Every finding on record at Woodside Village

Based on record review and review of facility policy, the facility failed to provide appropriate supervision and/or assistance to prevent an accident for 1 of 1 discharged resident (Resident #4) who fell while ambulating. Failure to apply a gait belt around the resident's waist prior to ambulation resulted in Resident #4's fall with major injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented following the incident.Findings include: Review of the facility policy titled Standards of Care occurred on 07/01/26. This policy, dated 05/01/24, stated, . Routine Care . Each of the following is part of the routine care provided by care givers . A gait belt will be used for all assisted transfers and ambulation. The gait belt must be pulled snug for the resident's safety. Review of Resident #4 medical record occurred on all days of survey. Diagnoses included chronic fatigue syndrome, fracture of the right humerus, osteoarthritis of the right shoulder and bilateral knees, and repeated falls. The quarterly Minimum Data Set (MDS), dated [DATE], identified functional limitations in upper and lower extremity range of motion [ROM], required substantial assistance during transfers, utilized a walker, and sustained a major injury during a fall.The progress notes identified the following:* 06/08/26 at 9:11 a.m., At 0635 [6:35 a.m.] this nurse heard someone crying. This nurse went to the tub room and saw resident sitting on her bottom with her legs outstretched towards the entrance of the tub room. Staff member was supporting resident's upper back. When asking resident what happened, resident stated, I fell down. It seemed like my walker handle came out or something. [NAME] brakes/handles assessed and determined to be in safe, working condition. resident rates pain a 9 on a scale of 0-10. This nurse called [daughter] and explained the situation to her. This nurse stated that resident was having a lot of pain to her shoulder and felt that she should be seen at the ER [emergency room]. This nurse called and updated [physician]. Resident left facility at 0720.* 06/08/26 at 13:28 [1:28 p.m.], . [Facility] is reviewing the incident this AM concerning resident. Preliminary review indicates res [resident's] CP [care plan] was not followed . Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the corrective actions for other residents who may be affected by the deficient practice as follows:* Completed an investigation into Resident #4's fall with major injury,* Determined the CNA transferred Resident #4 without placing a gait belt around her waist, resulting in a fall with major injury, and placed all residents at risk for falls with/without injury,* Placed the CNA who transferred Resident #4 on administrative leave,* Re-educated staff on their standards of care/gait belt use,* Completed quality assurance audits to ensure resident safety during transfers.

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 14 sampled residents (Resident #24 and #97) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP) and hand hygiene/glove change has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 03/26/26. This policy, revised March 2025, stated, . Gloves and gowns are applied prior to performing the high contact resident care activity. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . device care or use. urinary catheter . Review of the facility policy titled Handwashing/Hand Hygiene occurred on 03/26/26. This policy, revised October 2024, stated, . Hand hygiene is indicated . Before moving from work on a soiled body site to a clean body site on the same resident . - Review of Resident #24's medical record occurred on all days of survey and identified EBP. Observation on 03/24/26 at 3:00 p.m. showed a certified nurse aide (CNA) (#3) applied gloves and emptied Resident #24's urinary catheter collection bag. The CNA failed to apply a gown prior to completing high-contact resident care. - Observation on 03/24/26 at 4:27 p.m. showed a CNA (#5) changed Resident #97's soiled incontinent product. The CNA cleansed the rectal/perineal area using a disposable wipe and without changing gloves, applied a barrier cream to the resident's buttocks. During an interview on 03/26/26 at 9:00 a.m., an administrative nurse (#4) stated she expected staff to wear a gown and gloves when emptying a urine collection bag and to remove gloves, perform hand hygiene, and apply clean gloves, after perineal care and before applying an ointment.

Based on record review, review of the facility report incident (FRI) investigation, and review of facility policy, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #4) who displayed physical behaviors towards another resident. Failure to protect residents from physical abuse may result in injury, fear, anxiety, and mental anguish. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include:Review of the facility policy, Prohibition and Prevention of Resident Abuse, Neglect, Exploitation Mistreatment and Misappropriation of Property, occurred on 12/22/25. This policy, dated 10/02/24, stated, . Policy A. Every resident has the right to be free from abuse . mistreatment . Residents must not be subject to abuse by anyone, including, but not limited to: . other residents . E. Definitions 1. Abuse - the willful infliction of injury . intimidation . with resulting physical harm .or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse may also occur . regardless of the resident's cognitive status.The surveyor determined a deficient practice existed on 09/14/25. The facility implemented and completed corrective action on 09/25/25.Review of Resident #4's medical record occurred on all days of survey. The care plan stated, I have potential for behaviors directed at others r/t [related to] cognitive impairment, disorientation and decreased impulse control r/t Lewy Body Dementia. I have impaired social interaction and may misinterpret others' actions leading to aggressive behaviors.Review of the facility's FRI investigation, dated 09/15/25, stated, At approximately 9:40 a.m. [Resident #4] was sitting . in a recliner. [Resident #7] began walking down the hallway in [Resident #4's] direction. Per camera review, upon noticing [Resident #7], [Resident #4] raised his hand and gestured in a 'shooing' manner towards [Resident #7]. As [Resident #7] continued to approach, [Resident #4] began to rise from his recliner . He then made physical contact with [Resident #7] by pushing him on the left arm and shoulder and grabbing his left wrist which caused [Resident #7] to momentarily lose his balance. [Resident #4] continued to push [Resident #7], who eventually sat down onto the nearby recliner. [Resident #4] then sat in the recliner adjacent to [Resident #7]. Shortly thereafter, [Resident #7] began to stand again. [Resident #4] stood as well. [Resident #7] did not appear to respond verbally or physically and was nonreactive. [Resident #4] then made a fist and raised it toward [Resident #7's] face but did not strike him . [Name of nurse] observed the incident from the hallway and began approaching to help intervene. As [name of nurse] neared, [Resident #4] shoved [Resident #7] with both hands in his stomach. [Resident #7] was able to maintain his balance and did not fall as he had a hold of [Resident #4's] left hand. The nurse was able to separate [Resident #7] from [Resident #4]. No further altercations or interactions between these two residents the remainder of the day. Nursing reports neither resident has recall of the event.Based on the following information, non-compliance at F0600 is considered past non-compliance. The facility implemented corrective actions for residents affected by the deficient practice as follows:Immediate Actions Taken:* Staff intervened and separated the two residents to prevent further escalation and assessed for injury. No injuries noted. * Other residents in vicinity redirected to ensure safety.* Incident reported to charge nurse and on-call administration. Report made to the North Dakota Department of Health and Human Services on 09/14/25. * Responsible parties of both residents and the Medical Doctor on-call notified of the incident on 09/14/25 by the charge nurse.* Both residents monitored the remainder of the day. Follow-Up Actions: * Completed initial meeting and investigation of incident on 09/15/25* Documented 72-hour status monitoring of both residents in electronic medical record system.* Resident #4 and #7's care plans reviewed and revised on 09/15/25. * Psychiatric Nurse Practitioner continues to conduct health consultations/medication reviews for both residents. Provider saw both residents on scheduled provider rounds on 09/17/25. * Staff education provided on 09/19/25 to the dementia unit staff on de-escalation strategies for dementia behaviors and resident-to-resident altercations.* Registered Nurse Care Coordinator provided information concerning therapeutic response techniques at the neighborhood Quality of Care meeting on 09/25/25.

Based on record review, review of the facility reported incident (FRI) investigation, and review of facility standard of care policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 closed record resident (Resident #7) who sustained a fall. Failure to remove the wheelchair foot pedals may have contributed to Resident #7's fall. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include:Review of the facility Standards of Care occurred on 12/22/25. This form, dated 10/06/25 stated, . Foot pedals will be used for all residents being transported for extended distances and removed when stationary or unless Care Planned. Review of Resident #7s medical record occurred on 12/22/25. The care plan, dated 11/04/25, stated, Ambulation: I need assist of 1 with a gait belt, hand held assist. Review of the FRI investigation, dated 11/05/25, stated, At approximately 7:50 AM CNA [certified nurse aide] [CNA #1] brought [Resident #7] to the dining room table in a wheelchair. [CNA #1] left [Resident #7] at the table with wheelchair pedals in place and then returned to the residents room down the hall to retrieve a bag of garbage. On his way to throw the garbage he stopped to speak to the RN [registered nurse] [nurse name]. In [CNA #1] written report of the incident, he indicated that on the wheelchair pedals there was a sticker that stated pedals stay on at all times. [Nurse name] confirmed that [CNA #1] had asked her about this and she clarified to [CNA #1] that the pedals should be removed. [CNA #1] did not return to [Resident #7] to remove the wheelchair pedals, instead walking to the utility room to discard the garbage. As [CNA #1] was returning toward the dining room, [Resident #7] stood up and fell, striking the back of his head on a dining room chair. [Resident #7] had been hospitalized for pneumonia and returned to our facility on 11/4/25. The wheelchair was left in his room as it was used to transport him back from the hospital. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for residents affected by the deficient practice as follows:*The nurse immediately assessed Resident #7.*Completed an investigation related to Resident #7's fall. *Resident #7's primary decision maker and physician notified. *Monitoring of Resident #7 for any signs of injury, distress or change in condition. *Incident reported to the Department of Health and Human Services. *CNA (#1) terminated on 11/11/25. *Resident #7's care plan reviewed. *Staff education provided on 11/05/25 regarding foot pedals removed from wheelchair when resident is stationary.*Wheelchair positioning audits completed.

Based on record review, review of the facility reported incident and investigation documents, and review of facility policy, the facility failed to provide appropriate supervision and devices to prevent an accident for 1 of 9 sampled residents (Resident #87) investigated for falls. Failure to ensure staff utilized footrests properly on the wheelchair caused facial injuries to Resident #87 and placed all residents transferred via wheelchair at risk for falls and/or injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 09/07/24. The facility completed the corrective action on 09/13/24. The final facility reported incident report, dated 09/13/24, stated, . [Resident #87] was being pushed in her wheelchair by CNA [certified nurse aide #8] and [Resident #87's] foot pedals were on her wheelchair but moved off to the side and not in position. When [CNA #8] started to push the wheelchair forward, [Resident #87] placed her feet down on the floor and as a result she fell face first onto the floor. The wheelchair foot pedals were not in the proper position nor used during this transport. [Resident #87] suffered a small laceration on the bridge of her nose from her glasses . She had a laceration and a hematoma to her forehead as well as swelling under her R [right] eye. Review of the facility policy titled Standards of Care occurred on 01/08/25. This policy, dated 05/01/24, stated, . Foot pedals will be used for all residents being transported for extended distances and removed when stationary or unless Care Planned. Review of Resident #87's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified dependance on staff for wheelchair transfers. The current care plan stated, . Locomotion . I use a manual WC [wheelchair] for locomotion. staff assist of one for longer distances . Foot pedals need to be on my WC when pushing the WC. The progress notes stated the following: * 09/07/24 at 1:57 p.m., . Resident on floor in hallway . * 09/10/24 at 10:14 a.m., . Res [resident] had a fall from her wheelchair 9/7/2024 and was injured. Further investigation of the fall revealed that foot pedals were on the wheelchair but not in proper position and not utilized while res was being transported in the hallway. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by: * Completed an investigation on 09/13/24, including an interview with the CNA #8 who transferred Resident #87 via wheelchair. * Determined the CNA #8 provided wheelchair transport to Resident #87 without the foot pedals in the proper position. * Placed CNA #8 on administrative leave on 09/10/24 until further investigation and education was provided. * Email education to all staff, dated 09/10/24, stated, Foot pedals or leg rests always need to be used when pushing a resident in a wheelchair. It is never acceptable to allow a resident's feet to dangle when pushing them, not even for a short distance. * Memo dated 09/13/24 addressed to all staff, stated, ANYTIME a resident is being pushed in their wheelchair the foot pedals MUST BE ON. * CNA #8 and all other nursing staff signed rosters indicating review and understanding of the 09/13/24 memo. * The charge nurses were responsible for reviewing education provided in the 09/13/24 memo after the 09/07/24 fall. * Continue weekly quality assurance audits to ensure resident safety during wheelchair transport.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #126) observed during tracheostomy cares and 1 of 1 supplemental resident (Resident #283) observed during insulin administration. Failure to practice infection control standards related to glove use/hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene occurred on 01/08/25. This policy, dated October 2024, stated, . Hand hygiene is indicated . After contact with blood, body fluids or contaminated surfaces; After touching a resident; After touching the resident's environment . The use of gloves does not replace hand washing/hygiene. Review of the facility policy titled Insulin Pen Injections occurred on 01/08/25. This policy, dated January 2023, stated, . Technique . Gather equipment . Perform hand hygiene . Preparing insulin pen . Apply clean gloves . Select appropriate site . Administer injection. - Review of Resident #126's medical record occurred on all days of survey. The record identified a tracheostomy, enhanced barrier precautions, and a recent Influenza A infection. Observation on 01/09/25 at 11:38 a.m. showed a staff nurse (#5) applied a gown and gloves, prepared for the sterile portion of Resident #126's tracheostomy cares, and handed the resident a paper napkin to cough into during care. The nurse (#5) completed the sterile portion of the care, removed the sterile gloves, performed hand hygiene, and applied clean gloves to complete the non-sterile portion of the care. The nurse removed the used paper napkin from Resident #126's hands, cleansed the ostomy site with cotton swabs and a solution of peroxide and saline, and threw the cotton swabs into the garbage. The nurse (#5) handed the same used paper napkin to the resident, and with the same gloves, touched many items in the resident's room, then removed the gown and gloves, performed hand hygiene, and exited the room. The nurse (#5) failed to remove the soiled gloves, perform hand hygiene, and apply new gloves before moving on to other tasks. During an interview on 01/08/25 at 2:35 p.m., two administrative nurses (#6 and #7) stated they expected staff to remove their contaminated gloves and perform hand hygiene before moving on to other tasks. - Review of Resident #283's medical record occurred on 01/08/25. Physician's orders showed Insulin Glargine 12 units and Novolog 3 units sub-cutaneous injections daily. Observation on 01/08/25 at 8:41 a.m. showed a nurse (#4) performed hand hygiene and without applying gloves, administered Resident #283's insulin injections. During an interview on 01/08/25 at 4:53 p.m., an administrative staff member (#2) confirmed she expected nurses to wear gloves while administering an injection.

Based on information provided by the complainant, record review, review of the facility's policy and staff interview, the facility failed to notify the resident representative for 1 of 1 confidential resident (Resident A) who experienced a fall. Failure to notify the resident representative of a fall limits their ability to make informed decisions regarding medical care. Findings include: Information received from the complainant indicated the facility staff failed to notify the resident's representative of a fall. Review of the facility policy titled Fall Investigation occurred on 01/23/24. This policy, dated December 2022, stated, . Calls and notifications . These notifications are a standard of care. include notification to family or responsible party. Include name, date and time of notification. Licensed nurse completing form needs to sign and date upon completion. Review of Resident A's medical record occurred on 01/23/24. An admission Minimum Data Set (MDS), dated [DATE], identified receiving an anticoagulant (blood thinner) and hemodialysis. Diagnoses included atrial fibrillation and a history of deep vein thrombosis (blood clot). Medications included apixaban (anticoagulant) 2.5 milligrams twice daily. An artriovenous fistula (access for hemodialysis) located in the resident's left arm and utilized for dialysis on Monday, Wednesday, and Friday. Resident A's progress notes showed the following: * 12/24/23 at 2:54 a.m., . Resident was found in his bathroom by staff at 0045 [12:45 a.m.]. Resident was sitting in the corner right below his sink and bathroom cupboard. Resident stated that he was trying to move his W/C [wheelchair] in his bathroom as it was blocking the toilet. Resident stated he couldn't find his call light and tried to call for assistance but instead transferred himself. While moving the W/C in the bathroom he slipped and fell . Vitals and resident was assessed for injury. Resident denied pain and was only complaining of a cold bottom from sitting on the bathroom floor. Total hoyer lift [full body mechanical lift] used to get resident off the floor. Resident then used toilet after getting assisted off the floor. * 12/26/23 at 11:29 a.m., Health Status Note Data: Discoloration noted to left low back. Action: NP [nurse practitioner] notified. Voicemail left with PDM [primary decision maker]. No further documentation noted in the progress notes regarding the discoloration on Resident A's left low back or PDM's response. The medical record lacked evidence staff notified the resident representative of Resident A's fall or cause for bruising. During an interview on 01/23/24 at 5:00 p.m., an administrative staff member (#1) confirmed staff failed to notify the resident representative of Resident A's fall.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 26 sampled residents (Resident #103). Failure to accurately code the MDS does not allow each resident's assessment to reflect their status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, pages J-34 and J-36 stated, . J1800: Any Falls Since Admission/Entry . Code 1, yes, if the resident has fallen since the last admission . J1900: Number of Falls Since Admission/Entry . Code 1, one, if the resident had one major injurious fall since admission/entry or reentry or prior assessment . - Review of Resident #103's medical record occurred on all days of survey. A progress note, dated 10/18/2023 at 2:25 p.m., stated, . Aware of activity [fall] that occurred on 10/17/2023. [Resident #103] is independent with transfers and ambulation. [Resident #103] was taking [sic] to [Hospital] via ambulance which x-rays showed closed displaced fracture of right femoral neck. Resident was admitted to [Hospital] . The discharge/return anticipated MDS, dated [DATE], failed to identify a fall at J1800 and a fall with major injury at J1900 C. During an interview on 11/30/23 at 10:00 a.m., a managerial nurse (#6) confirmed staff failed to code a fall with major injury on the MDS.

Based on observation, record review, review of the facility's policy, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 12 sampled residents (Resident #112) observed during stand-lift transfers. Failure to ensure proper use of a mechanical stand-lift resulted in Resident #112 experiencing pain and placed him at risk for possible accidents with/without injury. Findings include: Review of the facility policy titled . Sit-to-Stand Lift occurred on 11/30/23. This policy, revised January 2017, stated, . Encourage the resident to use their arms and legs while being lifted. Note: Resident must be able to weight bear during transfer. - Review of Resident #112's medical record occurred on all days of survey. Diagnoses included a history of falls. The current care plan stated, . I transfer with the stand lift with assist of 1 from wheelchair or toilet and assist of one to get out of bed. Observation showed the following: * 11/27/23 at 3:21 p.m., a certified nurse aide (CNA) (#7) toileted Resident #112. The CNA lifted Resident #112 approximately six inches in a sit-to-stand lift before transferring him into and out of the bathroom. Resident #112 remained in a semi-seated position with the harness straps pulling upward into his armpits, raising his shoulders to ear level, extending his elbows out horizontally. As the CNA (#7) transferred Resident #112 out of the bathroom, one of the resident's elbows hit the doorframe, and he stated, ow, ow, ow in a loud voice. The CNA failed to ensure Resident #112 could bear weight while in the stand lift and failed to ensure his arms cleared the doorframe before pushing him out of the bathroom. * 11/28/23 at 9:40 a.m. and at 3:01 p.m., two CNAs (#8 and #10) toileted Resident #112. The CNAs lifted Resident #112 approximately twelve inches in the sit-to-stand lift before transferring him into and out of the bathroom. Resident #112 remained in a semi-seated position with the harness straps pulling upward into his armpits, raising his shoulders to ear level. The CNA (#8 and #9) failed to ensure Resident #112 could bear weight while in the stand lift. During an interview on 11/30/23 at 10:00 a.m., an managerial nurse (#6) confirmed staff should ensure residents can bear weight while utilizing the stand lift and should report to the charge nurse if they are unable to do so.

Based on observation and staff interview, the facility failed to maintain the food preparation and service area in a sanitary manner for 1 of 3 kitchenettes (Prairieview) observed. Failure to serve food in a sanitary environment has the potential to result in contamination of food and could result in a foodborne illness. Findings Include: Observation of the Prairieview kitchenette occurred on 11/29/23 at 11:00 a.m. with an administrative dietary staff member (#9). Observation showed a tower fan with accumulated dust clumps blowing toward the food service area where staff prepared food for residents. During an interview on 11/30/23 at 8:33 a.m., an administrative dietary staff member (#9) confirmed the facility does not have a process or schedule for cleaning fans and expected them to be dust free.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 1 of 4 neighborhoods (Oakcrest) observed with Covid-19 outbreak, and 1 of 1 sampled residents (#60) observed with a catheter. Failure to practice infection control standards related to use of personal protective equipment (PPE), and proper care of a catheter has the potential to spread infection throughout the facility. Findings Include: PERSONAL PROTECTIVE EQUIPMENT Review of the facility policy titled Transmission-Based Precautions occurred on 11/30/23. This policy, revised July 2023, stated . Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection . are additional measures that protect staff, visitors, and other residents from becoming infected . Droplet precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets . Masks and eye protection will be worn when entering the room . During an interview on 11/27/23 at 1:30 p.m., an administrative staff member (#1) identified Covid positive residents on the Oakcrest neighborhood and stated staff were to wear N95 respirators and eye protection while on the neighborhood. Observation showed the following: * 11/27/23 at 6:00 p.m., an administrative nurse (#2) left the Oakcrest neighborhood without removing her N95 facemask and goggles and went to the administrative wing to make copies. * 11/28/23 at 7:57 a.m., an unidentified staff member exited the closed double doors of the Oakcrest neighborhood wearing an N95 facemask and goggles. The staff member stood by the elevator, looked at her phone, then re-entered the neighborhood. The staff members failed to remove their PPE before exiting the Covid area. URINARY CATHETER CARE Review of the facility policy titled Guidelines for Preventing Urinary Tract Infections Catheter-Associated occurred on 11/30/23. This policy revised June 2019 stated, . always practice hygiene and standard precautions when handling catheter systems . do not place the drainage bag on the floor . Review of resident #60's medical record occurred on all days of survey. A physician's order, dated 03/02/23, identified an indwelling Foley catheter. The current care plan, dated 3/01/23 stated . I have an indwelling Foley catheter related to urinary retention . history of urinary tract infections (UTI's) . I have a dignity bag for my catheter . ensure catheter bag cover is on (Dignity Bag) Observation on 11/28/23 at 9:05 a.m. showed a urine collection bag attached to Resident #60's lower leg. As the resident propelled in a wheelchair, the drainage tip of the collection bag dragged on the carpeted floor. Facility staff failed to secure the urine collection bag to the resident's leg to prevent the tip from touching the floor and failed to place the collection bag in dignity bag for privacy and protection. During an interview on 11/30/23 at 10:43 a.m., an administrative nurse (#1) stated she expects staff to position urine bags to keep them from dragging on the floor and to place them in a dignity bag. 42397

Based on observation, review of facility policy, and staff interview, the facility failed to store food and beverages in a sanitary manner for 3 of 4 dining/kitchenette areas (Heartland, Prairieview, and Oakcrest). Failure to discard milk-based nutritional beverages by the throw by date, maintain clean refrigerators for storage of food and beverages, and label food prior to placing in the refrigerator or freezer has the potential to result in the spread of foodborne illness to residents, staff, and visitors. Findings include: Review of the facility policy titled Food Storage occurred on 11/02/22. This policy, revised 2017, stated the following: . N. All refrigerator units are kept clean . O. Refrigeration: . All foods should be covered, labeled and dated. P. Frozen Foods: . Foods should be covered, labeled and dated. Observation of the posting on the main kitchen's freezer door on 11/02/22 at 2:13 p.m. stated, Starting Monday August 9th Mighty Shakes [a milk-based nutritional supplement] will be labeled with a throw by date instead of the date they were pulled from the freezer. Observation during the dietary tour on 11/02/22 at 12:28 p.m. with the food service supervisor (#5) showed the following: * Heartland: - One unlabeled/undated container of food in a hallway refrigerator. * Prairieview: - Three unlabeled/undated food containers in a kitchenette freezer. - Four containers of chocolate Mighty Shakes with throw by dates of 10/31/22 in a kitchenette refrigerator. * Oakcrest: - Four containers of vanilla Mighty Shakes with throw by dates of 10/31/22 in a kitchenette refrigerator. - A small overflow resident refrigerator contained an unlabeled/undated bag of corn on the cob and plastic food container, and an orange substance covered the bottom of the refrigerator. During an interview on 11/02/22 at 2:13 p.m., the food service supervisor (#5) stated she expected staff to dispose of unlabeled/undated food found in the refrigerators/freezers and dispose of Mighty Shakes based on the throw by date.

Based on 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 2 sampled residents (Resident #14) who experienced a significant change in status. 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 identity and implement appropriate care approaches. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.15), dated October 2017, 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 or more areas of decline or two or more 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 #14's medical record occurred on all days of survey. An admission Minimum Data Set (MDS) dated [DATE] identified the resident was independent with bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, eating, toilet use, and supervision with hygiene. The medical record identified Resident #14 was hospitalized [DATE] - 07/21/22. A quarterly MDS, dated [DATE], identified the resident required extensive assistance with bed mobility, transfers, walk in room, locomotion on and off the unit, dressing, eating, toilet use, and hygiene. A resident progress note dated 07/28/22 at 1:49 p.m., stated, [resident] triggered for significant change in status on MDS, however, it was expected upon return from hospital on 07/21/22, that he would have a change, but would improve . Continued improvements expected. A Quarterly MDS dated [DATE] identified the resident required extensive assist with bed mobility, transfers, walk in room, locomotion on and off the unit, dressing, eating, toilet use, and hygiene. The record lacked evidence why staff failed to complete a SCSA following Resident #14's continued decline. During an interview on 11/02/22 at 8:00 a.m., a care coordinator (#4) confirmed staff failed to complete a significant change in status assessment after Resident #14 did not return to status after hospital return 07/21/22 and after further observation from the Quarterly MDS completed 07/27/22.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to implement pressure ulcer prevention measures for 1 of 5 sampled residents (Resident #87) utilizing pressure-relieving devices. Failure to ensure orders for pressure-relieving boots were followed and consistent with the care plan and the treatment administration record (TAR) (and updated on the care plan and TAR) may result in the development of new and/or reopening of previously healed pressure ulcers. Findings include: Review of the facility policy titled Skin Prevention Protocol occurred on 11/03/22. This policy, revised November 2020, stated, . Purpose: To prevent the breakdown of skin integrity . and incorporating interventions to alleviate/minimize pressure . Review of the facility policy titled Physician Orders, Transcription of occurred on 11/03/22. This policy, revised June 2007, stated, . All new orders are to be transcribed to the appropriate location, such as . TAR . Review of Resident #87's medical record occurred on all days of survey and showed the following: * Current signed physician's orders included, Prevalon boot (specialized boot to relieve pressure) to bilateral feet for potential for high risk skin breakdown to be worn at all times . A skin assessment dated [DATE], showed the resident had a stage 2 pressure ulcer to his left foot first toe acquired in the facility and healed on 09/07/22. A second skin assessment, dated 09/20/22, showed another stage 2 pressure ulcer to his right foot second toe acquired in the facility and healed on 9/20/22. * Current care plan stated, . I have an actual impairment to skin integrity on my left great toe and right second toe . Please follow prescribed treatments and/or interventions as ordered. I wear prevalon boots and heel protectors on when in bed. The October and November 2022 TAR included the following, Prevalon boot to bilateral feet for potential for high risk skin breakdown to be worn at all times . The facility failed to ensure the care plan matched the current orders and TAR. Random observations on all days of survey showed Resident #87 in his wheelchair or recliner without Prevalon boots. During an interview on 11/02/22 at 11:34 a.m., a nurse (#1) verified Resident #87's record contained no order for the change of Prevalon boots at all times to only when in bed. The facility failed to ensure the medical record correctly and consistently reflected the use of pressure-relieving boots to prevent new pressure ulcers and/or the reoccurrence of healed pressure ulcers.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 2 of 8 sampled residents (Resident #12 and #41) observed during a transfer. Failure to use a gait belt and or use it correctly when transferring a resident placed the residents at risk for falls and injury. Findings include: Review of the facility policy titled Gait Belt occurred on 11/03/22. This policy, revised 2017, stated, 1. Policy: Valley Senior Living will utilize gait belts to aid in the transfer of residents from a sitting to standing position for residents who are partially dependent, have some weight-bearing capacity, and are cooperative. - Review of Resident #12's medical record occurred on all days of survey. The current care plan stated, TRANSFER . I transfer with assist of one with a gait belt . Observation on 11/02/22 at 1:50 p.m. showed a certified nursing assistant (CNA) (#2) assisted Resident #12 off the toilet with a gait belt placed around the resident's waist. The CNA instructed the resident to stand as she lifted under the resident's arms. The CNA failed to use the gait belt to transfer the resident from the toilet to the wheelchair. - Review of Resident #41's medical record occurred on all days of survey. The current care plan stated, TRANSFER . I transfer with assist of one and a gait belt . Observation on 11/01/22 at 9:42 a.m. showed a CNA (#3) transferred Resident #41 from the wheelchair to the bed. The CNA pulled on the back of the resident's pants during the transfer. The CNA failed to use a gait belt during the transfer. During an interview on the morning of 11/03/22, an administrative nurse (#1) confirmed she expected staff to follow the care plan and utilize a gait belt to transfer Resident #12 and #41.

Based on observation, record review, and staff interview, the facility failed to provide/offer fluids to 1 of 6 sampled residents (Resident #8) observed during cares and required staff assistance for fluid intake. Failure to offer/encourage fluid intake may result in dehydration, constipation, and urinary tract infections. Findings include: Review of Resident #8's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . I have an ADL [Activity of Daily Living] self-care performance deficit r/t [related to] Dementia and right-sided weakness . I require total assistance by staff to eat . Provide and serve a pureed diet and honey/moderately thick liquids . Encourage good nutrition and hydration in order to promote healthier skin. Observation on 11/01/22 at 10:45 a.m. showed a certified nursing assistant (CNA) (#9) and an unidentified CNA assisted Resident #8 with cares and transferred the resident to the wheelchair. The resident had a disposable cup full of thickened liquid and a nosey cup (cup with opening for the nose) on the bedside table. The CNAs failed to offer the resident thickened liquids with cares. Observation on 11/02/22 at 10:40 a.m. two CNAs (#9 and #10) assisted the resident into bed and failed to offer fluids to the resident. Observation on 11/02/22 at 4:15 p.m. showed two CNAs (#11 and #12) assisted Resident #8 into the wheelchair and transported the resident to the TV area. The CNAs failed to offer fluids to the resident. A large nosey cup full of an orange thickened liquid and a disposable cup of thickened water sat on the resident's bedside table, untouched. During an interview on 11/03/22 at 10:30 a.m., an administrative nurse (#8) stated she expected staff to offer Resident #8 fluids with every interaction.

Based on record review, facility policy review, and staff interview, the facility failed to ensure orders for as needed (PRN) [CONDITION(S)] drugs were limited to 14 days for 1 of 1 sampled resident (Resident #105) receiving a PRN antianxiety medication. Failure to ensure the physician renewed the PRN order after 14 days may result in the resident receiving an unnecessary medication. Findings include: Review of the facility's policy titled [CONDITION(S)] Drugs occurred on 11/03/22. This policy, revised April 2017, stated, . PRN orders for [CONDITION(S)] drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration [sic] the PRN order. Review of Resident #105's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, depression, and anxiety. The current physician's orders identified [MEDICATION(S)] [antianxiety medication] Tablet 0.5 MG [milligrams]. Give 0.5 mg by mouth every 4 hours as needed for anxiety . re-eval [re-evaluate] with hospice nurse every 30 days and document visit. Resident #105's medical record identified the resident discharged from hospice care on 09/23/22. The medical record identified the physician last evaluated the PRN [MEDICATION(S)] on 10/04/22. The record lacked evidence the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication every 14 days after discharged from hospice. During an interview on 11/02/22 at 10:38 a.m., a care coordinator (#4) confirmed the provider failed to review the PRN medication every 14 days.

Based on observation, review of facility policy, and resident and staff interview, the facility failed to ensure an environment free from accident hazards on 4 of 4 resident neighborhoods (Heartland, Hearthstone, Oakcrest, and Prairieview). Failure to ensure safe water temperatures and secure chemical storage may result in injuries to residents. Findings include: HOT WATER TEMPERATURES Review of the facility policy titled Hot Water Temperature Procedure occurred on 06/10/21. This policy, revised October 2017, stated, . Hot water shall be provided for essential functions of the skilled nursing centers, assisted living, and independent living areas. Water shall be maintained at 115 [degrees] Fahrenheit. During an interview on 06/08/21 at 5:33 p.m., Resident #90 stated, It [the water] gets a little hot, but I like it. You could get scalded if [you] stay in it too long. Water temperature measurements obtained in each of the four resident neighborhoods on the morning and afternoon of 06/08/21 and the morning of 06/09/21 showed the following: *Room 110: 126.1 degrees Fahrenheit (F) *Room 111: 125.3 F *Room 114: 126.6 F *Room 117: 125.8 F *Room 123: 120.6 F *Room 138: 122.1 F *Room 142: 125.5 F *Room 145: 124.1 F *Room 150: 122.8 F *Room 151: 120.4 F *Room 154: 120.5 F *Room 164: 120.3 F *Room 211: 127.3 F *Room 214: 124.7 F *Room 240: 122.4 F *Room 246: 127.3 F *Room 247: 125.7 F *Room 245: 125.4 F During an interview on the morning of 06/10/21, administrative staff members (#1 and #2) agreed the water was too hot for residents. CHEMICAL STORAGE Review of the facility policy titled Security Procedures for Access to Supplies occurred on 06/10/21. This policy, revised May 2016, stated, . All chemicals must be kept in visual sight of the housekeeper/custodian unless in locked storage area. Observations on 06/07/21 at 1:01 p.m., 06/09/21 at 10:54 a.m., and 06/10/21 at 10:00 a.m. on Prairieview neighborhood, showed cleaning chemicals (Symmetry foaming hand sanitizer, Easy Task Wipes and Generations Bowl Cleaner) unsecured on a cleaning cart and unattended by a housekeeper (#4). During an interview on 06/10/21 at 11:20 a.m., a housekeeping director (#5), confirmed staff should lock all chemicals inside the housekeeping cart.

Based on observation, record review, review of the facility policy, and staff interview, the facility failed to ensure proper respiratory care for 1 of 1 sampled resident (Resident #50) with orders for oxygen (O2) therapy. Failure to provide oxygen as ordered may complicate the resident's respiratory status. Findings included Review of the facility policy titled Oxygen Therapy occurred on 06/10/21. This policy, dated October 2018, stated. Assessment . Review resident's medical record for medical order for oxygen, note delivery method, flow rate . Documentation . Record the respiratory assessment findings, method of oxygen delivery, oxygen flow rate . in electronic medical record. Review of Resident #50's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 04/04/17, showed, O2 continuously at 3 Liters per nasal cannula (NC) every shift . The current care plan stated, . I have [CONDITION(S)]/[CONDITION(S)] . OXYGEN SETTINGS: O2 @ 3L [liters] per nasal cannula continuously. Observations on 06/08/21 at 10:21 a.m., 06/09/21 at 8:19 a.m., and 06/10/21 at 11:19 a.m. showed Resident #50 lying in her bed with a nasal cannula in place and the oxygen concentrator flow rate set at 4 liters. During an interview on 06/10/21 at 11:37 a.m., an administrative staff member (#3) confirmed Resident #50's oxygen flow rate is ordered at 3L and staff should set the concentrator at 3L, not 4 liters.

Based on observation, record review, and resident and staff interview, the facility failed to provide treatment and services in a manner to maintain the highest practicable physical well-being for 1 of 5 sampled residents on hospice(Resident #97). Failure of staff to adequately control the resident's pain resulted in Resident #97 experiencing pain/discomfort. Findings include: Review of the facility policy titled Pain Management occurred on 06/10/21. This policy, dated December 2001, stated, . Pain in residents will be assessed and treated properly and consistently to ensure the highest level of pain relief possible. Review of Resident #97's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician's orders showed, . [MEDICATION(S)] (Concentrate) Solution 20 MG[milligrams]/ML[milliliter]. Give 2 milligram by mouth every 1 hours as needed for SOB [shortness of breath] / Pain give 0.1mL . APAP Tablet 325 MG (Acetaminophen) Give 650 mg by mouth two times a day for pain . [Document] Pain medication offered and declined . Resident #97's medical record identified admission to Hospice on 05/25/21 and an unstageable pressure injury to her coccyx with a treatment ordered every other day or as needed. A significant change minimum data set (MDS), completed on 04/27/21, indicated the resident rated her pain 7 of 10 (signifying intense pain per the numeric pain scale) and experienced frequent pain in the last 5 days causing her to limit her day-to-day activities. The MDS also showed a BIMS (Brief Interview for Mental Status) of 13, identifying the resident as cognitively intact. Observation on 06/08/21 at 10:01 a.m., showed a staff nurse (#6) perform a dressing change to Resident #97's coccyx. The resident verbalized pain multiple times during the procedure. The nurse stated she premedicated the resident prior to the dressing change. Review of the resident's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Random observations showed Resident #97 calling out for help from her room: * On 06/08/21, shortly after the coccyx dressing change completed, Please help me. I hurt. * On 06/08/21 at 10:40 a.m., Please help me. I hurt. Please help the pain go away. Please come and help. * On 06/09/21 at 2:33 p.m., Please help me. Please. Please help me. Observations showed facility staff failed to enter Resident #97's room to assess her needs. Review of Resident #97's eMAR, May 25, 2021 through June 9, 2021, identified the resident took all doses of her scheduled Tylenol, did not refuse/decline any offers for pain medications, and received the as needed [MEDICATION(S)] only once a day on 9 of the 16 days, when the resident could have received the [MEDICATION(S)] every hour. The medical record lacked evidence of routine pain assessment and monitoring. During an interview on 06/09/21 at 2:33 p.m., Resident #97 stated she did not feel her pain was controlled, reached out and stated, I want my bottom to feel better. Please help me. During an interview on 06/10/21 at 10:28 a.m., and administrative staff member (#3) agreed the facility did not effectively control resident #97's pain.