Every finding on record at Wentz Living Center

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 4 sampled residents (Resident #2 and #5) observed during toileting cares and one supplemental resident (Resident #16) observed during medication preparation. Failure to practice infection control standards related to hand hygiene and glove use has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Specific Personal Protective Equipment occurred on 03/24/26. This undated policy, stated, . Hand hygiene . All employees are to wash hands . after removing gloves. Review of the facility policy titled Administratin [sic] of Oral Medication occurred on 03/24/26. This policy, dated March 2022, stated, . Perform hand hygiene prior to medication pass. Do not touch any medications when opening a pill bottle or unit dose package. May apply gloves as needed after proper hand hygiene to obtain a medication that is not contaminated. -Observation on 03/23/26 at 3:02 p.m. showed two certified nurse aides (CNAs) (#2 and #3) assisted Resident #2 with toileting. One CNA (#2) applied gloves, provided incontinence care, and with the same gloves, pulled up the resident's pants, and utilized the mechanical lift to transfer the resident from the toilet to the recliner. The CNA (#2) assisted in removing the sling from behind the resident, placed a blanket on the resident, handed the resident a glass of water, then removed her gloves and performed hand hygiene. The CNA (#2) failed to remove gloves and perform hand hygiene after completing toileting cares and before performing other tasks. -Observation on 03/24/26 at 11:14 a.m. showed two CNAs (#6 and #7) applied gowns and gloves, transferred Resident #5 to the toilet with a mechanical lift and removed the soiled brief. One CNA (#6) emptied the urine collection bag, and without performing hand hygiene and changing gloves, raised the resident from the toilet. This CNA (#6) applied a barrier cream to the resident's buttocks after the other CNA (#7) performed perineal care. Both CNA's (#6 and #7) removed the soiled gloves and without performing hand hygiene, applied new gloves, placed a new brief, and adjusted Resident #5's pants. The CNA (#6) removed the soiled gloves, and without performing hand hygiene or applying new gloves, transferred Resident #5 to the wheelchair, removed the lift sling, placed the urine collection bag beneath the resident's wheelchair, and gathered the garbage. The CNAs (#6 and #7) failed to perform hand hygiene after removing soiled gloves and before applying clean gloves. -Observation of medication administration on 03/24/26 at 8:18 a.m. showed a medication aide (MA) (#4) prepared medication for Resident #16. The MA (#4) opened a medication bottle and used her bare finger to obtain a pill. The MA (#4) failed to perform hand hygiene prior to medication preparation and failed to apply gloves before removing a single pill from the medication bottle. During an interview on 03/24/2026 at 4:05 p.m., an administrative nurse (#1) confirmed she expected staff to remove soiled gloves and complete hand hygiene after peri care and before performing other tasks. She also confirmed she expected staff to perform hand hygiene or apply gloves before touching medications or use a spoon if unable to shake out the prescribed amount. During an interview on 03/24/26 at 4:10 p.m., an administrative nurse (#5) confirmed she expected staff to perform hand hygiene after removing gloves and before applying clean gloves.

Based on observation, record review, review of the facility reported incident (FRI) report, facility policy review, and staff interviews, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #1) who sustained a fall with fractures. Failure to use the appropriate sling sized during a full body mechanical lift transfer resulted in an avoidable fall and fractures for Resident #1 and places all residents at risk for falls and/or injuries. During the investigation survey, the team consulted the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 05/29/24 at 3:00 p.m. The IJ resulted from a failure by the facility to assess residents for the proper sized sling for use during a full body mechanical lift transfer. This failure resulted in a resident sustaining a fall and fractures. *05/29/24 at 4:00 p.m. The survey team notified the administrator and director of nursing of the IJ situation, provided them with the IJ template, and requested a plan for removal of the immediate jeopardy. * 05/29/24 at 6:30 p.m., The facility provided (via email) an IJ removal plan. The removal plan contained the following: * Therapy or nursing will assess sling size per policy developed * Therapy or nursing staff will communicate to the charge nurse of appropriate sling size, a comment order will be entered into provider orders, it will be care planned in the activities of daily living section and sent to the Kardex for easy certified nurse aides (CNAs) viewing. * Education will be provided to all nursing/CNA staff working the evening and night shift of 5/29/24 and day shift 5/30/24. Each CNA or nurse upon their first shift since this survey will be educated by reviewing the policy, care plan, Kardex and signing the education form. *05/30/24 at 10:00 a.m., the survey team accepted the IJ removal plan. The survey team verified the implementation of the plan and removed the IJ as of 05/29/24. The deficient practice remained at a scope and severity of a G after removal of the IJ. Findings included: Review of the facility policy titled Mechanical Dependent Lift occurred on 05/29/24. This policy, dated December 2019, failed to include assessments for the proper sling size for resident's dependent on mechanical lifts for transfers. Review of the facility's initial incident report, submitted to the state agency on 05/28/24, identified Resident #1 slipped out of the sling and onto the floor. Review of Resident #1 medical record occurred on 05/29/24. The care plan identified, .The resident has an ADL [Activities of Daily Living] selfcare performance deficit . requires dependent Mechanical lift . A nursing progress note, dated 05/28/24 at 1:54 p.m., identified the following: . resident is laying on floor . They [CNAs] [certified nursing aides] stated she fell out of sling. During an interview on 05/29/24 at 10:40 a.m., a staff member (#2) stated, We grabbed the Hoyer lift [full body mechanical lift] and used the sling that was with the lift. During the transfer the resident shifted in the sling and fell to the floor. Observation of Resident #1's room during this interview showed a small sling in the resident's bathroom. During a telephone interview on 05/29/24 at 11:13 a.m., a staff member (#3) stated, we placed the resident in the sling, which was a medium. During an interview with a staff member (#4) on 05/29/24 at 1:13 p.m., the staff member confirmed the CNAs used a medium sized sling. During an interview on 05/30/24 at 3:33 p.m., an administrative nurse (#1) agreed residents should have been assessed for sling sizes. The facility failed to assess Resident (#1) for the appropriate device (transfer sling) for a full body mechanical lift and provide staff with the information and education regarding transfers. This resulted in a fall with major injury for Resident #1.

Based on observation, review of facility policy, and staff interview, the facility failed to prepare, store, and serve food in a sanitary manner in 1 of 1 kitchen. Failure to monitor the quaternary (quat) sanitizer concentration may result in unsafe food storage/preparation and foodborne illness. Findings include: Review of the facility policy titled Kitchen/Table Pail occurred on 01/04/24. This policy, dated 01/03/24, stated, The kitchen pail is to be used for wiping down hard surfaces in the designated kitchen area. This pail will use our Sani-T-10 [quat] solution from dispenser on wall . is changed out to be tested with QUAC [quat] test strips three times a day per schedule and recorded and whenever changed out. The PPMs for the pail should read 150-400. If sanitizer levels are not within correct range, notify dietary manager. Observation on 01/03/24 at 8:50 a.m. showed a dietary staff member (#5) filled a pail with Sani-T-10 plus solution and water. The staff member failed to test the mixture with a QUAC test strip and stated he did not routinely do so. A second dietary staff member (#6) tested the mixture with a QUAC test strip and the strip failed to register a concentration. The dietary staff member (#6) discarded the mixture and prepared a new kitchen pail. Test of the second mixture with the QUAC strip showed a concentration of 200 ppm. During an interview with staff members (#5 and #6) after the above observation, they confirmed kitchen staff do not routinely test or log the sanitizer concentration of the mixture and failed to provide a log of sanitizer testing. During an interview on 01/03/24 at 9:15 a.m., the dietary manager (#7) confirmed she expected staff to test the kitchen pails per policy and log the results.

Based on observation, facility policy review, and staff interview, the facility failed to ensure staff followed standard infection control practices for 2 of 3 sampled residents (Resident #13 and #15) observed during personal cares. Failure to follow infection control practices related to hand hygiene and glove use has the potential to spread infection within the facility. Findings include: Review of the facility policy titled:Hand Hygiene: Use of alcohol-based hand rub occurred on 01/04/24. This policy, revised October 2021, stated, . hand hygiene . before and after resident contact . assisting a resident with personal cares . after contact with resident's skin . bodily fluids or excretions . Review of the facility policy titled; Perineal Care occurred on 01/04/24. This policy, revised October 2021, stated, PURPOSE: To prevent infections . wash urethral area first and rectal last . remove your gloves . perform hand hygiene . may apply a barrier cream . apply gloves . apple barrier cream to gloves . remove gloves . perform hand hygiene . - Observation on 01/02/24 at 11:48 a.m. showed a certified nursing assistant (CNA) (#1) entered Resident #13's room and performed incontinent bowel movement cares, removed the contaminated gloves, and donned new gloves. The CNA (#1) failed to perform hand hygiene after removing the contaminated gloves and prior to donning new gloves and applying a protective barrier cream to the resident's bottom. The CNA (#1) removed the gloves, assisted the resident with the blankets and call light and left the room without performing hand hygiene. - Observation on 01/03/24 at 10:51 a.m. showed a CNA (#1) donned gloves and provided perineal care for Resident #15. The CNA cleansed the rectal area of stool using a wet wipe and without removing the soiled gloves, applied a protective barrier ointment to the resident's bottom. During an interview on 01/04/24 at 11:50 a.m., a supervisory nurse (#3) confirmed she expected staff to perform hand hygiene upon entering and exiting a resident's room and in between glove changes. 40489

Based on observation, review of facility policy, record review and staff interview, the facility failed to use an assistive device necessary to prevent accidents for 1 of 5 sampled resident (Resident #185) observed during gait belt transfers. Failure to use a gait belt during a transfer resulted in pain to Resident #185 and may result in falls and/or injuries. Findings include: Review of the facility policy titled Gait Belts occurred on 01/04/23. This policy, dated October 2021, stated, . PURPOSE: To prevent injury to the resident . Gaitbelts [sic] are used . when nursing deems necessary. Review of Resident #185's medical record occurred on all days of survey. Diagnoses included repeated falls, pain and mild cognitive impairment. A physical therapy note, dated 01/02/24 at 4:09 p.m., stated, . Transfer: Supine-sit transfers . Sit-stand with CGA {contact guard assist] today with use of gait belt. During an observation on 01/02/24 at 5:09 p.m. a certified nurse aide (CNA) (#2) assisted Resident #185 from a lying position in the bed to a sitting position by pulling on the resident's left arm. The resident grimaced in pain and placed his right hand on his left shoulder The CNA stated, Is that left shoulder still bothering you? Without using a gait belt the CNA pulled on the back of the resident's pants to assist him to a standing position and provided hands on assistance on the resident's waist/bottom as the ambulated using the front wheeled walker. Observation showed the resident was unsteady and shuffled his feet and the CNA stated, Whoa you're a little wobbly today. The CNA held under the resident's left arm while he fell backwards on to the toilet. The resident finished using the toilet and the CNA pulled under the resident's arm to lift him up from the toilet. As the resident was ambulating out of the bathroom, he stated he needed to use the bathroom again. The CNA pulled under the resident's left arm as the resident sat down on the toilet. The resident finished using the toilet and the CNA pulled under the resident's left arm to a standing position. The CNA placed her hands on the resident's waist/buttocks for assistance as he ambulated to the recliner. The CNA held onto the back of the resident's pants as she lowered him into the recliner. During an interview on 01/04/23 at 11:51 a.m., an administrative nurse (#3) confirmed facility staff should not be pulling on or under Resident #185's arms or on clothing and should use a gait belt.

Based on observation and staff interview, the facility failed to ensure safe and secure storage of medications in 2 of 2 medication carts (nurses medication cart and medication assistant's cart). Failure to store all medications securely may result in unauthorized access to medications. Findings include: - Observation on 01/25/23 at 11:27 a.m. showed a registered nurse (RN) (#4) removed four insulin pens from a drawer in the medication cart and placed them on top of the cart. The nurse pushed the medication cart down the hallway to the consultation room and stated, I'll be right back. The nurse returned to the medication cart at 11:32 a.m. Several residents were lined up in the hallway directly across from the medication cart waiting for access to the dining room for lunch. The nurse (#4) failed to securely lock the insulin pens in the medication cart in her absence. - Observation on 01/26/23 at 10:36 a.m. showed a unattended medication cart located on the C wing with an inhaler and a bottle of eye drops on top of the cart. During an interview on 01/26/23 at 10:31 a.m., an administrative nurse (#1) stated she expected staff to keep all medications locked securely in the medication cart when unattended.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision necessary to prevent accidents for 1 of 8 sampled residents (Resident #16) who required staff assistance for transfers. Failure to stay with the resident in the bathroom as care planned places the resident at risk for falls and/or injuries. Findings include: Review of the facility policy titled Care Plans - Baseline and Comprehensive Person-Centerted [sic] occurred on 01/26/23. This policy, revised October 2022, stated, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . to meet a resident's medical, nursing, and mental and psychosocial needs . Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of Resident #16's medical record occurred on all days of survey and included diagnoses of unspecified dementia, fracture of unspecified part of neck of femur and history of falling. The current care plan stated, . TOILET USE: The resident requires one assist with toileting. FALLS . Do not leave me unattended while toileting as I am a high fall risk. Review of Resident #16's medical record occurred on all days of survey. A progress note dated 07/13/2022 at 12:56 p.m., stated, . Resident yelling for help, CNA [certified nursing assistant] found him on the floor in his bathroom in his room. Laying on his right side . He was on the toilet and fell when getting off . During an observation on 01/24/23 at 10:31 a.m., a CNA (#3) assisted Resident #16 from the wheelchair to the toilet using a gait belt. The CNA showed the resident where the call light was located. The CNA stated that the resident sits on the toilet for about 20 minutes. The CNA closed the bathroom door and walked out of the resident's room into the hallway. At 10:37 a.m., the CNA checked on the resident and at 10:44 a.m., the CNA assisted the resident off the toilet. During an interview on 01/25/23 at 2:51 p.m., an administrative nurse (#1) stated, I would expect staff to stay within eyesight of the resident.

Based on record review, review of facility policy, review of resident rights guide, and resident and staff interviews, the facility failed to provide care in a manner and environment that maintained or enhanced the resident's dignity for 1 of 12 sampled residents (Resident #6). Failure to allow Resident #6 the choice to use her own beverage does not respect her personal preference and violates her rights to a dignified existence. Findings include: Review of the policy titled, Resident Rights occurred on 01/26/23. This policy, dated October 2022, stated, . It is the policy of this facility to protect and promote the right of each resident . including the right to a dignified existence, self-determination . The North Dakota Long Term Care Ombudsman Program Resident's Rights Guide, dated 08/01/19, stated, . The facility staff must treat you courteously, fairly and with dignity. Review of Resident #6's medical record occurred on all days of survey. The current care plan stated, . Allow resident to make choices . Respect her choices and resident rights. Progress notes included the following: * 01/15/23 at 3:10 p.m., . Behavior Note . [Resident #6] was in the dining room now at snack time and nurse went up behind her and informed her that I would have to ask her to leave the dining room as she has her pop cup on her chair which she was [sic] been informed is a [sic] infection control issue . * 01/15/23 at 11:44 p.m., . Behavior Note . [Resident #6] came from her room and she did not leave her pop cup in her room she put it on a table in the activity room. [Resident #6] has been instructed numerous times by multiple staff that this is an infection control issue, pop cup taken to her room. * 12/19/22 at 1:05 p.m., . Behavior Note Res. [Resident] brought her pop into the dining room at dinner. Res. has been talked to numerous times about this. Reminded res. that she can not have her pop in the dining room and that she needed to return it to her room. Res stated 'I'll just throw it away'. Resident threw pop away and returned to meal. * 12/15/22 at 1:35 p.m., . Behavior Note . Res did not have her oxygen tank filled prior to staff getting her up for Bingo, but she refused to stay in her room and wait on her concentrator before getting to activity room even though Bingo doesn't start until 1345 [1:45 p.m.]. Res then brings a can of diet coke to the activity room and cracks it open, sets it on the table, and when activity staff tells her that she can't have it in the activity room she gets verbally rude and upset with activity aide, 'well why can the activity staff have theirs in here then?' . * 12/3/22 at 3:00 p.m., . Behavior Note . [Resident #6] waiting in dining room for snack & asks multiple staff for 3 cups of ice for her water bottle. Nurse comes to dining room and sees [Resident #6] has her water bottle with her, which she knows she shouldn't have & has been reminded of multiple times. [Resident #6] getsupset [sic] when told to leave dining room and go put water bottle back in her room. [Resident #6] then finds out that the ice machine is currently out of ice at this current moment, and she will have to wait a few moments for it to produce more ice. She has a panic attack, freaking out on all staff members accusing them of doing everything wrong, breaking the machine, filling ice waters for residents incorrectly, and continuously accusing CNAs [certified nurses' assistant] of being in the wrong. Meanwhile, res still won't leave the DR [dining room] with her water bottle so had to be reminded again. Observation on 01/25/23 at 1:49 p.m., showed a twenty ounce bottle of pop on a table with four unidentified residents and one unidentified staff member during bingo in the activity room. During an interview on 01/24/23 at 4:40 p.m., when asked she feels about not being allowed to have her persona beverage container in the dining room/activity room, Resident #6 stated as far as she knows she is allowed to have it in the activity room but not the dining room. The resident stated she feels like she's a child when staff tell her she has to leave the dining room because she has her personal pop container in her chair and that it upsets her. During an interview on 01/25/23 at 3:15 p.m., when asked why Resident #6 was not allowed to bring her personal beverage container and/or bottle of pop in the dining room, a dietary staff member (#6) stated she had been told this by a previous dietary staff member. During an interview on 01/25/23 at 3:17 p.m., an administrative staff member (#2) stated Resident #6 is not allowed to bring her personal beverage container and/or bottle of pop to the dining room because it is brought from her room, it is an infection control issue because she touches her cup and it is dirty. The administrative nurse (#2) also stated the resident can have her personal beverage container and/or twenty ounce bottle of pop in the activity room. During an interview on 01/25/23 at 3:31 p.m., two administrative staff members (#1 and #5) stated Resident #6 is not allowed to have her personal beverage container or bottle of pop in the dining room or activity room whether it is on the table or in the holder attached to her wheelchair. An administrative staff member (#5) stated, We started this during Covid due to infection control, no residents are allowed to bring personal items into the dining room. The facility failed to honor the resident's right allowing her to have her personal beverage container and/or bottle of pop in the activity room/dining room and failed to treat the resident with dignity and respect her individual preferences.

Based on record review, review of the facility policy and staff interview, the facility failed to report a violation involving potential neglect immediately to the State Survey Agency and the results of the investigation within five working days for 1 of 1 sampled resident (Resident #29) who experienced an injury of unknown origin. Failure to identify Resident #29's injury may have resulted from neglect, report the incident, and report the results of the facility's investigation to the State Survey Agency per the facility's policy, placed Resident #29 and other residents at risk for possible neglect and/or injury. Findings include: Review of the facility policy titled, ABUSE POLICY occurred on 09/15/21. This policy, revised September 2017, stated, . NEGLECT: Means . it includes failure to carry out resident services as directed or ordered by the physician or other authorized personnel, failure to give proper attention to resident or failure to carry out resident services through careless oversight . any facility staff witnessing or possessing knowledge of any act or suspected act involving neglect . including injuries of unknown source . must immediately notify the charge nurse, who will then contact the Director of Nursing . all allegations must be reported to the Department of Health . no later than two hours . all allegations must be thoroughly investigated . final written investigation results will be submitted to the Department of Health within five working days . Review of facility policy titled Accident and Near Miss Investigation occurred on 09/15/21. This policy, revised August 2010, stated, . An accident/incident/near miss is defined as any unusual happening that may or does cause physical harm to a resident . All maintenance problems noted in the facility are potential safety hazards and therefore are treated as near-miss incidents . all of the above should be reported immediately to supervision . recommendations for prevention/correction are required . every accident/near miss will be investigated . reported to the immediate supervisor within 10 minutes . supervisor required to fill out an ACCIDENT/INCIDENT REPORT. During an interview on 09/15/21 at 11:02 a.m., an administrative nurse (#1) confirmed the facility's failure to identify Resident #29's injury may have resulted from neglect and therefore failed to report the incident to the State Survey Agency, complete a thorough investigation, and report the results of their investigation to the State Survey Agency. Refer to F580

Based on record review, review of facility policy, and staff interview, the facility failed to notify the physician and/or resident representative for 1of 1 sampled resident (Resident #29) who experienced an injury. Failure to promptly notify the physician and/or resident representative of an injury limited their ability to make informed decisions regarding medical care. Findings include: Review of the facility policy Accident and Incident Reports: Residents occurred on 09/15/21. This policy, revised October 2010, stated, . Any staff member who witnesses an incident will report the incident to the charge nurse for them to assess the situation, provide first aide if needed, and complete an incident report . obtain a statement of what occurred from anyone who witnessed the incident and/or the resident if capable . if the fall involved a possible head injury, complete neuro checks per policy . notify the attending physician . notify the family or responsible party . document in the nurses notes . notify your supervisor . notify oncoming nurse . -Review of Resident #29's medical record occurred on all days of survey. The nursing progress notes identified the following: * On 08/20/21 at 04:18 p.m., . an administrative staff (#2) noted . Resident did share she has had pain occasionally within the past 5 days on her head . rated the pain as mild . informed the charge nurse (#2) of residents pain . * On 08/20/21 at 6:24 p.m., . Resident voices headache . Tylenol given for pain . * 08/20/21 at 08:51 p.m., . Resident rated pain a 3 on pain scale . A facility incident report completed 08/20/21 at 12:00 p.m. described the following: . a staff member (#3), presents to nurse following her assessment with Resident (#29) where resident reported her head hurts from the fall she had in the bathing room. There is no charting about this incident that staff (#3) saw so she brought it to Nurse (#7) attention. I questioned resident and she reports it happened 'a few days ago in the bathing room' and she hit her head and has a bump. Nurse (#7) assessed resident's head and no bump noted however she does report tenderness to back right side of head. The bath aide (#5) that gave Resident #29 a bath was not here today to verify information, but another CNA (#8) here today was aware of the incident because the bath aide told her Tuesday (sic) what had happened. Appears the bathing chair wasn't completely connected when bringing chair out of the tub to the bath stand with wheels so the black plastic seat ended up falling when it got to the connecting point and resident hit her head . no documentation noted in the chart of the incident. A timeline report provided by the facility administrative nurse (#1) of the incident identified the following: * On 08/16/21, . Resident #29 was in the bathing room finishing her bath when staff (#5) brought the chair out of the tub and it did not latch on the rail, causing the resident to be unsteady/jerk . the staff (#5) stating she was unaware of resident hitting her head, or did not see it happen .the staff (#5) did not report the incident to the nurse (#6) on duty . reported it to maintenance (#4) . another CNA [certified nursing assistant] (#8) told the staff nurse (#6) . the nurse did not write up any notes/incident at this time. * On 08/20/21 at 5:25 p.m., . a staff member, (#3) indicated in the report following the assessment with Resident #29 . resident reported her head hurt from the fall in the bathing room . there is no charting about this incident . it was brought to staff member (#9) attention . staff member (#3) questioned the resident and resident reports it happened a few days ago in the bathing room . staff nurse (#7) assessed resident's head and no bump noted however she does report tenderness to the back right side of head . During an interview on 09/15/21 at 10:30 a.m., an administrative staff (#1) acknowledged staff failed to notify Resident #29's physician and/or resident representative.

Based on record review, review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, and staff interview, the facility failed to assess each resident's pneumococcal status and provide education to residents and/or their legal representatives regarding the benefits and potential side effects of receiving the vaccination for 4 of 4 sampled residents (Resident #3, #5, #12, and #17) and 1 supplemental resident (Resident #6) reviewed for immunization status. Failure to offer pneumococcal vaccine to all residents, provide education to residents and their legal representatives, and document the administration or refusal has the potential for non-immunized residents to contact pneumonia and also spread the infection to other residents, visitors, and staff. Findings include: Review of the CDC: Vaccines and Preventable Diseases webpage(https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html), last reviewed (MONTH) 6, (YEAR), stated, . CDC recommends pneumococcal vaccination (PCV13 or Prevnar13, and PPSV23 or [MEDICATION NAME]) for all adults [AGE] years or older: Give a dose of PCV13 to adults [AGE] years or older who have not previously received a dose. Then administer a dose of PPSV23 at least 1 year later. If the patient already received one or more doses of PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23. - Review of Resident #3's medical record occurred on 11/24/19. The resident was admitted in (MONTH) (YEAR). The record showed Resident #3 received the PPSV23 vaccine on 12/31/15 (prior to admission), the record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. - Review of Resident #5's medical record occurred on 11/24/19. The resident was admitted in (MONTH) (YEAR). The record showed Resident #5 received the PPSV23 vaccine on 03/10/15 (prior to admission), the record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. - Review of Resident #6's medical record occurred on 11/24/19. The resident was admitted in (MONTH) (YEAR). The record showed Resident #6 received the PPSV23 vaccine on 09/04/18 the record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. - Review of Resident #12's medical record occurred on 11/24/19. The resident was admitted in (MONTH) (YEAR). The record showed Resident #12 received the PPSV23 vaccine on 03/01/18 (prior to admission), the record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. - Review of Resident #17's medical record occurred on 11/24/19. The resident was admitted in (MONTH) 2019. The record showed Resident #17 received the PPSV23 vaccine on 10/03/16 (prior to admission), the record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. The facility failed to follow the CDC recommendations for pneumococcal vaccine administration. During an interview on 11/27/19 at 10:40 a.m., two administrative nurse (#3 and #5) verified the facility failed to assess residents for pneumococcal immunization and/or follow the CDC recommendations for the pneumococcal vaccinations.

Based on observation, policy review, record review, and staff interview, the facility failed to provide adequate assistance for 1 of 3 sampled residents (Residents #17) observed during a sit-to-stand mechanical lift transfer. Failure to ensure proper use of the stand lift, including use of the leg strap, placed Resident #17 at risk of experiencing pain/discomfort and/or possible accidents with/without injury. Findings include: Review of the facility policy titled Policy for Mechanical Standing Lift Use occurred on 11/27/19. This policy, dated (MONTH) 2019, stated, . 2. Proper use of sit to stand mechanical lift: a. Apply the harness to the resident. b. Pull the lift up to the resident, place their feet on the foot plate. c. Attach the harness straps to the lift. d. Strap resident legs on the foot plate with the foot strap (strap legs to the shin support pad with the leg strap). Review of Resident #17's medical record occurred on all days of survey. The current care plan stated, . ADLS (activities of daily living): The resident has an ADL self-care performance deficit r/t (related to) Confusion, . (history of) TIAs ([MEDICAL CONDITION]), Impaired balance . TRANSFER/AMBULATION: The resident requires Mechanical Lift (brand name) with (1) staff assistance for ALL transfers. Left hand weakness d/t (due to)[MEDICAL CONDITION] (YEAR). W/C (wheelchair) PRIMARY as res. (resident's) legs become weak. Observation on 11/25/19 at 5:30 p.m. showed a certified nurse aide (CNA) (#2) wheeled Resident #17 into the bathroom. The CNA applied a sit-to-stand mechanical lift harness and chest safety strap to the resident and lifted the resident out of the wheelchair. The resident failed to support herself on her legs which resulted in her body bent at an angle at the waist with her arms horizontal to the floor, elbows bent and pointed upward, and her lower legs pulled away from the shin support pad. The CNA (#2) failed to apply the leg strap to secure Resident #17's legs to the shin support pad. The CNA lowered the resident on the toilet. When the resident finished, the CNA cued her to hold the lift handles, raised the resident with the mechanical lift from the toilet to a half-way sitting/standing position, therefore bearing no weight, with her arms straight out from her sides and her elbows bent and pointed upward. The resident was unable to stand nice and tall as the CNA instructed. The CNA (#2) completed perineal cares and transferred Resident #17 into her wheelchair. Observation showed the leg strap unused. During an interview on 11/27/19 at 7:50 a.m., a nurse administrator (#3) stated staff are to use the leg strap with a stand-lift transfer per protocol.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 1 sampled resident (Resident #80) with a pressure ulcer. Failure to routinely assess, monitor, and measure pressure ulcers and ensure appropriate treatment may result in delayed healing of a pressure ulcer. Findings include: Review of the facility policy titled Pressure Ulcer Stages and Intervention occurred on 11/27/19. This undated policy stated, . All stage 2 and greater pressure ulcers will result in documenting in (name of electronic medical record) program for that resident on a weekly basis using the NCC (Napoleon Care Center)-weekly observation tool. The NCC Wound - Weekly Observation Tool included the following instructions: To be completed by a Licensed Nurse on each wound weekly. Use the following definitions for staging of pressure ulcers: . Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. VISIBLE TISSUE . [MEDICATION NAME] tissue present (pink) . Granulation tissue present (beefy red) . Slough tissue present (yellow, tan, white, stringy) . Observation on 11/25/19 at 5:20 p.m. showed a certified nurse aide (CNA) (#4) provided Resident #80 perineal cares while in bed. Observation showed an ulceration to the subcutaneous tissue in the area between the right buttock and the right upper posterior thigh, approximately the size of a quarter (2.5 centimeters), with a tan base and dark pink wound edges. The CNA applied a moisture barrier cream and a 2x2 gauze to the ulcer and placed pillows under the resident's legs. Review of Resident #80's medical record occurred on all days of survey. A FNP's (Family Nurse Practitioner) progress note, dated 10/08/19, stated, . this resident (#80) is refusing repositioning while in bed as well as depends (incontinent brief) change at night. She has a small pressure ulcer below her right buttock cheek. An order, dated 10/08/19, stated, (Brand of moisture barrier cream) ointment twice daily to skin cracks in the crack of her buttock until healed. The care plan, dated 10/14/19, stated, SKIN: The resident has Actual impairment to skin integrity of the Right buttock as of 9/17/19. Follow facility protocols for treatment of [REDACTED]. Provide treatment for [REDACTED]. Res. (resident) is to be assisted out of w/c (wheelchair) and repositioned in bed 1-2 times a day as she is not able to complete consistent full or partial weight shifts for pressure relief and has a history of skin breakdown on her seated surface. The care plan, dated 11/13/19, stated, PRESSURE ULCER: The resident has (Stage 2) pressure ulcer (R (right) lower buttock) r/t (related to) disease process, Hx (history) of ulcers, Immobility . Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing per facility policy. Avoid positioning the res. incontinence product on the right buttock wound. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Res. has refused 2 hours repositioning as per facility policy. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Resident #80's nurses' notes or assessments showed the following: * 09/17/19 at 5:30 p.m., The nurse noted 2 very superficial open areas each measuring approximately 0.3 cm (centimeters) with red scratch like areas surrounding area to the base of the right buttock. * 9/25/19 at 11:37 a.m., . lower right buttock crease skin conts (continues) to be sore and open 0.5cm oval shape . * 10/09/19 at 9:53 a.m., NURSING MEASURE: SKIN NOTE REQUIRED WEEKLY TO ASSESS LOWER R BUTT[NAME]K CREASE SKIN BREAKDOWN NOTED ON 9/17/19. sore to crease of buttocks and thigh conts to be present unchanged in condition, pink center, no surrounding redness noted, no drainage. (Name of moisture barrier cream) applied . The nurse failed to measure and stage the wound, now identified as a pressure ulcer by the FNP. * 10/16/19 8:16 a.m., NURSING MEASURE: SKIN NOTE REQUIRED WEEKLY TO ASSESS LOWER R BUTT[NAME]K CREASE SKIN BREAKDOWN NOTED ON 9/17/19. opening appears deeper with pink/yellow center no surrounding redness, no pain with cleansing, (name of moisture barrier cream) and 2x2 applied. The nurse failed to measure the pressure ulcer. * 10/23/19 12:09 p.m., . Right upper posterior aspect of thigh area continues to be monitored for further breakdown due to res persistent resistance to cares/repositioning. Area is chronically scarred in nature with no s/s (signs or symptoms) of infection. (Name of moisture barrier cream) applied w/ (with) cares, along w/continued monitoring. The nurse failed to measure the pressure ulcer. * 10/30/19 7:29 a.m., NURSING MEASURE: SKIN NOTE REQUIRED WEEKLY TO ASSESS LOWER R BUTT[NAME]K CREASE SKIN BREAKDOWN NOTED ON 9/17/19. Sore to right buttocks is worsening in condition, deeper, more fleshy, with serosanquineous (sic) drainage, no pain with cleansing wound, resident with minimal feeling in area, does not want to listen to staff about laying on side instead of back, wound in crease of buttock and thigh. Informed staff to leave brief elastic out of area. The nurse failed to measure the pressure ulcer. * 11/07/19 at 9:00 p.m., (returned from two day hospital stay) . When this nurse asked to do a skin assessment she stated ,'I refuse' repeatedly. she does get a bath tomorrow. Will continue to monitor. * 11/11/19 at 10:00 a.m., FNP shown the sore to right buttock thigh area which is healing and with decreased depth serousy drainage small amount. orders recd (received) to reposition resident q (every) 4hours while in bed. (Name of resident) informed FNP 'I am not turning at night and you can't make me,' also to continue using the (name of moisture barrier cream) and 2x2's and having it changed q4 hours and PRN (as needed). The nurse failed to measure the pressure ulcer from (MONTH) 8-11 after the resident's refusal on the 7th. * 11/13/19 at 10:04 a.m. and 11/21/19 at 1:04 p.m., On both dates, a nurse completed the NCC Wound - Weekly Observation Tool and identified a facility-acquired Stage 2 pressure ulcer to the right buttock/thigh area, which originated as a Stage 2 pressure ulcer on 10/08/19, with unchanged appearance with moist [MEDICATION NAME] tissue present (pink), small amount serous drainage, measuring length of 1.8 cm, width of 2.0 cm and depth of 0.2 cm, with no tunneling or undermining and white periwound tissue with no redness, and evaluated the pressure ulcer as healing. The facility lacked data to ensure the pressure ulcer was healing based on the assessments from (MONTH) 13-21, 2019, as the facility failed to obtain measurements for the five-week period from (MONTH) 8 - (MONTH) 13 to compare to the ulcer's current status. During an interview on 11/26/19 at 4:00 p.m., an administrative nurse (#3) stated the resident's skin issue on the right buttock started as an abrasion, and when the nurse practitioner (NP) assessed the area on 10/08/19, the NP called the wound a pressure ulcer. On 11/27/19 at 7:55 a.m., the nurse (#3) agreed the moisture barrier cream was not an appropriate treatment for [REDACTED].

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 2 of 12 sampled residents (Resident #3 and #28) and 1 supplemental resident (Resident #29). Failure to accurately complete Section K (Swallowing/Nutritional Status) and Section N (Medications) of the MDS does not allow each resident's assessment to reflect their current status/needs, and has the potential to affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION K: SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI User's Manual, revised (MONTH) (YEAR), page K-5-6 stated, . Code 0, no or unknown: if the resident has not experienced weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available . Code 2, yes, not 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 not planned and prescribed by a physician . - Review of Resident #28's medical record occurred on all days of survey. The resident's current MDS, dated [DATE], identified weight loss. Resident #28's weight at the time of the MDS was 169 pounds (lbs.) (One month prior, on 09/05/19, Resident #28's weight was 172.0 lbs (a loss of 1.8%, not significant). Six months prior, on 05/10/19, Resident #28's weight was 180.0 lbs (a loss of 6.7%, not significant). - Review of Resident #29's medical record occurred on all days of survey. The resident's current MDS, dated [DATE], identified weight loss. Resident #29's weight at the time of the MDS was 208 lbs. (One month prior, on 10/09/19, Resident #29's weight was 213.0 lbs (a loss of 2.4%, not significant). Six months prior, on 05/10/19, Resident #29's weight was 222.0 lbs (a loss of 6.4%, not significant). SECTION N: MEDICATION The Long-Term Care Facility RAI User's Manual, revised (MONTH) (YEAR), page N-6 and N-7, stated, . Steps for Assessment: 1. Review the resident's medical record for documentation that any of these medications were received by the resident during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). - Review of Resident #3's medical record occurred on all days of survey. An annual MDS, dated [DATE], identified an anticoagulant administered on seven days of the seven day look back period; however, the resident's medical record lacked evidence of anticoagulant administration during that time. During an interview on 11/27/19 at 10:50 a.m., an administrative nurse (#6) agreed she failed to code the above sections of the MDS accurately.

Based on observation and staff interview, the facility failed to post preceding years of survey results with plans of correction or post a notice of the availability of the survey results for residents, family members, and/or legal representatives for 3 of 3 days of survey. Failure to post or make available the Health and Life Safety Code survey results for the prior three years is an infringement of the residents' rights. Findings include: Observations on (MONTH) 25-27, 2019 showed the recent Life Safety Code survey, completed on 09/18/19 and Federal/State Health survey completed on 11/15/18, posted on a bulletin board located in the resident dining hallway. The facility failed to include the Life Safety Code and Federal/State Health surveys from (YEAR) and (YEAR) or post a notice of their availability. During an interview on 11/27/19 at 11:29 a.m., an administrative staff member (#1) acknowledged the facility had not posted the preceding years of (YEAR) and (YEAR) Health and Life Safety Code survey results or a notice of their availability.

Based on observation, review of facility policy/procedure, review of manufacturer's directions, and staff interview, the facility failed to store food under sanitary conditions and ensure the correct concentration of sanitizer in 1 of 1 kitchen (main). Failure to ensure staff prepared sanitizer solutions according to manufacturer's directions resulted in a concentration above the recommended level and had the potential to be toxic; and failure to store food away from contact with condensation/ice build-up has the potential to result in contamination of food. Findings include: Review of the facility's undated policy titled QUAT KLEEN stated, . Directions: Rinse with water to get all food off and then put in QUAT KLEEN solution (2 ounces QUAT KLEEN per 1 gallon of water). Keep in solution for at least 60 seconds making sure to immerse completely. Remove and let air dry. Prepare a fresh solution daily or more frequently as soil is apparent. Need to use these directions for solution to work effectively. - Observation on 11/13/18 at 11:39 a.m. showed the following: * Condensation/ice build-up on the ceiling in the walk-in cooler and on top of a box of bread and the covers of ready-to-eat cream pies. Two areas of ice build-up on the floor. * Empty sanitizer bucket in the sink in the dishwashing room. When asked about the sanitizers, a staff member stated they mix Quat (quaternary ammonium) sanitizer in the buckets and the concentration should be between 950 -1500. One staff member stated we use one medicine cup to 2 - 3 quarts. Another staff member stated, we really don't measure the water, but we measure the sanitizer. - Observation of the kitchen on 11/15/18 at 9:15 a.m. showed the following: * Continued condensation/ice build-up on the ceiling in the walk-in cooler and on the covers of ready-to-eat cream pies. * Review of the DISHWASHER TEMPS & PAILS SANITIZER log from (MONTH) 1 - (MONTH) 15, (YEAR) showed the concentration of sanitizer in the table and kitchen pails between [PHONE NUMBER] parts per million (ppm). A dietary staff member (#8) stated staff use the sanitizer on tables and countertops. The staff member stated staff have been mixing 2 ounces of sanitizer to 2 gallons of water. Review of the manufacturer's instructions on the bottle for Food Contact Quat Sanitizer D stated . Directions For Use . To Sanitize Food Contact Surfaces: Use Food Contact Quat Sanitizer to sanitize hard nonporous surfaces of . food utensils, dishes, sink tops, countertops . apply a . solution . (0.25 - 0.68 oz. (ounce) of Food Contract Quat Sanitizer per gallon of water) (150-400 ppm active quat) . During an interview on the morning of 11/15/18, the dietary staff member (#8) confirmed staff should follow the manufacturer's directions when preparing the sanitizer solution.

Based on observation, review of facility policy and staff interview, the facility failed to ensure staff followed appropriate infection control practices related to disinfecting equipment and hand hygiene for 3 of 7 sampled residents (Residents #6, #30, and #31) during personal cares. Failure to follow appropriate infection control practices has the potential for the transmission of communicable diseases and infections to residents and staff. Findings include: Review of the facility policy titled Policy for General Cleaning and Maintenance of Equipment occurred on 11/15/18. This undated policy, stated, It is the policy of this facility that all resident care equipment will be cleaned and decontaminated after use and will be prepared for reuse by the same or another resident. All equipment . will be cleaned and decontaminated immediately after use. - Observation on 11/13/18 at 3:40 p.m. showed two certified nursing assistants (CNAs) (#2 and #3) utilized a sit-to-stand mechanical lift to transfer Resident #30 from the recliner to the toilet, and back to the recliner. The CNAs failed to disinfect the sit-to-stand lift after resident use. Observation on 11/13/18 at 5:18 p.m. showed two CNAs (#2 and #3) utilized a sit-to-stand mechanical lift to transfer Resident #30 from the recliner to the toilet, and then to the wheelchair. The CNAs failed to disinfect the mechanical lift after resident use. Observation on 11/14/18 at 4:42 p.m. showed two CNAs (#4 and #5) utilized a sit-to-stand mechanical lift to transfer Resident #30 from the recliner to the toilet, and then to the wheelchair. The CNAs failed to disinfect the mechanical lift after resident use and before storage. - Observations on 11/14/18 at 8:59 a.m. and 11/14/18 at 10:49 a.m. showed two CNAs (#6 and #7) assisted Resident #6 to the bathroom using a sit-to-stand mechanical lift. The CNAs returned the lift to a storage area and failed to sanitize it after use. During interview on 11/15/18 at 11:00 a.m., an administrative nurse (#1) stated she expects staff to wipe off high touch areas on lift equipment after each use with red top disinfecting wipes. - Observation on 11/14/18 at 2:44 p.m. showed a CNA (#4) emptied Resident #31's urinary drainage bag into a graduate cylinder. A small amount of urine spilled on the floor. The CNA emptied the urine in the toilet in the bathroom, obtained a disinfectant wipe and wiped the floor by the resident's bed. The CNA discarded the wipe and her gloves in the garbage can in the bathroom. Without performing hand hygiene, the CNA donned another pair of gloves and provided perineal care to Resident #31. During interview on 11/15/18 at 11:30 a.m., an administrative nurse (#1) stated she expects staff to perform hand hygiene after cleaning the floor and prior to donning new gloves to provide perineal care.

Based on observation, record review and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 6 of 14 sampled residents (Resident #1, #5, #6, #7, #9, and # 23). Failure to revise the care plan limited the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings include: - Review of Resident #9's medical record occurred on all days of survey. The current care plan stated, Problem: POTENTIAL FOR SKIN BREAKDOWN: Redenned (sic) area to Right ankle bone noted 10/8/17. Problem: EATING . supplements as desired due to not eating meat. Goal: To eat 80% of meals on a daily basis. Approaches . 4 oz (ounce) [MEDICATION NAME] Jc (juice) Daily & (and) PRN (as needed) . A progress note, dated 10/09/17 at 4:31 a.m., stated, Reddened area right ankle bone 3.0 cm (centimeters) in diameter. A skin assessment, dated 10/19/17, stated, SKIN IN GOOD CONDITION NOTED WITH BATH TODAY. During an interview on 12/06/17 at 2:59 p.m., an administrative nurse (#1) confirmed Resident #9's ankle healed, but staff failed to update the care plan. A progress note, dated 11/13/17 at 10:41 a.m., stated, . Suggest promoting more dairy and vegearian (sic) protein products like milk, peanut butter, yogurt, eggs and possible tofu. Facility staff failed to revise Resident #9's care plan to reflect the interventions mentioned in the 11/13/17 progress note and failed to develop measurable goals. - Review of Resident #23's medical record occurred on all days of survey. The current care plan stated, Problem: EATING . Goal: To eat 75% of meals on a daily basis. Approaches . supplement drink at meals BID (two times a day) . Facility staff failed to revise Resident #23's care plan to reflect current weight loss interventions and failed to develop measurable goals. - Review of Resident #20's medical record occurred on all days of survey and identified falls on 10/24/17, 11/19/17, and 12/04/17. Resident #20's fall current care plan lacked specific measurable goals for the resident's falls. - Review of Resident #5's medical record occurred on all days of survey. The current care plan stated. Problem: EATING: Wt (weight) 125 lbs. (pounds). Resident does not drink milk, will offer hot chocolate. Resident prefers Small Portions, regular diet. Goal: To eat 80% of meals on a daily basis. Approaches: DIET: Regular diet with supplements as desired. 1-1's (one to one) per CDM (certified dietary manager) and RD (registered dietician). Monitor and record meal intakes. Weights as ordered. Review of Resident #5's weights showed the following: * 07/05/17 - 136.0 lbs. - admission weight * 08/03/17 - 125.0 lbs. * 09/07/17 - 125.0 lbs. * 10/12/17 - 126.0 lbs. * 11/09/17 - 118.0 lbs. * 11/30/17 - 117.0 lbs The above weights showed a 13.97% weight change in 5 months and a significant weight loss of 6.35% in 1 month. During an interview on 12/05/17 at 3:34 p.m., a dietary supervisor (#4) stated if Resident #5 eats 75% of a meal or less, she should receive a supplement. She said dietary staff kept track of the resident's meal intake and gave the supplement to the certified nursing assistant to administer. The supplement would be given as a snack at 10 a.m., 2 p.m., and evening. The facility failed to identify weight loss as a problem on the care plan, identify a measurable/resident centered goal, and provide pertinent information regarding supplement use as an approach/intervention. - Review of Resident #6's medical record occurred on all days of survey. The current care plan stated, Problem: SMOKING: Resident has a history of smoking and does not want to use a nicotine patch on admission. Resident does smoke outside in designated area. Competency evaluation for independent smoking and cognitive evaluation completed by social services. Res. (resident) must stop smoking in order to have knee surgery, Res. refuses. Goal: Resident will be and remain non-smoking in 90 days with safety and hygiene maintained on a daily basis. Observation showed Resident #6 smoking outside in the designated smoking area on 12/04/17 at 12:11 p.m. and at 3:56 p.m. During an interview on 12/06/17 at 9:15 a.m., a dietary supervisor (#4) and an administrative nurse (#1) confirmed Resident #6's care plan failed to address the resident's continued smoking During an interview on 12/06/17 at 2:00 p.m., an administrative nurse (#5) reviewed Resident #6's smoking care plan and confirmed the goal failed to address the resident's current smoking status. - Review of Resident #7's medical record occurred on all days of survey and identified [DIAGNOSES REDACTED]. The current care plan stated, Problem: ASPIRATION PNEUMONIA/TIA ([MEDICAL CONDITION]): . hospital for pneumonia 1/18/17, hospital for pneumonia 10/5-10/10/17. Goal: Resident will be free of signs & symptoms of URI (upper respiratory infection) &/or cold symptoms in 14-21 days. A progress note, dated 10/10/17 at 5:11 p.m., stated, hospitalized [DATE]-10/10/17 with pneumonia left pleural effusion, acute CKD ([MEDICAL CONDITION]). Received IV (intravenous) antibiotics while hospitalized . Facility staff failed to update Resident #7's care plan goal following the hospitalization return on 10/10/17 and resolution of the treated diagnosis. The current care plan further stated, Problem: onset 03/23/2012. [DIAGNOSES REDACTED]. Has anxiety, confusion, restlessness and some anger @ (at) times. Has hx (history) physical aggression with staff and resistant to cares. Can become verbally abusive towards staff. exited building 02/11/17; attempted to exit building 04/28/17; wander guard put in place. No behaviors reported 10/16/17. Goal: Symptoms of DT's ([MEDICAL CONDITION] tremens) will be resolved in 1-2 weeks. The facility staff failed to provide a current and measurable goal for the problems listed in the resident's care plan. - Review of Resident #1's medical record occurred on all days of survey and identified the resident had recurrent skin issues related to incontinence. Resident #1's care plan lacked specific measurable goals and approaches for the resident's skin issues.

Based on observation, record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5 percent on 1 of 2 days of medication administration (12/04/17) for 2 of 12 residents (Resident #11 and #23) observed during medication pass. Twelve medication errors occurred, resulting in a 36% error rate. Failure to ensure staff correctly administered medications per physicians' orders may result in reduced efficacy or in residents experiencing adverse health effects. Findings include: Review of the facility policy titled Medication Administration Guidelines occurred on 12/06/2017. This policy, dated August 2012, stated, . Medications will be administered in a timely manner. Consider the condition of the resident and type of medication . Medications may be given up to one hour before and one hour after the designated time . Medication administration times may vary to meet individual resident needs. Observation during the medication pass on 12/04/17 at 12:15 p.m., showed a Medication Assistant II (MA II) (#2) charted, Not Administered (N) (12:00 p.m. scheduled medications) for Resident #11 and #23 due to Resident sleeping. The MA II (#2) failed to notify the nurse or reattempt medication administration. Review of Resident #11's December 1-6, 2017 electronic Medication Administration Record [REDACTED] * 12/04/17 at 12:21 p.m. - [MEDICATION NAME] Powder 17 grams (GM) daily for constipation. Not Administered (N) Reason: Resident asleep (also held 12/01/17 and 12/05/17) * 12/04/17 at 12:21 p.m. - [MEDICATION NAME] 100 milligram (MG) capsule take 2 capsules (200 MG) by mouth (PO) twice daily for [MEDICAL CONDITION]. (N) Reason: Resident asleep (also held 12/01/17 and 12/05/17) * 12/04/17 at 12:21 p.m. - [MEDICATION NAME] 50 MG tablet PO three times per day for [MEDICAL CONDITION]. (N) Reason: Resident asleep (also held 12/01/17 and 12/05/17 at noon) * 12/04/17 at 12:21 p.m. - Tylenol 325 MG tablet 2 tablets (650 MG) PO three times a day for cervical disc degeneration. (N) Reason: Resident asleep (also held 12/01/17 and 12/0517 at noon) * 12/04/17 at 12:21 p.m. - Senna 8.6 MG tablet one tablet PO three times daily for constipation. (N) Reason: Resident asleep (also held 12/01/17 and 12/05/17 at noon) Review of Resident #23's December 1-6, 2017 eMAR showed the following: * 12/04/17 at 12:15 p.m. - Aspirin [MEDICATION NAME] Coated (EC) 81 MG tablet take 2 tablets (162 MG) PO daily for unspecified [MEDICAL CONDITION]. (N) Reason: Resident asleep (also held 12/01/17) * 12/04/17 at 12:15 p.m. - [MEDICATION NAME] 24 hour Extended Release 180 MG capsule PO daily for essential (primary) hypertension. (N) Reason: Resident asleep (also held 12/01/17) *12/04/17 at 12:15 p.m. - [MEDICATION NAME] 60 MG capsule PO daily for other recurrent [MEDICAL CONDITION]. (N) Reason: Resident asleep (also held 12/01/17) *12/04/17 at 12:15 p.m. - [MEDICATION NAME] 20 MG tablet PO daily for heart failure. (N) Reason: Resident asleep (also held 12/01/17) *12/04/17 at 12:15 p.m. - Senna 8.6 MG tablet 2 tablets PO daily for constipation. (N) Reason: Resident asleep (also held 12/01/17) The MA II (#2) failed to administer Resident #11 and #23's medications per physician orders and failed to report this error to a nurse. Failure to administer the medications as ordered and scheduled may result in non-therapeutic and adverse consequences to the residents' health.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.14), and staff interview, the facility failed to ensure accurate coding of Minimum Data Sets (MDSs) for 2 of 14 sampled residents (Resident #2, and #5). Failure to accurately complete Section K (Swallowing/Nutritional Status) of 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 2016, pages K-4 through K-6 stated, K0300: Weight Loss: . Steps for Assessment: This item compares the resident's weight in the current observation period with his or her weight at two snapshots in time: *At a point closest to 30-days preceding the current weight. *At a point closest to 180-days preceding the current weight. Coding Instructions . Code 0, no or unknown: if the resident has not experienced weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. 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 orders [REDACTED]. Coding Tips . If the resident is losing a significant amount of weight, the facility should not wait for the 30 or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status. Review of Resident #5's medical record occurred on all days of survey. Recorded weights were reviewed and are as follows: * 07/05/17 - 136.0 lbs. (pounds) * 08/03/17 - 125.0 lbs. * 09/07/17 - 125.0 lbs. * 10/04/17 - 126.0 lbs. For the significant change MDS, dated [DATE], staff coded Section K0300 as a physician planned weight loss. During an interview on 12/06/17 at 10:30 a.m., a dietary staff supervisor (#4) confirmed staff should have coded an unplanned weight loss at K0300 for the 10/05/17 MDS. - Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The MDS, dated [DATE], failed to identify a tube feeding. Observation on all days of survey showed Resident #2 with a percutaneous endoscopic gastrostomy (PEG) tube in place. The September 2017 Medication Administration Record [REDACTED]. During an interview on 12/06/17 10:36 a.m., a dietary supervisor (#4) identified she should have coded a tube feeding on the 09/27/17 MDS.