Every finding on record at Wishek Living Center

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#3) obtained the proper qualifications to serve as the director of food and nutrition services. Findings include:During an interview on 06/23/26 at 2:31 p.m., a dietary manager (#3) stated she had not completed the certified dietary manager course. During an interview on 06/23/26 at 4:46 p.m., an administrative staff member (#5) confirmed the facility hired the dietary manager on 12/01/25 and did not enroll in the certified dietary manager courses until 06/02/26.The facility failed to ensure the dietary manager (#3) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure proper storage, labeling, and service of food items in 1 of 1 kitchen. Failure to label food taken out of the original container, discard expired food, handle food safely and maintain a clean environment may result in foodborne illness to residents, staff, and visitors. Findings included:Review of the facility policy titled Food Handling/Restriction of removal from Dining Room occurred on 06/24/26. This policy, dated February 2014, stated, . at all times . while being . served or transported, . food shall be protected from potential contamination, including dust . The 2022 Food and Drug Administration (FDA) Food Code, Annex 3, Chapters three and six, . 3-301.11 stated, . no bare hand contact with ready-to-eat foods . 3-302.12 . food or food ingredients that are removed from their original packages for use . shall be identified with the common name of the food . 3.501.17 . refrigerated, ready to eat, time/temperature control for safety food . shall be clearly marked to indicate the date or day by which the food shall be consumed . when held at a temperature of 5 C (41 F) or less for a maximum of 7 days . 6.501.12 . physical facilities .shall be cleaned as often as necessary to keep them clean .- Observation of the kitchen on 06/22/26 at 12:07 p.m., showed the following: * Dried spills/splatters on the floors * Food debris/crumbs on the floor in the dry storage area * The walk-in cooler showed eight unlabeled, unmarked plastic squeeze bottles contained an unidentified liquid substance; four clear plastic squeeze bottle dispensers; labeled thousand island dressing and dated 4/14/26; and a clear plastic bag of lettuce and a bag of shredded cheese with an unreadable label. * The walk-in freezer showed an opened, unsealed bag of chicken strips and a large brown splattered substance on the floor. - Observation on 06/22/26 at 3:15 PM showed two 16 ounce containers of dry grated parmesan cheese in the walk-in cooler with a use by date of 12/20/25.- Observation of the residents' dining room on 06/23/26 at 9:30 a.m. showed a table fan with clumps of dust on the fan grates, and a pedestal fan with a thick dark coating of dust/dirt along the edges of the blades. - Observation on 06/23/26 at 7:59 a.m. showed a dietary aide (#4) peeled a banana, removed the banana from the peeling with his bare hands, placed it on the plate, and served it to the resident.During an interview on 06/23/26 at 2:31 p.m., a dietary staff member (#3) stated she expected staff to label and date all food items, wear gloves per food handling standards, discard items by the use by date, and maintain a clean, sanitary kitchen.

Based on record review, review of facility policy, and staff interview, the facility failed to show the resident or their representative received a bed-hold notice for 4 of 4 sampled residents (Resident #1, #2, #3, and #23) and 1 closed record (Resident #37) reviewed for hospital transfers. Failure to provide a written copy of the bed-hold notice does not allow the residents and/or their representative to make informed decisions regarding their rights. Findings include: Review of the facility policy titled Bed Hold Policy and Procedure Policy occurred on 06/24/26. This policy, dated 01/01/24, stated, . Two copies of the Facility's Bed-Hold Policy will be presented to the resident and/or resident representative. The first at the time of admission, and the second, each time a resident is admitted to a hospital . the resident or their representative is requested to immediately notify the Facility of their bed-hold decision. -Review of Resident #1's medical record occurred on all days of survey and identified hospital transfers on 02/06/26, 02/08/26, and 04/06/26. The medical record lacked evidence the facility provided the resident/resident representative with a written bed-hold notice and obtained their decision. -Review of Resident #2's medical record occurred on all days of survey and identified a hospital transfer on 05/17/26. The medical record lacked evidence the facility provided the resident/resident representative with a written bed-hold notice and obtained their decision.-Review of Resident #3's medical record occurred on all days of survey and identified hospitalizations on 03/25/26, 04/10/26, 04/17/26, and 05/24/26. The medical record lacked evidence the facility provided the resident/resident representative with a written bed-hold notice and obtained their decision. -Review of Resident #23's medical record occurred on all days of survey and identified a hospital transfer on 03/30/26. The medical record lacked evidence the facility provided the resident/resident representative with a written bed-hold notice and obtained their decision.- Review of Resident #37's medical record occurred on 06/23/26 and identified a hospitalization on 03/29/26. The medical record lacked evidence the facility provided the resident/resident representative with a written notice of transfer and bed-hold notice and obtained their decision. During an interview on 06/23/26 at 3:13 p.m., an administrative nurse (#1) stated the facility contacts the resident's representative by phone, writes the representative's name and date on the notice of transfer form, and places it and the bed hold policy in the mail. The facility was unable to provide evidence the resident and/or the resident representative received the bed-hold information and provided the facility with their decision.

Based on record review, review of facility policy, review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, and staff interview, the facility failed to offer residents the pneumococcal immunization to 4 of 5 residents (Resident #7, #9, #14, and #31) reviewed for immunization status. Failure to offer the 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 contract pneumonia and spread the infection to other residents, visitors, and staff. Findings included: Review of the facility policy titled Influenza and Pneumococcal Standing Orders Policy/Procedure occurred on 05/14/25. This policy, dated September 2024, stated, . All residents, regardless of age and medical condition, should receive the pneumococcal vaccine at least once unless there is a documented contraindication . All residents admitted to this facility shall be assessed to determine their current pneumococcal . vaccination status. Documentation of the resident's immunization status will be maintained in the electronic medical records . Pneumococcal vaccination status is completed after the admission process regardless of the date in the year . Vaccination is offered to residents who cannot provide documentation of previous pneumovax vaccination. Those who are unsure or do not know their status will be immunized, unless the resident declines or has a medical contraindication or allergy . The immunization records of all residents will be reviewed in September of each year. Review of the CDC: Vaccines and Preventable Diseases webpage (https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html), last reviewed October 26, 2024, stated, . CDC recommends pneumococcal vaccination . Age [AGE] years or older who have . Not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21 . Previously received only PPSV23: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose . Previously received both PCV13 and PPSV23 but no PPSV23 was received at age [AGE] years or older: 1 dose PCV20 or 1 dose PCV21 at least 5 years after the last pneumococcal vaccine dose. - Review of Resident #7's medical record occurred on 05/14/25. The record lacked evidence the facility assessed Resident #7's pneumococcal immunization status and offered PCV20 or PCV 21 at least 5 years after the resident's last pneumococcal vaccine dose. - Review of Resident #9's medical record occurred on 05/14/25. The record lacked evidence the facility assessed Resident #9's pneumococcal immunization status and offered PCV15, PCV20, or PCV21 at least 1 year after the last PPSV23 dose. - Review of Resident #14's medical record occurred on 05/14/25. The record lacked evidence the facility assessed Resident #14's pneumococcal immunization status and offered PCV15, PCV20, or PCV21 when vaccination status is unknown. - Review of Resident #31's medical record occurred on 05/14/25. The record lacked evidence the facility assessed Resident #31's pneumococcal immunization status and offered PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose The facility failed to follow the CDC recommendations for pneumococcal vaccine administration and the facility's policy. During an interview on 05/14/25 at 11:20 a.m., an administrative nurse (#1) confirmed the medical records lacked provider assessments for pneumococcal immunizations, confirmed the resident's pneumococcal vaccinations were not up to date, and stated he/she was unaware of the current CDC recommendations regarding pneumococcal vaccinations.

Based on observation, record review, review of facility policy, and staff interviews, the facility failed to follow standards of infection control and prevention for 1 of 3 sampled residents (Resident #22) observed with a wound. Failure to use enhanced barrier precautions (EBP) for residents with wounds has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 05/14/25. This policy, dated 04/01/24, stated, . An order for enhanced barrier precautions will be obtained for residents with . Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) . even if the resident is not known to be infected . Review of Resident #22's medical record occurred on all days of survey and identified an unstageable pressure injury (PI) on 03/04/25. The wound culture results, dated 05/02/25, showed a wound infection. Resident #22's current care plan stated, . The resident has Unstageable pressure injury to right heel. 4/15/25 Open wound to tip of right great toe. 4/30/25 Several new impairments observed on right leg anterior [front] right gt [great] toe and lateral [outer] ankle area etiology [origin] unknown-no pressure in any of these areas. Concerns of diabetes and circulation being a factor. Random observations on all days of survey showed no EBP signage on the door or in the room and no personal protective equipment outside of Resident #22's room. During an interview on 05/13/25 at 2:18 p.m., a certified nurse aide (CNA) (#2) stated Resident #22 is not in EBP. During an interview on 05/13/25 at 3:21 p.m., an administrative nurse (#1) stated staff should have placed Resident #22 in EBP. The facility failed to place Resident #22 in EBP for PI/wounds.

Based on record review and review of the facility reported incident investigation, the facility failed to ensure food served accommodated resident allergies for 1 of 1 resident (Resident #1) who was hospitalized for an allergic reaction. Failure to ensure resident allergies are noted and followed while serving meals resulted in hospitalization and treatment for an anaphylactic reaction. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 04/19/24. The facility implemented corrective action and completed all staff education on 04/22/24. Review of Resident #1's medical record occurred on 05/02/24 and included diagnoses of dementia and an allergy to fish on admission. The resident's current care plan stated, Resident has known allergy to: Fish . Resident will not receive (med, food, substance) to which he has a known allergy. Be alert to food allergies. Resident's diet card noted Fish/Seafood allergy. Review of Resident #1's progress notes identified the following: * 04/19/24 2:12 p.m. nurse entered dining room @ [at] 1250 [12:50 p.m.] to see resident with eyes closed . noted resident to be slow to respond . pale/grey in color. Resident taken back to . room . BP [blood pressure] 76/47, T [temperature] 96.9, P [pulse] 92, R [respirations] 16, 02 [oxygen saturation] 92% on RA [room air]. 10 mins [minutes] and resident was slumped to L) [left] side, color was more pale/grey, and was again slow to respond. BP taken 57/37, notified resident coordinator who came to room and assessed. Physician notified of status and wanted resident seen in ER [emergency room ], Son [name] notified and consented to have resident transferred . Resident did loose [sic] consciousness x [times] 2 for seconds at a time . manual BP's taken unable to read/hear, could not get 02 readings, oxygen started 2L/NC [2 liters per nasal canula] for comfort, noted . [resident] to be red in color. Resident transferred to ER by ambulance, left facility @ 2pm. * 04/19/24 3:59 p.m. [provider name from hospital] called and stated that resident will be admitted to hospital for alergic [sic] reaction . Son [name] contacted and is aware, hospital has updated him on status. * 04/22/24 1:00 p.m. Resident returned from hospital approximately 10:15 this morning. hospitalized on ,d+[DATE] . for . anaphylactic reaction. The facility's investigation report, dated 04/19/24, stated, . [kitchen staff] in charge of reading the cards that lists the resident's diet, allergies, and likes/dislikes. [kitchen staff] read [Resident #1's] name and did not say anything else on the card . [Resident] was treated at the hospital for anaphylactic shock . Based on the following information, non-compliance at F806 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by: * The facility completed an investigation with interviews of staff that determined the cause of the incident. Kitchen staff failed to read and follow allergy (fish) noted on diet card. Resident #1 was served fish during lunch on 04/19/24. * Provided immediate dietary staff education regarding importance of reading diet cards every time. You must be reviewing these for every meal. When serving, the person reading cards must announce the resident, the diet, and any allergies or dislike pertaining to that day's meal. Additional dietary staff education completed the same day before dietary staff left regarding changing the format of the diet cards and placing the allergies in red lettering. * On 04/22/24 implemented the use of newly formatted resident diet cards with allergies noted in red lettering. * On 04/22/24 provided education via written information e-mailed to all staff regarding newly formatted resident diet cards with allergies noted in red lettering. The education included the process for breakfast, lunch, supper, and room tray delivery. * On 04/22/24 dietary staff educated and received hard copy of newly formatted resident diet card and process for serving food. * Random audits completed by dietary supervisor to ensure the new process is followed.

Based on record review, review of professional reference, review of facility policy, and staff interview the facility failed to provide care and services for 1 of 1 closed record (Resident #43) reviewed with a change in health status and transfer to the emergency room (ER). Failure to assess and monitor the resident's changing condition resulted in a worsening of symptoms and delay in emergency care. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 189, stated, . the nurse is still responsible for identifying and responding to data that indicate real or potential medical problems. and preventing development of the potential complication. Review of the facility policy titled Notification of Changes occurred on 03/13/24. This policy, dated November 2023, stated, Policy: The purpose of this policy is to assure the resident, provider and or family member . is immediately informed . when there is a change requiring notification. 2. Significant change in the resident's physical, mental, and psychosocial condition such as a deterioration in health . This may include: clinical complications. Review of Resident #43's medical record occurred on all days of survey. Diagnoses included dementia with other behavioral disturbances and adult failure to thrive. An admission Minimum Data Set (MDS), dated [DATE], identified substantial/maximal assist with activities of daily living (ADLs) such as eating, oral cares, hygiene, bathing, and dressing. Review of Resident #43's Emergency department (ED) physician's report, dated 02/28/24, stated, HPI [history of present illness]: . CNA [certified nurse aide] told nursing staff the [sic] when she checked the blood pressure it was 60s/40s [60s systolic over 40s diastolic] and pulse was 111 [beats per minute] . When seen in the ER there was . food particulate in the mouth . there was also a potassium pill in his mouth . Physical exam . Neurologic: No purposeful movement, Heart sounds: irregular, but appropriate, Lungs: clear sounds, Oropharynx: full of food particulate and pills. After it was cleaned out the mucosa was dry. Assessment and Plan: Dehydration, Acute renal failure, and altered mental status . Plan: admit to inpatient. Resident #43's nursing notes showed the following: * 02/26/23 8:25 p.m. BP [blood pressure] 75/55 . noted to have difficult time with holding up his head . took medication with much attempts . writer did hold head up to take medication then resident would allow his head to drop down in front of him . * 02/26/23 8:40 p.m. BP 67/49 . lethargic . call to residents [sic] family . will call for ambulance . Review of the facility's investigation and video evidence showed the nurse (#3) entered Resident $43's room at 6:44 p.m. with medication then stepped out to crush medications and re-entered at 6:49 p.m. At 7:45 p.m., the nurse (#3) entered the resident's room for the last time. At 9:12 p.m., video evidence showed the ambulance crew tranported the resident out of the facility. Review of facility investigation, dated 02/24/24, identified the following: * Family Nurse Practitioner (FNP) (#6) called administrative staff member (#1) with . grave concerns about [nurse #3 name] and her lack of assessment . he is upset that not only did she [nurse #3] not do a manual blood pressure before calling him, but that she [nurse #3] didn't even do the basic ABC's [airway, breathing, circulation] of assessments because his [Resident #43] airway was likely partially obstructed by all of the food that was pocketed in his mouth. * CNA (#4) stated, . [nurse #3] told me to go ahead and lay him [Resident #43] down in bed as she [sic] was just hanging his head and not eating. while in the lift . he went unresponsive . [nurse #3] said she [CNA #4] should lay [Resident #43] down and get his vitals . vitals were reported to name [nurse #3] . she [CNA #4] was not feeling comfortable with the situation and urged [nurse #3] 1 or 2 times to get him out of here . she felt the ambulance needed to be called as he did not look good. * Administrative staff member (#1) stated, . [nurse #3] did not complete an assessment and relied completely on the reported vital signs from the CNAs. The facility's nursing staff failed to monitor Resident #43's declining condition to prevent the development of additional complications. During an interview on 03/13/24 at 12:54 p.m., an administrative staff member (#1) stated, She expected nursing staff to complete a full assessment and verify the vital signs themselves.

Based on observation, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 resident (Resident #13) observed for insulin pen preparation. Failure to properly prepare insulin pens may result in the resident receiving an inaccurate dose of insulin. Findings include: Review of a professional online reference Insulin Lispro single-patient-use pen https://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf, occurred on 03/13/24. These instructions, dated July 2023, stated, Pull off the outer needle shield . to prime your pen, turn the dose knob to select 2 units. Hold your pen with the needle pointing up [vertically]. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps . Observation on 03/12/24 at 5:01 p.m. showed a nurse (#2) prepared Resident #13's insulin pen for administration. The nurse cleansed the tip of the pen with an alcohol swab, attached a needle and without removing the needle cap, dialed the insulin pen dose knob to 26 units (ordered stated 24 units), held the pen horizontally and expelled 2 units. The nurse (#2) failed to remove the needle cover, prime to 2 units only, and hold the device vertically to prime the pen. During an interview on 03/13/24 at 12:54 p.m., an administrative nurse (#1) stated, She expected nursing staff to prime the insulin pens properly.

Based on observation, review of facility policy, and staff interview, the facility failed to store food under safe and sanitary conditions in 1 of 1 kitchen area (main kitchen). Failure to store food at appropriate temperatures has the potential to result in foodborne illness or decreased food quality for residents, staff, and visitors. Findings include: Review of the facility policy, Monitoring of Cooler/Freezer Temperature and Maintenance occurred on 04/11/23. This policy, dated 04/11/23, stated, Freezer temperatures will be checked and logged at least twice per day by designated personnel . all frozen storage must be maintained at or zero degrees Fahrenheit . if temperatures are above 10 degrees Fahrenheit for freezer, the dietary manager and maintenance department will be notified immediately for corrective action . if there is an ice buildup in the freezer, dietary is to completely empty the freezer and dispose of any freezer-burnt items . all foods shall be labeled, dated, monitored . deep cleaning of freezers will be done as needed . Review of facility policy Dietary Employee Personal Hygiene occurred on 04/11/23. This policy, dated 04/03/23, stated, . employee and food service employees in order to prevent contamination of food . hair restraints are required when in the kitchen at all times to prevent hair from contaminating food . Observations on 04/10/23 at 12:21 p.m. in the main kitchen with a dietary staff (#2) showed the following: * The upright freezer temperature log sheet, dated 01/01/23 to 04/10/23, showed 8 days of undocumented daily temperature recordings. * The freezer temperature log sheet, dated 01/01/23 to 04/10/23 showed 22 days of temperatures above zero degrees F, 7 of those days with temperatures 10 degrees F or greater. The facility lacked follow up from maintenance or dietary on freezer temperatures above 10 degrees F. * The freezer showed 36 bags of various food items, bread, breaded food items, and frozen potato products freezer-burnt and ice covered. * The freezer coils on the top, bottom and back of the freezer showed ice build up approximately 1/2 to 1 inch thick, and the metal shelves covered with ice. * On 04/10/23 at 1:23 p.m., a food vendor without a hair covering in the main kitchen delivering food items. During an interview on 04/12/23 at 2:30 p.m., a dietary supervisor (#2) confirmed she expected staff to record the freezer temperatures daily, report discrepancies with temperatures and follow up immediately, and anyone entering the kitchen to wear a hair covering in food areas.

Based on record review, review of facility policy, and staff interview, the facility failed to provide a written copy of the bed hold notice to the resident or their representative upon transfer for 4 of 5 sampled residents (Resident #26, #35, #37 and #44) with a recent hospital transfer. Failure to provide a bed hold notice does not allow the resident or their representative to make informed choices regarding their rights. Findings include: Review of the facility policy titled BED HOLD POLICY AND PROCEDURE occurred on 12/15/21. This policy, revised November 2016, stated, . [facility] will advise and inform all residents and their responsible parties of its Bed-Hold Policy . each time a resident is admitted to a hospital . the resident or their representative is requested to immediately notify the Facility of their bed-hold decision. - Review of Resident #26's medical record occurred on all days of survey. The record identified a hospitalization on [DATE], and staff notified his representative per telephone of the transfer. - Review of Resident #35's medical record occurred on all days of survey. The record identified a hospitalization [DATE]-November 3, 2021, and staff notified his representative per telephone of the transfer. - Review of Resident #37's medical record occurred on all days of survey. The record identified a hospitalization [DATE]-9, 2021, and staff notified his representative per telephone of the transfer. - Review of Resident #44's medical record occurred on all days of survey. The record identified a hospitalization [DATE]-15, 2021, and staff notified her representative per telephone of the transfer. Resident #26, #35, #37 and #44's medical records lacked evidence the residents/their representatives received a written copy of the bed hold notice and lacked documentation the residents/their representatives accepted or denied the bed hold. During an interview on 12/15/21 at 12:23 p.m., a managerial nurse (#1) stated the social service staff is responsible for providing a written copy of the bed hold notice to the resident/their representative and documenting in the medical record whether they accepted or denied the bed hold.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed standard infection control practices for 3 of 9 sampled residents (Resident #2, #6, and #45) observed transferred with a mechanical lift and for 5 of 6 fans observed in the kitchen. Failure to follow standard infection control practices related to cleaning mechanical lifts and cleaning of fans has the potential to spread infections within the facility. Findings include: MECHANICAL LIFTS Review of the facility policy titled Cleaning and Disinfection of Resident-Care Equipment occurred on 12/15/21. This policy, implemented 01/26/20, stated, . Multiple-resident use equipment shall be cleaned and disinfected after each use. - Observation on 12/14/21 at 10:35 a.m. showed two CNAs (#5 and #6) transferred Resident #6 into the wheelchair utilizing a Hoyer lift (full body mechanical lift). The CNAs (#5 and #6) failed to sanitize the lift prior to exiting the room. - Observation on 12/15/21 at 1:53 p.m. showed two CNAs (#9 and #10) transferred Resident #45 into the wheelchair utilizing a Hoyer lift. The CNAs (#9 and #10) failed to sanitize the lift prior to exiting the room and pushing it into the hallway. - Observation on 12/15/21 at 2:06 p.m. showed a CNA (#10) transferred Resident #2 into the wheelchair utilizing a stand lift. The CNA (#10) failed to sanitize the lift prior to exiting the room, pushing it into the hallway, and entering another resident's room with the same lift. FANS Observation in the kitchen on 12/15/21 at 10:30 a.m. showed an accumulation of dust/dirt on the fan blades and grates on the following:* One fan above the three-compartment.* Two fans in the dish machine room.* One fan above a counter in the kitchen.* One fan below a reach-in cooler in the food preparation area. During an interview on 10/15/21 at 10:45 a.m., two administrative dietary staff members (#3 and #4) stated staff are expected to clean the fans weekly.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and/or the State Long Term Care Ombudsman written notice of transfer for 2 of 5 residents (Resident #35 and #37) with a recent hospital transfer. Failure to provide a notice of transfer does not allow the resident and/or their representative to make informed decisions regarding their rights or inform the Ombudsman of the transfer. Finding include: Review of the facility policy titled GUIDE FOR IMPLEMENTATION OF TRANSFER OR DISCHARGE REQUIREMENTS occurred on 12/15/21. This policy, revised December 2016, stated, . The original notice must be given to the resident, with a copy given to the resident's representative(s) . A copy of the notice must be sent to a representative of the Office of the State Long-Term Care Ombudsman . - Review of Resident #35's medical record occurred on all days of survey. The record identified a hospitalization [DATE]-November 3, 2021, and staff notified his representative per telephone of the transfer. - Review of Resident #37's medical record occurred on all days of survey. The record identified a hospitalization [DATE]-9, 2021, and staff notified his representative per telephone of the transfer. Resident #35 and #37's medical records lacked evidence the resident/his representative received a written notice/copy of the transfer form and/or lacked evidence the facility informed the State Ombudsman of the hospital transfers. During an interview on 12/15/21 at 12:23 p.m., a managerial nurse (#1) stated the social service staff is responsible for providing a written copy of the transfer form to the resident/their representative and to the State Ombudsman.

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 4 sampled residents (Resident #13 with a skin injury. Failure to identify a skin injury/condition in a timely manner resulted in delayed treatment and may result in worsening of the skin injury/condition. Findings include: Review of the facility policy titled Guidelines for Skin Assessment and Prevention occurred on 12/15/21. This policy, revised November 2013, stated, . all residents will be assessed for the risk of skin impairment using the Braden scale assessment form [a tool that predicts the risk for developing a pressure ulcer or skin injury]. This will be completed . quarterly. Residents who score 15 or below [indicating mild to moderate risk] on the Braden Scale will have a full body skin inspection completed by the nurse weekly with their bath. Any findings will be documented in the residents' electronic medical record and interventions will be implemented per facility protocol. All residents will have a skin check weekly with their bath to be completed by the bathe aid. Any skin issues will be reported immediately to the nurse for further assessment and treatment if needed. The nurse will document the findings in the electronic medical record . CNA's [certified nurse aides] will inspect the resident's skin condition with all cares. Any adverse findings are reported to the nurse immediately. Review of Resident #13's medical record occurred on all days of survey. A physician's order, dated 10/12/18, stated, Weekly skin assessments due to Braden score of 14. The record showed Resident #13 received weekly baths. Observation on 12/14/21 at 9:26 a.m. showed a circular scab on the top of Resident #13's right great toe. Resident #13's medical record lacked evidence of a report or documentation of a right great toe skin injury and/or treatment. During an interview on 12/14/21 at 2:29 p.m., a managerial nurse (#1) stated he/she was not aware of a skin injury to Resident #13's right great toe and performed an assessment. At 3:09 p.m., the managerial nurse (#1) confirmed a skin injury/scab present on Resident #13's toe. The facility staff failed to identify and/or provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .

MEDICATION STORAGE 1. Based on observation, review of professional reference, and staff interview, the facility failed to store all medications in a secure manner in 1 of 3 medication carts (East). Failure to store all medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the professional nursing procedure reference, . Lippincott's Nursing procedures, sixth edition, pages 3-4, . verify the medication is being administered at the proper time . to reduce the risk of medication errors . never return unwrapped medications to containers . instead, dispose of them and return to pharmacy . Observation on 12/15/21 at 08:41 a.m., showed an unlabeled medication in a cup in the top drawer of the East medication cart. The medication aide (#11) stated she removed the medication from the medication cartridge for Resident (#3) at an unscheduled time and stated she planned to dispense the medication to the resident later. During an interview on 12/15/21 at 11:15 a.m., an administrative nurse (#1) stated the medication aide (#11), failed to follow acceptable practices for administering and storing medications. EXPIRED MEDICATIONS 2. Based on observation, review of facility policy, and staff interview, the facility failed to properly store medications in 1 of 1 medication storage areas. Failure to discard expired medications increases the risk of receiving outdated medications with reduced efficacy. Finding include: Review of the policy titled DISPOSITION OF MEDICATIONS occurred on 12/15/21. This undated policy stated, . The consulting pharmacist, Director of Nursing/RN (registered nurse) in charge of key are responsible for the proper disposal of drugs no longer eligible for use, such as those that have expired . all expired narcotics are to be recorded on a Drug destruction Log . Review of the double locked narcotic cabinet in the medication storage room occurred on 12/15/21 at 10:30 a.m. with two nurses, (#12 and #13). Observation showed 30-1 mg (milligram) tablets of [MEDICATION(S)] (an antianxiety medication) with an expiration date of 10/31/21 and 30-5/325 mg tablets of [MEDICATION(S)] (a narcotic) with an expiration date of 11/03/21. During an interview on 12/15/21 at 11:15 a.m., an administrative nurse (#1) agreed facility staff should have destroyed the expired medications.

Based on observation, review of facility menus and staff interview, the facility failed to serve food according to prepared menus during 1 of 1 observation of tray line (noon meal on 12/14/21). Failure to serve food according to the serving size on the menu has the potential to place residents at risk for inadequate nutrition and unplanned weight loss/gain. Findings include: Observation of the noon meal tray-line on 12/14/21 showed the following portion sizes served to residents on a regular diet: Beef Tips: 4-ounce ladle Fried Potatoes: #16 scoop (1/4 cup) Cheesy Beans: 3-ounce ladle (3/8 cup) Review of the menu identified the following portion sizes for a regular diet: Beef Tips: 3 ounces Fried Potatoes: 1/2 cup Cheesy Beans: 1/2 cup During an interview on 12/15/21 at 10:37 a.m., two administrative dietary staff members (#3 and #4) confirmed staff should follow the menu for correct serving sizes.

Based on review of resident's record, the facility's investigation into the incident, and facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 resident (Resident #4) discharged from the facility who fell during a full body mechanical lift transfer. Failure to safely utilize a mechanical lift resulted in Resident #4 falling from the lift and sustaining a serious injury and placed all residents requiring this type of transfer at risk for falls and/or injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: - Review of Resident #4's medical record occurred on 08/11/21. Diagnoses included transient cerebral ischemic attacks (TIAs), [CONDITION(S)] (CVA), [CONDITION(S)], [CONDITION(S)], and fracture of the left orbital floor. The quarterly Minimum Data Set (MDS), dated [DATE], identified dependance on two or more staff members for transfers. The care plan identified, . Resident requires extensive assist to complete ADL [activities of daily living] tasks . total lift assist of 2 for all transfers. Resident at risk for falls secondary to diagnosis, meds [medications], and occasional incontinence. dizziness due to BP [blood pressure], confusion at times. decreased physical functioning. An incident report, dated 08/03/21 at 7:31 a.m., identified, . Called to resident's room at 7:35 [a.m.] d/t [due] to resident having a fall out of transfer sling during a transfer with total lift from bed to w/c [wheelchair]. Entered room and resident laying on her back on floor and was alert. CNA [certified nursing assistant] supporting residents head and neck. 2 CNA staff were assisting with the transfer and report that the sling came out of the hook causing the sling to open and resident to fall onto floor. CNA staff reported that the resident did not lose consciousness. Observed right eye to have a laceration on eyelid and broken tooth. Nose and upper lip was [sic] bleeding. No rotation to bilateral LEs [lower extremities]. Resident was moving and anxious on floor. No apparent injury to neck. Resident was supported and lifted with sling to bed for comfort. A skin tear is observed to her right elbow and a left anterior shin. Ice was applied to right side of face. Resident's daughter [name] notified of fall and consents to ER [emergency room ] for further assessment. 911 called and arrived at 7:50 a.m. A hospital emergency room report, dated 08/03/21, identified, . The patient [was] brought in by ambulance. The history says that she fell from 2 to 3 feet high after a lift failed. She fell face first on her right side. She was actually bleeding from her face and mouth and was taken by ambulance to the emergency room . She has a small laceration on her forehead deep enough to be sutured, measuring 2 cm [centimeters] in length. Another 2 small ones parallel, also bleeding but this is mostly a fissure. The right eye is completely shut by hematoma. She had abrasions on both elbows and right knee. Legs have + [plus] 1 pitting [CONDITION(S)] below knees. She moves both legs to command laying down. Neck and head CT [cat scan] was negative for fracture or bleeding, but showed multiple facial fractures on the right side. Right hip x-ray showed fracture right iliac bone. The facility's Final Investigation Report identified, . We are unable to say for sure what exactly happened or how it happened. We can speculate that [Resident #4] may have been positioned just slightly too low in the sling and sat up and fell out of the side. We have educated the CNAs and will also work with the nurses at the next meeting to ensure they also know the protocol for total lift transfers. We have the lift that was used in the transfer put aside until the EZ Way technician can check it over and the sling was taken out as well. We will continue to do ongoing training with staff regarding total lift transfers to ensure this does not occur again in the future. During an interview on 08/11/21 at 5:00 p.m., an administrative nurse (#1) reported she added the following information to the policy after Resident #1 fell from the lift, Effective immediately the following steps must be followed during all total transfers: Two persons must be in the room. One to operate the lift and one to have the hands-on approach during the lift. Both team members must stop and call a time out once the straps have been placed. Both persons will check the straps to ensure proper placement. 8/4/2021. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the corrective action for the resident affected by the deficient practice by: * Completing an investigation with interviews of staff who assisted with the transfer on 08/03/21, * Determining staff likely positioned Resident #4 slightly to the side or too high in the sling resulting in her fall from the Hoyer lift and serious injury, and * Updating the facility's policy to include a hands-on approach and time out procedure to ensure proper placement. The facility put measures in place to ensure the deficient practice does not recur by: * Providing education to all CNA staff on August 3 and 4, 2021 ensuring a hands-on approach and time out procedure to ensure proper placement, * Auditing Hoyer lift transfers starting on 08/10/21. The survey team determined a deficient practice existed on 08/03/21. The facility implemented corrective action on 08/03/21, provided staff education on August 3-4, 2021, and audited Hoyer lift transfers through 08/10/21.

Based on observation, record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a significant change in status assessment (SCSA) for 1 of 14 sampled residents (Resident #10). Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facility's ability to accurately assess the resident's status, and identify and implement appropriate care approaches. Findings include: The Long- Term Care Facility RAI User's Manual (Version 1.5), dated (MONTH) (YEAR), page 2-22 stated, . A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without staff intervention . 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan . and page 2-25 stated, A SCSA is appropriate if there are either two areas of decline or two areas of improvement. This may include two changes within a particular domain (e.g., (for example) two areas of ADL (Activities of Daily Living) decline or improvement. Review of Resident #10's medical record occurred on all days of the survey. An Annual Minimum Data Set (MDS), dated [DATE], identified the resident as required extensive assist with transfers and toileting, and limited assist with eating. A quarterly MDS, dated [DATE], identified the resident as dependent with transfers and toileting, and extensive assist with eating. The current care plan stated, . check and change, total assist of two. Total lift for all transfers. Eating: supervision to extensive at times. (MONTH) need more assist with soups and supper meal. Review of Resident #10's medical record identified the following progress note: * 10-9-18- CNA (certified nurse aide) documentation reviewed for MDS. Resident is dependent on staff for transfers via the total lift and is also dependent on staff for toileting cares as resident is check and change. Care plan reviewed. During the survey the following observations of Resident #10 occured: * 01/02/19 at 12:13 p.m. in wheelchair in the dining room with a plate of food in front of her that she was not attempting to eat. * 01/02/19 at 12:20 p.m. an unidentified CNA feeding the resident at this time. * 01/03/19 at 08:39 a.m. two CNAs (#5 and #6) checked and changed the resident and assisted resident from the bed to the wheelchair using the total hoyer lift. * 01/03/19 at 02:54 p.m. two CNAs (#3 and #4) checked and changed the resident and assisted the resident from the bed to the wheelchair using the total hoyer lift. During an interview on 01/04/19 at 9:04 a.m. an administrative nurse, (#7) stated We (the facility) follow the RAI manual regarding completing significant change assessments and we would complete when there is two or more areas of change with ADLs. During an interview on the late morning of 01/04/19 an administrative nurse (#7) confirmed that Resident #10 required total assistance with toileting and transfers and required extensive assist with eating at times.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to follow professional standards of practice regarding medication administration for 1 of 7 residents (Resident #102) observed during medication pass. Failure to directly observe residents taking their medications may result in missed doses and/or adverse reactions. Findings include: Saxton and Clark's Geriatric Medication Handbook, 7th edition, American Society of Consultant Pharmacists, pages 148-149, stated, . Steps of Medication Administration . Patient observed while taking medications . Review of Resident #102's medical record occurred on all days of survey. A self-administration of medication assessment, dated 12/10/18, stated, . Staff will administer at this time d/t (due to) being new admission. Current physician's orders [REDACTED]. Observation of the noon medication pass on 01/02/19 identified a staff member (#1) prepared two medications for Resident #102 and left them with the resident, who was seated at the dining room table. The staff member did not observe the resident taking the medications and stated, He's a self administration. During the noon medication pass on 01/03/19, a staff member (#1) prepared two medications for Resident #102 and left them with the resident at the dining room table. During an interview on 01/04/19 at 10:21 a.m., a supervisory nurse (#2) confirmed Resident #102 may not self administer and staff should observe him taking his medications.

Based on observation, record review, resident interview, and staff interview, the facility failed to provide respiratory care consistent with physician's orders [REDACTED].#37) sampled residents receiving continuous oxygen . Failure to ensure oxygen is administered as ordered may complicate a resident's respiratory status. Findings include: Observation on all days of survey showed Resident #37 receiving oxygen from a portable tank via nasal cannula (NC) at 3 liters per minute (LPM). Review of Resident #37's medical record occurred all days of survey. The current physician's orders [REDACTED]. Medications as ordered by provider. The treatment administration record (TAR) included continuous oxygen at 4 LPM via NC. During an interview on 01/03/19 at 3:19 p.m., Resident #37 stated staff switched her from her oxygen concentrator to her portable oxygen and adjusted the flow rate. During an interview on 01/04/19 at 9:40 a.m., an administrative nurse (#2) confirmed the oxygen failed to match the physician's orders [REDACTED].

Based on record review and staff interview, the facility failed to provide rationale from the physician indicating the gradual dose reduction (GDR) recommended by the consulting pharmacist was contraindicated for 1 of 5 residents (Resident #26) reviewed for unnecessary medication. Failure of the physician to provide rationale of the contraindication may lead to the prolonged and unnecessary use of medications potentially resulting in adverse consequences. Findings include: - Review of Resident #26's medical record occurred all days of survey. physician's orders [REDACTED]. A consultant pharmacist's Departmental Note, dated 08/27/18, stated, Annual GDR for [MEDICATION NAME] due in September. A Progress Note from a nurse practitioner (NP), dated 09/12/18, rejected the recommendation and stated, As long as she is not showing any signs of side effects, we are going to continue the [MEDICATION NAME] at this dose indefinitely. The record lacked evidence the resident's physician provided rationale and/or confirmed the NP's rationale of why a GDR of [MEDICATION NAME] was contraindicated. During an interview with an administrative nurse (#2) on 01/04/19 at 8:54 a.m., she confirmed the attending physician failed to sign off on the rationale rejecting a recommendation for a GDR.