Every finding on record at Life Care Center of Seneca

The facility had a census of 39 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2024, Quarter 1 and 2, indicated the facility had excessively low weekend nurse staffing Review of the facility's weekend nursing schedules for the above Quarters revealed the facility had adequate staffing. On 04/30/25 at 08:00 AM, Administrative Nurse D verified the facility had not submitted the correct information for weekend nursing staffing and stated Administrative Staff B was responsible for submitting the PBJ information. Administrative Nurse D stated the Centers for Medicare and Medicaid Services (CMS) had done a PBJ audit in December and had cleared the facility. The facility's Staffing Posting and Payroll Based Journal (PBJ) Submission Policy, revised 04/22/25, documented the facility maintained adequate staff on each shift to meet residents' needs, posts daily staffing data, and furnishes staffing information to the state as specified in the Federal regulations. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

The facility had a census of 39 residents. The sample size included 13 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control procedures for R33 who had enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), and failed to adhere to personal cares and change gloves for Resident (R) 2 who had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) and failed to adhere to infection control procedures when dietary staff placed a rubber dish tub on the table with dirty dishes while the residents were still eating their meal. This placed the residents at increased risk for infection. Findings included: - On 04/29/24 at 10:00 AM, observation revealed Certified Nurse (CNA) N and CNA P entered the room of R2, who was on EBP. Observation revealed a sign posted on the outside of the resident's room giving instructions on personal protective equipment (PPE - gown and gloves). The PPE equipment and supplies were located in a plastic storage tote outside the resident's room in the hallway. Continued observation revealed CNA N and CNA P donned gowns and gloves and entered the resident's room. CNA N cleansed the resident's suprapubic tubing (a thin flexible tube that drains urine from the bladder through a small incision in the lower abdomen) and cleaned around the tubing insertion site and the first few inches of the catheter tubing. Then reposition the gauze sponge around the catheter tubing. CNA N removed her gloves and washed her hands. On 04/29/25 at 10:10 AM, observation revealed CNA N and CNA P transferred R2 from her bed to the shower chair with a sit-to-stand lift. R2 stated she just had a BM, and CNA N removed the resident's incontinent brief and cleansed the resident with peri wipes, then lowered the R2 onto the shower chair. Continued observation revealed CNA N continued to wear the same gloves she cleaned the residents with and opened the closet doors, and got the residents' shirt, pants, then went to her dresser and got a pair of socks. CNA N proceeded to open the resident bathroom door with the same gloves still on and got an incontinent brief. CNA N then removed her gloves and used hand sanitizer, and transported the resident to the shower room. On 04/30/25 at 08:00 AM, Administrative Nurse D verified that the staff should wear PPE when providing care for R2 and should change their gloves after personal cares. Administrative Nurse D said the facility would do some education with the staff regarding wearing PPE for resident care and when to remove the gloves between personal cares. The facility's Infection Prevention and Control Program policy, dated 06/13/2024, documented the facility has an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible, and reviews and updates the IPCP annually and as necessary. The facility has systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff, and visitors. This system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility, and procedures for reporting possible incidents of communicable disease or infections. Written standards, policies, and procedures for the program, which must include, but are not limited to, hand hygiene procedures to be followed by staff involved in direct resident contact. The policy documented the facility would ensure staff followed the IPCP's standards and procedures (hand hygiene and appropriate use of PPE), while other needs were specific to particular roles, responsibilities, and situations, such as injection safety and point of care testing. Surveyor: [NAME], [NAME] - R33's Electronic Medical Record (EMR) documented that R43 had diagnoses of obstructive and reflux uropathy (a condition where the normal flow of urine through the urinary tract is blocked, while reflux uropathy (vesicoureteral reflux or VUR) is when urine flows backward from the bladder to the ureters (small tubular structure that drains urine from the bladder) and kidneys (a pair of organs in the abdomen which remove waste and extra water from the blood (as urine), and help keep chemicals (such as sodium, potassium, and calcium) balanced in the body) instead of flowing forward). R33's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R33 had short and long-term memory problems and severely impaired cognition. The MDS documented R33 had a urinary catheter, frequent incontinence of urine, and no urinary tract infection (UTI - infection in any part of the urinary system). R33's Care Plan, revised 04/22/25, documented R33 dependent on staff with toileting. The plan documented the resident had a urinary catheter and instructed staff to encourage R33 to drink fluids and administer medications as ordered. The plan instructed staff to observe R33 for signs or symptoms of a UTI, provide catheter care every shift, position the catheter bag and tubing below the level of the bladder, and check the catheter tubing for kinks. The plan documented R33 was on enhanced barrier precautions (EBP). Review of R33's clinical record revealed R33 had positive UTIs on 09/07/24,12/19/24, and 04/23/25. On 04/29/25 at 09:20 AM, Certified Nurse Aide (CNA) M and CNA O donned a gown, applied masks, and gloves outside R33's room door, then entered the room with a sit-to-stand lift. CNA M placed a lift jacket on R33, while CNA O took off R33's heel protector boots. CNA O unhooked R33's catheter bag from underneath the wheelchair seat, draped it over the sit-to-stand lift machine, and placed the strap around the back of R33's lower legs. CNA O slowly raised R33 with the lift machine control and transferred him over the toilet. CNA M pulled R33's pants down, removed the incontinent brief, placed it in the trash, removed and discarded gloves, then CNA O lowered the resident onto the toilet. CNA M both stepped out of the bathroom so the resident could have privacy. R33 reported he was done. CNA M provided back perineal care and catheter care, removed and discarded gloves, applied new gloves, then placed a new incontinent brief on the resident. CNA O left R33's room with her gown still on, went down the west hall to the soiled utility, stood outside the soiled utility, then removed her gown and placed it in the soiled utility room. On 04/29/25 at 09:22 AM, CNA O verified she had left her gown on when she left R33's room and stated she should have taken it off and discarded it in the resident's room. On 04/30/25 at 10:33 AM, Administrative Nurse D stated that if a resident was on EBP, staff should remove his/her gown before he/she exited R33's room. The facility's Enhanced Barrier Precautions (EBP) Policy, revised 04/22/25, documented EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Personal protective equipment (PPE) for enhanced barrier precautions was only necessary when performing high-contact care activities. - On 04/28/25 at 12:06 PM, Dietary Staff (DS) BB placed a plastic tub of dirty dishes on a table where residents were eating their noon meal and continued to place dirty dishes in the pan from other tables. DS BB left the dirty dishpan on the table and asked residents who entered the dining room what they would like to drink. On 04/30/25 at 10:33 AM, Administrative Nurse D verified the above finding and stated she had been concerned also, so she asked Certified Dietary Manager (CDM) CC about the concern and was told staff could place the dirty dishpan on the table if it was only half full. On 04/30/25 at 10:43 AM, CDM CC stated staff should not place a dirty dishpan on a table with residents who are still eating. The facility's Infection Prevention and Control Program (IPCP) and Plan policy, revised 06/13/24, documented methods to reduce the risks associated with procedures, including applicable precautions, as appropriate, based on care, treatment, and service setting. 32358

The facility had a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure an environment free from chemicals and hazards for four cognitively impaired, independently mobile residents who resided in the facility. Findings included: - On 04/28/25 at 09:00 AM, observation during initial facility tour revealed an unlocked housekeeping room door on the East Hall. The housekeeping room contained the following: Two 32-ounce (oz) bottles of Diversey clinging toilet bowl cleaner, with the warning may cause burns, damage to eyes, and be harmful if swallowed, and keep out of reach of children. One 32-oz bottle of Diversey [NAME] Sporicidal disinfecting cleaner, with the warning may cause severe skin burns and serious eye damage and may be corrosive to metals, and keep out of reach of children. One gallon jug of Prominence heavy-duty cleaner, with the warning may cause eye irritation, mildly irritating to skin, irritating to mouth, throat, stomach, and respiratory tract. One 15-oz spray can of IND/COM disinfectant cleaner, with the warning may cause skin and eye irritation, and potentially severe burns and damage, and keep out of reach of children. On 04/28 at 09:05 AM, Maintenance Staff U verified the chemicals in the unlocked housekeeping room and stated the housekeeping door should be locked and the chemicals were to be stored in a locked, secure location. Maintenance Staff U verified the door had a keypad on the hallway door side, and on the inside of the door, it had a lever that allowed it to be positioned to keep the door unlocked. Maintenance Staff U verified the inside door lever was turned to the unlocked position, which allowed the door to remain unlocked. On 04/30/25 at 08:00 AM, Administrative Nurse D verified that the housekeeping room should always be locked and chemicals should not be accessible to the residents. The facility Storage of Chemicals, dated 06/17/2024, documented the facility would store chemicals in accordance with manufacturer guidelines while maintaining supervision while in use. The policy documented the resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The policy documented the facility would maintain supervision of chemicals when in active use, and when not actively in use, would be stored out of reach of residents in accordance with Globally Harmonized System (GHS) for classification and Labeling of Chemicals. The policy recorded all flammable and combustible materials must be clearly labeled, and they must be stored in approved storage cabinets or inside a storage area.

The facility had a census of 39 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of blood sugars (a system which measures blood glucose in the body) outside of ordered parameters for one resident, Resident (R) 28 and failed to hold insulin (medication that lowers the level of glucose [a type of sugar] in the blood) when the medication was out of the physician ordered parameters. This placed the residents at risk for adverse effects related to medication. Findings included: - The Electronic Medical Record (EMR) for R28 documented diagnoses of Diabetes Mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R28 had intact cognition. R28 required partial assistance of staff for upper body dressing, toileting, and ambulation. The MDS documented R28 received three days of insulin (a hormone that lowers the level of glucose in the blood) and seven days of antidepressant (a class of medications used to treat mood disorders) medication during the look-back period. R28's Quarterly MDS, dated [DATE], documented intact cognition. R28 required set-up assistance for eating, dressing, and personal hygiene. R28 received seven days of insulin and antidepressant medication during the lookback period. R28's Care Plan, dated 02/19/25, initiated on 05/09/24, directed staff to perform Accu-checks (blood glucose monitoring test) as ordered, administer medications as ordered, and provide her diet as ordered. The Physician's Order, dated 05/09/24, directed staff to notify the physician if R28's Accu-checks were below 70 milligrams (mg) per deciliter (dL) or above 400 mg/dL. R28's Medication Administrative Record, dated February 2025, documented R28's blood sugar was out of parameters and the physician was not notified for the following days. 02/15/25 - 61 mg/dl 02/18/25 - 48 mg/dl 02/21/25 - 56 mg/dl 04/23/25 - 52 mg/dl 02/27/25 - 55 mg/dl R28's Medication Administration Record, dated March 2025, documented R28's blood sugar was out of parameters, and the physician was not notified on the following day: 03/05/25 - 68 mg/dl The Physician's Order, dated 02/05/25, directed staff to administer Lantus (insulin) 20 units (U) at bedtime and hold if her blood sugar was less than 120 mg/dl. This order was discontinued on 02/26/25. R28's Medication Administration Record, dated February 2025, documented the following days R28 received her insulin when her blood sugar was out of the physician's ordered parameters: 02/18/25 at 08:04 PM - 100 mg/dl 02/20/25 at 07:15 PM - 99 mg/dl On 04/29/25 at 07:40 AM, Licensed Nurse (LN) G provided R28 her morning medication in her room without incident. On 04/29/25 at 11:55 AM, LN G stated R28's blood sugar parameters were standing orders provided at admission, and R28 has had problems with her blood sugars for a while. LN G verified R28 had received her bedtime Lantus when her blood sugar was out of parameters, and that staff should have notified the physician of her low blood sugars. On 04/30/25 at 07:53 AM, Administrative Nurse D stated she expected staff to follow the physician's orders and hold the Lantus medication if her blood sugars were out of parameters. She further stated that the physician should be notified if her blood sugar readings were out of parameters. The facility's Blood Glucose Monitoring policy, dated 09/23/24, documented, associates who obtain capillary blood glucose specimens would do so in accordance with their scope of practice and in accordance with all applicable local, state, and federal guidelines. Upon request, a policy for medication administration was not provided by the facility.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide dignified toileting care by leaving curtains and window blinds open for Resident (R) 3 and R16 during toileting activities, and R2 during suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) care. This placed the residents at risk for impaired dignity and decreased psychosocial well-being. Findings included: - R3's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), Down's syndrome (chromosomal abnormality characterized by varying degrees of mental retardation and multiple defects), abnormalities of gait and mobility, need for assistance with personal care, and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3's had severe cognitive impairment, dependent on staff for all functional activities and mobility. R3 was frequently incontinent of urine, always incontinent with bowel. The MDS further documented R3 received scheduled pain medication regimen and an anticonvulsant (a group of medications used to prevent seizures). R3's Care Plan, dated 03/17/25, documented R3 had an activities of daily living self-performance deficit related to diagnoses of dementia with behaviors and Down's syndrome. R3 was dependent on two staff for repositioning and turning, dressing, personal hygiene, and toileting. The care plan directed staff to check and change briefs, transfer with a Hoyer (total body mechanical lift) lift, but R3 only required one staff member for eating. On 04/28/25 at 12:00 PM, R3 was sitting in the dining room in her Broda chair (specialized wheelchair with the ability to tilt and recline) wearing a shirt with the side seam open, exposing her left side from mid waist area to breast fold, open two to three inches. On 04/29/25 at 08:44 PM, Certified Nurse Aide (CNA) M and CNA N took R3 into her room and closed the door to the hallway, then used a mechanical lift to transfer R3 from the Broda chair onto the bed. CNA M and CNA N proceeded to undress the resident from the waist down to check and change R3's brief. CNA M and CNA N provided incontinent care and brief change without drawing the curtain or the blinds to the window, which looked out to the patio and exit walkway. CNA M reported that staff placed a blanket across R3's lap when she was seated in the Broda chair, due to arm movements which would lift her shirt and expose her skin. On 04/30/25 at 08:11 AM, Administrative Nurse D stated her expectation of staff was to provide privacy for the residents during cares and in public places. The facility's Dignity policy, dated 09/26/24, documented the facility must treat each resident with respect and dignity and for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. - R16's Electronic Medical Record (EMR) included diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), history of falls, major depressive disorder (major mood disorder that causes persistent feelings of sadness), insomnia (inability to sleep), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with severe agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), and abnormalities of gait and mobility R16's Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had severe cognitive impairment, had physical and verbal behaviors directed toward others, one to three days of the seven-day look-back period. R16 was dependent on staff for toileting hygiene and lower body dressing. The MDS further documented R16 was always incontinent of urine and bowel. R16's Care Plan, dated 03/25/25, documented R16 had an activities of daily living self-care performance deficit related to dementia. The care plan instructed staff that R16 required extensive assistance of two staff for toileting and transfers. On 04/29/25 at 09:02 AM, while R16 was sitting in her wheelchair in her room, Certified Nurse Aide (CNA) M and CNA O explained they would assist R16 into the bathroom for toileting. R16 commented on being undressed in public, CNA M and CNA O reassured R16 and explained they would take R16 into the bathroom before undressing so she would be able to sit on the toilet. The staff then proceeded to wheel R16 into her bathroom and assisted R16 onto the toilet. Once R16 was finished in the bathroom, CNA M and CNA O provided toileting hygiene, applied a brief, and pulled up lower body clothing. During the process, the open bathroom door was in visual line of the exterior window, through which the exit and walkway to the courtyard. Staff failed to close the window drapes or window shades. On 04/30/25 at 08:11 AM, Administrative Nurse D stated her expectation of staff was to provide privacy for the residents during cares and in public places. The facility's Dignity policy, dated 09/26/24, documented the facility must treat each resident with respect and dignity and for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. 27168 - On 04/29/25 at 10:00 AM, observation revealed Certified Nurse Aide (CNA) N and CNA P positioned R2 flat in bed pulled her shirt up and pulled down her attends to expose above pubic area, then cleaned R2's urinary catheter tubing with peri wipes and repositioned the gauze sponge around the insertion of the catheter tubing. CNA N reattached the residents attends. The continued observation revealed the resident's two windows had the blinds half up and a visualization of the South Hall resident rooms/windows. On 04/30/25 at 08:00 AM, Administrative Nurse D stated staff should not provide personal cares for the residents without closing the blinds and providing the resident privacy. The facility's Dignity Policy, dated 09/26/2024, documented each resident has the right to be treated with dignity and respect, the interactions, and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating and resident's goals, preferences, and choices. The policy documented that staff must respect the resident's individuality as well as honor and value their input.

The facility had a census of 35 residents. The sample included 12 residents of which three were reviewed for urinary catheter (tube inserted into the bladder to drain urine). Based on observation, record review and interview one of the three reviewed, Resident (R) 89, lacked a baseline care plan on admission to the facility for straight catheterization (inserting a catheter into the bladder) twice a day. This placed the resident at risk for inappropriate care due to uncommunicated care needs. Findings included: - R89's Electronic Medical Record (EMR) documented diagnoses of neurogenic bladder (lack of bladder control caused by nerve damage) and urinary retention (difficulty urinating and emptying the bladder). R89's Physician Admission Orders on 08/09/23 documented straight catheterization twice daily. The Baseline Care Plan completed on admission lacked interventions for the staff for straight catheterization. On 08/22/23 at 09:40AM, observation revealed R89 laid on her bed. Further observation revealed Licensed Nurse (LN) G inserted a straight catheter to drain urine. On 08/22/23 at 11:40AM, Administrative Nurse E verified the baseline care plan lacked interventions for the use of a straight catheter. On 08/22/23 at 02:30PM, Administrative Nurse D verified the lack of a baseline care plan for use of the straight catheter. Administrative Nurse D verified she expected the baseline care plan on admission to include any special treatments. The Baseline Care Plan policy, dated 08/17/22, stated a baseline care plan will be developed for every resident within 48 hours of admission to provide initial set of instructions needed to provide effective and person-centered care of the resident that meets professional standards of care. The facility failed to develop a baseline care plan for R89 who received straight catheterization twice daily, placing the resident at risk for inappropriate care and services due to uncommunicated care needs.

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide dignity during dining for Resident (R) 24 when staff disregarded her repeated requests for assistance and for R11, who had uncombed hair and unclean clothing. This placed R24 and R11 at risk for impaired dignity and decreased psychosocial wellbeing. Findings included: - R24's Electronic Medical Record (EMR) recorded diagnoses of anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), moderate protein-calorie malnutrition, adult failure to thrive, muscle weakness, need of assistance with personal care, legal blindness, and generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R24 had intact cognition. The MDS documented R24 required extensive assistance from one staff for eating. The MDS recorded R24 had severely impaired vision and saw nothing (or only light). The Activity of Daily Living Care Area Assistance (CAA), dated 07/28/23, documented R24 required assistance with activities of daily living. The Care Plan dated 08/11/23 documented R24 required set up assistance by one staff to eat, due to visual impairment, and needed staff to set up her plate. The care plan directed staff to inform R24 of the location of food on the plate, silverware placement, and drink. The Physician Order, dated 04/25/22, directed staff to provide R24 a regular mechanically altered texture in a divided plate. The Progress Note, dated 05/24/23 at 04:27 PM, documented R24 continued eating at baseline and had been more receptive to allowing staff to help her. On 08/21/23 at 11:39 AM, observation revealed R24 sat in the dining room at a table and repeatedly asked for sugar in her coffee. There were numerous staff in the dining room and survey team member informed staff of R24's request for sugar in her coffee. Staff member provided R24 a spoon of sugar in her coffee and left promptly. R24 asked if staff provided two spoons of sugar, but staff had already left. Other staff members passed by R24, who continued to make her request out loud. Staff continued to serve food to other residents in the dining room. R24 then asked if she had food in front of her and an unidentified staff, who was talking to other residents, told R24 there was no food in front of her. R24 inquired if the staff was talking to her, but the staff did not respond to her. R24 continued to ask if she could have more sugar in her coffee and the question continued to be unanswered as staff passed by. When staff finally sat at R24's table, staff addressed her sugar request and let the kitchen staff know R24 was ready for her plate. On 08/23/23 at 09:35 AM, Certified Nurse Aide (CNA) N stated R24 needed extensive assistance with activities of daily living and eating. CNA N stated staff were to inform R24 where her food was located on the plate. CNA N reported staff used of the clock method for food placement description, and used straws for R24's liquids, reminding her often of food and drink placement. On 08/23/23 at 11:01 AM, Administrative Staff D reported R24 needed assistance at mealtime, and staff should have responded to R24's questions and requests. The facility's Dignity policy, dated 09/30/22, documented each resident had the right to be treated with dignity and respect. Staff and volunteers must interact with residents in a manner that considered the physical limitations of resident and assures communication and maintains respect. The facility failed to respond to R24's questions and request for assistance in the dining room which placed the resident at risk for a less dignified experience and decreased psychosocial wellbeing. 32360 - The Electronic Medical Record (EMR) for R11 documented diagnoses of chronic pain, intervertebral disc degeneration (the discs between the vertebrae lose cushioning, fragmentation and herniation related to aging), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals), and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 5 Day Medicare Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition and required extensive assistance of one staff for bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and personal hygiene. The Care Plan, dated 05/23/23, documented R11 had activities of daily living (ADL) self-care performance deficit related to impaired balance, chronic pain, and impaired cognition. The plan directed staff to provide extensive assistance for dressing, bathing, personal hygiene, and dressing. On 08/21/23 at 09:00 AM, observation revealed R11's hair was uncombed, and smashed to the back of her head. On 08/21/23 at 02:52 PM, observation revealed R11 was in her room, drinking a glass of juice. Her sweatshirt appeared dirty with dry food stains down the front of it. On 08/22/23 at 01:06 PM, observation revealed R 11 wore a shirt which looked dirty and had dry food stains down the front of it. On 08/22/23 at 10:00 AM, Certified Nurse Aide (CNA) M stated staff assisted R11 with all her ADL. CNA M stated R11 sometimes drooled on her clothing. On 08/23/23 at 09:00 AM, Administrative Nurse D stated she observed and assisted R11 daily and R11 had a habit of picking at her hair but staff should make sure R11's clothes were clean. The facility's Dignity policy, dated 09/30/22, documented each resident had the right to be treated with dignity and respect. Staff and volunteers must interact with residents in a manner that considered the physical limitations of resident and assures communication and maintains respect. The facility failed to promote care in a manner to maintain and enhance dignity, and respect for R11. This placed R11 at risk for impaired dignity and decreased psychosocial well being.

The facility had a census of 35 residents. The sample included 12 residents, with one reviewed for positioning, Resident (R) 11, and two reviewed for skin conditions not pressure related. Based on observation, record review, and interview, the facility failed to provide care and treatment in accordance with professional standards of practice with staff failed to reposition R11 when she was bent over at the waist in her wheelchair on multiple occasions. Staff further failed to provide interventions to staff to prevent bruises for R13. This placed the residents at risk for decreased function, pain, and further injury. Findings included: - The Electronic Medical Record (EMR) for R11 documented diagnoses of chronic pain, intervertebral disc degeneration (the discs between the vertebrae lose cushioning, fragmentation and herniation related to aging), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals), and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 5-Day Medicare Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition and required extensive assistance of one staff for bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and personal hygiene. The MDS further documented R11 did not ambulate and she had upper functional impairment on one side. The Care Plan, dated 05/23/23, documented R11 had an enabler bar to the left side of her bed to aide in turning, positioning, and exiting the bed. The care plan directed staff to provide one staff for turning, and repositioning; one staff to assist R11 for transfers; continue to offer and maneuver R11's wheelchair chair slowly as she refused wheelchair pedals. It directed staff to make sure she was able to hold her legs up. The Occupational Therapy Treatment Encounter, dated 06/12/23, documented the resident and caregivers were instructed on proper body mechanics and safe transfer techniques specifically wheelchair and toilet transfers in order to prevent a decline from current level of skill performance with partial carryover demonstrated during training. On 08/21/23 at 09:00 AM, observation revealed R11, sat in her wheelchair in the hallway. Her body leaned forward, bent at the waist, with her head down. On 08/21/23 at 11:08 AM, observation revealed R11, in the hallway, used two fingers on her right hand to propel her wheelchair as she used her left heel to help propel the wheelchair. Continued observation revealed R11 slowly propelled her wheelchair and staff did not offer to assist her. On 08/21/23 at 02:09 PM, observation revealed R11 sat in her wheelchair in her room. Her body leaned forward, bent at the waist, with her head down. On 08/22/23 at 07:15 AM, observation revealed R11 sat in her wheelchair, in the hallway. Her body leaned forward, bent at the waist, with her head down. Continued observation at 07:30 AM revealed R11 was still in the hallway, in the same position. On 08/22/23 at 01:15 PM, observation revealed R11, sat in wheelchair in her room. She was bent over and her chest almost touched her knees. Her eyes were closed. On 08/23/23 at 07:10 AM, observation revealed R11 was in the dining room, and her wheelchair was not completely under the table. R11 was bent over with her head almost resting on the dining table. On 08/22/23 at Certified Nurse Aide (CNA) M stated R11 often refused to be laid down in bed or recliner and verified R11 would feel better if she laid down. On 08/22/23 at 01:00 PM, Administrative Nurse E stated she was unsure if R11's refusal to lay down was documented in the care plan. She said she would make she put it in R11's plan of care. On 08/23/23 at 09:00 AM, Administrative Nurse D stated she often asked to assist R11 in her wheelchair and R11 would sometimes refuse the assistance. Administrative Nurse D further stated she would make sure there was documentation in the care plan that reflected R11's refusals and would make sure the care plan reflected how R11 was on a daily basis. The facility's Activities of Daily Living policy, dated 08/22/22, documented the resident would receive assistance as needed to complete activities of daily living and would assist residents with bed or wheelchair repositioning as necessary to promote good body alignment and to prevent skin breakdown. The facility failed to provide the necessary care and services to ensure appropriate wheelchair positioning for R11, placing the resident at risk for pain and decreased function. - The Electronic Medical Record (EMR) for R13 documented diagnoses of edema (excess fluid trapped in the body's tissue), repeated falls, chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation in room, dressing, toileting and personal hygiene. The MDS further documented R13 had a pressure ulcer. The Care Plan, dated 08/16/23, documented R13 was at risk for a break in skin integrity, received anticoagulant (blood thinner medication) therapy, and directed staff to perform weekly skin checks, observer for and report as needed adverse reactions. The care plan lacked interventions to prevent bruising. The Weekly Skin Assessment from 08/05/23 to 08/18/23 lacked documentation regarding the bruises on R13's hands and arms. On 08/21/23 at 10:15 AM, observation revealed two dark purple bruises to R13's right hand, multiple small bruises to her right arm, one purple bruise to her left hand and one to her left wrist. On 08/22/23 at 09:08 AM, observation revealed two dark purple bruises to R13's right hand, eight small bruises to her right arm, one purple bruise to her left hand and one to her left wrist. On 08/22/23 at 09:10 AM, Licensed Nurse (LN) G stated the bruises were probably from a couple falls that R13 had. On 08/22/23 at 08:50 AM, Certified Nurse Aide (CNA) M stated the resident has fallen and the bruises were likely from her falls. On 08/22/23 at 01:00 PM, Administrative Nurse E stated she would look at the care plan to see if there were interventions in place for the prevention of bruising. At 01:30 PM, Administrative Nurse E verified there were no interventions on the care plan and stated she received an order for Geri-sleeves for R13 to help prevent the bruising. On 08/23/23 at 12:15 PM, Administrative Nurse D verified the bruises to the resident's arms and hands, stated that they were probably from a blood draw and her falls. The facility Anticoagulation Therapy policy, dated 08/25/22, documented education was provided to the resident and families by nursing staff regarding the risks of anticoagulation therapy and any other assessed needs related to anticoagulation therapy are documented in the medical record. The facility failed to address and provide interventions to prevent bruises for R13 who was on anticoagulation therapy and had multiple bruises to her hands and arms. This placed the resident at risk for further injury.

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the required assistance for Resident (R) 24, who was legally blind and required extensive assist with eating and for R11, who required assistance with grooming. This placed the residents at risk for impaired quality of life and care. Finding included: - R24's Electronic Medical Record (EMR) recorded diagnoses of anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), moderate protein-calorie malnutrition, adult failure to thrive, muscle weakness, need of assistance with personal care, legal blindness, and generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R24 had intact cognition. The MDS documented R24 required extensive assist from one staff for eating. The MDS recorded R24 had severely impaired vision and saw nothing, or only light. The Activity of Daily Living Care Area Assistance (CAA), dated 07/28/23, documented R24 required assistance with activities of daily living. The Care Plan dated 08/11/23 documented R24 required set up assistance by one staff to eat, due to visual impairment, and needed staff to set up plate. The care plan directed staff to inform R24 the location of food on the plate, silverware placement, and drink. The Physician Order, dated 04/25/22, directed staff to provide R24 a regular mechanically altered texture in a divided plate. The Progress Note, dated 05/24/23 at 04:27 PM, documented R24 continued eating at baseline and had been more receptive to allowing staff to help her. On 08/21/23 at 11:39 AM, observation revealed R24 sat in the dining room at a table and repeatedly asked for sugar in her coffee. There were numerous staff in the dining room and survey team member informed staff of R24's request for sugar in her coffee. Staff member provided R24 a spoon of sugar in her coffee and left promptly. R24 asked if staff provided two spoons of sugar, but staff had already left. Other staff members passed by R24, who continued to make her request out loud. Staff continued to serve food to other residents in the dining room. R24 then asked if she had food in front of her and an unidentified staff, who was talking to other residents, told R24 there was no food in front of her. R24 inquired if the staff was talking to her, but the staff did not respond to her. R24 continued to ask if she could have more sugar in her coffee and the question continued to be unanswered as staff passed by. When staff finally sat at R24's table, staff addressed her sugar request and let the kitchen staff know R24 was ready for her plate. On 08/23/23 at 09:35 AM, Certified Nurse Aide (CNA) N stated R24 needed extensive assistance with activities of daily living and eating., CNA N stated staff were to inform R24 where her food was located on the plate. CNA N reported staff used of the clock method for food placement description, and used straws for R24's liquids, reminding her often of food and drink placement. On 08/23/23 at 11:01 AM, Administrative Staff D reported R24 needed assistance at mealtime, and staff should have responded to R24's questions and requests. The facility's Activities of Daily Living (ADL) policy, dated 08/22/22, documented the resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be documented and reported to the licensed nurse. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to provide R24 the required assistance with eating. This placed the resident at risk for impaired quality of life and weight loss. 32360 - The Electronic Medical Record (EMR) for R11 documented diagnoses of chronic pain, intervertebral disc degeneration (the discs between the vertebrae lose cushioning, fragmentation and herniation related to aging), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals), and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 5 Day Medicare Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition and required extensive assistance of one staff for bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and personal hygiene. The Care Plan, dated 05/23/23, documented R11 had activities of daily living (ADL) self-care performance deficit related to impaired balance, chronic pain, and impaired cognition. The plan directed staff to provide extensive assistance for dressing, bathing, personal hygiene, and dressing. On 08/21/23 at 09:00 AM, observation revealed R11's hair was uncombed, and smashed to the back of her head. On 08/21/23 at 02:52 PM, observation revealed R11 was in her room, drinking a glass of juice. Her sweatshirt appeared dirty with dry food stains down the front of it. On 08/22/23 at 01:06 PM, observation revealed R11 wore a shirrt which looked dirty and had dry food stains down the front of it. On 08/22/23 at 10:00 AM, Certified Nurse Aide (CNA) M stated staff assisted R11 with all her ADL. CAN M stated R11l sometimes drooled on her clothing. On 08/23/23 at 09:00 AM, Administrative Nurse D stated she observed and assisted R11 daily and R11 had a habit of picking at her hair but staff should make sure R11's clothes were clean. The facility's Activities of Daily Living policy, dated 08/22/22, documented the resident would receive assistance as needed to complete activities of daily living and any change in the ability to perform ADL would be documented and reported to the licensed nurse. The facility failed to provide appropriate cares for grooming for cognitively impaired R11, who had dirty clothes two of the three days on survey. This placed the resident at risk for poor hygiene.

The facility had a census of 35 residents. The sample included 12 residents, Based on observation, record review, and interview, the facility failed to revise care plans for two sampled residents, Resident (R) 11 for her refusals to be transferred to her bed or recliner, and R13's interventions to prevent bruising. This placed the residents at risk for unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R11 documented diagnoses of chronic pain, intervertebral disc degeneration (the discs between the vertebrae lose cushioning, fragmentation and herniation related to aging), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals), and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 5-Day Medicare Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition and required extensive assistance of one staff for bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and personal hygiene. The MDS further documented R11 did not ambulate and she had upper functional impairment on one side. The Care Plan, dated 05/23/23, documented R11 had an enabler bar to the left side of her bed to aide in turning, positioning, and exiting the bed. The care plan directed staff to provide one staff for turning, and repositioning; one staff to assist R11 for transfers; continue to offer and maneuver R11's wheelchair chair slowly as she refused wheelchair pedals. It directed staff to make sure she was able to hold her legs up. The Occupational Therapy Treatment Encounter, dated 06/12/23, documented the resident and caregivers were instructed on proper body mechanics and safe transfer techniques specifically wheelchair and toilet transfers in order to prevent a decline from current level of skill performance with partial carryover demonstrated during training. On 08/21/23 at 09:00 AM, observation revealed R11 sat in her wheelchair in the hallway. Her body leaned forward, bent at the waist, with her head down. On 08/21/23 at 11:08 AM, observation revealed R11, in the hallway, used two fingers on her right hand to propel her wheelchair as she used her left heel to help propel the wheelchair. Continued observation revealed R11 slowly propelled her wheelchair and staff did not offer to assist her. On 08/21/23 at 02:09 PM, observation revealed R11 sat in her wheelchair in her room. Her body leaned forward, bent at the waist, with her head down. On 08/22/23 at 07:15 AM, observation revealed R11 sat in her wheelchair, in the hallway. Her body leaned forward, bent at the waist, with her head down. Continued observation at 07:30 AM revealed R11 was still in the hallway, in the same position. On 08/22/23 at 01:15 PM, observation revealed R11, sat in wheelchair in her room. She was bent over and her chest almost touched her knees. Her eyes were closed. On 08/23/23 at 07:10 AM, observation revealed R11 was in the dining room, and her wheelchair was not completely under the table. R11 was bent over with her head almost resting on the dining table. On 08/22/23 at Certified Nurse Aide (CNA) M stated R11 often refused to be laid down in bed or recliner and verified R11 would feel better if she laid down. On 08/22/23 at 01:00 PM, Administrative Nurse E stated she was unsure if R11's refusal to lay down was documented in the care plan. She said she would make she put it in R11's plan of care. On 08/23/23 at 09:00 AM, Administrative Nurse D stated she often asked to assist R11 in her wheelchair and R11 would sometimes refuse the assistance. Administrative Nurse D further stated she would make sure there was documentation in the care plan that reflected R11's refusals and would make sure the care plan reflected how R11 was on a daily basis. The facility Comprehensive Care Plan and Revisions policy, dated 08/17/22, documented the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When changes occur, the facility should review and update the plan of care to reflect the changes to care delivery things can include additional interventions on existing problems, updating goal or problem statements, adding a short-term problem goal, and interventions to address a time limited condition. The facility failed to update R11's care plan to reflect her refusals to lay down in bed or sit in her recliner when she started to lean forward in her wheelchair. This placed the resident at risk for unmet care needs. - The Electronic Medical Record (EMR) for R13 documented diagnoses of edema (excess fluid trapped in the body's tissue), repeated falls, chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation in room, dressing, toileting and personal hygiene. The MDS further documented R13 had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The Care Plan, dated 08/16/23, documented R13 was at risk for a break in skin integrity, received anticoagulant (blood thinner medication) therapy, and directed staff to perform weekly skin checks, observe for and report adverse reactions. The care plan lacked interventions to protect skin from bruising. The Weekly Skin Assessment from 08/05/23 to 08/18/23 lacked documentation regarding the bruises on R13's hands and arms. On 08/21/23 at 10:15 AM, observation revealed two dark purple bruises to R13's right hand, multiple small bruises to her right arm, one purple bruise to her left hand and one to her left wrist. On 08/22/23 at 09:08 AM, observation revealed two dark purple bruises to R13's right hand, eight small bruises to her right arm, one purple bruise to her left hand and one to her left wrist. On 08/22/23 at 09:10 AM, Licensed Nurse (LN) G stated the bruises were probably from a couple of falls that R13 had. On 08/22/23 at 08:50 AM, Certified Nurse Aide (CNA) M stated the resident fell and the bruises were likely from her falls. On 08/22/23 at 01:00 PM, Administrative Nurse E stated she would look at the care plan to see if there were interventions in place for the prevention of bruising. At 01:30 PM, Administrative Nurse E verified there were no interventions on the care plan and stated she received an order for Geri-sleeves (protective sleeves used to protect fragile skin) for R13 to help prevent the bruising. On 08/23/23 at 12:15 PM, Administrative Nurse D verified the bruises to the resident's arms and hands, and stated that they were probably from a blood draw and R13's falls. The facility Comprehensive Care Plan and Revisions policy, dated 08/17/22, documented the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When changes occur, the facility should review and update the plan of care to reflect the changes to care delivery things can include additional interventions on existing problems, updating goal or problem statements, adding a short-term problem goal, and interventions to address a time limited condition. The facility failed to update R13's care plan with direction to staff with interventions to prevent bruising. This placed the resident at risk for unmet care needs.

The facility identified a census of 38 residents with three residents reviewed for abuse and neglect. Based on record review, observation and interview, the facility failed to provide the required supervision for Resident (R) 2 to prevent a resident to resident altercation directed at R1. On 06/25/23 at approximately 03:00 AM, R2 entered R1's room and stood at her bedside and R1 shoved R2 away from her bed and R2 hit R1 before staff intervened. The facility failed to protect R1 from abuse placing her at risk for injury, pain, and adverse effect on R1's psychosocial well-being. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R1 was independent with set up help only with bed mobility, transfer, ambulation, toileting, eating, and personal hygiene. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/01/23, documented R1 was inattentive and had disorganized thinking and the behaviors fluctuated. The Activity of Daily Living Functional/Rehabilitation Potential CAA, dated 02/01/23, documented R1 required some assistance with her activities of daily living. The Alteration in Psychosocial Well-being Care Plan, revised 02/14/23, directed staff to observe for changes in R1's mental status caused by situational stressors, observe for increased anxiety or changes in mood/behavior, and provide R1 opportunities to express feeling related to situational stressors. The Health Status Note, dated 06/25/23, documented at approximately 03:00 AM, R1 put on her call light and almost immediately started yelling for help. Upon staffs' arrival to R1's room, the nurse turned on the light by the door. At that time R2 stood next to R1's bed. When the lights came on, R2 started walking towards staff. R1 stated R2 hit her. The nurse placed herself between R1 and R2 and instructed R2 he needed to leave the room. R2 told the nurse to sit down and shut up until she (the nurse) got this figured out. Another staff member arrived to R1's room and escorted R2 out of R1's room and back to his room. R2 went to bed without difficulty. R1 and R2 were assessed. R2 did not remember the incident in less the five minutes after the incident and stated he had been out in the yard trying to find out if there was anything running in the yard. R1 stated that she thought that it was staff coming into her room to pass fresh ice water and towels when the door opened. R1 stated R2 came into her room and stood in the dark for a while when R1 asked R2 what he was doing and R2 responded with shut up. R2 turned the lights on in the room dimly, and walked across the room to stand at R1's bedside. R1 stated that R2 then told her he was sick and tired of her. R2 attempted to sit on R1's bed and R1 pushed R2 away. R2 stated, I'm going to make you pay for this. At that time, R2 struck R1's left forearm three times and once to her left cheek. R1 stated that while R2 was striking her R2 stated I'm sick of you and you're going to get some more. At this time, R1 stated she turned on her call light and started yelling for help. R1 denied R2 was trying to wake her up and R2 kept getting more and more angry with her saying it was her fault. After the assessment of R1, it was noted that R1 had some bruising underneath her left eye and left forearm. R1 accepted an ice pack to her left cheek but denied accepting an ice pack for her left forearm. The police department was called. A motion sensor alarm was placed on the outer frame of R2's door to alert staff when R2 was leaving his room. R1 was offered a different room but refused. On 06/28/23 at 10:30 AM, observation revealed R1 sat in her recliner watching TV. R1 had a large black and purple bruise on her left forearm and a small discoloration on her left cheek. On 06/28/23 at 10:30 AM, R1 stated that she did not know what was going on when R2 entered her room. R1 stated that she thought it was staff coming into her room, but then she saw that it was R2. R1 stated that it was not the first time that R2 had come into her room but normally she would tell him that it was not his room and to go on and R2 would leave. R1 pointed out the bruises on her left forearm. On 06/28/23 at 11:00 AM, Certified Nurse's Aide (CNA) M stated R2 had never exhibited any physical or verbal aggression towards anyone in the facility since his admission. CNA M stated R2 was easily re-directable. CNA M stated R1 did not seem to have any after effects from the incident and was up and around per her normal routine. On 06/28/23 at 11:30 AM, Administrative Nurse D stated she had come into the facility at 05:00 AM the morning of 06/25/23 and started on trying to get R2 placed in a behavioral unit and to make sure that R1 was okay. Administrative Nurse D stated that the behavioral unit accepted R2's insurance but had to wait until 07:00 AM when the admissions team arrived to see if they would accept R2 into the behavioral unit. Administrative Nurse D stated the facility received notification R2 was accepted into the behavioral unit and R2 was transferred on 06/25/23 at 10:40 AM. Administrative Nurse D stated that they had no idea that R2 had any aggressive behaviors towards others since he arrived at the facility ten days prior but she stated he did wander in the common areas. Administrative Nurse D stated that she had talked with R2's wife and she stated R2 had never had any physical aggression towards her when R2 was at home. Administrative Nurse D stated R2's room would be moved away from R1's room upon his return to the facility. Administrative Nurse D stated that she had no noticed any changes in R1's behavior since the incident and R1 was functioning per her normal routine. On 06/28/23 at 12:00 PM, Social Services Designee X stated that she had talked with R1 about the incident and that R1 had not shared and fears or feelings regarding the incident. Social Services Designee X stated R1 was just excited about moving out the nursing home and back to her own apartment. On 06/28/23 at 01:00 PM, Administrative Staff A stated that she had conversed with R1 everyday since the incident and R1 had not mentioned any fear or anxiety R1 might have had to her during their conversations. The facility's undated Protection of Residents: Reducing the Threat of Abuse and Neglect Policy, documented the facility would minimize the threat of abuse and/or neglect by incorporating clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends or any other individuals. The facility failed to protect R1 from abuse placing her at risk for injury, pain, and adverse effect on R1's psychosocial well-being.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for the 37 residents who received food from the facility kitchen. Findings included: - On 11/29/21 observation revealed: The refrigerator and freezers in the main kitchen lacked documentation of temperatures for 22 days in November 2021. The dry storage room freezers lacked documentation of temperatures for 22 days in November 2021. The dry storage refrigerator lacked documentation of temperatures for the entire month of November 2021. On 11/30/21 observation revealed: A metal fan mounted to the wall in the dishwashing room directed at the area the clean dishes exited the dishwashing machine covered with a thick layer of gray lint type material. A square ceiling vent above the serving steam table with gray/black lint type material on the edges. Clean cups and glasses stored on a shelf under the microwave next to a trash can. The oven doors had dark brown and black dry material that continued to the inside of the oven. The white mixer had dried debris on the stand and the metal blender had white paint missing from it which had flaked off. On 12/02/21 at 09:23 AM, Administrative Staff A verified the metal fan in the dishwasher room and the vent above the serving table had gray to black lint type debride on both, the oven had accumulating debride on the knobs, doors, and interior of the oven, the white mixer had dried debride on mixer stand/base, the paint peeling off the beater, and clean cups and glasses should not be stored next to a trash receptacle. Administrative Staff A also verified the lack of documented refrigerator and freezer temperatures for the month of November. The facility's undated Food and Nutrition Services policy documented the director of Food and Nutrition Service monitors the cleaning schedule to ensure the tasks are completed timely and appropriately, temperatures recorded at least daily on the Refrigerator/Freezer Temperature log. All equipment is cleaned and sanitized per department guidelines, and staff will be trained on how to operate and clean the machine and how to store items appropriately. The facility failed to store, prepare, and serve food under sanitary conditions for 37 residents who received their meals prepared in the facility kitchen.

The facility had a census of 37 residents. The sample included 12 residents with four reviewed for activities of daily living (ADL's). Based on observation, record review, and interview, the facility failed to provide the necessary services to maintain good personal hygiene, including bathing for three of four sampled residents, Resident (R) 7, 31 and 40 and good personal hygiene for R1. Findings included: - R7's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had moderately impaired cognition, required moderate assist from one to two staff for personal hygiene, and required extensive assist of one staff for bathing. The ADL Care Plan, dated 10/14/21, directed one to two staff to assist the resident with personal hygiene, which included changing the resident's clothing daily, and a shower every Friday. Review of the South Shower Schedule documented the resident schedule included a shower on Fridays on the 06:00 AM to 02:00 PM shift. The sheet documented the nurse aide would inform the charge nurse prior to the end of the shift if the resident refused her shower. The facility's June 2021 Bathing documentation revealed the resident received a shower on the following days: 06/04/21 and the next shower on 06/18/21. (14 days without a shower) 06/18/21 and the next shower on 06/30/21. (12 days without a shower) The facility's August 2021 Bathing documentation revealed the resident received a shower on the following days: 08/01/21 and the next shower on 08/27/21. (25 days without a shower) The facility's September 2021 Bathing documentation revealed the resident received a shower on the following days: 09/10/21 and the next shower on 09/30/21. (19 days without a shower) The facility's October 2021 Bathing documentation revealed the resident received a shower on the following days: 10/02/21 and the next shower on 10/15/21. (12 days without a shower) The facility's November 2021 Bathing documentation revealed the resident received a shower on the following days: 11/12/21 and the next shower on 11/26/21. (13 days without a shower) On 11/29/21 at 02:00 PM, observation revealed the resident wearing a gray with blue trim sweater top. Further observation revealed the sweater top with brown and yellow dried substance on the front, fingernails on both hands jagged and brown substance under nails on both hands. On 11/30/21 at 08:20 AM, observation revealed the resident seated in her wheelchair propelling herself down the south hallway. Further observation revealed the resident wearing the same clothes as the day before and her hair uncombed and sticking up in the back. On 12/01/21 at 07:50 AM, observation revealed the resident seated in the dining room in her wheelchair. Further observation revealed the resident wearing the same clothes as the day before and dried brown and yellow stains on her clothing. On 12/02/21 at 11:10 AM, observation revealed the resident lying on her bed with her eyes closed. Further observation revealed the resident wearing the same clothing as the day before with the same stains on the clothing. On 12/01/21 at 10:15 AM, Certified Nurse Aide (CNA) N stated R7 slept in her clothes and wore the same thing. CNA N stated it was difficult to remove the clothing from the resident and wash them as the resident had become combative at times making it difficult to provide R7 with cares. On 12/01/21 at 10:30 AM, CNA O stated R7 was to receive a shower every Friday and the reason she had not received some of her showers was because sometimes there was just too much going on to get done all the things staff needed to do for the residents. CNA O stated if staff do not get a resident's bath or shower completed on their shift, staff are to report to the charge nurse. On 12/02/21 at 08:10 AM, Licensed Nurse (LN) H stated the resident can be combative at times and made it difficult for them to give her a bath and R7's clothes should be changed daily. On 12/02/21 at 08:40 AM, Administrative Nurse D verified R7 should have her clothing changed daily and as needed, and she would expect staff to provide the resident her shower weekly as scheduled. Administrative Nurse D verified the resident had not received her shower on the scheduled days. The facility's Activities of Daily Living policy, dated 07/17/21, documented each resident is to be provided needed care and services that are resident centered, in accordance with the resident's preferences for care. The facility failed to provide R7 the necessary care and services for bathing and dressing, placing the resident at risk for poor hygiene. - Resident (R) 1's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS recorded R1 required extensive assistance with personal hygiene. The Care Plan, dated 10/11/21, informed staff R1 required two staff assist for personal hygiene, needs assistance with cleaning her glasses, and combing her hair. On 11/29/21 at 03:10 PM, observation revealed the resident seated in her wheelchair near the nurse's desk. Further observation revealed the resident with a dried substance surrounding her mouth, facial hair on chin approximately one inch long, fingernails on both hands jagged with a brownish yellow substance under the nails and hair uncombed. On 11/30/21 at 12:45 PM, observation revealed the resident seated in her wheelchair by the dining room. Further observation revealed the resident with a dark flaky substance on both hands, and on the front of her shirt. On 11/30/21 at 01:50 PM, observation revealed the resident seated in her wheelchair coming out of the living room area after attending an activity. Further observation revealed the resident with the same dark flaky substance on both hands and on the front of her shirt. On 12/01/21 at 10:10 AM, observation revealed the resident seated in her wheelchair, hair uncombed, and a dark brown substance under nails on both hands. On 12/01/21 at 10:15 AM, Certified Nurse Aide (CNA) N stated staff were to help R1 change her clothes, wash her hands and face and provide nail care. On 12/01/21 at 10:30 AM, CNA O stated the reason R1 had not had nail care done or personal hygiene was because sometimes there was just too much going on to get done all the things staff needed to do for the residents. On 12/02/21 at 08:10 AM, Licensed Nurse (LN) H stated she would expect the nurse aides to assist R1 with washing her hands and face as needed. On 12/02/21 at 08:40 AM, Administrative Nurse (AD) D stated the direct care staff were to provide and assist R1 with personal hygiene as needed. The facility's Activities of Daily Living policy, dated 07/17/21, documented each resident is to be provided needed care and services that are resident centered, in accordance with the resident's preferences for care. The facility failed to provide R1 the necessary care and services for personal hygiene, placing the resident at risk for poor hygiene. - R31's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition, required extensive of one staff with dressing, toileting, personal hygiene, and bathing. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 06/30/21, documented the resident required assistance of one staff for most ADL's to achieve her highest level of functioning. The ADL Care Plan, dated 10/04/21, directed staff to provide extensive assistance of one staff for personal hygiene and to assist with all ADL's as needed. The September 2021 Bathing Record documented the resident requested showers on Tuesday and Friday and documented the resident did not receive a bath or shower during the following days: 09/04/21-09/13/21 (10 days) 09/11/21-09/26/21 (16 days) On 11/29/21 at 05:03 PM, observation revealed the resident's hair was uncombed and smashed against the back of her head. On 12/01/21 at 09:10 AM, Certified Nurse Aide (CNA) M stated showers were given on the hall the resident lived on and if he or she refused, staff went back and asked several times. CNA M further stated the charge nurse would be notified if a resident had not gotten a bath or shower. On 11/30/21 at 11:10 AM, Licensed Nurse (LN) G stated the nurse aides chart if a resident refused showers and would ask the resident several times if she wanted a bath or shower. On 12/02/21 at 09:40 AM, Administrative Nurse D verified the resident had not had a bath or shower on the documented days. The facility's Activities of Daily Living policy, dated 07/17/21, documented a resident who was unable to carry out ADL's received the necessary care and services to maintain good nutrition, grooming, and personal hygiene. The facility failed to provide R31 bathing services, placing the resident as risk for poor hygiene. - R40's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and was independent with one staff assistance for personal hygiene and bathing did not occur during the seven-day lookback period. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 09/30/21, documented the resident required some assistance with ADL's. The ADL Care Plan, dated 10/11/21, documented the resident able to shower himself one time a week with set up and supervision. The care plan further documented the resident often refused. The November 2021 Bathing Record documented the resident requested baths or showers on Thursday evenings. The record documented the resident had not received any baths or showers during the following days: 11/19/21 - 11/30/21 (12 days) On 11/30/21 at 09:10 AM, observation revealed the resident unshaven and had dried food on his jeans. On 12/01/21 at 08:40 AM, observation revealed the resident had the same jeans on from the previous day and had dried food on them. On 12/02/21 at 08:08 AM, observation revealed the resident had the same jeans on from the previous two days and had more dried food on them. On 12/01/21 at 09:10 AM, Certified Nurse Aide (CNA) M stated showers were given on the hall the resident lived on and if he or she refused, staff would go back and ask several times. CNA M further stated the charge nurse would be notified if a resident had not gotten a bath or shower. On 11/30/21 at 11:10 AM, Licensed Nurse (LN) G stated the nurse aides chart if a resident refused showers and stated the resident dressed himself and at times would ask for assistance. Licensed Nurse G further stated if the residents' clothes were dirty staff told him to change them. On 12/02/21 at 09:40 AM, Administrative Nurse D verified the resident had not had a bath or shower on the documented days. The facility's Activities of Daily Living policy, dated 07/17/21, documented a resident who was unable to carry out ADL's received the necessary care and services to maintain good nutrition, grooming, and personal hygiene. The facility failed to provide R40 bathing services, placing the resident as risk for poor hygiene.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff served one resident from each table and the tablemates had to wait for long periods of time for their meals. This deficient practice affected Resident (R) 7, R9, R11, R12, R16, R18, R22, R25, and R38. Findings included: - On 11/29/21 at 04:50 PM, observation revealed R18 and R9 sat at the same dining room table. Further observation revealed R9 received her supper meal and R18 had to wait and did not receive her meal until 45 minutes after her tablemate, when this surveyor asked when the resident would be receiving her supper meal. On 11/30/21 at 12:00 PM, observation revealed R22 and R9 seated at the same dining room table. Further observation revealed R9 received her meal at 12:38 PM and R22 did not receive her meal until 12:54 PM, 16 minutes later. On 11/30/21 at 12:46 PM, observation revealed R7 had not received her noon meal. Further observation revealed R7 asked Dietary Staff BB several times when R7 would receive her meal and DS BB did not acknowledge the resident's questions. On 11/30/21 at 01:00 PM, observation revealed R38 and R12 sat at the same dining room table. Further observation revealed R38 received his meal though R12 did not receive his meal until 01:15 PM On 12/1/21 at 11:45 AM, observation revealed R11 and R25 sat at the same dining room table, Further observation revealed R11 was served her meal and R25 had to wait 15 more minutes for her meal. On 12/1/21 at 01:15 PM, observation revealed R18 and R16 sat at the same dining room table. Further observation revealed R16 laid her head on the dining table while R18 ate her noon meal. Continued observation revealed R16 did not receive her meal until 01:30 PM. On 11/30/21 at 12:30 PM, Dietary Staff CC stated the meal was slow that day due to trying to train a person in the kitchen. On 12/02/21 at 09:40 AM, Administrative Nurse D stated there are a lot of concerns with the dining process that they are trying to work on. The facility's Resident Dining Services policy, dated April 2019, documented a process was in place to ensure residents received a pleasant dining experience in a timely manner and residents seated together and served in consecutive order so they can eat at the same time. The facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff served one resident from each table and the tablemates had to wait for long periods of time for their meals.

The facility had a census of 37 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to report to the Director of Nursing, physician and medical director medication concerns for two of five sampled residents. Resident (R) 9's pulses out of physician ordered parameters, and medication not held when pulses were out of physician ordered parameters for R31. Findings included: - R9's Physician Order Sheet (POS), dated 11/29/21, documented diagnoses of diastolic [CONDITION(S)] (occurs when your left ventricle can no longer relax between heartbeats because the tissues have become still and won't fill up with blood before the next heart beat), [CONDITION(S)] (rapid, irregular heart beat) and hypertension (high blood pressure), The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting and personal hygiene. The assessment documented the resident received anticoagulant (medication to inhibit the clotting of blood) and diuretic (medication to promote the formation and excretion of urine). The [CONDITION(S)] Care Plan, dated 11/12/21, directed staff to obtain vital signs per protocol and give cardiac medications as ordered. The Physicians Order, dated 11/17/20, directed staff to administer [MEDICATION(S)] (a blood pressure medication to treat heart failure), 180 micrograms (mcg) one tablet daily. The staff were directed to hold and report to the physician if the resident's heart rate was less than 60 beats per minute (bpm)and give and report to the physician if heart rate was more than 120 bpm. The Medication Administration Record (MAR), dated September 10, 2021, documented the resident's pulse was 55. The record documented the [MEDICATION(S)] medication was held but the physician was not notified of the out of parameter pulse. The MAR, dated September 17, 2021, documented the resident's pulse was 52. The record documented the [MEDICATION(S)] medication was held but the physician was not notified of the out of parameter pulse. The Physicians Order, dated 01/26/21, directed staff to administer [MEDICATION(S)] ER 24 (a high blood pressure medication), 180 milligrams (mg) one tablet daily for the diagnosis of [CONDITION(S)]. The staff were directed to hold and report to the physician if the resident's heart rate was less than 60 bpm and give and report to the physician if heart rate was more than 120 bpm. The MAR, dated September 17, 2021, documented the resident's pulse was 53. The record documented the [MEDICATION(S)] medication was held but the physician was not notified of the out of parameter pulse. The MAR, dated September 25, 2021, documented the resident's pulse was 52. The record documented the [MEDICATION(S)] medication was held but the physician was not notified of the out of parameter pulse. The Medication Regimen Reviews, dated 09/28/21, 10/20/21, and 11/29/21, failed to identify pulses out of physician ordered parameters. On 11/30/21 at 09:31 AM, observation revealed the resident seated in her wheelchair, looking out of her window in her room. On 12/02/21 at 08:41 AM, Licensed Nurse (LN) G verified the physician had not been notified of the out of parameter medications. On 12/02/21 at 09:40 AM, Administrative Nurse D stated she expected staff to follow the physician's order if the resident's pulse was out of parameters and was unaware the pharmacist did not address the concern. The facility's Medication Regimen Review policy, dated 11/28/16, documented the Consultant Pharmacist would identify an urgent medication irregularity during the review that required immediate action and would notify the nurse and request the facility contact the attending physician to communicate the issue and obtain direction or new orders. If the irregularity did not require urgent action but should be addressed before the consultant pharmacist next monthly review, the facility staff and the consultant pharmacist would confer on the timeliness of attending physician responses to identified irregularities based on the specify resident's clinical condition. The facility's Consultant Pharmacist failed to report to the Director of Nursing, physician and medical director R9's physician ordered out of parameter pulses, placing the resident at risk for physical decline. - R31's Physician Order Sheet (POS), dated 11/29/21, documented diagnoses of [CONDITION(S)] (a condition with low heart output and the body becomes congested with fluid), [CONDITION(S)] (rapid, irregular heart beat) and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment documented the resident received anticoagulant (inhibited the clotting of blood) and diuretic (medication to promote the formation and excretion of urine). The [CONDITION(S)] Care Plan, dated 10/04/21, directed staff to give cardiac medications as ordered and report any signs and symptoms to the physician. The Physicians Order, dated 06/23/21, directed staff to administer [MEDICATION(S)] (a blood pressure medication to treat heart failure), 125 micrograms (mcg) one tablet daily. The staff were directed to hold and report to the physician if the resident's heart rate was less than 60 beats per minute (bpm) and give and report to the physician if heart rate was more than 120 bpm. The Medication Administration Record (MAR), dated August 26, 2021, documented the resident's pulse was 57. The record documented the [MEDICATION(S)] medication was given and the physician was not notified of the out of parameter pulse. The Physicians Order, dated 06/23/21, directed staff to administer [MEDICATION(S)] (an antihypertensive medication), 6.25 milligrams (mg) one tablet daily for the diagnosis of hypertension. The staff were directed to hold and report to the physician if the resident's heart rate was less than 60 bpm and give and report to the physician if heart rate was more than 120 bpm. The MAR, dated August 26, 2021, documented the resident's pulse was 57. The record documented the [MEDICATION(S)] medication was given and the physician was not notified of the out of parameter pulse. The MAR, dated October 19, 2021, documented the resident's pulse was 42. The record documented the [MEDICATION(S)] medication was refused by the resident and the physician was not notified of the out of parameter pulse. The Medication Regimen Reviews, dated 09/30/21, 10/31/21 and 11/30/21, failed to identify pulses out of physician ordered parameters. On 12/02/21 at 08:00 AM, observation revealed the resident was seated in the dining room waiting for breakfast. On 12/02/21 at 08:47 AM, Licensed Nurse (LN) G verified the medication were given and the physician was not notified regarding the out of parameter pulses. On 12/02/21 at 09:40 AM, Administrative Nurse D stated she expected staff to follow the physician's order if the resident's pulse was out of parameters and was unaware the pharmacist did not address the concern. The facility's Medication Regimen Review policy, dated 11/28/16, documented the Consultant Pharmacist would identify an urgent medication irregularity during the review that required immediate action and would notify the nurse and request the facility contact the attending physician to communicate the issue and obtain direction or new orders. If the irregularity did not require urgent action but should be addressed before the consultant pharmacist next monthly review, the facility staff and the consultant pharmacist would confer on the timeliness of attending physician responses to identified irregularities based on the specify resident's clinical condition. The facility's Consultant Pharmacist failed to report to the Director of Nursing, physician, and medical director R31's physician ordered out of parameter pulses, placing the resident at risk for physical decline.

The facility had a census of 37 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold, and report physician ordered out of parameter pulses for two of five sampled residents, Resident (R)9 and R31. Findings included: - R9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting and personal hygiene. The assessment documented the resident received anticoagulant (medication to inhibit the clotting of blood) and diuretic (medication to promote the formation and excretion of urine). The [CONDITION(S)] Care Plan, dated 11/12/21, directed staff to obtain vital signs per protocol and give cardiac medications as ordered. The Physicians Order, dated 11/17/20, directed staff to administer [MEDICATION(S)] (a blood pressure medication to treat heart failure), 180 micrograms (mcg) one tablet daily. The staff were directed to hold and report to the physician if the resident's heart rate was less than 60 beats per minute (bpm) and give and report to the physician if heart rate was more than 120 bpm. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record documented the [MEDICATION(S)] medication was held but the physician was not notified of the out of parameter pulse. The MAR, dated September 17, 2021, documented the resident's pulse was 52. The record documented the [MEDICATION(S)] medication was held but the physician was not notified of the out of parameter pulse. The Physicians Order, dated 01/26/21, directed staff to administer [MEDICATION(S)] ER 24 (a high blood pressure medication), 180 milligrams (mg) one tablet daily for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff were directed to hold and report to the physician if the resident's heart rate was less than 60 bpm and give and report to the physician if heart rate was more than 120 bpm. The MAR, dated September 17, 2021, documented the resident's pulse was 53. The record documented the [MEDICATION(S)] medication was held but the physician was not notified of the out of parameter pulse. The MAR, dated September 25, 2021, documented the resident's pulse was 52. The record documented the [MEDICATION(S)] medication was held but the physician was not notified of the out of parameter pulse. On 11/30/21 at 09:31 AM, observation revealed the resident seated in her wheelchair, looking out of her window in her room. On 12/02/21 at 08:41 AM, Licensed Nurse (LN) G verified the physician had not been notified of the out of parameter medications. On 12/02/21 at 09:40 AM, Administrative Nurse D stated she expected staff to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Monitoring Parameters for Blood Pressure and Pulse policy, dated 02/08/17, documented it was the practice of the facility to monitor certain medications with either a pulse or blood pressure to monitor the effectiveness of the medications. The policy further documented the following guidelines have been established with the Medical Director and the primary care physicians for reporting of abnormal pulse or blood pressure. The pulse ranges for all medications are expected to fall in the range of 60 to 120 unless otherwise individually established. Any pulse outside of this range should be reported to the charge nurse for further assessment. If the pulse is less than 60, hold, the charge nurse will report findings to the physician. If the pulse is greater than 120, give and the charge nurse will report findings to the physician. The facility failed to report R9's out of parameter pulses to the physician, placing her at risk for physical decline. - R31's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment documented the resident received anticoagulant (inhibited the clotting of blood) and diuretic (medication to promote the formation and excretion of urine). The [CONDITION(S)] Care Plan, dated 10/04/21, directed staff to give cardiac medications as ordered and report any signs and symptoms to the physician. The Physicians Order, dated 06/23/21, directed staff to administer [MEDICATION(S)] (a blood pressure medication to treat heart failure), 125 micrograms (mcg) one tablet daily. The staff were directed to hold and report to the physician if the resident's heart rate was less than 60 beats per minute (bpm) and give and report to the physician if heart rate was more than 120 bpm. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record documented the [MEDICATION(S)] medication was given and the physician was not notified of the out of parameter pulse. The Physicians Order, dated 06/23/21, directed staff to administer [MEDICATION(S)] (an antihypertensive medication), 6.25 milligrams (mg) one tablet daily for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR, dated August 26, 2021, documented the resident's pulse was 57. The record documented the [MEDICATION(S)] medication was given and the physician was not notified of the out of parameter pulse. The MAR, dated October 19, 2021, documented the resident's pulse was 42. The record documented the [MEDICATION(S)] medication was refused by the resident and the physician was not notified of the out of parameter pulse. On 12/02/21 at 08:00 AM, observation revealed the resident was seated in the dining room waiting for breakfast. On 12/02/21 at 08:47 AM, Licensed Nurse (LN) G verified the medication were given and the physician was not notified regarding the out of parameter pulses. On 12/02/21 at 09:40 AM, Administrative Nurse D stated she expected staff to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Monitoring Parameters for Blood Pressure and Pulse policy, dated 02/08/17, documented it was the practice of the facility to monitor certain medications with either a pulse or blood pressure to monitor the effectiveness of the medications. The policy further documented the following guidelines have been established with the Medical Director and the primary care physicians for reporting of abnormal pulse or blood pressure. The pulse ranges for all medications are expected to fall in the range of 60 to 120 unless otherwise individually established. Any pulse outside of this range should be reported to the charge nurse for further assessment. If the pulse is less than 60, hold, the charge nurse will report findings to the physician. If the pulse is greater than 120, give and the charge nurse will report findings to the physician. The facility failed to hold medication and report R31's out of parameter pulses to the physician, placing her at risk for physical decline.

The facility had a census of 52 residents. Based on observation, record review, and interview, the facility failed to provide a clean, comfortable, homelike environment in one of three dining rooms and two of three halls. Findings included: On 01/26/2020 at 10:58 AM, observation, during initial tour, revealed: One East hall bathroom with six holes in the wall, approximately ¼ inch in diameter, half of the grab bar missing on the wall, and the room had numerous sizes of black marks on the wall beside the resident's bed. One East hall room with gouges in the sheet rock, approximately 2 feet (ft) by 6 inches (in) behind the resident's recliner. East hall side rail below the fire extinguisher with end of tubing missing. Hall outside the main dining room with numerous sizes of missing paint on the wall all along the hallway. Three entrances door frames with dents in the frame approximately two to three inches from the floor. Main dining room with a 2 ft area of missing mopboard across from the juice station. Brown recliner in the commons area in front of the nurse's station with a 6 in x 6 in area of missing fabric on the right arm of the recliner. Wall behind the nurse's desk with an approximately 3 ft x 6 in scraped area and the medication room door frame with numerous areas of missing paint. West hall side rail loosely connected with an approximately ¼ in gap between the elbow and straight tubing. On 01/29/2020 at 08:18 AM, Maintenance Staff (MS) U verified the above observations. MS U stated when staff note an environmental issue, they should fill out a work order and place it on his clipboard in charting room, his mailbox, or tape it to the maintenance room door. The facility's Maintenance Department policy, dated 07/25/19, documented the department would provide ongoing monitoring of the facility for areas needing repair, and if needed, would report to the executive director for approval of the repairs needed. The facility failed to provide a clean, comfortable, homelike environment for the 52 residents who resided in the facility, placing the residents at risk of an unhomelike experience.

The facility had a census of 52 resident. Based on observation, record review, and interview, the facility failed to prepare pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) by methods that conserved nutritive value, flavor, and appearance for five of five residents who received pureed diets. Findings included: - On 01/21/2020 at 11:10 AM, observation revealed Dietary Staff (DS) BB prepared five pureed meals. DS BB placed five servings of chili into a blender and added several saltine crackers until the desired consistency without following a recipe. Continued observation revealed DS BB obtained five servings of cinnamon rolls, placed them in a clean blender and added half and half milk product to moisten rolls until the desired consistency without following a recipe. On 01/22/2020 at 01:50 PM, DS BB verified she had not followed the pureed recipe for the chili or cinnamon rolls. On 01/22/19/2020 at 02:30 PM, DS BB provided a pureed chili recipe which consisted of blending food thickener as needed and checking the product consistency periodically. DS BB reported she did not have a pureed cinnamon roll recipe. The facility's undated Pureed Diet and Food Preparation policies documented food is prepared by methods that conserve nutritive value, flavor, and appearance, and if liquid or other items are added, a standardized recipe must be used. The facility failed to prepare pureed foods by methods that conserved nutritive value foods for the five residents who received a pureed diet, placing the residents at risk for inadequate nutrition.

The facility identified a census of 59 residents. The sample included 10 residents. Based on observation, interview and record review the facility failed to report an allegation of potential abuse, neglect and/or exploitation to the State agency for Resident #29. Findings included: - The Electronic Medical Record (EMR) for resident #29 documented the [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment for resident #29 dated 9/20/18 revealed a cognitively intact resident with a Brief Interview for Mental Status (BIMS) score of 14. He/she required staff assistance with most ADSL's (activities of daily) and used a wheel chair for locomotion. The cognitive loss care plan dated 10/29/18 and revised 1/7/19 documented the resident experienced anxiety, and dementia with behaviors and delusions. The care plan directed staff to promote dignity and to provide orientation and validation. The [MEDICAL CONDITION] medication care plan dated 10/29/18 and revised 1/7/19 documented the resident had paranoia. He/she did not like people involved in inter-racial relationships and would target staff with untrue accusations. The care plan directed staff involved in inter-racial relationships to not provide care or be assigned to the resident's unit. Staff members were directed to provide care with a second staff member as a witness if possible. The EMR consistently documented the resident as having target behaviors of making false accusations about staff. Review of the social service note dated 8/2/18 documented that the resident was making false accusations about staff member Q. When interviewed by the social worker, the resident stated it was nasty when white people are married to black people. During interview on 1/9/19 at 8:30 AM the resident stated a nurse spit in his/her face and said to stop talking about this nurse. The resident stated he/she told the director of nursing (DON) and the administrator of the incident. During interview on 1/9/19 at 8:40 AM administrative nurse D stated that the resident reported a nurse spit in his/her face last evening on 1/8/19. Administrative staff D confirmed that this was not reported to the state due to knowing resident #29's history of targeting staff and false accusations. During interview on 1/9/19 at 9:00 AM administrative staff A revealed he/she was not aware of this allegation until reported to him/her by the DON on 1/9/19. 01/09/19 09:58 AM administrative staff E stated the resident has had issues with people in bi-racial relationships since he/she got here. This is not something new, he/she targets staff members in such relationships and makes false accusations about them. Staff K was removed from working the South hall in (MONTH) (YEAR). The resident also did this to staff Q in early August. Staff Q is also in a bi-racial relationship and the resident was making false accusations about him/her. Staff Q was removed from working the South hall in (MONTH) (YEAR). Review of the facility's Abuse and Neglect Policy revised 2/2/18 documented all alleged or suspected violations involving mistreatment, abuse, neglect, exploitation, and injuries of unknown origins will be immediately reported to the administrator/DON. The administrator/DON will report such allegations to the State Agency in accordance with State law. The facility failed to report an allegation of abuse to the state agency.

The facility identified a census of 60 residents, which resided on three units. Based on observation, interview, and record review, the facility failed to effectively sanitize resident rooms and equipment. Findings included: - On 11/8/17 at 7:56 A.M., housekeeping staff Y entered a resident's room to complete the daily room cleaning. Housekeeping staff Y donned gloves and at 7:58 A.M., sprayed the bathroom sink and toilet with Clorox Healthcare Disinfectant. At 8:01 A.M., he/she wiped the sink surface, and then wiped the toilet, which adhered to the 1 to 3 minute dwell time to disinfect surfaces. Housekeeping staff Y wore the same gloves throughout the duration of the room cleaning and touched other surfaces within the resident's room including the window blinds, bedside tables, privacy curtains, and the resident's wheelchair. Housekeeping staff Y did not cleanse the all of the surfaces within the resident's room including the bed rails, door knobs, call lights, and mirror. On 11/8/17 at 8:18 A.M., housekeeping staff Y stated he/she cleaned the door knobs and call lights in the resident's rooms weekly and confirmed that he/she did not cleanse all surfaces in the resident's room during the daily room cleaning. On 11/8/17 at 8:25 A.M., housekeeping supervisor Z stated he/she expected housekeeping staff to change their gloves after sanitizing the toilet. He/she further expected housekeeping staff to wipe all room surfaces including the door knobs, bed rails, and call lights. On 11/8/17 at 3:37 P.M., administrative nursing staff E stated he/she expected housekeeping staff to follow the facility policy and clean all surfaces in the resident's room daily and to change gloves after sanitizing the toilet surfaces. The facility's undated Daily Room Cleaning policy documented for staff to change gloves between cleaning dirty surfaces and starting a new task and to clean the resident's room using a Clorox wipe, including the over-bed table, bedside table, call light, door knobs, phone, windowsill, doorframes, shelves, walls, and doors. The facility failed to clean resident rooms in a sanitary manner to help prevent the development and transmission of disease and infection.

The facility reported a census of 53 residents. The sample included 3 residents. The facility identified 16 cognitively impaired and independently mobile residents. Based upon observation, record review and interview, the facility failed to ensure 2 of 3 residents (#1 and #2) received adequate supervision and appropriate interventions to prevent elopement after identified exit seeking behavior. Resident #2 exited the facility without staff supervision on 6/8/16. Resident #1 exited the facility without staff knowledge, crossed the street, and was found by outside provider KK in a convenience store approximately 15 minutes later. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 (indicated moderately impaired cognition). The resident wandered, which put him/her at a significant risk for injury. He/she was independent with locomotion on the unit. The Care Area Assessments (CAAs) for cognition, behavior, Activities of Daily Living (ADLs), and falls dated 6/16/16 revealed a care plan would be developed, but lacked detailed information. The Risk of Elopement/Wandering assessment dated [DATE] identified the resident was not at risk for elopement. It included the resident walked down the wrong hall when he/she looked for his/her room. The Risk of Elopement/Wandering assessment dated [DATE] reported the resident was now at risk for elopement due to changes noted in his/her dementia. The resident approached exit doors and engaged the alarm. The resident's care plan dated 6/27/16 indicated the resident wandered. He/she had a dog, which he/she let outside. Staff observed the resident ambulate in the hall to let the dog outside, but he/she did not have the dog with him/her. Staff also observed the resident ambulate in the hall without his/her walker. The care plan instructed staff to redirect the resident away from inappropriate areas, engage in diversional activities, and remind the resident to use the walker. The care plan lacked new interventions after the elopement on 6/16/16. The nurse's note dated 6/16/16 at 11:35 AM documented staff would complete a significant change MDS assessment due to the resident required more direction with daily tasks, and used a walker to assist with ambulation. The nurse's note dated 6/16/16 at 2:15 PM recorded the door alarm on the east door sounded. Staff responded and found the resident standing in the doorway without his/her walker. Staff brought the resident back inside the facility. The clinical record lacked interventions to provide adequate supervision to prevent another elopement after this incident. According to wunderground.com, the temperature on 6/16/16 at 2:53 PM was 96.1 degrees with a heat index of 101.6 degrees. Review of nurse's notes dated 6/17/16 to 8/26/16 documented increased confusion and forgetfulness. The nurse's note dated 9/4/16 at 4:12 PM revealed outside provider KK entered the building to make a delivery. Upon leaving, he/she told staff that he/she might have let one of their residents out of the front door. Licensed nursing staff H responded and found this resident outside with visitors. He/she assisted the resident back inside the facility. This information conflicted with the interview from outside provider KK. Review of the witness statement from licensed nursing staff H, with the date of the incident of 9/4/16 indicated the resident was found across the street inside the hardware store. According to wunderground.com, the temperature on 9/4/16 at 2:53 PM was 81.0 degrees with a heat index of 83.3 degrees. On 9/8/16 at 8:25 AM, the main entrance to the facility lacked signage outside the door, to instruct visitors not to let anyone out of the door without checking with staff. On 9/8/16 at 11:44 AM, the resident ambulated in the hall with a walker. He/she wore a wander guard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on his/her right wrist. On 9/8/16 at 11:45 AM, the resident stated he/she could not remember leaving the building on 9/4/16. On 9/8/16 at 11:56 AM, outside provider KK stated he/she entered the building on 9/4/16 at 3:15 PM. He/she noted there was a person (resident #1) who stood near the door. As provider KK opened the front door, this person said, I think I will go for a walk, so he/she held the door open. Upon leaving the building, provider KK observed the same person walking in the street with a shuffling gait and without a walker. Provider KK went back into the facility and informed staff. He/she stated staff went to the resident's previous place of employment, and he/she went across the street to the convenience store, where he/she found the resident. He/she denied observing any signage on the outside of the building about assisting anyone out of the building. Provider KK further stated the resident was outside of the facility for 10 to 15 minutes. On 9/8/16 at 2:26 PM, direct care staff Q denied the resident exhibited exit seeking behavior or wandered. On 9/8/16 at 4:54 PM, licensed nursing staff H stated the resident had pushed on the east door, but had never attempted to exit through the front door. Staff H said during the night, the resident came to the nurse's desk fully dressed, and announced he/she was going to work. On 9/8/16 at 12:35 PM, administrative nursing staff D stated staff informed him/her the resident only pushed on the east door on 6/16/16, and did not go through it. Staff D further said if he/she really thought the resident was at risk for an elopement, there would have been measures put in place to ensure he/she did not elope. Staff D stated the resident was only confused due to the hospitalization of his/her family member/roommate from 6/16/16 to 6/19/16, almost 3 months prior to the incident on 9/4/16. The facility's policy Elopement Policy, undated, recorded staff reassessed residents who developed wandering behavior after admission, and staff identified appropriate interventions in the plan of care. The facility failed to ensure this cognitively impaired resident with a history of exit seeking received adequate supervision and appropriate interventions after exit seeking behavior was identified to prevent elopement. Resident #1 exited the facility without staff knowledge on 9/4/16, crossed the street, and was found in a convenience store approximately 15 minutes later. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 9/9/16 at 4:00 PM by initiating the following: New signage placed at the front entrance alerting visitors to not allow residents outside without staff's acknowledgement; revision of policy and procedure to implement changes to prevent a reoccurrence; in-services on elopement policy to all associates; education to staff to alert nursing administration and Executive Director of residents with new exit seeking behavior and any decreased safety awareness; education to nursing administration to do immediate follow up and intervention with the wander guard system on any resident with new exit seeking behavior and any decreased safety awareness, and education on elopement assessments which will be reviewed by DON; all residents were assessed for elopement risks and decreased safety awareness; review of residents with new exit seeking behavior and any decreased safety awareness daily and on weekends by administrative nurse on call with a log kept for 4 weeks to monitor; and education given to all new hires that includes the new updates to the policy. The deficiency remained at a scope and severity of a D. - The physician orders [REDACTED].#2 included a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition, with daily wandering behaviors. The resident had a non-injury fall since admission and was independent with transfers. The quarterly Minimum Data Set ((MDS) dated [DATE] included a BIMS score of 14, which indicated intact cognition, did not have wandering behaviors, required supervision of one staff for walking in the halls and extensive assist of one staff with walking in the room. The Care Area Assessments (CAA) dated 3/1/16 for behaviors included [DIAGNOSES REDACTED]. He/She wandered daily and tried to find his/her room. The CAA for falls included the resident was at risk for falls, had cognitive impairment and wandered. Staff assisted as needed, and reminded the resident to use his/her walker correctly. The care plan dated 3/17/16 included the resident liked being outside when the weather was nice, and used a front wheeled walker while walking. The resident forgot his/her walker and will walk without it. Staff helped to remind the resident to take his/her walker when walking. A revision dated 9/8/16 included a wanderguard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) (placed) on right wrist, and was checked each shift to ensure working. The Fall Risk assessment dated [DATE] noted a score of 19 and on 8/8/16 a score of 19. Scores of a 10 or higher indicated a high risk for falls. The Risk for Elopement and/or wandering assessment dated [DATE] noted the resident was not at risk. The note dated 9/17/16 included the resident's family took the resident out occasionally, and noted the facility monitored the resident for 2 weeks after a witnessed event when the resident pushed on the front door. Staff responded, and the resident wanted to sit outside. There had been no other occurrences since that time. The note further documented staff and family attended the resident while he/she sat outside. The resident came inside the facility without incident. The Nurse's Note (NN) dated 6/8/16 at 10:29 PM documented staff heard the door alarm to the front door sound and it kept sounding. Staff was on break and looked out the window, and saw the resident out front with another resident's family. The other resident's family assisted the resident to a chair in front of the building. The staff member on break stated the alarm to the front door was shut off, but the staff opened the blinds and watched the resident from the window until the resident came back inside the building. The NN dated 6/10/16 at 8:13 PM noted the resident exited the building on June 8th at 6:30 PM. The resident pushed the door until the alarm sounded. Staff responded to the event, and saw the resident seated outdoors under the supervision of a visitor. Another staff was on break and visualized him/her during this time. The resident sat outdoors for approximately 20 minutes with the family, and then was asked if he/she wanted to return inside. He/she willingly re-entered the building. A nursing note addendum on 6/13/16 at 7:05 AM documented an elopement checklist was initiated to monitor the resident's whereabouts every 30 minutes for 2 weeks. Staff would re-evaluate the need at that time for further elopement monitoring and elopement risk. The physician's orders [REDACTED]. Review of the elopement checklist dated June 2016 lacked information on the resident's location and what the resident was doing. Staff documentation on the checklist started two days after the resident exited the building unattended on 6/8/16. The form included staff initials beside a 30 minute increment list of times from 6/10/16 at 10 AM through 6/23/16 at 5:45 PM. The physician's telephone order dated 9/8/16 directed staff to place a wanderguard bracelet to the resident's right wrist and to check it every shift for placement. The NN dated 9/8/16 at 3:21 PM noted an order was received to utilize a wanderguard bracelet due to the resident frequently wandered down halls to look for his/her room, and stated he/she was going to leave soon, because his/her family was coming to get him/her, when in fact they were not. Observation on 9/8/16 at approximately 12:20 PM as the resident left the dining area from the noon meal, the resident used his/her front wheeled walker. His/her gait appeared steady and the resident was slightly stooped over. Observation on 9/8/16 at 6:30 PM, the resident sat in a regular chair, in the common area near the nurse's station with his/her legs propped up on his/her walker positioned in front of him/her. The resident wore a wandergard bracelet on his/her right wrist. On 9/8/16 at 4:35 PM, direct care staff O identified the resident as an elopement risk, and referred to a dry erase board, in a room behind the nurse's station which listed the elopement risk residents. Staff O further stated the resident wore a wanderguard bracelet. He/she said if a resident eloped or exited the building, staff approached and spoke calmly to the resident to get the resident to come back inside (the facility). On 9/8/16 at 4:40 PM, direct care staff P identified the resident at risk for elopement, due to after supper, the resident wanted to leave to see family. He/she stated the resident went to the door, and came back. Further, he/she stated the resident wore his/her jacket and sat in the chair. Staff P indicated a certain chair near nurse's station. He/she stated this resident wore a wanderguard bracelet. On 9/8/16 at 6:25 PM, licensed nursing staff I confirmed the resident exited the facility on June 8, 2016. Staff I also confirmed the elopement checklist was not started for 2 days until June 10, 2016 after the elopement. He/she stated the elopement checks were to be started immediately, and a wanderguard was placed immediately if indicated. Staff I further stated the 30 minute elopement checks were discontinued on 6/24/16, but was unsure why they were discontinued. He/she confirmed the resident has some memory problems and dementia. On 9/8/16 at 7:00 PM administrative nursing staff D confirmed the resident left out the front door, the door alarmed and the resident was with a visitor. Staff D stated he/she felt the visitor was adequate for the resident's supervision. This staff confirmed the visitor was not a family member to the resident, but of another resident. Staff D confirmed the two week elopement checks were started on 6/10/16, two days after the resident exited, not immediately, and were started after an IDT (interdisciplinary team) meeting. The facility's policy Elopement Policy, undated, recorded staff reassessed residents who developed wandering behavior after admission, and staff identified appropriate interventions in the plan of care. The facility failed to provide timely and appropriate supervision for this cognitively impaired mobile resident after he/she exited the facility without staff supervision on 6/8/16.

The facility identified a census of 37 residents with 14 residents utilizing lift chairs. Based on observation, interview, and record review the facility failed to ensure the residents' environment remained free of accident hazards for 1 of 3 (#1) residents sampled for accidents. Resident #1 sustained a fall from a malfunctioning lift chair known to facility staff and sustained a hip fracture. Findings included: - Resident #1 had a [DIAGNOSES REDACTED]. His/her right arm was flaccid (a part of the body soft and hanging loosely or limply), and had weakness of his/her right leg. Review of the Minimum (MDS) data set [DATE] a significant change assessment listed the resident had a Brief Interview for Mental Status score of 12 which indicated moderate cognitive impairment. The resident required extensive assistance of two staff with transfer and was not steady, only able to stabilize with staff assistance with surface to surface transfer. Review of the care plan last updated 4/5/15 revealed on 9/2/14, staff added an electric lift chair to the care plan. Staff assessed the resident for safe use of the chair on 2/17/15, but did not use the controls he/she let staff change the positions of the chair as needed. Review of the nurse's notes revealed on April 5, 2015 at 10:00 A.M. staff found the resident on the floor with blood, a one centimeter open area to his/her scalp, and a hematoma (localized swelling filled with blood caused by a break in the wall of a blood vessel) at the top of the resident's head. Staff had positioned the resident's feet on the floor and left the room to get the sit to stand lift to transfer the resident from the lift chair to the wheelchair. When staff returned, the lift chair was in the upright position with the resident lying on the floor on his/her right side. The resident stated to staff " the chair did not stop". On April 6, 2015 the resident had bruising and edema (swelling) of the right shoulder and the facility sent the resident to a local hospital. An x-ray of shoulders and hips determined the resident sustained [REDACTED]. The resident transferred to the hospital for surgical repair of the hip. Review of the facility investigation revealed 4 staff members of the facility were aware the controls of the lift chair were not functioning properly since April 2nd or 3rd and 2 staff could not recall what day the malfunction was reported to maintenance staff. Review of the witness statement for direct care staff O dated 4/7/15 not timed stated the chair would sometimes get stuck in the up or down position but after wiggling the remote it would go back to working. It was reported to maintenance. Review of the witness statement for direct care staff P dated 4/7/15 and not timed stated on April 3 he/she knew the lift chair would stick in the on position. He/she also knew if staff wiggled the button was wiggled it would stop. He/she felt it was not a major issue, but should have removed the chair from service. Review of the witness statement for direct care staff Q dated 4/7/15 and not timed stated buttons on the recliner were sticky, he/she knew for a week it did not function properly. He/she was told the chair was reported to maintenance. Review of the witness statement for direct care staff R dated 4/7/15 at 10:45 A.M. stated on the 2nd or 3rd of April he/she noticed the buttons on the lift chair were not working properly they were sticking, and the control did not work properly. If staff pushed the button again it would stop moving up or down. Direct care staff R told the maintenance staff about the problem with the chair control not working properly. Observation on 4/20/15 at 11:20 A.M. revealed resident #1 laid in his/her in the lowest position. An electric lift chair was in his/her room. Interview on 4/30/15 at 11:22 A.M., resident #1 revealed he/she no longer sat in the lift chair because he/she was afraid of it since he/she sat in it and it moved and he/she fell . Interview on 4/30/15 at approximately 3:30 P.M., direct care staff S revealed staff was inserviced on the electric lift chairs. Staff was also directed that if a chair was found not to be working that it should be taken out of the room and a work order should be written. Interview on 4/30/15 at 4:00 P.M. with Maintenance staff X revealed there was a break in communication he/she was working on another project, staff mentioned the chair, and did not put a written request in, and he/she forgot to check the functioning of the chair. Interview on 4/30/15 at 4:30 P.M. with administrative nurse D revealed an inservice was completed for all staff on what to do if a piece of equipment malfunctions, as well as a work order system was developed with duplicate copies going to maintenance and administration. The chairs were checked on a weekly basis for a month and now will be checked monthly. Although requested the facility failed to produce a policy on staff reporting a malfunctioning item to maintenance dated prior this incident. The facility failed to adequately maintain this cognitively impaired, dependent resident's electric lift chair when it malfunctioned. The resident sustained [REDACTED].

The facility had a census of 55 residents. The sample included 17 residents. Based upon observation, record review and staff interview the facility failed to ensure that 2 (#62, #48) of 3 sampled residents maintained acceptable parameters of nutritional status. Findings included: - Review of resident #48's Physician order [REDACTED]. The resident's admission Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 11/18/11 recorded the resident scored 11 (mild cognitively impaired), required staff supervision with eating, weighed 153 pounds, had not experienced a weight loss, and did not receive any nutritional approaches. The resident's nutritional status care area assessment (CAA) did not trigger for this MDS. The resident's care plan for 11/29/11 to 2/27/12 documented the resident received a house nutritional supplement in the AM and PM, included an entry dated 1/3/12 that documented the resident had experienced a weight loss and the facility would offer the resident large portions at each meal. A nutritional data collection/assessment completed by a registered dietician on 11/19/11 documented the resident weighed 161 pounds, was not eating well prior to admission (11/9/11) consumed an average of 75 percent (%) of meals, and the resident's weight was within the health weight range. A nutritional progress note completed by a registered dietician and dated 12/8/11 (no time) documented the resident weighed 167 pounds, weight was up 5.6 pounds since admission, the resident's appetite was good, and continued to receive a regular diet. A nutritional progress notes completed by a registered dietician and dated 12/27/11 (no time) documented the resident weighed 157 pounds, staff reported the resident's appetite was good, the resident's weight had decreased 10 pounds in 3 weeks, and the dietician recommended the resident receive fortify foods to increase his/her caloric intake. A nutritional progress note completed by a registered dietician and dated 1/9/12 (no time) documented the resident weighed 157 pounds, received fortified foods, had received large portions since 1/3/12 to increase the resident's intake, staff continued to monitor the resident's weight, and if the resident's weight continued to decrease the resident may need nutritional supplements. A quarterly nutritional progress note dated 1/12/12 (no time) documented the resident had a good appetite, did not require staff assistance during meals, all possible foods were fortified, and the facility offered the resident large portions at each meal. A laboratory report dated 1/9/12 recorded the resident's serum [MEDICATION NAME] level at 3.2 grams/deciliter (g/dL) with normal reference range of 3.4-5.0 g/dL. The report recorded the resident's serum protein level at 6.8 g/dL with normal reference range of 6.4-8.2 g/dl. The resident's weight sheet recorded the resident's weights as follows: 11/10/11: 157 pounds (day after admission) 11/21/11: 161 pounds 12/5/11: 167 pounds 12/12/11: 160 pounds 12/19/11: 158 pounds 12/26/11: 157 pounds 1/16/12: 151 pounds 1/23/12: 147 pounds (a decrease of 10 pounds or a 6.36% weight loss since 11/10/11) Review of the resident's Medication Administration/Treatment Administration Record revealed the resident received nutritional supplement twice a day from 11/9/11 until 11/30/11 for nutritional deficiency. On 12/5/11 the facility received a physician's orders [REDACTED]. The resident had remained on this dosage of [MEDICATION NAME] since that date but continued to loose weight. On 12/27/11 the facility received a physician's orders [REDACTED]. On 1/3/12 the facility received a physician order [REDACTED]. On 1/19/12 at 7:25 A.M. the resident ate his/her breakfast meal which consisted of a 1/2 bowl of oatmeal,, 1 slice of bacon, 3 smoky cocktail links and 1/2 bowl of fruit. At 7:55 A.M. the resident had finished eating the breakfast meal and consumed 100% of all food offered. On 1/19/12 at 12:05 P.M. the resident ate his/her lunch meal which consisted of pork, green beans, and mashed potatoes. At 12:25 P.M. the resident had consumed all of the food offered. On 1/23/12 at at 8:05 A.M. dietary staff M prepared the resident's breakfast meal which included 1/2 cup of cold cereal, 1 slice of bacon, 2 ounces of ham and 2 fried eggs. The resident's dietary card included the resident received fortified foods and large portions. At 8:30 A.M. the resident had consumed 100% of the breakfast meal. Review of the facility's breakfast menu for week 4 day 23 (according to dietary staff M) was the breakfast menu for 1/23/12 included residents on a regular diet would receive 2 eggs of resident's choice. On 1/23/12 at 12:20 P.M. the resident ate his/her lunch meal which consisted of a hamburger steak, peas rolls, roasted potatoes, and a roll. During interview with dietary staff M at 12:25 P.M. the staff stated fortified foods included butter added to potatoes and gravy was placed on meats. At that time, dietary staff M confirmed the resident did not have butter on the potatoes nor gravy on the hamburger steak. During interview with dietary staff M on 1/23/12 at approximately 1:05 P.M. the staff confirmed the resident was not offered large portions or fortified foods at the lunch meal. Dietary staff M stated the resident should have received 1 1/2 serving of the meat and potatoes at the lunch meal. During interview with administrative nursing staff D on 1/24/11 at approximately 12:45 P.M. the staff confirmed the resident had experienced a weight loss since admission. Administrative nursing D also confirmed the resident had physician's orders [REDACTED]. The facility failed to offer large portions and fortified foods to this resident with a weight loss as physician ordered. - Review of resident #62's Physician order [REDACTED]. Review of the resident's admission Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 10/25/11 identified the resident scored a 10 (mild cognitive impairment) on the Brief Interview for Mental Status (BIMS) identified the resident required limited staff assistance with bed mobility, transfers, walking in the room and corridor, and locomotion on and off the unit, required extensive staff assistance with dressing and had eaten 1 to 2 times in the last 7 days. The MDS recorded the resident had no swallowing problems, weighed 122 pounds, had not experienced a weight loss, and did not receive nutritional approaches. The resident's nutritional status care area assessment (CAA) for this MDS did not trigger. The resident's care plan dated 11/11/11 to 1/30/12 addressed the resident was on a regular diet, received large portions, and did not require staff assistance during meals. An entry to the resident's care plan dated 1/9/12 documented staff fortified all of the resident's foods, and staff offered him/her juice several times a day. The resident's nutrition data collection assessment dated and signed by a Registered Dietician on 10/28/11 (no time) documented the resident was admitted to the facility on [DATE](the resident weighed 123 pounds on 10/20/11), consumed 75 percent (%) of meals, and the resident's weight was within the healthy weight range. A nutritional progress note completed by a Registered Dietician on 12/27/11 (no time) documented the resident weighed 121 pounds which was at the low end of the resident's healthy weight range; the resident's appetite was good, and recommended to increase the resident ' s portion sizes at meals to increase the resident's caloric intake. A nutritional progress note dated 1/9/12 (no time) documented the resident weighed 124 pounds, the resident's appetite was good, the nursing staff recommended the resident have his/her foods fortified to increase intake, and the facility would continue to monitor the resident's weights. This weight did not match the weight in the clinical record. A quarterly nutritional progress note dated 1/19/12 (no time) documented the resident weighed 124 pounds, the resident received large food portions at meals, and all possible foods were fortified. This weight did not match the weight in the clinical record. A nurse's note dated 1/11/12 timed 9:45 A.M. documented the Registered Dietician saw the resident, the facility received orders to fortify the resident's foods, and the facility would continue to monitor the resident's weights on a weekly basis. Review of the resident's weights recorded the following: 10/20/11: 123 pounds (day after admission) 11/22/11: 127 pounds 12/26/11: 124 pounds 01/09/12: 119 pounds (weight loss of 5 pounds in 1 week, or a 6.29% weight loss since 11/22/11) 01/16/12: 119 pounds 01/23/12: 117 pounds (further weight loss of 2 pounds in 1 week, or a 7.87% weight loss since 11/22/11). Review of the resident's diet seven day look back documentation for 1/3/12 through 1/9/12 documented the resident consumed an average of 75% of his/her food at meals. The seven day look back documentation lacked evidence the facility offered the resident A.M. or P.M. snacks. The seven day look back period documentation recorded the resident usually consumed 100% of the night time (HS) snacks. Review of the resident's diet seven day look back documentation for 1/11/12 through 1/17/12 documented the resident consumed an average of 75% of his/her food at meals. The seven day look back documentation lacked evidence the facility offered the resident A.M. or P.M. snacks. The seven day look back documented recorded the resident refused the HS snack 3 times and consumed 100% on the other 3 HS. Review of the resident's diet order and communication form dated 12/27/11 read to offer large portions at meals. The resident's diet order and communication form dated 1/9/12 documented to fortify all of the resident's foods. On 1/19/12 at 7:25 A.M. the resident received his/her breakfast meal which included (1) fried egg, 1 slice of toast, 3 smoky cocktail links, and 1/2 bowl of oatmeal. At 7:45 A.M. the resident had finished eating the breakfast meal and had consumed 100 percent of the egg, toast, links and 75% of the oatmeal. On 1/23/12 at 7:40 A.M. dietary staff M prepared the resident's breakfast meal which consisted of 1 slice of bacon, 1 piece of ham (2 ounces), and 1/2 cup of cream of wheat. During interview with dietary staff M at that time, the staff stated the cream of wheat was not fortified. Review of the resident's dietary card revealed the resident should receive large portions and fortified foods. At 7:50 A.M. the resident had finished eating the breakfast meal and the resident consumed 100% of all food offered. On 1/23/12 at 12:40 P.M. the resident ate the lunch meal which consisted of a hamburger steak, potatoes, peas, and a roll. At 12:55 P.M. the resident had finished the lunch meal and consumed 100% of all food offered except the roll. During interview with dietary staff M on 1/23/12 at approximately 1:05 P.M. the staff confirmed the resident was not offered large portions at the breakfast meal and also confirmed the cream of wheat was not fortified. Dietary staff M also confirmed the resident did not get large portion of meat or potatoes at lunch. Dietary staff M stated the resident should have received 1 1/2 serving of the meat and potatoes at the lunch meal. During interview with direct care staff R on 1/23/12 at approximately 3:15 P.M. the staff stated the HS snacks consisted of cookies, chips, cheese puffs, graham crackers and juice. Dietary staff stated the resident's HS snack was usually grape juice and a chocolate chip cookie. During interview with direct care staff S on 1/24/11 at approximately 12:18 P.M. the staff reported at 9:00 A.M. the facility passed ice to residents but no snacks and at 2:00 P.M. juice was offered to all residents. During interview with administrative nursing staff D on 1/24/11 at approximately 12:45 P.M. the staff confirmed the resident had experienced a weight loss since admission. Administrative nursing D also confirmed the resident had physician's orders [REDACTED]. The facility failed to offer this resident with weight loss large portions and fortified foods at all meals as planned.

The facility identified a census of 41 residents. Sample size included 14 residents of which 4 were reviewed for supervision. Based on record review and interview, the facility failed to provide supervision for 1 (#41) resident that resulted in injury and death. Findings included: - Resident #41's closed record physician's orders [REDACTED]. The significant change Minimum Data Set 2.0 dated [DATE] revealed the resident had short term memory problems, decisions were poor, cues/supervision required, was easily distracted, mental function varied over the course of the day, had moderately impaired vision, side vision problems/decreased peripheral vision, did not ambulate, required extensive assistance of one staff with locomotion on and off the unit, required extensive assistance with dressing, toileting, personal hygiene, and bathing, unable to test standing balance without physical support, unsteady sitting balance, and had the [DIAGNOSES REDACTED]. The Resident Assessment Protocol (RAP) for delirium dated [DATE] assessed the resident was confused and thinks people do things they do not. The resident had a [DIAGNOSES REDACTED]. The RAP for cognition dated [DATE] documented the assessment that the resident had short term memory problems, could remember things from weeks ago but ten minutes was hard, the resident would ask the same person the same thing numerous times and did not remember the previous conversation, the resident did not think things out and staff assist with decision making, the resident needed cues, sometimes repeatedly, on meal times and activities, and the the resident heard things the way he/she wanted to and not always the way they were said which I " feel contributes to the delusions. " The RAP for vision dated [DATE] documented the assessment that the resident ' s vision was a problem. The resident could see objects if he/she could get them close to him/her, they could identify them. The resident had macular degeneration and glaucoma. The resident had " adjusted to (his/her) poor vision well with (his/her) memory problems. " The resident had a few other residents that were always willing to help and also a few staff members the resident looked for and recognized their voices. The up-dated care plan dated [DATE] listed the problem of cognition. It also included that due to his/her [DIAGNOSES REDACTED]. The interventions included: takes razadyne daily for [DIAGNOSES REDACTED]. This care plan also listed the problem of visual deficit secondary to glaucoma and macular degeneration, the resident ' s vision was poor, the resident can see objects but usually able to identify things, the resident held things in his/her hand to help him/her out with the intervention to make sure you announce self when you were around him/her so the resident was aware that someone is there. The up-dated care plan also listed the problem of needing assistance with activities of daily living due to his/her poor eye site and decreased mobility due an to old femur fracture and arthritis, with the interventions for the use of the sit to stand lift as needed and the resident liked to wheel him/herself freely around the building. The Fall Risk Evaluation dated [DATE] identified the resident at a score of 22 with a score of 10 or higher identifying the resident at risk for falls. The Ophthalmic Progress Note dated [DATE] identified the resident had advanced glaucoma and advanced macular degeneration. The Physician's Progress Note dated [DATE] documented the resident had alzheimer's type dementia, hallucination of uncertain origin. The resident said that periodically he/she saw things. The resident stated it did not happen every day and primarily he/she saw people. The Social Service note dated [DATE] and timed 10:10 A.M. revealed the family stated it was fine for the resident to sit outside by the door bell and check on him/her every half hour or so. Interview on [DATE] at 4:20 P.M. with the resident sitting outside with the resident on [DATE] stated, he/she did not see the resident go down the sidewalk. This resident stated the staff told him/her that resident #41 "had fallen or something." The Social Service note dated [DATE] and timed 12:40 P.M. identified the resident as alert but having more confusion. The nurse's note dated [DATE] and timed 1:20 P.M. revealed the physical therapy {aide}yelling that a person was laying on the ground outside. The staff observed the resident laying semi-prone with his/her left arm behind them and the face on the ground. Administrative staff C was at the resident's side. Noted large amount of blood under the resident's face. Staff notified the Emergency Medical Services and physician of the accident. The note stated staff suspected that the resident wheeled too close to the curb and fell forward with the wheel chair landing on top of him/her. The ambulance arrived at 1:40 P.M. and the facility transferred care of the resident to the emergency medical technicians. The Radiology Report dated [DATE] revealed the resident had a large acute left subdural hematoma. The nurse's note dated [DATE] at 5:00 P.M. revealed the resident expired at the hospital. Consultant A stated on [DATE] at 3:00 P.M. he/she was doing therapy in the therapy room that has a door and a window to the front of the building. This consultant saw the resident sitting in his/her wheel chair outside of the building away from the door. He/she looked up and saw the resident wheeling down the sidewalk. When he/she looked up again he/she saw the resident wheeling him/herself very fast down the sidewalk. They yelled for staff and by the time they exited the building the resident was on the ground and the wheel chair was on top of the resident. Administrative staff C was getting out his/her car and came running over to the resident. He/she stated blood was coming from under the resident's head. Administrative staff B on [DATE] at 4:15 P.M. stated the resident usually would sit outside for 30 to 45 minutes depending on the day. The resident sat by the door and would ring the door bell when he/she wanted to come back into the building. He/she identified the place where the resident sat that day which was away from the entrance of the door. Nurse B on [DATE] at 4:25 P.M. stated the front office staff would keep an eye on the resident's when they sat outside. The investigation lacked evidence the office staff saw this resident wheeling down the side walk and falling. The facility's investigation revealed the resident rolled his/her wheel chair off the edge of the sidewalk/curb, the wheel chair tipped and the resident fell out and landed on his/her left side, striking their head on the cement. The wheel chair had tipped over and was partially on top of the resident. The resident was outside approximately five minutes before the incident happened. Confidential interview with an alert and oriented resident on [DATE] at 4:20 P.M. revealed resident #41 "was so confused, (he/she) would ask me five times the same think," at one sitting. The facility's Policy for Supervision of Residents Inside and Outside of Facility with no date revealed that residents with unpredictable behavior patterns or severe cognitive impairment will be monitored by a staff member or family member while outside the facility. The policy also stated the facility would allow the residents the freedom to enjoy both the inside and outside spaces of the facility to the maximum extent of their abilities while monitoring for their safety. The clinical record lacked evidence the facility provided supervision for this cognitively and visually impaired resident that sustained an injury and died .