident #4 and #5) reviewed. Failure to ensure the administration of a [MEDICATION NAME] (an opiate pain reliever) patch to the correct resident resulted in Resident #4's decreased level of consciousness and admission to the emergency department (ED), and may result in avoidable pain for Resident #5. Findings include: Review of the "Nursing 2013 Drug Handbook" described the use and adverse effects of [MEDICATION NAME] system, on page 576-579. The handbook described indications as "To manage persistent, moderate to severe chronic pain in opioid-tolerant patients who require around-the-clock opioid [MEDICATION NAME] for an extended time. . . Adverse reactions . . . clouded sensorium, confusion . . . sedation . . . arrhythmias, chest pain, hypertension, [MEDICAL CONDITION] . . ." Review of facility policies occurred on 02/12/14. These policies stated the following: *"Medication Administration: [MEDICATION NAME] Drugs" (dated March 2010): "PURPOSE: To administer medication for systemic or local effect by way of applying to skin . . . PROCEDURE: . . . 6. Examine patient's chest, back and shoulders for any residual medication patches. Remove previous patch and wipe away any remaining medication. . . ." * Review of the facility policy titled "Medication Management Guidelines: Errors" occurred on 02/12/13. This policy, dated 08/11/06, stated, ". . . An 'error' means any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. . . . Actions To Take Following A Medication Error . . . Complete the Incident Report and the Occurrence Investigation Report, as outlined in the Quality Assessment and Assurance manual; After the error is resolved, participate in a root cause analysis - asking why five (5) times . . . Type of error . . . wrong patient, wrong time or interval, wrong documentation . . . Performance Improvement . . . If harm to patient occurred, suspend employee pending investigation and follow appropriate disciplinary action including reporting incident to the licensure board if appropriate . . ." *"Medication Administration: Medication Pass" (dated March 2010): "PURPOSE: To safely and accurately prepare and administer medication according to physician order and patient needs . . . 9. Administer medication . . . identify patient by: calling name, checking identification band, referring to photo . . . document initials on MAR for each medication administered . . ." Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, page 73-75, stated, " . . . The Incident Report . . . The report should be completed as soon as possible and filed . . . " Page 262 stated, ". . . Nursing Discharge/Referral Summaries . . . If a client is transferred . . . from a long-term facility to a hospital, a report needs to accompany the client to ensure continuity of care in the new area. It should . . . describe the condition of the client before the transfer. . . . A thorough transfer summary will facilitate communication and promote continuity of care in these situations. . . ." Page 267 stated, ". . . Practice Guidelines: Documentation . . . DO . . . Be timely. A late entry is better than no entry; however, the longer the period of time between actual care and charting, the greater the suspicion. . . ." Page 862, stated, ". . . Process of Administering Medications . . . 1. Identify the client. . . . One of the Joint Commission's National Patient Safety Goals is to improve the accuracy of client identification. This goal requires a nurse to use at least two client identifiers whenever administering medications. . . . In the long-term care setting . . . the requirement for two identifiers is appropriate at the first encounter. Thereafter, one identifier can be facial recognition . . . Clinical Alert: Do not ask 'Are you John Jones?' because the client may answer 'yes' to the wrong name. . . ." - Review of Resident #4's medical record occurred on February 11-12, 2014. [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] (a pain medication), [MEDICATION NAME] (an antidepressant), vitamin D3, multivitamin, [MEDICATION NAME] (an antidepressant), calcium, [MEDICATION NAME] (an appetite stimulant), [MEDICATION NAME] (for overactive bladder), and [MEDICATION NAME] ([MEDICAL CONDITION] eye drops). Resident #4's nurses' notes stated the following: *01/11/14 at 11:00 p.m.: ". . . 1800 (6:00 p.m.) Pt's (patient's) son called this author into room to remove pocketed food from pt mouth, pt was asked to open mouth and noted to have delayed reaction to following commands which was unusual for her. Son concerned that 'not acting herself.' Pt less talkative as usual, eye contact poor until spoken to but will only look towards you for moment, responds to questions appropriately but delayed in response, eyes glassy, flat affect, noted to be continuous chewing on Rt (right) side even though nothing in mouth. VS (vital signs) 97.9 (temperature) - 88 (pulse) - 16 (respirations) - 101/60 (blood pressure), O2 (oxygen) sats (saturations) 95% RA (room air). Neuro (neurological) check done and WNL (within normal limits), Lt (left) sided weakness which has been present since [MEDICAL CONDITION]. During assessment, son questioned a patch that was on pt, upon inspection found [MEDICATION NAME] (a [MEDICATION NAME]) 50 mcg (micrograms) dated 01/11/14 on pt Lt chest, pt does not have an order for [REDACTED]. . [MEDICATION NAME] applied in a.m. and was on for less than 10 hours. . . . Pt monitored through the shift, noted to need assistance with meal, pocketing food and meds, normal manneurisms (sic) and behaviors more evident later in the shift . . ." Although the record showed the "effective date" for this note was 01/11/14 at 11:00 p.m., further record review identified the "created date" for this note was 01/12/14 at 4:31 p.m. (nearly 24 hours after the discovery of the medication error). During an interview on the morning of 02/12/14, a supervisory nurse (#2) confirmed the "created date" is the date/time that staff actually made the entry. An "Incident Report" provided by the facility also identified the medication error. Staff completed the report on 01/12/14 at 10:38 p.m. (over 24 hours after the discovery of the medication error). During an interview on the morning of 02/12/14, an administrative nurse (#2) stated she would expect staff to complete an incident report at the time of the incident or shortly thereafter. Resident #4's nurses' notes further stated: *01/12/14 at 3:14 a.m.: ". . . Pt noted to have increased b/p (blood pressure) this noc (night), re-check b/p at 3a (3:00 a.m.): 204/86. At 3a, called on call for (physician name), and orders rec'd (received) for [MEDICATION NAME] (an antihypertensive) 0.1 mg (milligram) PO (by mouth) every hour until b/p less than 160 systolic. . . ." *01/12/14 at 7:36 a.m.: ". . . Note b/p already decreased at 6a (6:00 a.m.): 160/78 and gave most likely last clonodine (sic) needed. . . ." *01/12/14 at 1:40 p.m.: ". . . Was reported to pt (patient) nurse by family that pt has decreased LOC (level of consciousness). Family and nurse agreed that pt should be seen in ED for decreased LOC. Oncall (sic) (physician name) notified and T.O. (telephone order) order (sic) for pt to be seen in ED for evaluation. Incident report filled out from yesterday. . . ." Resident #4's transfer form, completed by the facility and dated 01/12/14 at 12:53 p.m., identified the "Reason for Transfer" as "Decreased LOC." Staff provided no further health history regarding Resident #4's condition (such as the accidental application of the [MEDICATION NAME], the resident's elevated blood pressure, and the initiation of the [MEDICATION NAME]). Failure to include relevant and important information on the transfer form does not allow ED staff to receive an accurate presentation of Resident #4's health status, and does not allow for continuity of care. The ED Provider Note, dated 01/12/14 at 2:34 p.m., stated the following: ". . . Chief Complaint . . . Lethargy . . . History is extremely limited because the patient is not talking and unable to follow commands appropriately or provide history. The history is provided by the patient's son. . . . The patient's chief complaint is of worsening lethargy, confusion, altered mental status, and weakness. . . . The patient reportedly had a right-[MEDICAL CONDITION] days ago . . . Then she left the hospital to go to the nursing home several days ago, the patient was able to actually ambulate with assistance, and carry on a conversation. Her son states now she is unable to ambulate or lift her legs at all, speak with him, or follow commands. The was a period in time yesterday where the patient inadvertently had a [MEDICATION NAME] placed for approximately 8 hours, which was not intended for her and actually was her roommates medication. . . ." A nurse's note from the ED, dated 01/12/14 at 6:53 p.m., stated, ". . . Patient given 0.2 mgs (milligrams) [MEDICATION NAME] (a medication used to counter the effects of opiate overdose, specifically the depression of the central nervous and respiratory systems) and she began to awaken and respond to us and questions. Patient understood she was being admitted to floor. . . ." Resident #4's hospital record following her admission on 01/12/14 stated, ". . . Assessment/Plan . . . Active Hospital Problems . . . UTI (lower urinary tract infection). Culture pending. Continue [MEDICATION NAME] (an antibiotic) pending cultures. . . . [MEDICAL CONDITION] (disorder of the brain) acute. Multifactorial with accidental drug overdose and UTI. . . . Narcotic overdose. [MEDICATION NAME] removed. . . ." Information submitted by the complainant identified the nurse who identified the medication error (on the evening of 01/11/14) contacted the nurse who applied the [MEDICATION NAME] earlier that morning. The nurse who applied the patch stated she had asked Resident #4, "Are you (Resident #5)," to which Resident #4 replied "yes." Then nurse then applied the patch to Resident #4, instead of Resident #5. An interview with administrative nursing staff (#1 and #2) on the afternoon of 02/11/14 confirmed the above information. Facility staff incorrectly administered an opioid pain medication to Resident #4 medication. This resulted in decreased level of consciousness and lethargy for Resident #4, as well as an admission to the ED and the administration of emergency [MEDICATION NAME]. - Review of Resident #5's record occurred on February 11-12, 2014. Resident #5's medication regimen through the length of stay included [MEDICATION NAME] 50 mcg per hour [MEDICATION NAME] applied every 72 hours. The Medication Administration Record [REDACTED]." The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of Resident #5's "Controlled Substance Record" for the [MEDICATION NAME] identified the dates and times nursing staff obtained a patch; the number of patches remaining; and the nurse who obtained (signed out) the patch. The controlled substance record identified nursing staff members obtained a [MEDICATION NAME] for Resident #5 at 8 a.m. and 6 p.m. on 01/11/14. Review of Resident #5's MAR indicated [REDACTED]. During interview on 02/11/14 at 5:45 p.m. a nurse manager (#2) stated she lacked awareness of how Resident #5 received two [MEDICATION NAME]es on 01/11/14, unless one of them "fell off in the shower." The nurse stated Certified Nursing Assistants (CNAs) are instructed to let the nurse know if a patch falls off during bathing. The manager stated she was unaware if there was an incident report on the missing patch. During interview on 02/11/14 between 5:45 p.m. and 6 p.m., an administrative nurse (#1) stated the [MEDICATION NAME] scheduled for Resident #5 at 8 a.m. was administered to the roommate, Resident #4. The administrative nurse stated the nurse making the error did not work that unit very often and was a "prn" (as needed - fill in) nurse. Review of the nurses' staffing schedule between December 11, 2013 and February 11, 2014 showed the facility scheduled the "prn" nurse between six to 10 days in a two week period. The nurse stated to her knowledge no incident report was completed; however, she informed the nurse there should be an incident report. The nurse (#1) stated an incident report would include the investigation of the incident. A request for additional information, including the facility's investigation of the incident, the contributing and causative factors were requested and not provided. The administrative nurse stated corrective action included education and performance improvement with the nurse causing the error, and education to all the nurses. During interview on 02/12/14 at 9:15 a.m. an administrative nurse (#1) and nursing manager (#2): * confirmed no incident report was completed for Resident #5's missed dose of [MEDICATION NAME] at 8 a.m. on 01/11/14 or dose administered at 6 p.m. * incident reports are required to be completed at the time of the incident * an incident report was done initially for Resident #4, but the nurse completing the report chose the wrong category (an example offered: a fall verses a fall with injury), so the nurse was requested to fill out another one. The nurse manager stated the nurse who applied the patch to Resident #4 wrote a progress note in Resident #4's record which she thought would automatically transfer over to Resident #4's incident report * would expect documentation on Resident #4's and #5's MAR indicated [REDACTED]. * if medication is not given at the time scheduled, would expect this identified on the MAR * stated the nurse looked for the patch "all over" Resident #4's body and couldn't find it. The nurse failed to make a report at the time regarding not finding the previously applied patch on Resident #4 * identified photographs as a means of resident identification during medication pass; however, record review identified no photo available of Resident #4. After the error occurred the facility changed the process to ensure every resident had a photograph with the resident's MAR; however, during observation of medication pass on the afternoon of 02/11/14 Resident #4's MAR indicated [REDACTED] During interview on the afternoon of 02/11/14, a staff nurse (#3) stated resident identification is by a picture of the resident with the MAR "normally." The nurse stated residents also have the option to wear arm bands. During interview on the afternoon of 02/11/14, a staff nurse (#4) stated for identification of residents during medication pass in the dining room she carries the resident's picture, and asks the residents their name. The nurse stated for residents within their room, she will do several checks including resident's name on door; arm bracelet if wearing; and photo identification. Review of the inservice training and skills checklist provided for the nursing staff following the incidents on 01/11/14 occurred on both days of survey. The nurse's schedule identified 34 nurses worked on the units between 01/22/14 and 02/04/14. Review of individual nurse's education and skills demonstration records identified 11 of the 34 nurses had not received the education and return demonstration. The skills checklist included "Identify patient by calling name, checking ID (identification) and photograph." Facility staff incorrectly administered an opioid pain medication to Resident #4 medication to Resident #5. This may have resulted in unresolved pain for Resident #5, and resulted in decreased level of consciousness and lethargy for Resident, as well as an admission to the ED and the administration of emergency [MEDICATION NAME].

Based on record review, resident interview, and staff interview, the facility failed to provide the necessary assistance to prevent falls and injury for 2 of 2 sampled residents (Resident #3 and #12) who experienced falls and/or incontinence. The lack of appropriate assessment and provision of assistance resulted in Resident #3 experiencing a fall and incontinence, and Resident #12 experiencing a fall with injury. Findings include: - Resident #3's medical record, reviewed July 27-28, 2011, identified [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], identified no concerns with short and long term memory, independent with daily decision making; decisions consistent/reasonable, extensive assist of two+ persons for transfers and toilet use, and occasional urinary and bowel incontinence. Resident #3's Plan of Care identified the following: * On 07/06/11, ". . . Focus: ADLs (activities of daily living) . . . Interventions: . . . Check for incontinence frequently and provide incontinent care as needed . . . Focus: Falls . . . Interventions: Administer medication per physician's orders [REDACTED]. . . of any falls. . . ." * On 07/13/11, ". . . Focus: Falls . . . Interventions: "Keep furnishings . . . consistently arranged." Resident #3's Task List Report, dated 07/27/11, identified, "TRANSFERS . . . ADL Assist - Usually 1 person with walker. . . . TOILETING . . . Everyday Q (every) shift: 6 AM - 2 PM, 2 PM - 10 PM, 10 PM - 6 AM . . . " The "(Name) Medical Center, Fargo: Interagency Discharge Form", dated 07/25/11, stated, ". . . Fall risk level high. . . ." Resident #3's fall assessment, effective date 07/25/11 at 11:35 p.m., identified, ". . . B. Physical Performance Limitations: 1. Difficulty maintaining sitting balance . . . 3. Difficulty maintaining standing position . . . 5. Gait problem . . . G. Documentation: . . . 2. Additional observations/comments not captured in the previous sections: Pt (patient) has bed alarm due to increased risk o (of) trying to get out of bed to go to the bathroom. Assured pt that if light is turned on, staff will come and assist. . . ." The "Nurse's Notes" identified the following: * On 07/26/11 at 1:15 am, ". . . At 1:15 a.m. CNA (certified nurse assisstant) reported that 911 was called regarding Room 26A. Pt had gotten up out of bed by herself wanting to go to (the) bathroom. Pt was on the floor by the bathroom door. Pt stated that she went down slowly to the floor. Pt told her roommate to call 911. Pt deny (sic) having any (increased) pain or discomfort then she has been having. Pt assisted back to bed (with) 3 staff and use of the lift. CNA had been in the room earlier and LPN (licensed practical nurse) had been in room at 12:30 a.m. to give pt scheduled med (medication). Pt did not say (at) that time that she needed to get up. Call light on and alarm on bed was on. Family was notified. (Name of physician assistant) notified. Pt as given prn (as needed)pain med after being back into bed for sacral pain. Will monitor. . . ." The "Comprehensive Examination", dated 07/26/11, identified ". . . Fall Risk High . . . pt fell this am early Visited (with) her re (regarding) fall. She said she got up despite the alarms and that something grabbed her (wound vac) and pulled her back (and) she fell . . . . lying in bed very upset (and) raising her voice when questioned admits that alarms were going off (and) still got OOB (out of bed). . . . No injury noted. States her buttocks hurt but not unusual. . . . lots of blaming but not of herself for disregarding alarm lg (large) ulcer to sacrum leaking . . . Discussed alarms and use of call lights Replaced wound vac, tissue is pale. Ultram on hold d/t (due to) GI (gastrointestinal) Bleed recently. . . . She is off of Coumadin for a week d/t GI bleed . . ." Resident #3's fall report, dated 07/26/11, identified ". . . CHF . . . Visual impairment . . . Impulsivity or poor safety awareness . . . Pt was going to the bath room my (sic) herself. Call light was on, and alarm was on. Pt did not wait for help. Staff had been in the room earlier times two, pt did not say anything about needing to get up. Pt on the floor by the bath room door. . . ." The "Incident Report", dated 07/26/11 at 1:15 a.m., identified ". . . Fall without injury. . . . Pt was going to the bathroom by herself. Pt was found on the floor by the bathroom door. Pt did not want for staff to help her. . . . Pt was assisted by 3 staff and use of the lift to put pt in bed. Pt was clean (sic) up wound vac started. V/S (vital signs) started and pain med was given. . . ." Resident #3's medication administration record (MAR) and nurse's medication notes identified the following: * On 07/26/11 at 12:30 a.m., "Dilaudid 2 mg . . . sacaral (sacral) 4/10 (on the pain scale) . . ." In an interview on 07/27/11 at 10:00 a.m., the nursing staff member (#2 - the charge nurse on that shift) confirmed she "was in (the resident's room) earlier to give meds," and the resident "didn't have other needs" (at that time). In an interview on 07/28/11 at 2:00 p.m., two administrative staff members (#3 and #4) also confirmed the nurse had "passed meds to Resident #3 at 12:30 p.m." In an interview on 07/27/11 at 5:30 p.m., Resident #3 stated, "There was an alarm the day I fell . They have something that says 'Beep-beep sit down.' You do, but it don't shut up. I laid there (in bed) and waited for 15 - 20 minutes. I thought I'd pee the bed if I didn't try to go. This thing (wound vac) pulled me back. I just went down. I was lying on the floor I bet 15 minutes. I was hollering for help. No one came. I told her . . . (Resident #12) to call 911. (Resident #12) called. I don't know if it (the call) went to 911, or where. They brought something in to get me up. It worked." In an interview on 07/28/11 at 8:45 a.m., Resident #12 stated, "(Resident #3) said she had to go pee. The bed alarm was going off. What I'd been doing with (Resident #3) is . . . when she says 'I have to pee.' . . . If they didn't come fast enough, she'd try to get up on her own. If they didn't answer her call light, I'd turn mine on too. I thought if they didn't answer one, maybe they would answer two. I pushed my call light before she fell ." She further stated, "I looked at my clock on the wall. (Resident #3) waited 15-20 minutes before getting up herself. Oh yes, that monster (bed alarm) was going off. It didn't do any good. It irritated (Resident #3) to no end. I think she would have been more patient, had she gotton a response when it went off." She further stated, "She was on the floor 15 minutes at least . . . calling out. She told me, '(Resident #12) call 911.' I did. I could at least do that for her. After that (call to 911), they appeared very rapidly - within 10 minutes." In an interview on 07/27/11 at 10:00 a.m., the nursing staff member (#2) stated, "The CNAs were doing rounds . . . in and out of rooms. I was in another resident's room. When I came out, the CNA said someone had called 911. (Resident #3) told her roommate to call 911. The call light and bed alarm were sounding when the CNA entered. They turned them off before I came in. (Resident #3) was on the floor by the bathroom when I came in. I checked her for injuries." She confirmed staff did not hear/respond to the alarms by stating, "That was the first time I was aware of the fall . . . was when 911 called. No one heard the alarms. No one heard her calling for help." In an interview on 07/28/11 at 2:00 p.m., two administrative staff members (#3 and #4) stated, "Her (Resident #3) alarm was sounding. The nurse was passing pain medications. The CNAs were two doors away. They didn't hear it. It wasn't very loud. We've tried to make it louder since. They couldn't hear the alarm from the nurse's station either. Her roommate called 911. 911 received the call between 1:00-1:15 a.m. They didn't log the exact time, because they didn't dispatch anyone. (Her roommate) told us they waited just a few minutes at that point . . . after 911 was called. Another CNA took the call from 911. She checked the call light board. Only one was on at the time." When asked questions regarding their expectations for answering call lights in a timely manner, they stated they "would expect calls to be answered promptly." They "would like to see them answered in 5 minutes." In an interview on 07/27/11 at 5:30 p.m., Resident #3 stated, "It seems if you have to go to the bathroom . . . you want someone to rush along. They don't do that here. I've waited long enough that I've peeded and pooped the bed. Yes, I discussed it with staff. They say, 'We got here as soon as we could get here.' I don't like to pee in bed . . . poop in bed. I don't do that well. For heaven sake, I'm a grown lady." In an interview on 07/28/11 at 8:45 a.m., Resident #12 confirmed Resident #3 "did soil herself waiting for them (staff)." She further stated, "Yes, I have discussed my (own) concerns with them (staff). They quite truthfully said there just isn't enough time to do everything they are expected to do." In an interview on 07/28/11 at 12:00 p.m., a nursing staff member (#1) stated, "(Resident #3) is continent. She wears a brief just in case. She has urgency. I really have to get in there." The facility failed to 1) recognize Resident #3 as being at high risk for falls, 2) put additional interventions into place, and 3) meet Resident #3's needs in a timely manner which resulted in her experiencing a fall and incontinence. - Resident #12's medical record, reviewed July 27-28, 2011, identified [DIAGNOSES REDACTED]. The MDS, dated [DATE], identified a BIM (Brief Interview for Mental Status) score of 15; cognitively intact. In addition, the MDS indentified extensive assist of one person for transfers and toilet use, and always continent of bowel and bladder. Resident #12's Plan of Care identified the following: * On 05/09/11, ". . . Focus: Falls . . . Interventions: Administer pain medication as ordered and observe for effectiveness, Assess for fall risk upon admission and reassess as needed, Encourage to transfer and change positions slowly, Notify physician and family . . . of any falls, Provide assist to transfer and ambulate as needed . . ." * On 05/10/11, ". . . Focus: ADLs . . . Interventions: . . . Transfer with one assist with SB (sliding board). . . ." * On 05/16/11, ". . . Focus: Urinary incontinence . . . Interventions: . . . Provide assistance with toileting or provide incontinence care as needed . . . " In an interview on 07/28/11 at 8:45 a.m., when asked if staff respond in a timely manner, Resident #12 stated, "They are incredibly slow. Nights are bad. Weekends are bad. I have waited for up to an hour and a half, which was until I could transfer myself. I ended up falling one time, because I needed to go to the bathroom. I was trying to get on the commode. Yes, I had my call light on before I tried to transfer onto the commode. When I fell , I wasn't near my call light . . . so I called out. One of my neighbors heard me, and came to check on me. They saw me on the floor and went to search for help." Resident #12's fall report, dated 06/03/11, identified ". . . Decline in functional status . . . Incontinence . . . Missing limb . . . Low levels of physical activity . . . Pain . . . Resident attempted to self transfer to commode using a sliding board alone. Was found laying on her floor in her room, left stump was bleeding and opened. VSS (vital signs/stable), c/o (complaints of) some pain to stump area, ROM (range of motion) was normal for her, denies hitting her head. . . ." Resident #12's event report, dated 06/03/11, identified ". . . 06/02/11 at 11:00 p.m. . . . Resident was found on floor in her room. She reports she was self transferring to the commode using a sliding board and it slipped and she fell . At the time of assessment it was noted that her dressing to the left amputation site had fallen off and the outer left edge had opened with a moderate amount of blood noted from the site. Area was cleansed with normal saline and rebandaged. Monitoring for further bleeding. Currently there has been no bleeding noted since initial fall. Neuro-checks are WNL (within normal limits), VSS. . . . History of falls . . . Wound to left amputation site opened when she fell . . . Resident continues to be alert and oriented, c/o 4/10 mpain (sic) to stump site. . . . Suggest the PA/NP (physician assistanct/nurse practioner) look at site to dtermine (sic) if further orders are necessary. . . ." The facility made the following additions to the Plan of Care: * On 06/06/11, ". . . Focus: Falls . . . Interventions: "Reinforce need to call for assistance . . ." * On 06/15/11, ". . . Focus: Falls . . . Interventions: "Bed in low position." The facility failed to 1) meet Resident #12's needs in a timely manner which resulted in her experiencing a fall, and 2) an injury to her stump.