Every finding on record at Tioga Medical Center LTC

Based on record review and staff interview, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment for 1 of 12 sampled residents (Resident #6) reviewed for advanced directives. Failure to ensure the medical record accurately reflected each resident's code status limited the facilities ability to communicate to direct care staff and emergency personnel the residents' choice in the event of a medical emergency.Findings include:Review of facility policy titled Advance Directives Policy occurred on 06/03/26. This policy, dated June 2017, stated, Policy: It is the resident's right to formulate an Advance Directive, and to accept or refuse medical or surgical treatment. On admission, the facility will determine if the resident has executed an Advance Directive and if not, determine whether the resident would like to formulate an Advance Directive. copies will be made and placed on the chart . facility will periodically assess the resident .Review of Resident #6's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified impaired cognition. A physician's order signed on 05/12/25 stated code level: DNR (do not resuscitate). The health care directive, signed by Resident #6 on 04/04/21, stated, Health Care Directive . 3. Regarding end of life matters: . (a) [Resident #6's initials] I do not want my life to be prolonged if, to a reasonable degree of medical certainty, my situation is hopeless. I direct that: I WOULD ACCEPT: CONTINUOUS CIRCULATION FOR CELL SALVAGE, HEART-LUNG MACHINE, DIALYSIS, FRACTIONS-DISCUSS, I HAVE A PACEMAKER, MEDICATIONS. The medical record lacked documentation reflecting the accurate code status for Resident #6. During an interview on 06/03/26 at 2:26 p.m., an administrative staff member (#1) confirmed staff failed to obtain an updated advance directive to reflect Resident #6's code status.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident's provider of a change in condition for 1 of 1 sampled resident (Resident #3) reviewed for hospitalization. Failure to notify the provider timely of a change in condition delayed physician testing/treatment and contributed to Resident #3's hospitalization.Findings include: Review of the facility policy titled Notification of Changes occurred on 06/02/26. This undated policy, stated, . The facility must inform the resident/patient, consult with the resident's/patient's physician . when there is a change requiring such notification. Circumstances requiring notification include: Significant change in the resident's/patient's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status. This may include: Life-threatening conditions, or Clinical complications.Review of Resident #3's medical record occurred on all days of survey and identified current use of anticoagulants (a medication to thin the blood/prevent blood clots). The nurse progress notes, dated Friday, 12/12/25, stated the following:* 2:12 p.m., CNA [certified nurse aide] reported that the resident had a black tarry stool. All four quadrants active upon auscultation. Resident reports no pain. Notified the DON [Director of Nursing]. Will continue to monitor. Stool sample will be collected with the next bowel movement. * 3:40 p.m., Obtained stool specimen, taken to lab for evaluation. * 5:10 p.m., D.O.N. spoke with the Provider on call and he didn't want to give any new orders regarding the positive stool specimen results. Provider suggested we wait for the Provider on Monday to give any orders. D.O.N. did mention to the Provider on call that resident was a full code, but Provider on call cont [sic] to suggest waiting for the Provider on Monday [12/15/25]. A provider telephone encounter note, dated 12/17/25 (Wednesday), stated, Patient notified to have dark tarry stools. Provider that was on ordered FOBT [fecal occult blood test] which is positive. Hgb [hemoglobin] drawn today shows 5.8 [normal range: 13.5 to 17.5 grams per deciliter]. Last Hgb was 8.6 on 10/23/25. [Name of hospital] called. Accepting Attending is [name of physician]. Ground transport being set up.During an interview on 06/02/26 at 4:30 p.m. an administrative staff member (#2) confirmed the provider notification occurred on 12/17/25 and not on 12/15/25 as requested. The facility failed to contact the provider on 12/15/25 as directed by the on-call provider, which resulted in delayed treatment and hospitalization.

Based on observation, record review, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), the facility failed to complete a Minimum Data Set (MDS) that accurately reflected the resident's status for 1 of 1 sampled resident (Resident #22) with a restraint. Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2025, pages P-1 and P-5, stated, . PHYSICAL RESTRAINTS: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body . Coding Instructions . code the frequency of use: Code 0, not used . Code 2, used daily .Review of Resident #22's medical record occurred on all days of survey. Diagnosis included Huntington's disease (a disease that causes involuntary, irregular, and unpredictable muscle movements often affecting the arms and legs). The current care plan stated, . I prefer to use Huntington's package thigh belts [a belt attached to the chair and over the thighs] to provide safety and allow me to sit upright in my Broda chair. Staff will monitor belt use and ensure my comfort with this device. Please remove my thigh belt at my request .Observation on 06/01/26 at 12:40 p.m. showed Resident #22 seated in wheelchair with the straps of the thigh belt fastened behind the chair. When asked if the resident could release the strap, the resident stated, No.Review of the Resident #22 quarterly MDS, dated [DATE], showed the facility failed to code the thigh belt as a restraint.

42397 46964 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 12 sampled residents (Resident #3, #8, #9, #17 and #20) and one supplemental resident (Resident #6). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION H: BLADDER AND BOWEL The Long-Term Care Facility RAI User's Manual, revised October 2024, page H-6, stated, . H0200: Urinary Toileting Program . Steps for assessment: H200C, Current Toileting Program . 1. Review the medical record for evidence of a toileting program being used to manage incontinence during the 7-day look-back period. Note the number of days during the look-back period that the toileting program was implemented or carried out. Coding Instructions . Code 1, yes: for residents who are being managed during 4 or more days of the 7-day look-back period, with some type of systematic toileting program (i.e., bladder rehabilitation/bladder retraining, prompted voiding, habit training/scheduled voiding). - Review of Resident #9's medical record occurred on all days of survey. An annual MDS, dated [DATE], showed facility staff coded H200C 1, indicating a daily toileting program. The medical record lacked evidence of an individualized/resident-centered toileting program. - Review of Resident #20's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], showed facility staff coded H200C 1, indicating a daily toileting program. The medical record lacked evidence of an individualized/resident-centered toileting program. During an interview on 03/12/25 at 1:15 p.m., an administrative staff member (#2) confirmed Residents #9 and #20 did not have an individualized/resident-centered toileting program. SECTION P: RESTRAINTS AND ALARMS The Long-Term Care Facility RAI User's Manual, revised October 2024, pages P1-5, stated, . PHYSICAL RESTRAINTS: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. P0100: Physical Restraints . Coding Instructions: . After determining whether or not an item . is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back or it was used but did not meet the definition. Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period. - Review of Resident #3's medical record occurred on all days of survey. A Bed Rail Assessment, dated 02/05/25, stated, . Would the side rail be considered a restraint? . 'No.' If no the side rails do not meet the definition of a restraint for this resident. A quarterly MDS, dated [DATE], showed facility staff coded section P0100A, bed rail as 2 used daily. - Review of Resident #17's medical record occurred on all days of survey. A Bed Rail Assessment, dated 02/05/25, stated, . Would the side rail be considered a restraint? . 'No.' If no the side rails do not meet the definition of a restraint for this resident. A quarterly assessment MDS, dated [DATE], showed facility staff coded section P0100A, bed rail as 2 used daily. During an interview on 03/12/25 at 1:15 p.m., an administrative staff member (#2) confirmed bed rails were not a restraint for Residents #3 and #17 and staff failed to code the quarterly MDSs correctly. The Long-Term Care Facility RAI User's Manual, revised October 2024, pages P-9 through P-11 stated, An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. Code 2, used daily: if the device was used daily during the look-back period [seven days]. Other alarm includes devices, such as alarms on the resident's bathroom and/or bedroom door, toilet seat alarms or seatbelt alarms. - Review of Resident #6's medical record occurred on all days of survey. A significant change assessment MDS, dated [DATE], showed the facility coded other alarm used daily. The record lacked evidence the resident used an alarm the RAI manual defined as other. - Review of Resident #8's medical record occurred on all days of survey. A significant change assessment MDS, dated [DATE], showed the facility coded other alarm used daily. The record lacked evidence the resident used an alarm the RAI manual defined as other. - Review of Resident #20's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], showed the facility coded other alarm used daily. The record lacked evidence the resident used an alarm the RAI manual defined as other. During an interview on 03/12/25 at 9:55 a.m., an administrative staff member (#2) confirmed, the facility staff coded the facility's exit doors as the other alarm and verified the MDSs for Residents #6, #8 and #20 were coded incorrectly.

Based on observation, record review, and resident and staff interview, the facility failed to ensure appropriate care and services for 1 of 2 sampled residents (Resident #26) reviewed for edema (fluid retention). Failure to ensure consistent implementation and resident refusals of support stockings may result in worsening edema. Findings include: Review of Resident #26's medical record occurred on all days of survey and identified a diagnosis of congestive heart failure. A physician's order, dated 01/23/25, stated, [NAME] Hose [support stockings to control edema] on in the AM and Off at HS [bedtime] . for Edema. The current care plan stated, . I have a diagnosis of . congestive heart failure . edema . I will remain free of complications related to diagnosis through next review date. I would like staff to monitor for and document any edema and notify my provider as needed. A nursing progress note, dated 01/24/25 at 9:37 a.m., stated, . Does have edema noted to bilateral [both] lower legs at which time resident stated her legs feel itchy at those times . A provider progress note, dated 02/25/25, stated, . Doing ok. Also wondering if her LE [lower extremities] edema will ever resolve. Plan . 3. Regarding her edema - encouraged to elevate legs as much as possible. Observation on 03/10/25 at 10:56 a.m., showed Resident #26 seated in the recliner with her feet on the floor, visible swelling to both lower legs, and no support stockings present. The resident stated, I'm supposed to wear them [support stockings] but I refuse because they hurt. A note on the resident's dresser stated, Put your feet up when in your chair. The resident stated, I forget, when asked about elevating her feet. Observation on 03/11/25 at 7:47 a.m., showed Resident #26 seated on the toilet in the bathroom, dressed, visible swelling present, and without support stockings present. A certified nurse aide (CNA) (#4) stated, She refused to wear them [support stockings]. Review of Resident #26's medication administration record (MAR) dated March 10-11, 2025, showed the ted hose documented as applied on both days. During an interview on 03/11/25 at 4:50 p.m., an administrative nurse (#1) confirmed she expected the CNAs to inform the nurse if the resident refused to wear the ted hose, the nurse to visualize the ted hose are in place prior to documenting on the MAR, and document any refusals.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 2 sampled residents (Resident #12) reviewed for as needed (PRN) psychotropic medication use. Failure to limit PRN psychotropic medication use to 14 days unless re-evaluated by a practitioner placed the resident at risk of receiving unnecessary medications and experiencing adverse drug effects and consequences related to their use. Findings include: Review of the facility policy titled Use of Psychotropic Medication occurred on 03/12/25. This policy, dated February 2023, stated, . PRN orders for all psychotropic drugs shall be used . for a limited duration (i.e. 14 days) . If the . prescribing practitioner believes that it is appropriate for the PRN order to extend beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of Resident #12's medical record occurred on all days of survey. A current physician's order included Ativan (an antianxiety medication) 0.5 milligrams (mg) intramuscularly every six hours as needed for anxiety, with a start date of 06/26/24. The order lacked a stop date. The medical record lacked follow-up documentation from the provider since ordering the PRN medication and within the limited duration (14-day) period. During an interview on 03/12/25 at 11:25 a.m., an administrative nurse (#1) confirmed the facility failed to have the provider reevaluate the resident for further need of the antianxiety medication after 14 days.

Based on observation, record review, policy review, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 2 sampled residents (Resident #3 and #26) observed in enhanced barrier precautions (EBP). Failure to practice infection control standards related to EBP, catheter care, 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 03/12/25. This policy, dated April 2024, stated, . 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. PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include: . dressing . providing hygiene . assisting with toileting . device care or use . Review of the facility policy titled Hand Hygiene occurred on 03/12/25. This policy, revised August 2022, stated, . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, patients, and visitors. 'Hand hygiene' is a general term for cleaning your hands . 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 Resident #3's medical record occurred on all days of survey. The current care plan stated, . I require Enhanced Barrier Precautions (EBP) related to my suprapubic catheter . Observation on 03/10/25 at 10:44 a.m. showed an enhanced barrier precaution sign outside of Resident #3's room. Observation on 03/11/25 at 10:24 a.m. showed Resident #3 seated in a wheelchair in his room. The certified nurse aide (CNA) (#4) entered Resident #3's room wearing a gown and gloves. The CNA (#4) emptied the resident's catheter collection bag into a urinal, changed gloves without performing hand hygiene, placed a barrier on the resident's side table next to the resident's water glass, and placed the urinal containing urine on the barrier to read the measurement. The CNA (#4) emptied the urinal into the toilet, rinsed and stored the urinal, and changed gloves without performing hand hygiene. The CNA (#4) applied a gait belt to Resident #3 and assisted the resident to bed. The CNA removed her gloves, and without performing hand hygiene, covered the resident with a blanket and adjusted the side table. The CNA (#4) failed to perform hand hygiene when changing or removing gloves and touching other surfaces, and failed to follow infection control practices when emptying the catheter. - Review of Resident #26's medical record occurred on all days of survey. The current care plan stated, . I require Enhanced Barrier Precautions (EBP) related to my Jackson Pratt (JP) Drain [a closed-suction medical device used to collect fluids from surgical sites] . Observation on 03/10/25 at 10:56 a.m. showed an enhanced barrier precautions sign outside Resident #26's room. Observation on 03/11/25 at 7:47 a.m. showed Resident #26 seated on the toilet, a JP drain present, and the CNA (#4) wore gloves and performed perineal cares. After cares, the CNA removed her gloves and adjusted the resident's brief and pants. Observation on 03/11/25 at 10:55 a.m. showed Resident #26 seated in the recliner. A nurse (#5) washed her hands, donned gloves, and emptied the resident's JP drain. The CNA (#4) and the nurse (#5) failed to don a gown when performing high-contact resident care activities. During an interview on 03/12/25 at 8:40 a.m., an administrative nurse (#3) confirmed she expected staff to wear proper PPE when performing high-contact resident care activities, perform hand hygiene when removing gloves and before applying new gloves, and follow proper infection control techniques when emptying a catheter.

Based on observation, record review, facility policy, and staff interview, the facility failed to ensure posting of staff information on 2 of 3 days of survey (March 10-11, 2025). Failure to post staffing data does not allow residents and visitors information related to the number of licensed and unlicensed staff on duty each shift. Findings include: Review of the facility policy titled Nurse Staffing Posting Information dated 10/01/24, stated, . The Nurse Staffing Sheet will be posted on a daily basis . The facility will post the Nurse Staffing Sheet at the beginning of each shift. Nursing schedules and posting information will be maintained in the Human Resources Department for review. Observation on all days of survey showed a Nurse Staffing Posting Information form posted on a board in the hall by the residents' dining room. Review of the staffing form on 03/10/25 and 03/11/25 showed the staffing form dated 03/07/25. The facility failed to post a current staffing form for March 10th and 11th, 2025. Review of previous staff posting identified staff failed to complete the staffing form for March 8-11, 2025. During an interview on 03/12/25 at 9:51 a.m., an administrative nurse (#1) stated the night shift is responsible for staff posting, and confirmed the it had not been completed for March 8-11, 2025.

Based on review of the facility reported incident (FRI), policy review, and staff interview, the facility failed to protect a resident's right to be free from physical abuse for 1 of 2 sampled residents (Resident #1) who sustained a fracture. Failure to ensure an environment free from abuse resulted in a fracture to Resident #1 and placed all residents at risk for abuse, fear, and anxiety. Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation occurred on 02/11/25. This policy, dated June 2021, stated, . Resident to Resident Altercations . Residents who are abusive to other residents must be monitored . Documentation must be in place to identify steps taken . the corrective action taken, and follow-up monitoring . 6. Prevention of Abuse . b. Observe residents behavior and their reactions to other residents . Identify areas of the . environment that may make abuse . more likely to occur, such as secluded areas. Review of the initial FRI occurred on all days of survey and identified an altercation between Residents #1 and #2 which resulted in a fall and hip fracture for Resident #1 on 02/08/25. Review of Resident #1's medical record occurred on 02/11/25. Diagnoses included dementia and anxiety. The care plan, updated 01/14/25, stated, . I have a history of aggressive behavior towards other residents . ensure that I am monitored while around other residents. I will need redirection when I target another resident. I sit at the table closest to the dining room entry. Review of Resident #1's progress notes stated the following: * 01/12/25 at 5:25 p.m., . 1545 [3:45 p.m.] a family member came to notify this nurse that 2 residents were arguing in the dining room. This nurse went to investigate and found [Resident #1] pinned between the wall and the other resident's walker . There were no injuries sustained . All witnesses state. [Resident #1] came into the dining room . yelling and cursing directed towards another resident. [Resident #1] . took the bottles of hand sanitizer . and threw it [sic]. She then was bumping [Resident #2] with a chair. [Resident #2] . started pushing [Resident #1] around the dining room with his walker. He . pinned her between the wall and his walker. He was upset with her and verbally saying things to her as to how she was acting. [Resident #2] was escorted out of the dining room. * 02/08/25 at 8:30 p.m., . CNA [certified nurse aide] reports to nurse . Resident is on the floor in the dining room . nurse . responds to dining room to find resident . on the floor sitting up. She [Resident #1] is reporting 'he [Resident #2] pushed me' . This altercation was . witnessed by other residents. Other residents reported that she came into the dining room looking for her grandson, she had gone up to resident [Resident #2] . grabbed his wheelchair and opened up the seat, when he [Resident #2] stated, 'get out of my stuff' It was reported that resident than [sic] walked up to [Resident #2] and pushed him twice in the chest, leading him to push the resident. Resident . is sitting on the floor stating her leg hurts . She states 'ouch' and rubs her left thigh. * 02/08/25 at 8:37 p.m., . addendum: Event occurred at 1830 [6:30 p.m.] 02/08/25. Review of Resident #2's medical record occurred on 02/11/25. Diagnoses included anxiety disorder and dementia. The care plan, updated 01/14/25, stated, . monitor me for agitation when around other residents and provide redirection as needed. I sit at the table farthest away from the dining room entry near TV [television]. Review of Resident #2's progress notes stated the following: * 02/08/25 at 6:30 p.m., . Resident sitting at his table in dining room with two other residents and a resident from the independent living. CNA informs this nurse that another resident [Resident #1] is on the floor. This event was not witnessed by staff, but was witnessed by other residents. This nurse. responds to dining room. [Resident #2] reports he pushed resident [Resident #1] down because she opened his walker when he told her not to touch it the resident [Resident #1] had pushed his chest two times and [Resident #2] pushed her to the floor. [Resident #2] continues to tell resident to shut up, your [sic] faking it, your [sic] not really hurt you liar. During an interview on 02/10/25 at 5:10 p.m., an adminstrative nurse (#1) stated after the incident on 01/12/25, the facility changed the seating arrangments in the dining room and educated staff on the behaviors between Resident #1 and #2 and to redirect them as necessary. During an interview on 02/11/25 at 11:20 a.m., an administrative nurse (#1) stated facility staff were not present in the dining room at the time of the incident on 02/08/25. During an interview on 02/11/25 at 1:00 p.m., an administrative nurse (#1) stated staff received verbal education related to the plan of action for Resident #1 and #2 which included seating them at opposite sides of the dining room, observe and provide redirection when in close proximity of each other or when they target another resident, and at least one staff member in the dining room when residents are there.

Based on record review, review of facility policy, and staff interview, the facility failed to investigate and report to the State Survey Agency (SSA) potential incidents of abuse/neglect for 1 of 1 sampled resident (Resident #26) who experienced a major injury. Failure to investigate and report allegations of potential abuse/neglect to the SSA places all residents at risk of potential abuse/neglect. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 01/31/24. This policy, dated January 2021, stated, . It is the policy of this facility to report all allegations of abuse/neglect/exploitation . including injuries of unknown sources . immediately to . appropriate agencies in accordance with state and federal regulations within prescribed timeframes. Immediately: Means as soon as possible . not later than 2 hours after . events that cause the allegation involve or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse . Injuries of unknown source: . injury was not observed by any person, or the source of injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury. Review of Resident #26's medical record occurred on 01/29/24. Nurses' notes identified the following: * 01/10/24 6:20 a.m., the CNA [certified nurse aide] heard a loud thud sound in the resident's room and saw the resident on the floor lying on his right side near the drawer of his roommate. This nurse hurriedly assessed the resident and, he was alert with memory lapses and some confusion wherein he couldn't recognize nurse [nurse name] whom he usually knows. Bump was noted on back of his head on the right side, wound abrasion noted on tip of his nose. The resident complained of headache, nausea, and vomiting. head CT [computed tomography] scan result showed bilateral subarachnoid hemorrhage (heavy discharge of blood from the blood vessels) along frontal and temporal lobe. The record lacked evidence the above incident was reported to the SSA as possible abuse/neglect. During an interview on the morning of 02/01/24, two nurses (#1 and #2) confirmed the fall was unwitnessed and the resident appeared to be confused about what had happened. The nurse (#1 and #2) confirmed the facility failed to report the above incident to the SSA.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 11 sampled residents (Resident #5). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, Section K: Swallowing/Nutritional Status, pages K-3 through K-6, stated, . K0200A: Weight: 1. Base weight on the most recent measure in the last 30 days. K0300: Weight Loss . Coding Instructions . Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician's order. Code 2, yes, not on physician-prescribed weight-loss regimen: if . the weight loss was not planned and prescribed by a physician. Review of Resident #5's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified a weight of 143 pounds and no weight loss. Weights recorded by staff included: 06/01/23 = 151.0 pounds (lbs) 09/01/23 = 145.4 lbs 11/27/23 = 134.3 lbs On 11/27/23, these weights reflected a 7.6% weight loss over 3 months and a 11.1% loss over 6 months. During an interview on 01/31/24 at 10:00 a.m., a dietary manager (#3) confirmed staff entered Resident #5's weight incorrectly on the 12/05/23 MDS and failed to code Section K as weight loss.

Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASRR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 4 sampled residents (Resident #13) reviewed for PASRR. Failure to complete a change in status assessment with a newly diagnosed mental illness and/or change in treatment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASRR Provider Manual, revised December 2020, page 13, states, . Change in Status Process: Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC [mental illness, intellectual disability, and conditions related to intellectual disability (referred to in regulatory language as related conditions or RC)] was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #13's medical record occurred on all days of survey. A PASRR Level I screen, dated 02/25/21, included a mental health diagnoses of major depression. The outcome by the contracted agency, dated 03/1/21, stated, . A level II evaluation is not required, this level 1 is approved with a level 1 negative outcome. If changes occur or new information refutes these findings, a new screen must be submitted. A psychiatry note, dated 07/07/23, stated, . behaviors have improved with risperidone [antipsychotic] - accusing people of people stealing from him - other concerns toward his in-laws. once you get on [name of Resident #13]'s bad side - he really becomes very paranoid - and he does not forget. AXIS 1: F20.9 [diagnosis code for schizophrenia] . A physician's progress note, dated 7/13/23, stated, . was begun on risperidone in addition to his zoloft [antidepressant] . dx [diagnosis] . schizophrenia, unspecified. plan . we will follow his response to the risperidone for his behaviors. The medical record lacked evidence of an updated Level I screen with the new diagnosis of schizophrenia and an antipsychotic medication. During an interview on 02/01/24 at 10:00 a.m., a social worker (#4) agreed a new diagnosis of schizophrenia required submission of an updated Level I screen and confirmed the facility failed to complete a change in status Level I screen for Resident #13.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to provide appropriate assistance and assistive devices for 1 of 4 sampled residents (Resident #3) observed during a transfer. Failure to use a gait belt and provide appropriate assistance during a pivot transfer places the resident and staff at risk for accidents, falls, and/or injuries. Findings include: Review of the facility policy titled Transfer/Gait Belts occurred on 01/31/24. This policy, dated November 2015, stated, . Staff transferring residents will properly apply and use a transfer/gait belt . transferring residents whose . balance is impaired . strength is decreased . Review of Resident #26's medical record occurred on all days of survey. The current care plan stated, . Limited assist/one-person physical assist. Resident transfers with assistance but is unable to walk. Can stand well enough to transfer. A progress note, dated 11/28/2023 at 4:14 p.m., stated, . one person stand by assist for transfers with gait belt. Observation on 01/29/24 04:02 p.m. showed a certified nurse aide (CNA) (#5) assisted Resident #3 to a standing position from the edge of the bed by lifting under the left arm. The resident's left arm stayed next to his body and tremored while he pivoted to the right without assistance from the CNA. The CNA failed to apply a gait belt before assisting with the transfer. During an interview on 01/30/24 at 6:00 p.m., Resident #3 confirmed his left arm weakness. During an interview on the morning of 02/01/24, an administrative nurse (#1) stated she expected staff to transfer Resident #3 with a gait belt and not lift under his arm.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of controlled medications for 1 of 1 medication cart. Failure to store medications securely may result in unauthorized access to medications. Findings include: Review of the facility policy titled Medication Storage occurred on 02/01/24. This policy dated January 2020, stated, . Schedule II drugs and back up stock for III, IV, and V medications are stored under double-lock and key. This policy failed to address the requirement of controlled medications II-V needing to be locked in a permanently affixed compartment within the medication cart. Observation of the medication cart with a nurse (#2) occurred on 02/01/24 at 11:10 a.m. and showed a bottle of gabapentin (nerve pain medication) for Resident #13 stored with non-controlled medications and not double locked. The nurse (#2) stated, I was unaware this needed to be locked. During an interview on the morning of 02/01/24, an administrative nurse (#1) confirmed staff failed to double lock the controlled medication.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 1 of 7 sampled residents (Resident #26) observed during toileting cares. Failure to follow infection control standards has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the policy/procedure titled Hand Hygiene occurred on 02/01/24. This policy, dated January 2022, stated, . Hand hygiene is indicated and will be performed. After assistance with personal body functions . Observation on 01/29/24 at 2:49 p.m. showed two certified nurse aides (CNAs) (#5 and #6) transferred Resident #26 onto the toilet. The CNA (#5) donned gloves and performed perineal cares. Without removing the soiled gloves, the CNA (#5) transferred Resident #26 to bed, adjusted the resident in bed, moved the resident's bedside table, closed an open bag of chips, moved the resident's water, and adjusted the resident's call light pendant. The CNA (#5) then removed the soiled gloves and performed hand hygiene. The CNA (#5) failed to remove gloves and perform hand hygiene after perineal cares and before assisting the resident with other tasks. During an interview on the morning of 02/01/24, an administrative nurse (#1) stated she expected staff to remove gloves after personal cares and perform hand hygiene.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 08/11/21 Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 3 of 13 sampled residents (Resident #9, #11, and #226). Failure to review/revise the care plans to reflect residents' current status limited the staff's ability to communicate needs and ensure continuity of care for each resident. Findings include: Review of the facility policy and procedure title Multidisciplinary Care Plan occurred on 01/12/23. This policy, dated August 2003, stated, An interdisciplinary team . will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Assessment and care plan evaluation must be ongoing. Monitor the resident's response to care and adjust the care plan accordingly. The care plan team/staff should attempt to manage risk factors whenever possible. Nursing staff will be [sic] review individual care plans at least monthly. - Observations of care for Resident #9 showed the following: * 01/09/23 at 3:11 p.m. showed two certified nursing assistants (CNAs) (#3 and #4) transferred Resident #9 from the bed to the bathroom with the mechanical sit to stand lift. * 01/10/23 at 7:46 a.m. showed a CNA (#2) transferred Resident #9 from the wheelchair to the bathroom with a gait belt and assist of one. Review of Resident #9's medical record occurred on all days of survey and included diagnoses of Dementia and weakness. The current care plan stated, . Transfers assist of two and standing lift, due to knee weakness . 1-2 person pivot as knee can tolerate . During an interview on 01/11/22 at 4:30 p.m., a nurse manager (#1) stated CNAs would decide if Resident #9 felt comfortable to pivot transfer. - Observation on 01/10/23 at 11:06 a.m. showed two CNAs (#5 and #6) transfer Resident #226 utilizing a full body mechanical lift. Review of Resident #226's medical record occurred on all days of survey and included a diagnoses of Dementia. The current care plan stated, . May use a Hoyer lift and the assistance of two for transfer, but at times is able to transfer with the assist of two and a gait belt. The care plans lacked clear direction for resident transfers. During an interview on 01/11/23 at 5:10 p.m., a nurse manager (#1) stated the CNAs would make the decision of how to transfer Residents #9 and #226, because the nurse is usually busy. The manager agreed a nurse should make the assessment not a CNA, and the care plan needed updating to reflect this. - Review of Resident #11's medical record occurred on all days of survey. Diagnoses included heart disease, weakness, and repeated falls. The physician's orders included Eliquis (an anticoagulant) 2.5 milligrams twice a day. The care plan lacked a problem, goals, and interventions related to use of an anticoagulant. During an interview on 01/12/23 8:30 a.m., a nurse manager (#1) stated she would expect anticoagulant use addressed in Resident #11's care plan. 39211 42397

Based on observation, record review, professional reference, and staff interview, the facility failed to provide appropriate supervision by a licensed nurse to prevent accidents for 2 of 2 residents (Resident #9 and #226) who had two different transfer modes noted on their care plan. Failure to provide supervision of certified nurse aides by a licensed nurse regarding resident transfer modes may result in resident falls and/or injury. Findings include: Review of the North Dakota Administrative Code (NDAC) online at www.ndlegis.gov/information/acdata/pdf/54-05-02.pdf stated, . Standards related to registered nurse scope of practice. Develop a plan of care based on nursing assessment and diagnoses that prescribe interventions to attain expected outcomes. 5. Revise nursing interventions consistent with the client's overall health care plan. Review of the NDAC online at www.ndlegis.gov/information/acdata/pdf/33-43-01.pdf stated, . 33-43-01-12. Supervision and delegation of nursing interventions. An individual on the department's nurse aide registry [CNA] may perform nursing interventions which have been delegated and supervised by a licensed nurse. - Observations of care for Resident #9 showed the following: * 01/09/23 at 3:11 p.m. showed two CNAs (#3 and #4) transferred Resident #9 from the bed to the bathroom with the mechanical sit to stand lift. * 01/10/23 at 7:46 a.m. showed a CNA (#2) transferred Resident #9 from the wheelchair to the bathroom with a gait belt and assist of one. Review of Resident #9's medical record occurred on all days of survey and included diagnoses of Dementia and weakness. The current care plan stated, . Transfers assist of two and standing lift, due to knee weakness . 1-2 person pivot as knee can tolerate . During an interview on 01/11/22 at 4:30 p.m., a nurse manager (#1) stated CNAs would decide if Resident #9 felt comfortable to pivot transfer. - Observation on 01/10/23 at 11:06 a.m. showed two CNAs (#5 and #6) transfer Resident #226 utilizing a full body mechanical lift. Review of Resident #226's medical record occurred on all days of survey and included a diagnosis of Dementia. The current care plan stated, . May use a Hoyer [full body] lift and the assistance of two for transfer, but at times is able to transfer with the assist of two and a gait belt. The care plans lacked clear direction for CNAs during resident transfers without first requiring a licensed nurse assessment. During an interview on 01/11/23 at 5:10 p.m., a nurse manager (#1) stated the CNAs would make the decision of how to transfer Residents #9 and #226, because the nurse is usually busy. The manager agreed a nurse should make the assessment not a CNA. 42397

Based on record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure resident's medication regimens were free of unnecessary medications for 2 of 5 sampled residents (#2 and #19) reviewed. Failure to monitor the resident's laboratory values may result in residents experiencing adverse consequences related to the medication and result in the resident receiving an unnecessary medication. Findings include: Review of the facility policy titled Medication Regimen Review occurred on 01/12/23. This policy, dated June 2017, stated, . Medication Regime Review (MRR) is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. Each residents' drug regimen remains free of unnecessary drugs. An unnecessary drug is any drug when used: . Without adequate monitoring. Prescriber's Digital Reference at https://www.pdr.net/drug-summary, accessed 01/19/23, stated, . Geriatric patients . are more likely to have reduced valproic acid clearance and higher serum concentrations of free valproic acid. The geriatric patient may require initial dosing reductions or close monitoring of serum concentrations . Hematologic effects including leukopenia, neutropenia, and agranulocytosis [low white blood cells] have been associated with antipsychotic use. may cause metabolic changes. Increased blood sugar, dyslipidemia (increased cholesterol and/or triglycerides) . Clinical monitoring of . serum [blood] lipid [fatty acid] profiles is recommended during aripiprazole [antipsychotic] treatment. Loop diuretics [furosemide] may induce metabolic alkalosis associated with hypokalemia [low potassium levels] and hypochloremia [low chloride levels] . Serum electrolytes . should be monitored frequently during furosemide therapy. Thiazides [diuretic] may also worsen dilutional hyponatremia [low sodium level], especially in elderly individuals. Patients receiving diuretics should be monitored for clinical signs of acid/base, fluid, or electrolyte imbalances. - Review of Resident #2's medical record occurred on all days of survey. Diagnoses included Dementia and Bipolar Disorder. A significant change Minimum Data Set (MDS), dated [DATE], identified seven days of diuretic use, and seven days of antipsychotic use. Current physician's orders identified: * 10/01/21 Depakote ER (extended release) (valproic acid) 250 mg (milligrams) 1 tablet daily (seizure medication used for mood stabilization) * 12/09/22 Abilify (aripiprazole)10 mg 1 tablet at HS (bedtime) (antipsychotic medication) * 06/03/20 Potassium Cl ER 20 MEQ (milliequivalent) tablet BID (two times a day) (potassium supplement) * 06/03/20 Furosemide 20 mg daily (loop diuretic medication) Resident #2's medical record showed monthly pharmacist reviews with no recommendations made and lacked physician's orders for monitoring of laboratory values since 01/19/22. - Review of Resident #19's medical record occurred on all days of survey. Diagnoses included Dementia, Hypertension and Anxiety. A quarterly MDS, dated [DATE], identified seven days of diuretic use. Current physician's orders identified: * 10/03/22 Hydrochlorothiazide 12.5 mg daily (thiazide diuretic medication) this was a change from Benazapril-HCTZ 20-12.5 mg daily (a combination antihypertensive/thiazide diuretic medication) on 04/02/22. Resident #19's medical record showed monthly pharmacist reviews with no recommendations made and lacked physician orders for laboratory value monitoring since 12/28/21, prior to resident admission on 01/06/22. During an interview on 01/11/23 at 10:15 a.m., a nurse manager (#1) confirmed the pharmacist reviewed the medications monthly and failed to recommend lab monitoring for Resident #2 and #19. The nurse manager also confirmed both resident record lacked physician's orders for laboratory value monitoring.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents who use psychotropic medications receive gradual dose reductions (GDRs), unless clinically contraindicated, for 1 of 5 sampled residents (Resident #2) reviewed for psychotropic medication. Failure to attempt a GDR, or document the reason a GDR is clinically contraindicated, placed residents at risk for receiving unnecessary medications and experiencing adverse consequences. Findings include: Review of the facility policy titled Use of Psychoactive Medication occurred 01/12/23. This policy, dated June 2017, stated, . Patients/residents on antipsychotic medication will have a gradual dose reduction or drug holiday attempted twice in a 12-month period, unless medication documentation shows such an attempt would be harmful to the patient/resident. All patient/residents on psychoactive medications will undergo a gradual dose reduction or drug holiday at least once every four months unless medically contraindicated as documented in the clinical record. Gradual dose reduction should be attempted before concluding that a gradual dose reduction is clinically contraindicated. If the gradual dose reduction is causing adverse effects, it is discontinued. Documentation of the decision and reason should be included in the medical record. Review of Resident #2's medical record occurred on all days of survey. Diagnoses included Dementia, Bipolar Disorder and Depression. A significant change Minimum Data Set (MDS) dated [DATE], identified seven days of antipsychotic and antidepressant medications used. Current medication orders identified: * 10/01/21 Depakote ER (extended release) 250 mg (milligrams) for dementia with behaviors * 12/09/22 Abilify (an antipsychotic medication) 10 mg for depression with behaviors, increased from a dose of 5 mg started on 10/01/21. * 08/14/20 Escitalopram (an antidepressant medication) 30 mg for depression Resident #2's medical record lacked evidence of a GDR or documentation for clinical contraindication for the Depakote ER, Abilify, or Escitalopram at any time the medications were prescribed. During an interview on 01/11/23 at 10:15 a.m., a nurse manager (#1) confirmed the facility failed to perform GDRs for Resident #2's psychoactive medications.

Based on observation, review of facility policy, review of manufacturer's directions, review of professional reference, and staff interview, the facility failed to ensure staff followed standard infection control practices for 3 of 3 residents (Resident #22, #25, and #26) observed during blood glucose tests with a shared blood glucose meter. Failure to clean and disinfect shared glucose meters and glucose testing supply surfaces has the potential for cross-contamination and may result in the transmission of blood-borne pathogens to other residents. During the recertification survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on the evening of 08/09/21. The IJ potential resulted from observation of a staff nurse (#5) failing to disinfect a shared blood glucose meter between residents. These findings placed residents in immediate danger due to the potential for cross contamination with a blood-borne pathogen and the need for education on disinfecting a shared blood glucose meter between residents. * 08/09/21 at 5:44 p.m., 5:50 p.m., and 6:15 p.m. - The survey team contacted the management staff at the State Survey Agency (SSA) to report the findings and to discuss a potential IJ situation. * 08/09/21 at 6:20 p.m. - The survey team notified the Director of Nursing of the IJ situation and requested they develop a plan for abatement of the immediate jeopardy. * 08/09/21 at 7:35 p.m. - The facility provided a written plan of correction (via email) for the IJ. * 08/10/21 at 8:22 a.m. - The survey team reviewed and accepted the facility's revised version of the written plan of correction for the IJ. * 08/10/21 at 8:48 a.m. - The survey team abated and reduced the IJ situation from a scope/severity of J to a scope and severity of D. * 08/10/21 at 9:08 a.m. - The SSA notified the regional office of the immediate jeopardy abatement. Findings include: Review of The Food and Drug Administration's (FDA) guidance for manufacturers regarding appropriate products and procedures for cleaning and disinfection of blood glucose meters, from the FDA's website (http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm 5.htm), stated, Point of care blood testing devices such as blood glucose meters should be used only on one patient and not shared. If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use following the guidelines provided in device labeling. The disinfection . should be effective against HIV, [CONDITION(S)], and [CONDITION(S)] B virus. Outbreak episodes have been largely due to transmission of [CONDITION(S)] B and C viruses. However, of the two, [CONDITION(S)] B virus is the most difficult to kill. Please note that 70% [MEDICATION(S)] solutions are not effective against [CONDITION(S)] bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device. Review of the Manufacturer's User Manual for the Clarity BG1000 Blood Glucose Monitoring System stated, . Cleaning and Disinfecting. The meter should be cleaned and disinfected to prevent the transmission of blood borne pathogens as follows. Cleaning is to remove germs, dirt, and impurities from surfaces or objects. Disinfection is to kill germs on surfaces or objects. Cleaning Instructions: Use CaviWipes® towelette [a cleaner/disinfectant that is effective against many harmful organisms] to wipe the meter exterior of the front, the back and sides thoroughly. Disinfection Instructions: The meter must be cleaned and disinfected between patient uses by wiping it with a CaviWipes® Towelette in between tests. After cleaning the meter with a CaviWipes® Towelette use a second CaviWipes® Towelette to thoroughly wet the pre-cleaned meter surface. Allow it to remain wet for two minutes at 68 degrees F [Fahrenheit] as specified by the manufacturer of the disinfectant wipes and allow to air dry. Observation on 08/09/21 at 4:44 p.m., 4:58 p.m. and 5:25 p.m., showed a staff nurse (#5) carried a basket containing blood glucose testing supplies, including a glucose meter, to separate areas of the facility to check Residents #22, #25 and #26's blood glucose level. The nurse placed the basket on a non-sanitized surface, checked a resident's blood glucose level, and without disinfecting the glucose meter, placed the meter back into the basket, and without disinfecting the basket, carried the basket to the next resident. The nurse (#5) failed to disinfect the glucose meter between residents and before placing it back in the basket and failed to disinfect the exterior of the basket between surfaces and locations. Review of the facility policy titled ASSURE 3 BLOOD GLUCOSE METER' occurred on 08/09/21 stated, . To clean the outside of your Assure 3 meter, use a lint-free cloth dampened with soapy water or [MEDICATION(S)], or diluted bleach (dilute 1 ml sodium hypochlorite in 99 ml of water to achieve 1:100 dilution). The facility policy failed to identify the blood glucose meter currently used by the facility (Clarity BG1000 Blood Glucose Monitoring System) and also failed to identify the CaviWipes® towelettes the facility uses to clean and disinfect the blood glucose meter. During an interview on 08/09/21 at 6:24 p.m., an administrative nurse (#2) stated she expects facility staff to disinfect the blood glucose meter between each resident use and prior to placing it back into the supply basket. The nurse (#2) also stated the facility staff are expected to lay down a paper towel or sanitize the area prior to setting the blood glucose supplies/basket down.

Based on record review, review of facility policies, and staff interview, the facility failed to implement nutritional interventions to promote healing and prevent recurrence of pressure ulcers, and failed to consistently monitor the pressure ulcers for 1 of 2 sampled residents (Resident #4) with a current pressure ulcer and 1 closed record resident (Resident #10). Failure to implement nutritional interventions resulted in delayed healing and recurrence of pressure ulcers. Findings include: Review of the facility's "Pressure Ulcer Treatment" policy occurred on 08/25/11. The policy, revised August 2003, stated, "Assessment is the starting point in preparing to treat or manage an individual with a pressure ulcer. Assess the pressure ulcer(s) initially and weekly thereafter for location, stage, size (length, width, and depth), sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue or [MEDICATION NAME] . . . If no progress, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, make modifications if necessary . . . Nutritional assessment and management is important to ensure that the diet of the individual with a pressure ulcer contains nutrients adequate to support healing . . . All individuals with pressure ulcers will have an on going nutritional assessment through the Nutritional Risk Committee. . . ." Review of the facility's "Prevention Pressure Sores" policy occurred on 08/25/11. The policy, revised October 2005, stated, ". . . It is our policy to identify adults at risk of pressure ulcers and to define early interventions for prevention. Our goals are to: 1) identify at risk individuals who need prevention and the specific factors placing them at risk . . . All individuals at risk will have a daily systematic skin inspection during routine AM cares provided by the CNA (certified nursing assistant), with particular attention to bony prominences. All skin problems . . . are reported to the charge nurse for assessment and investigation . . . The Braden scale will be used for predicting pressure sore risk. Bed or chair bound individuals or those whose ability to reposition is impaired should be considered at risk for pressure ulcers . . . Risk should be periodically reassessed. Care should be modified according to the level or risk. Frequency of reassessment depends on patient status. Periodic reassessment is required for individuals with changes in activity and mobility status . . . An immediate prevention plan should be instituted for those 'at risk' when areas of potential pressure areas are identified. This plan should be reassessed and changes made as needed. . . ." Review of the facility's "Pressure Sore Nutritional Intervention" policy occurred on 08/25/11. The policy, dated April 2009, stated, "POLICY: The resident with skin breakdown will receive appropriate intervention to promote healing. PROCEDURE: 1. Appropriate form will be completed by nursing. This will be completed once a week until skin is healed. The dietitian and the director of dietary services will refer to this in charting progress of nutritional care. 2. LRD/CDM (licensed registered dietician)/(certified dietary manager) will complete a nutritional assessment including estimated protein needs, vitamin/mineral needs, weight history, and intake of meals. Protein will be increased in the resident's diet according to estimated needs and based on resident's food preferences . . . 4. Extra protein supplements will be outlined on the care plan . . . 6. For skin breakdown - 1 oz. (ounce) ProSource 3x/day (3 times per day); [MEDICATION NAME] 8 oz. bid (twice a day); 1 oz. extra meat, egg, or cheese." - Review of Resident #10's closed medical record occurred on 08/25/11. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS), dated [DATE], identified the resident required extensive assistance with bed mobility, transfers, and personal hygiene. The MDS further identified Resident #10 as frequently incontinent of bladder, occasionally incontinent of bowel, not on a toileting program, at risk for pressure ulcers, and had no unhealed pressure ulcers. A quarterly MDS, dated [DATE], identified Resident #10 continued to require extensive assistance with Activities of Daily Living, always incontinent of bowel and bladder, at risk for pressure ulcers, and had no unhealed pressure ulcers. (Refer to F278) A Progress Note, dated 02/14/11 at 1:45 p.m., stated, "Does have a reddened area on left upper inner buttock that looks as though the skin was rubbed off . . . area approx. (approximately) .5 x .5 cm. (centimeters)." The record lacked documentation regarding the reddened area for the following three weeks. On 03/02/11 at 3:41 p.m., Resident #10's Progress Notes stated, ". . . resident was examined and noted to have 1.2 cm x 1.6 cm dark colored blister to coccyx area. . . ." The record showed staff assessed the area weekly until 04/19/11 at 11:40 a.m., when the notes stated, "Observed area of pressure sore to residents (sic) left buttock. Area is covered with a fragile layer of [MEDICATION NAME] tissue. No open areas noted at this time. Outline of wound still visible. . . ." A note dated 05/02/11 at 3:20 p.m. stated, "Observed coccyx region and previous pressure ulcer has now healed. Will continue to monitor as needed." Although Resident #10's Progress Notes dated 02/14/11 identified a reddened area on the left buttock with "the skin rubbed off," an Initial/Annual Nutritional Assessment, dated 02/16/11, identified Resident #10's skin as intact. The Nutritional Assessment lacked interventions specified in facility policy (ProSource, [MEDICATION NAME], extra meat, egg, or cheese) to promote healing of Resident #10's pressure ulcer. A Quarterly Nutritional Assessment, dated 05/18/11, failed to identify the recently healed pressure ulcer and lacked nutritional interventions to address the resident's risk for recurrence of pressure ulcers. When requested, on 08/25/11 at 10:50 a.m., administrative nurses (#2 and #4) failed to provide information identifying care plan interventions in place during the time Resident #10 had the open area on her buttock (February - May 2011). The record identified the facility transferred Resident #10 to the hospital on [DATE]. The resident returned to the facility on [DATE] at 3:59 p.m. An admission note stated. ". . . Resident has a 3 cm by 3.3 cm red area with a blister in left upper buttocks area . . ." A note dated 06/25/11 at 3:24 p.m., stated ". . . No open areas noted at this time. . . ." Resident #10's most recent care plan, dated 05/18/11, stated, "Potential skin integrity impairment due to: B&B (bowel and bladder) incontinence & impaired mobility." The care plan failed to identify the history of skin breakdown and/or the pressure ulcer which developed on 06/17/11, and lacked nutritional interventions implemented to promote healing and prevent recurrence of pressures ulcers for Resident #10. Failure to monitor Resident #10's pressure ulcer weekly and to implement nutritional interventions to aid healing, as per facility policy, contributed to the original pressure ulcer increasing in size from 0.5 x 0.5 cm on 02/14/11 to 1.2 x 1.6 cm on 03/02/11; slowed healing of the ulcer; and may have contributed to the development of a second pressure ulcer in the same area on 06/17/11. - Review of Resident #4's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], identified the resident required extensive assistance of two staff members with bed mobility and transfers, and limited assistance of one staff member with personal hygiene. The MDS further identified Resident #4 as frequently incontinent of bladder, continent of bowel, and not on a toileting program. The MDS showed the resident was at risk for pressure ulcers, with one current Stage II pressure ulcer. An annual MDS, dated [DATE], identified the resident required extensive assistance with bed mobility, transfers, and personal hygiene, continent of bladder and bowel, not at risk of pressure ulcers, and had no current pressure ulcers. (Refer to F278) On the morning of 08/23/11 two certified nursing assistants (CNAs) (#7 and #16) assisted Resident #4 with toileting. Observation during cares showed an open ulcer to the left side of the resident's coccyx. Review of Progress Notes for Resident #4 revealed the following: * An initial wound assessment completed by the wound care specialist, dated 06/20/11, stated, "LOCATION OF WOUND: coccyx. STAGE OF WOUND: Stage 2 . . . WIDTH . . . 1.0 cm. LENGTH . . . 1.0 cm. DEPTH . . . 0.1 cm . . . TREATMENT: [MEDICATION NAME] applied liberally." * The second wound assessment completed by the wound care specialist, dated 06/28/11, stated, "LOCATION OF WOUND: coccyx. STAGE OF WOUND: Stage 2 . . . coccyx wound is 0.4 cm in width, 0.7 cm in length and 0.1 cm depth, superior to this a sacral wound noted at 0.2 cm width, 1.2 cm length and 0.1 cm depth . . . TREATMENT: [MEDICATION NAME] applied liberally. Not currently on any supplements, able to move and position herself at this time in bed or in chair. Encouraged resident to lie down on bed for naps if possible and to adjust position of recliner." * An entry made by a nurse, dated 08/09/11, stated, "Resident continues to have open area on buttocks Calmoceptine (sic) applied after peri cares. PT called and notified that open area on buttocks has not healed yet and message left." * A wound assessment completed by the wound care specialist, dated 08/10/11, stated, "TYPE OF WOUND: possible pressure sore. LOCATIONS OF WOUND: coccyx, 4 small superficial wounds noted, right sided coccyx 1.5 cm width and length, mid coccyx is 1.0 cm width and length, left sided coccyx is 0.8 cm width and length, and lateral left coccyx is 0.5 cm width and length. All open areas are superficial and less than 0.1 cm in depth . . . TREATMENT: [MEDICATION NAME] applied liberally. She is transferring over to hospital for pneumonia and we will continue to monitor the wound there." * An entry by a nurse, dated 08/12/11, stated, "(Resident #4) returned from the hospital . . . top of coccyx has approx (approximately) a 3.5 cm by 3 cm open area ([MEDICATION NAME] applied) . . . Resident has air pressure relieving mattress on bed, and a pressure relieving cushion in her WC and recliner . . ." * A wound assessment completed on 08/15/11 identified a "possible pressure sore" on the coccyx measured at "1.5 cm width and 2.1 cm length and a superficial depth." The treatment remained the same with [MEDICATION NAME] applied liberally. * The most recent wound assessment, completed on 08/22/11, identified a "possible pressure sore" to the coccyx measured at "0.1 cm width by 1.0 cm length." The assessment identified the treatment of [REDACTED]. Review of Resident #4's Long Term Care Nursing Assessment Summaries identified "no skin problems noted" during the assessment completed on 07/26/11; and "pressure ulcer present to coccyx, [MEDICATION NAME] being applied" during the assessment completed on 08/16/11. Other than the Long Term Care Nursing Assessment Summary completed on 07/26/11, Resident #4's medical record lacked evidence the facility monitored the pressure ulcer and documented their assessment on a weekly basis from 06/28/11 to 08/09/11, as per facility policy. During an interview on 08/23/11 at 3:35 p.m., a wound care specialist (#14) identified nursing staff notifies her when a resident has a new open area and then she completes an initial assessment, with weekly assessments thereafter until healed. The staff member (#14) confirmed the pressure ulcer developed on 06/20/11 and stated the pressure ulcer to Resident #4's coccyx was healed when she completed her weekly assessment during the week of 07/05/11 (staff member #14 unsure of exact date she saw resident). The staff member (#14) stated she "failed to document." The staff member (#14) stated the nursing staff notified her regarding the reopening of the pressure ulcer on 08/09/11 and she then completed her assessment on 08/10/11. The most recent nutritional assessment completed since the resident's pressure ulcer originated on 06/20/11 included a Quarterly Nutritional Assessment, dated 08/03/11, which identified the resident with intact skin. This nutritional assessment failed to identify the resident's recent pressure ulcer and lacked nutritional interventions to address the resident's risk for recurring pressure ulcers. An interview with a dietary staff member (#3) occurred on 08/24/11 at 8:35 a.m. The staff member (#3) stated nursing staff failed to notify the dietary department of Resident #4's pressure ulcer, identified on 06/20/11. The staff member (#3) stated she was first informed Resident #4 had a pressure ulcer during the resident's care conference on 08/10/11. The staff member (#3) identified she did not call the dietician and waited to notify her during her next visit scheduled on 08/24/11. The staff member (#3) confirmed the facility failed to assess Resident #4's increased nutritional needs and failed to implement nutritional interventions to promote healing of the pressure ulcer. The facility last completed a Braden Scale (used for predicting pressure sore risk) for Resident #4 on 06/18/09, showing a score of 19, indicating high risk. During an interview on the afternoon of 08/24/11, an administrative staff member (#2) stated the facility's policy included completing a Braden Scale every week during the first month for new admissions and again with a change in a resident's condition. Review of Resident #4's prior care plan, dated 06/21/11, showed the problem of "Impaired skin impairment at risk r/t (related to) incontinence, decreased mobility, decreased intake, red coccyx." Approaches for this problem included: "* Resident is toileted upon request with good peri cares after incontinence * Apply Colmoseptine (sic) to open areas after toileting hygiene * Encourage resident to continue to reposition herself in bed * Encourage fluids and balanced diet * Pressure relieving cushion in WC (wheelchair) * Notify PT (physical therapist) skin specialist of open areas * Pressure relieving (sic) mattress on bed * Encourage resident to change positions frequently, move to recliner etc." The resident's current care plan, dated 08/16/11, showed the problem of "Impaired skin integrity-open area to coccyx," with the goal of "Resident will have adequate care for existing skin breakdown and will remain free from further skin breakdown." Approaches for this problem included: "*Assess skin * Notify MD (medical doctor) of skin breakdown * Apply ointment * Reposition/provide comfort * Wound care consult * Pressure relieving bed device * Notify charge nurse of any skin breakdown, changes, etc. * Pillow to (left) side under covers to prevent sliding * Apply [MEDICATION NAME] to open area after good peri cares." The care plans lacked nutritional interventions implemented to promote healing of Resident #4's current pressure ulcer and to prevent recurring pressure ulcers from developing. During an interview on the afternoon of 08/24/11, two administrative nurses (#2 and #4) confirmed the lack of dietary interventions to promote the healing of Resident #4's pressure ulcer and identified the medical record lacked evidence the dietary department received notification of Resident #4's pressure ulcers in June 2011 and August 2011. The staff members (#2 and #4) confirmed the resident's medical record lacked evidence of assessment and monitoring of the pressure ulcer from 06/28/11 - 08/09/11. Failure to consistently and accurately assess and monitor Resident #4's pressure ulcer and to implement nutritional interventions to aid in healing, as per facility policy, contributed to recurrence and delayed healing of the pressure ulcer.