Every finding on record at Lifecare Greenbush Manor

Based on interview and document review the facility failed to ensure 1 of 3 residents (R1) were free from physical and verbal abuse during cares when a nurse aid (NA) made derogatory statements and provided rough care during activities of daily living (ADL) services which was witnessed by another employee and had other witnessed incidents of verbal abuse that went unreported due to staff feeling intimidated or fearful of retaliation. Findings Include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of non-traumatic brain dysfunction. R1 was dependent upon staff for all cares, repositioning, transfers, and frequently incontinent of bowel and bladder. R1's diagnoses report dated 10/15/15, also identified she was suffering from dementia.R1's care plan dated 9/26/25, identified she had an activities of daily living (ADL) self-care performance deficit related to weakness and memory loss. Staff were directed to provide extensive to total assistance of one to two for personal hygiene and toilet use. She had behavioral symptoms and severe impaired cognition, memory loss related to dementia, asks repetitive questions, lacks safety awareness, can be combative with cares, will holler or sing out loud. Staff were directed to provide opportunity for positive interaction/attention, reassurance regarding her stay, and monitor/document/report changes in behaviors/mood/cognition and any signs/symptoms of depression, anxiety, mood as per facility monitoring protocols. Facility investigation dated 10/13/25, identified on 10/9/25 at 3:00 p.m. NA-B reported she observed NA-A wipe R1 aggressively and rough while providing peri cares. She poked or went deeper than needed and heard NA-A address R1 by stating, God you fucking stinking [sic]. You're no fucking help. During peri cares NA-B observed R1 grimacing and was asked if she was okay, R1 stated no two times. Resident interviews were completed without concerns. Staff peer reviews were completed and identified NA-A provided resident cares appropriately but was not warm and fuzzy in her interactions, always cranky, verbally inappropriate while she provided cares, stated fucking sticks in front of the resident, and staff feared retaliation by NA-A due to being confrontational. NA-A denied allegation but was witnessed by one employee. NA-A was suspended immediately and terminated after investigation. Informal education was and is being provided at daily stand-up meeting about the importance of speaking out immediately when you believe something wrong had occurred. Allegations: verified.Review of Daily Nurse Communication Sheets from 10/9/25 through 10/15/25, identified: -10/9/25, 10/13/25, 10/14/25, 10/15/25, and 10/16/25, no documentation regarding R1 and incident -10/10/25 Handwritten note at bottom of page *Reminder - All staff are mandated reporters for vulnerable adults (VA).Review of NA-A's personnel file disciplinary actions taken: -9/15/25 at 3:00 p.m. Comments made one evening in the dining room in front of residents. This type of behavior was not acceptable and will not be tolerated at this facility. We are here to provide services to them with dignity and respect. Retaliation was against the facility's policy and will lead to further disciplinary actions if identified or observed. During an observation on 10/14/25 at 1:49 p.m., 2:20 p.m., and 3:56 p.m. R1 laid in a low bed with room lights off, shade pulled down, television on and family member sat next to her bed in a chair. During an observation on 10/14/25 at 4:00 p.m., nursing assistant (NA)-C and NA-D entered R1's room and she opened her eyes. NA-C introduced herself and informed R1 they were there to complete a check and change and get her repositioned, R1 was observed to smile. NA-D rolled R1 onto left side and NA-C pulled her pants down, removed soiled brief, completed peri cares, applied barrier cream and placed a clean brief underneath her. NA-C explained each step to her while she was rolled R1 onto her right side and pulled up her pants. R1 did not verbally respond. R1 was repositioned onto her right side, pillow placed behind her back and covered with a blanket. The bed mattress had raised sides and was lowered down to the floor. Call light was clipped to her shirt and head of bed elevated to approximately 30 degrees. Interactions were appropriate with no concerns.During an interview on 10/14/25 at 2:00 p.m., family member (FM) stated R1 was defenseless, not coherent much of the time, woke up for short periods of time, smiled, did not talk much, and was unable to tell her what happened. Their sister had called and made her aware there was an allegation a NA was too physical during cares with a witness. During an interview on 10/14/25 at 2:26 p.m. NA-B stated she assisted NA-A with cares on 10/6/25, in the afternoon. R1 laid in bed with a sling lift sheet located underneath her and was incontinent of stool. NA-A stated out loud, R1 you fucking stink and you're no help. R1 was rolled towards her and NA-A cleaned up her bottom. R1 was very stiff, and her extremities were hard to move. She indicated NA-A was aggressive with cares, wiped R1 ruff, hard, and scraped her bottom. R1's reaction was obvious, she flinched physically, and her face winced like she tasted something bad. NA-A slapped the wipes onto her bottom and appeared to hurt R1 physically by the way she responded. R1 did not deserve to be treated like that. NA-B asked R1 if she was ok and she stated, no immediately and when she asked R1 if she was okay, she also stated no. When R1 responded quickly to the question twice it was serious, and in the moment appeared painful. Once cares were completed NA-A stormed out of the room, slammed the door, which was a frequent occurrence. NA-B stated she remained with R1, apologized and informed her she would do something about how she was treated. Prior to this incident she had witnessed NA-A in the dining room one day when they served pork chops. While NA-A cut up a resident's porkchop, which were kind of tough, she stated out loud in front of the resident, she can choke as much as I care. NA-A occasionally made comments to NA-B like, I'm sick of her (meaning resident) or I do not want to do her today. During an interview on 10/14/25 at 2:30 p.m., NA-C stated she had witnessed verbal concerns with NA-A previously, she had a snatchy tone (short with the residents) at times. The NA-A no longer worked at this facility. She had not seen any physical concerns; but did not believe she would not do that in front of the nurse. She had witnessed NA-A inappropriately make comments about a resident directly in front him by stating, he shit his pants, and had an attitude and was irritable with resident cares especially with behaviors. The last three to four months NA-A bullied staff and lacked good bedside manners. NA-A had called R1 lazy and unable to do things any more or help with her cares, in front of her. During an interview on 10/15/25 at 2:45 p.m., NA-F stated R1 was assist of one to two for cares and check and change every two to three hours. She was able to respond to a yes or no question verbally or nod her head, depending on the day. Approximately two weeks ago she had a bad shift with NA-A, went after her verbally, fisty, replied with a certain attitude, displayed confidence, bullied, and made her uncomfortable. The past month NA-A showed signs of being annoyed with R1, stated out loud in front of her she was an agger like [NAME] and rough handled during cares, yanked her around. She overheard NA-A verbally in a loud voice demanding a resident to stand up, come on, let's go (voice carried). NA-A had verbally stated to her regarding a resident, I'm fucking done with her you can talk care of her. She reported her concerns to DON the first Thursday of October 2025. NA- A created stress for staff, and afraid of her, she would verbally attack those that reported her.During an interview on 10/15/25 at 2:53 p.m., NA-A stated on 10/9/25, after dinner approximately 1:00 p.m. she assisted NA-B with R1's check and change. Everything went fine, we were laughing and R1 was giggling with us. She had cleaned R1's front peri area along with NA-B. R1 was rolled over onto her side and she cleaned her bottom, no excessive pressure was used. R1 tended to stiffen herself when turned or repositioned and pushed against us, can be frustrating and made it harder at times (especially when the sling was placed underneath her). She had not recalled saying anything offensive to R1or sworn in front of residents. R1 spoke few words and some days she randomly sang out loud. Two to three weeks prior to this day she was pulled into the DON's office and was informed she was reported for saying something inappropriate in the dining room. None of the staff liked her, felt she was being targeted, retaliation, and false aquations were made. She received a call on 10/10/25, asked to come in, unable to, interviewed, later that day was called back and terminated. Last shift worked was on 10/9/25. During an interview on 10/16/25 at 11:25 a.m., care coordinator registered nurse (RN)-B stated on 9/6/25 at approximately 3:00 p.m. NA-B made her aware of the incident with R1 during cares and NA-A, before she finished her explanation of what happened she was taken to the social service office and asked to repeat her story. It was a no brainer, needed to be reported, made her sick to her stomach and we do not talk to our residents like that here. R1 had dementia and this incident did not appear to impact her when she cleaned her bottom, did not see any irritation or emotional or physical harm.During an interview on 10/16/25 at 9:38 a.m. DON stated she was contacted on 10/9/25 at approximately 3:44 p.m. and incident happened at 2:00 p.m. NA-A had made rude comments and inappropriately wiped R1 during cares and said ouch (assumed it was the way she wiped her). NA-A was suspended immediately pending investigation. She had asked staff why they did not come forward sooner with concerns regarding NA-A and she was informed NA-A was intimidating and bullied them. Verbal abuse was verified and hard to determine when she wiped was abuse, however approach was not ok. NA-A was not a person that should have been working with residents in the nursing home and was terminated. Informal education was provided to staff immediately during stand-up and passed along from shift to shift. Mandatory education will be completed for all staff by 10/24/25.During an interview on 10/16/25 at 1:36 p.m., assistant administrator stated a couple of weeks prior to the 10/9/25, on 9/15/25 she was made aware of an incident involving NA-A and a resident in the dining room. NA-A served a resident chicken, NA-B asked if she usually cut up the chicken and NA-A stated she did not care, she could choke on the bone for all she cared. NA-B verbalized fearful of retaliation. NA-A was interviewed and did not deny the incident happened. She was notified of the R1's incident that occurred on 10/9/25 at 3:44 p.m. NA-A had left for the day, was not allowed to work again, and terminated on 10/10/25. Facility policy [NAME] Adult-Resident Abuse, Neglect, Mistreatment and Misappropriation of Property dated 2/19/25, identified each resident will be free from abuse, neglect, mistreatment, and misappropriation of property. Abuse can include but is not limited to physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse, or involuntary seclusion from any source. All residents will be protected from abuse, neglect, and harm while they reside at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. In the event of suspected maltreatment, the needs of the resident will be immediately (upon knowledge) assessed, and the safety of the resident will be ensured. The resident will be assessed for physical appearance, skin injuries, trauma, or changed in resident affect, mood, and behavior. The investigation will consist of at least the following: a root cause analysis of all circumstances surrounding the incident. Ensuring safety and well-being for the vulnerable adult is of utmost priority. Examine, assess and interview the resident immediately upon knowledge to determine any injury. Verbal abuse was defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability.

Based on interview and record review the facility failed to ensure 1 of 3 residents (R1) who were involved in an allegation of rough care/abuse by staff had and initial and ongoing skin and behavioral tracking to monitor for sign of abuse. Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified serve impaired cognition without behaviors and that she was dependent upon staff for all cares, repositioning, transfers, and frequently incontinent of bowel and bladder. Facility investigation dated 10/13/25, identified on 10/9/25 at 3:00 p.m. NA-B reported she observed NA-A wipe R1 aggressively and rough while providing peri cares. She poked or went deeper than needed and heard NA-A address R1 by stating, God you fucking stinking [sic]. You're no fucking help. During peri cares NA-B observed R1 grimacing and was asked if she was okay, R1 stated no two times. Resident interviews were completed without concerns. Staff peer reviews were completed and identified NA-A provided resident cares appropriately but was not warm and fuzzy in her interactions, always cranky, verbally inappropriate while she provided cares, stated fucking sticks in front of the resident, and staff feared retaliation by NA-A due to being confrontational. NA-A denied allegation but was witnessed by one employee. NA-A was suspended immediately and terminated after investigation. Informal education was and is being provided at daily stand-up meeting about the importance of speaking out immediately when you believe something wrong had occurred. Allegations: verified. Review of R1's task history orders for 10/9/25, identified: -Description: Monitor for peri area and buttocks for bruising, injury, or increase complaints of pain related to 10/9/25 incident. -Description: Monitor behavior for signs and symptoms (s/s) of emotional distress related to incident on 10/9/25. Located on the history order sheet - Progress notes last six months: no progress notes found for the above two orders. R1's behavior tracking log form dated October 2025, identified no documentation entered. R1's NA documentation monitor behavior symptoms every located in electronic medical record under tasks identified the following options: frequent crying, repeats movement, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate, rejection of care, none of the above observed.Review of NA behavior monitoring documentation from 10/8/25 through 10/15/25 identified: -On 10/9/25, all three shifts documented none of the above observed. -On 10/10/25, two shifts documented none of the above observed and one shift failed to document-On 10/11/25, one shift documented none of the above observed and two shifts failed to document -On 10/12/25, all three shifts documented none of the above observed. -On 10/13/25, one shift documented none of the above observed and two shifts failed to document -On 10/14/25, one shift documented none of the above observed and two shifts failed to document -On 10/15/25, two shifts documented none of the above observed and one shift failed to document R1' progress notes from 10/4/25 through 10/11/2, identified: -On 10/4/25 at 10:22 a.m. Weekly body audit: skin pink, dry, and intact with some scattered bruising. No concerns for trimming nails currently.-On 10/7/25 at 1:54 a.m. Typically sleeps well at night, checked for incontinence on routine rounds . head of bed (HOB) elevated and bed in low position with floor mattress. -On 10/7/25 at 9:10 p.m. On coumadin, had fall last week, noted faded bruising on left shin 4 centimeters (cm) with yellow outer edges, older bruise and healing and denied pain. -On 10/11/25 at 11:01 a.m. Weekly body audit: received a bath this a.m. skin intact, no new areas of concern noted. She was on coumadin, no new bruising. Current weight 189.7 pounds (lbs.). R1's daily report sheets (handwritten entries)10/7/25 through 10/15/25 reviewed with no documentation of incident information, skins checks or behavior monitoring. Review of Daily Nurse Communication Sheets from 10/9/25 through 10/15/25, identified: -10/9/25, 10/13/25, 10/14/25, 10/15/25, and 10/16/25, no documentation regarding R1 and incident -10/10/25 Handwritten note at bottom of page *Reminder - All staff are mandated reporters for vulnerable adults (VA). 10/11/25, and 10/12/25 missing documents During an interview on 10/15/25 at 11:25 a.m., licensed practical nurse (LPN)-A stated nursing staff were expected to have completed a weekly skin check on every resident and important to check for bruising, pressure ulcers, and open areas. She had heard about an incident related to R1alleging rough handling and verbal abuse. She had not been informed of any additional assessments required for R1 though a daily skin assessment should have been entered into the EMAR/TAR and/or documented in the progress notes so that R1's skin could have been monitored closely. Behavior documentation would have been expected to be completed by the nurse (EMAR/TAR) daily and every shift. The NAs would be expected to document daily every shift under tasks in the electronic record system, check boxes with options. During an interview on 10/15/25 at 4:45 p.m., registered nurse (RN)-C stated she was aware of a complaint regarding R1 but had no specific details. When there was an allegation of abuse the nurse would be expected to assess and document at least every shift on behavior/mood and skin. Any changes could have indicated an adverse effect of the incident, emotional/physical harm and residents with cognition issues/deficits required an assessment to have looked for non-verbal cues. The behavior tracking would be expected to be completed by the NA every shift using the task log and if left blank she would assume negative behavior but unsure. At the end of the shift, she recapped with the NAs for any updates. R1 was unable to answer questions and generally very calm. No changes had been noticed in her behaviors that she was aware of. During an interview on 10/16/25 at 9:38 a.m., DON stated she was contacted on 10/9/25 at approximately 3:44 p.m. and incident happened at 2:00 p.m. NA-A had made rude comments and inappropriately wiped R1 during cares and said ouch (assumed it was the way she wiped her). NA-A was suspended immediately pending investigation. We placed monitoring for bruising in R1's electronic medication record (EMAR)/Treatment administration record (TAR). DON verified she was not able to identify in R1's medical record skin monitoring and indicated it appeared it was missed. No formal assessment was completed and documented after the allegation of physical/verbal abuse. The nurse would have been expected to assess the skin especially the per area for bruising. Would have been important to have a separate entry/assessment to assure the nurses were specifically assessing the areas (peri area/buttocks). From there, DON added she would have expected the nurse to assess this every shift and sign it off, and a progress note would have been expected. There was a daily report book (saved for six months then discarded) the nurse would document appointments, labs, behaviors/falls/illness/family visits. DON reviewed R1's entries on the daily report book and verified no documentation from 10/9/25 through 10/15/25 regarding skin and/or behaviors. The expectation for nursing behavior documentation would have not been any different with an allegation of abuse and was documented by exception only. The NAs were to document any concerns on a tracking form (discarded by the nurse) during their shift but do not always get used and instead communicate with the nurse instead. The NAs were expected to document behaviors under tasks section in the electronic record system, unsure as to how often they should document. During an interview on 10/16/25 at 11:25 a.m., care coordinator RN-B stated on 9/6/25 at approximately 3:00 p.m. NA-B made her aware of the incident with R1 during cares. The expectation would be the nurse on duty to have completed an assessment after the allegation of abuse on10/9/25 and that was not done. A weekly skin assessment was completed on 10/11/25, but that was first time an assessment was documented since the incident. We trust our administration team and if they deemed more skin assessing was needed it would have been added. The nursing staff were expected to document in progress note any time there was a change in condition. After the allegation of abuse, there was no scheduled behavior charting added to be completed by the nurse. We relied on the NAs to bring that to our attention and report it. The nurse would observe the skin when they assist with a transfer and pass medications. She was not asked to add behavior charting to R1's medical record. RN-B stated there was behavior charting, check off list under tasks for the NA's and would be expected to complete it daily every shift. RN-B verified there was not consistent documentation under the behaviors task list by the NAs. During an interview on 10/16/25 at 1:36 p.m., assistant administrator stated she was notified of the R1's incident that occurred on 10/9/25 at 3:44 p.m., NA-A had left for the day, was not allowed to work again, and terminated on 10/10/25. The staff nurse would have been expected to complete an assessment including skin and emotional as soon as the alleged perpetrator was removed and document. Important to assess immediately to collect a baseline identify injuries and extent of them. The care coordinator in this case should have collected the data and completed the initial assessment (must be licensed staff) right away. Behaviors and skin assessments should have been completed and monitored daily every shift for at least the first three days to identify a baseline, worsening condition and physical or emotional changes had occurred. If no changes were identified such as behaviors of abuse and/or skin the order would have been discontinued or extended. She entered R1's orders for nursing to monitor skin and behaviors and had not realized for some reason it did not go onto the TAR. Those assessments were not completed. She would have expected the care coordinator nurse to monitor and review the notes over the weekend and should have been caught at that time. NAs were expected to document under tasks every shift R1's behaviors and if none were identified a check mark should have been place in the last column none observed. The five-day facility investigation report did not identify as initial assessment was completed after the incident and should have to identify the severity of the abuse. Facility policy [NAME] Adult-Resident Abuse, Neglect, Mistreatment and Misappropriation of Property dated 2/19/25, identified each resident will be free from abuse, neglect, mistreatment, and misappropriation of property. Abuse can include but is not limited to physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse, or involuntary seclusion from any source. All residents will be protected from abuse, neglect, and harm while they reside at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. In the event of suspected maltreatment, the needs of the resident will be immediately (upon knowledge) assessed, and the safety of the resident will be ensured. The resident will be assessed for physical appearance, skin injuries, trauma, or changed in resident affect, mood, and behavior. The investigation will consist of at least the following: a root cause analysis of all circumstances surrounding the incident. Ensuring safety and well-being for the vulnerable adult is of utmost priority. Examine, assess and interview the resident immediately upon knowledge to determine any injury. Verbal abuse was defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability.

Based on observation, interview and record review the facility failed to ensure an indwelling cathether was secured in a manner to prevent infection for 1 of 1 residents (R26) reviewed for catheter. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had severe cognitive impairment and utilized an indwelling urinary catheter. Diagnoses included heart failure and kidney disease. R26's care plan dated 9/20/23, identified R26 had an indwelling catheter in place due to urinary retention and required extensive assist of one to two for toileting. During an observation on 3/6/24, at 8:00 a.m. R26 was transferred to the wheelchair to go to the dining room for breakfast. Licensed practical nurse (LPN)-A placed R26's catheter on a clip underneath the wheelchair seat and the catheter bag rested directly on the floor. Nursing assistant (NA)-A wheeled R26 out of her room to the dining room. The catheter bag was creased and folded on the floor and the bag and catheter tubing were to be dragging on the floor. During interview on 3/6/24, at 8:00 a.m. NA-A stated the catheter bag and tubing should not be on the floor. R26's wheelchair was so low and she thought the catheter tubing was longer and so it ended up on the floor. NA-A would notify the nurse and see what could be done. During observation on 3/6/24, at 9:00 a.m. R26 remained seated in her wheelchair in the dining room. Her catheter bag and urine filled tubing remained directly on the floor. When interviewed on 3/6/24, at 9:15 a.m. LPN-A stated staff usually secured R26's catheter under her wheelchair seat and it did not drag or rest on the floor. They used a buckle under the seat to secure the catheter and the buckle must be stretched. LPN-A would go in and fix it so the catheter and tubing would be positioned properly. It was important to position the catheter properly to prevent infection. When interviewed on 3/6/24, at 12:20 p.m. the director of nursing (DON) stated catheters should be put into a protective cover bag and should be positioned properly so they are not resting on the floor. It was important to position catheter bag and tubing properly to prevent contamination and infection. The facility's undated policy Infection Control-Use of and Care for Indwelling Urinary Catheters identified catheter bag and tubing should not touch the floor and should be covered with a washable cloth bag for privacy and dignity.

Based on observation, interview and document review the facility failed to comprehensively assess for the use of a mechanical lift chair 1 of 1 resident (R3) observed to use a mechanical lift chair. Findings include: R3's quarterly Minimum Data Set, dated dated dated [DATE], identified R3 had severe cognitive impairment, required assistance with transfers and had functional impairment of range of motion in both lower extremities. R3 had two or more since admission without injury. R3's care plan dated 12/5/22, directed staff to place the mechanical lift chair remote control out of reach, and unplug recliner when occupied. On 4/11/23 at 4:28 p.m., R3's was observed in her mechanical lift chair. The chair was in the reclined position with the foot rest extended straight out. R3 was seated in an upright position with her legs extended straight out in front of her and was attempting to get out of the chair without staff assistance. The call light was not on. R3 stated she was trying to get into her wheelchair. Surveyor alerted staff that R3 was attempting to get out of the mechanical lift chair. Nursing assistant (NA)-D entered R3's room and offered to assist R3 into her wheelchair. NA-D stated R3 made frequent attempts to self transfer out of the recliner, so staff needed to elevate the foot rest, put the remote out of reach in the pocket of the recliner, and unplug the lift chair from the wall. R3's medical record lacked a safety assessment for use of a mechanical lift chair. During interview on 4/12/23 at 2:18 p.m., registered nurse (RN)-C stated R3 had a history of falls. On 1/24/23, R3 was found on the floor with the mechanical lift chair in the standing position. R3 previously was seated in the mechanical lift chair with the TABS alarm (an alarm where a string attaches to the clothing of the resident on one end, and an affixed box at the other, when the resident moves, the string pulls out of the box and an alarm sounds) clipped to her shirt. Staff heard the alarm sounding and found R3 sitting on the floor with her feet out in front of her. R3 didn't use the call light for staff assistance. The facility implemented and intervention to keep the mechanical lift chair remote out of reach of R3; however, an assessment for the safe use of the mechanical lift chair was not completed, to ensure resident safety with self transferring from a chair in reclined position. During interview on 4/12/23 at 8:17 a.m., NA-D stated R3 would raise the mechanical lift chair to the upright position and attempt to self transfer out of the chair. At times, staff had to take R3's chair remote away or unplug the chair to ensure the resident's safety. During observation on 4/12/23 at 8:24 a.m., R3 was seated in the chair in her room. The chair was in the reclined position and the TABS alarm was clipped to the back of R3's shirt. The remote was in the pocket of the chair and out of reach of the resident. During interview on 4/12/23 at 4:19 p.m., the director of nursing (DON) stated resident assessments should be completed upon admission, quarterly, annually and with any significant changes. Assessments for mechanical lift chair would be completed based on when the resident received the chair, their cognition and if the resident appeared safe with the chair. A policy for safe mechanical lift chair use was requested; however the facility did not have a policy.

Based on observation, interview and document review, the facility failed to to act on continued complaints of pain for 1 of 1 residents (R82) reviewed for pain. Findings include: R82's admission Minimum Data Set (MDS) dated [DATE], identified R6 had moderate cognitive impairment. R6 reported frequent and moderate pain. R6 received non-pharmacological pain interventions as well as scheduled and as needed (PRN) pain medications. Diagnoses included a wedge compression fracture (a break in the vertebrae, the bones that make up your spine, caused by force) of the lower spine and low back pain. R82's physician orders dated 3/27/23, included the following: - Duragesic-50 transdermal patch (used for persistent moderate to severe pain) 72 hour 50 mcg/hours (hr) Apply 50 mcg patch transdermally one time a day every 3 day(s) related to wedge compression fracture of second lumbar vertebra. - Lidocaine external patch 5 % (used to help reduce itching and pain from certain skin conditions and may also be used to help relieve nerve pain). Apply to lower back topically every 24 hours for on for 12 hours - off for 12 hours related to low back pain - Morphine sulfate (concentrate) oral solution (used to treat severe pain) 100 milligram (mg)/5 milliliter (ml) give 0.25 ml by mouth every 4 hours PRN pain/discomfort related to wedge compression fracture of second lumbar vertebra. - Tramadol hcl (used to help relieve moderate to moderately severe pain) 50 mg oral tablet give 50 mg by mouth every 8 hours as needed for pain/discomfort related to wedge compression fracture of second lumbar vertebra. - Tylenol extra strength (used to treat mild to moderate pain) 500 mg tablets give 2 tablets by mouth three times a day related to wedge compression fracture of second lumbar vertebra. - Xanax (an antianxiety medication) give 0.125 mg by mouth every 4 hours as needed for anxiousness for 14 days dated 4/3/23 R82's care plan dated 4/2/23, directed staff to encourage weight bearing exercise as tolerated to help maintain bone mass, give pain medications as ordered by the physician and monitor/document for side effects and effectiveness, and provide pillows, etc. to help maintain comfortable position. The care plan also identified R82 had an alteration in musculoskeletal status related to aging condition of her body and chronic conditions and directed staff R82 needed to change position (every 1-2 hours) along with alternated periods of rest with activity out of bed in order to prevent respiratory complications, dependent edema, flexion deformity and skin pressure areas. R82's pain Care Area Assessment (CAA) dated 4/9/23, identified R82 was having severe back pain when first admitted to the facility. R82's pain improved, and R82 used as needed morphine and Tramadol less. R82 was being managed by Tylenol 1,000 mg three times a day, Lidocaine patch 5%, and Duragesic patch 50 microgram (mcg). Vertebroplasty (a procedure in which a special cement is injected into a fractured vertebra - with the goal of relieving spinal pain and restoring mobility) was done to help with pain. Plan to maintain or improve R6's pain to maintain quality of life. The CAA did not address R82's non-pharmacological pain interventions. On 4/10/23 at 2:18 p.m., R82 was observed sitting in her wheelchair with her elbows resting on the tops of her thighs, back hunched, and rocked her wheelchair back in forth with her feet. R82 stated she recently was admitted to the facility due to a fall at home. R82 was having back pain that had worsened after having a dressing changed to her lower back and stated she told nursing staff. R82 was given Tylenol but it was not helping. It was pretty good until that dressing change. R82 never had pain like that before and uff, I just can't stand it. R82 rated her pain at a 7 on a 0-10 scale (a score of 0 means no pain, and 10 means the worst pain you have ever known). R82's April 2023 Electronic Medication Administration Record (EMAR) identified on 4/10/23 at 4:37 p.m., R82 was given morphine sulfate (concentrate) oral solution 100 mg/5 ml give 0.25 ml by mouth for pain; however, the administration was documented as ineffective and there was no evidence R82's pain was followed up on. During observation on 4/10/23 at 6:12 p.m., R82 was sitting at the supper table in her wheelchair with her meal in front of her. R82 continued to grimace with movement and was rocking her wheelchair back and forth with her foot. R82 ate approximately 25% of her meal and stated it tasted good, but I just can't. During a telephone interview on 4/11/23 at 4:06 p.m., registered nurse (RN)-A stated on 4:30 p.m. on 4/10/23, she did give R82 a dose of morphine sulfate due to complaints of increased pain. Approximately two hours later, R82 reported her pain was unchanged. RN-A stated she did not offer any non-pharmacological interventions or other PRN pain medications. as R82 routinely complained of pain when going to the bathroom or standing up. Further, R82 routinely reported her pain at a 6-7 and, because of this, RN-A stated additional pain medication was not warranted. During an interview on 4/12/23, at 2:17 p.m. the director of nursing stated she expected staff to offer something more such as another PRN pain medication to relieve R82's pain and/or to try something non-pharmacological such as an ice pack or hot pack. The facility policy Pain Assessment/Monitoring Procedure revised 2/14, identified if a resident stated they had pain, take his/her word for it. Pain was a subjective experience. The policy identified indicators of pain included frowning, abnormal body posture, grimacing, and decrease in usual activities. If the resident continued to experience pain, the pain medication needed to be re-assessed. Non-pharmacological interventions included: altering the environment for comfort, ice pack, mild heat, repositioning, and diversions.

Based on interview and document review, the facility failed to comprehensively assess and implement interventions for specific identified behavior triggers for 1 of 3 residents (R17) reviewed for dementia care. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 had a severe cognitive impairment and R17 did not exhibit behaviors during the look back period. A diagnosis of dementia without behavioral disturbance was included. R17's cognitive loss/dementia Care Area Assessment (CAA) dated 5/5/22, identified R17 had a severe cognitive impairment. R17's risk factors were identified as verbal or physical abuse by staff or others, avoidance by staff or others, social isolation, neglect of cares, unmet needs, increased signs/symptoms of depression. R17 was very hard of hearing and directed staff to utilize a pocket talker and/or visual aids to communicate with R17. The CAA did not address interventions for his risk factors. R17's care plan revised 3/21/23, directed staff to do the following: - Reminisce with the R17 using photos of family and friends. - When conflict arose, remove R17 to a calm safe environment and allow to vent/share feelings. - R17 would refuse staff assistance to change incontinent product or toileting at times due to his progressive dementia. Staff were to reapproach at a later time, different staff members, encouragement, or distraction if agitated, combative or declining cares. R17's Behavior Tracking Log dated March 2023, identified the following: - On 3/4/23 at 7:00 p.m., care was attempted and R17 appeared calm in R17's bathroom. R17 refused cares and wanted to go take care of the cows and/or farm. Staff attempted distraction and change of staff, but the behavior remained the same. - On 3/7/23 at 6:00 p.m., care was attempted in the dining room. R17 had dumped a whole pepper shaker in his lap. Staff redirected and provided distraction and the behavior stopped. - On 3/20/23 at 6:30 a.m., care was attempted in R17's bathroom. R17 was combative, hitting, and yelling out. 1-2 staff did calm him down then R17 started back up again. During an interview on 4/11/23 at 3:13 p.m., nursing assistant (NA)-E stated staff were told R17 had Alzheimer's disease and R17's mood/behaviors could go from 0-10 quickly. R17 preferred female caregivers, but NA-E personally didn't have any problems when taking care of R17. If R17 became angry and/or combative, NA-E would attempt to calm him using a soft voice, distraction, but ultimately because R17 preferred females he would request assistance from a co-worker. During a telephone interview on 4/11/23, at 4:16 p.m. registered nurse (RN)-A stated R17 exhibited behaviors of anger, combativeness or refusal of care. Usually, R17 just said no. RN-A would instruct the nursing assistants to just walk away and reapproach in 20 minutes. Either R17 would or he wouldn't allow the care. During a telephone interview on 4/11/23, at 4:26 p.m. NA-A stated R17 was hard to take care of most of the time. R17 had increased behaviors on the evening of 3/19/23, but finally went to bed. NA-A let R17 sleep all night but did check on him to make sure he was safe. When R17 woke the morning of 3/20/23, NA-A believed R17 needed to have cares completed because he had been sleeping for 12 hours, wasn't toileted and was incontinent of bowel and bladder. R17 was refusing to get out of bed or to stand. Because of this, NA-A obtained a standing lift and used the lift to assist R17 to the bathroom, but R17 continued to be resistive with cares and refused. NA-A asked NA-B to assist him with R17's cares and they were able to get him dressed the best they could. R17 did say no and refused cares, and when cares didn't stop, R17 began yelling, swearing, and striking out. NA-A stated he had considered stopping cares, but believed cares needed to be finished because R17 had a history of skin breakdown. R17 continued to refuse cares, yell, hit and swear at NA-A and NA-B. I don't know what his deal was. During interview on 4/12/23 at 11:12 a.m., NA-B stated R17 did well with her usually. NA-B would ask R17 if he wanted to get up and if not, if R17 was safe, NA-B would go back and try again later. R17 did refuse cares and staff were to try to get him to use the bathroom. R17 had dementia and it was important on how staff approached R17. R17 could be happy one minute, then unhappy the next. R17 did better with female caregivers than male caregivers. There were male caregivers that did fine with R17, but NA-A was loud and abrasive. On the morning of 3/20/23, NA-B assisted NA-A with R17's cares. NA-B asked R17 if he wanted to get up, but R17 did not begin moving. NA-B did not want to push him, but NA-A entered the room and began telling R17 loudly we were going to get you up. R17 did not want to, but NA-A stated nope, we're going to get you up and dressed. R17 wasn't having anything to do with it. - R17 was refusing to stand and NA-A obtained a bedside commode, but R17 continued to refuse. NA-A then obtained the standing lift because they couldn't get R17 into his wheelchair. NA-B stated she knew R17 wasn't care planned to use a standing lift, but wanted to ensure R17 was safe and did not fall. R17 began hitting, kicking, striking out while NA-A and NA-B transferred him using the standing lift to his wheelchair. R17 was yelling get out, don't touch me. Once R17 was on the toilet, NA-A left the room. NA-B calmly asked R17 if she could finish his cares and R17 agreed as long as NA-A did not return. R17 completed cares without further resistance. NA-B stated she did not speak up during the incident to tell NA-A to stop nor did she request help from other staff. After NA-B assisted R17 to breakfast, she reported the incident to the licensed practical nurse (LPN)-A. During a telephone interview on 4/12/23 at 11:46 a.m., LPN-A stated NA-B reported NA-A and NA-B continued to provide morning cares to R17 even though he refused on 3/20/23. LPN-A then reported the incident to the director of nursing (DON) when she arrived to the facility approximately at 8:00 a.m. that morning. LPN-A stated R17 did have behaviors. If you try to help, he will push you away. R17 will kick, hit, and yell. For example, if he fell asleep at the dining table, if you try to assist him to his room he will become angry. Staff were directed to make sure R17 was safe, then reapproach later. You just make it worse if you keep fighting the bear. R17 did have triggers for his behaviors. Sometimes, he just did not want to be touched. R17 was very hard of hearing and had a communication board in his room. R17 did not have any preferences for male or female caregivers, but it was how you approached him; with a calm clear voice. During an interview on 4/12/23 at 11:57 a.m., NA-C stated you just never knew because R17 was one of those people that just refused a lot. When it came to refusing, sometimes he would say no, get out, or he would just ignore you. Plus, R17 was one where if you kept asking, it would make it worse. NA-C stated R17 was usually cooperative for her. NA-C would ask if he needed to go to the bathroom. If R17 said no, NA-C would ask in a different way to make sure he heard her, but if R17 continued to ignore her or say no, she would leave and go back later. If R17 still refused, she would tell the nurse or another staff member to try. During an interview on 4/12/23, at 12:28 p.m. LPN-B stated R17 refused cares a lot and it was how staff approached him. However, R17 had no specific trigger for his behaviors. R17 was a farmer and habitually rose early in the morning. Sometimes, R17 believed he was busy with farm work and if staff tried to toilet him or do cares, R17 just didn't have time for it. Staff were to reapproach when he refused. During an interview on 4/12/23, at 2:39 p.m. the DON stated she had not reviewed R17's care plan herself but the staff had talked about his behaviors during the interdisciplinary team (IDT) meeting. R17's behaviors had worsened in the past few months and he had become more resistive, possibly due to pain. The DON was unaware of what R17's behavior triggers were, but she was told he worries about the farm, the cows, and how his son will be able to take care of it. The DON had never been told R17 preferred female caregivers, preferred a calm, quiet voice, and/or would become angry with repeated questions, but all of that should have been in R17's assessment and care plan. The DON believed the incident happened not because of how R17 reacted to the situation, but how NA-A reacted to R17. Because of this, R17's care plan did not need new interventions. Staff not familiar with a residents care would need to review the care plan, but did expect staff to reapproach any resident who refused cares. The undated Care Planning policy, identified a care plan would be developed and maintained on each resident according to the RAI guidelines. The comprehensive care plan had been designed to: A. incorporate identified problem areas. B. Incorporate risk factors associated with identified problems. C. Build on the resident's strengths. D. Reflect treatment goals and objectives in measurable outcomes. E. Identify the professional services that are responsible for each element of care. F. Maintain and prevent declines in the resident's functional status and/or functional levels. A dementia care policy was requested but not received.

Based on interview and document review the facility failed to report bruising of unknown origin to the State Agency (SA) according to federal regulations for 1 of 2 residents (R12) reviewed for abuse. Findings include: R12's admission Minimum Data Set (MDS) dated [DATE], identified R12 had moderate cognitive impairment and required extensive assistance to complete activities of daily living. R12's care plan dated 5/20/21, identified a risk for bruising related to the use of aspirin. R12's progress notes identified the following: - 6/7/21, Staff identified a bruise to R12's upper inner thigh and lower perineal area. The bruise measured 7 centimeters (cm) in length and 3.5 cm wide was dark purple in color and non- blanchable. - 6/15/21, The bruising to the area between R12's right labia and buttock was healing well. During interview on 6/16/21, at 12:50 p.m. registered nurse (RN)-B stated R12 bruised easily. During assessment of a buttock wound a bruise was identified on R12 in between her labia and butt cheek. RN-B described the area as very dark purple. RN-B stated R12 was interviewed and said no one had hurt her but stated, we know she isn't reliable. and indicated R12 could not reliably recall events. RN-B stated the bruise had not been reported to the SA. At 1:12 p.m. the director of nursing (DON) stated the bruising had not been reported to the SA. The DON stated they were waiting for lab results and the therapist said the pressure from R12 leaning may have cause the bruising. The DON stated the facility had a guide they used to determine if something was reportable to the SA and anytime they found something they would report right away. The DON stated R12's bruise wasn't reported because of the other reasons (referring to the therapist assessment and awaiting lab results). The facility policy Vulnerable Adult- Resident Abuse, Mistreatment and Misappropriation of Property dated 9/26/17, directed staff to report allegations of abuse including injuries of unknown origin immediately but no later than two hours after the event.

Based on interview and document review the facility failed to thoroughly investigate bruising of unknown origin for 1 of 2 residents (R12) reviewed for abuse. Findings include: R12's admission Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairments and indicated she required extensive assistance to complete activities of daily living. R12's care plan dated 5/20/21, identified a risk for bruising related to the use of aspirin. R12's progress notes identified the following: - 6/7/21, Staff identified a bruise to R12's upper inner thigh and lower perineal area. The bruise measured 7 centimeters (cm) in length and 3.5 cm wide was dark purple in color and non- blanchable. - 6/15/21, The bruising to the area between R12's right labia and buttock was healing well. During interview on 6/16/21, at 12:50 p.m. registered nurse (RN)-B stated R12 bruised easily. During assessment of a buttock wound a bruise was identified on R12 in between her labia and butt cheek. RN-B described the area as very dark purple. RN-B stated R12 was interviewed and said no one had hurt her but stated, we know she isn't reliable and indicated R12 could not reliably recall events. R12's bruise was discussed at IDT and labs were ordered. RN-B stated they had looked at all angles as to what may have caused the bruising. RN-B did not have any information related to an investigation but stated the social worker may have written something down. At 1:12 p.m. the director of nursing (DON) stated they were waiting for lab results and stated the therapist said the pressure from R12 leaning may have cause the bruising. Usually the facility went through the process of interviewing everybody but said there was no investigation into the bruising. On 6/17/21, at 9:47 a.m. the social worker (SW) stated she did not have any documentation of an investigation related to R12's bruise. The SW stated a thorough investigation included interviewing the resident and any staff involved in the alleged incident. A facility policy Vulnerable Adult- Resident Abuse, Mistreatment and Misappropriation of Property dated 9/26/17, indicated an investigation would include contain at least: a review of the complaint, interviews with the resident, witnesses and staff having contact with the resident.

Based on interview and document review, the facility failed to ensure the infection control program included ongoing surveillance, trending and analysis of resident infections. This had the potential to affect all 40 residents residing in the facility as well as staff and visitors. Findings include: On 1/15/19, at 1:07 p.m. the infection control program was reviewed with the infection control coordinator (ICC). The ICC provided an overview of the infection control program and indicated she was responsible for the oversight of the program. The ICC stated her main office was located at the Roseau Hospital and indicated she was on site at the facility one day a week. The ICC stated the computer in her office had a shared drive and she had remote access to the infection surveillance logs of the facility. The ICC confirmed the process was to review the infection surveillance logs every two to three days and to determine if there were trends. The ICC revealed the facility transitioned over to a new infection surveillance log form on 1/1/2019, and as a result, a new hard drive had just been placed on her computer in her office the day before. The ICC further stated she was not aware of the infections listed for the month of (MONTH) 2019, since she did not have access to the shared drive for that month during the transitional period. The infection surveillance logs were reviewed for the past 12 months which revealed infections varying from gastrointestinal illnesses, upper and lower respiratory tract infections, urinary tract infections and skin infections. The ICC shared a map, which was used to assist her in determining trends and patterns. The facility log for (MONTH) 2019, contained the following column headers: unit name, resident name, room number, admitted , existing infection, infection type, body system of infection, surveillance definition met, symptoms, onset date, devices, date of insertion, date of removal, device days, infection risk factors, diagnostic performed, test date, type of test, specimen source, results, antibiotic resistant organism, antibiotic name, class, dose, route, frequency, provider, antimicrobial rx origin, antibiotic start date, antibiotic end date, total days of therapy, meets criteria, antibiotic reassessment/time out, other antimicrobial prescribed, transmission based precautions required, if yes/specify and date symptoms resolved. There were five infections for five different residents documented which revealed the following information: one resident was on an antibiotic for [MEDICATION NAME] (for prevention) to treat urine without symptoms, one resident was placed on an antibiotic for lower respiratory infection due to low oxygen saturation levels and unresponsiveness episode, one resident placed on an antibiotic for a urinary tract infection with a fever and [MEDICAL CONDITION] activity, one resident placed on an antibiotic for [MEDICATION NAME] due to other infection type without symptoms, and one resident placed on an antibiotic for other infection type with symptoms of hallucinations and potential urinary tract infection. The ICC stated the practice was to include all infections on the infection surveillance log. The ICC confirmed the facility had a UTI algorithm for nursing staff and physicians to follow. The ICC stated the nursing staff and physicians were not following the algorithm since two of the residents listed on the log were on antibiotics for [MEDICATION NAME] purposes and did not have symptoms of active infections. On 1/15/19, at 1:23 p.m. director of nursing (DON) entered the room and clarified for the (MONTH) 2019, log one of the residents was on a [MEDICATION NAME] antibiotic due to chronic urinary catheter use and had been on antibiotics for years as a result. Further, the DON stated the other resident on [MEDICATION NAME] was on antibiotics due to a recent pacemaker placement. The ICC verified the infection surveillance log lacked the information, which would have indicated those two residents were on antibiotics for those reasons. The ICC confirmed she was not aware of those two specific instances. On 1/16/19, at 8:26 a.m. the ICC confirmed she was on site at the facility one day a week and did review the log remotely once a week in addition. The ICC further stated the licensed nurses would contact her if there was an infection control concern or a reportable communicable disease noted. The ICC confirmed she did not receive communication from nursing staff at the facility regarding the infections documented on the log for (MONTH) 2019, and further stated a communication problem existed somewhere in the process. A facility policy titled Long Term Care Infection Control Definitions of Infections for Surveillance in Long Term Care Facilities reviewed 8/2018, included definitions that focused on infections for which surveillance is expected to be useful. The policy indicated three important conditions that applied to all the definitions: all symptoms must have been new or acutely worse and were not to include residents who had chronic symptoms such as cough or urinary symptoms that were not associated with infection. However, a change in the resident's status was an important indication that an infection could have been developing. Additionally, the policy indicated noninfectious causes of signs and symptoms were to be considered before a [DIAGNOSES REDACTED]. The last definition on the policy indicated an identification of infection should not have been based on a single piece of evidence and microbiological and radiological findings were to be used only to confirm clinical evidence of infection. It further indicated the physician [DIAGNOSES REDACTED]. On 1/18/19, the facility faxed a policy titled Long Term Care Infection Tracking last reviewed on 5/2016. The policy instructed licensed staff to report infections to the physician and DON or designee and to carry out any physician orders [REDACTED]. The policy further instructed the nurse managers or designees to collect nurse report data and written documentation every 24-72 hours. The policy indicated the infections or signs/symptoms of infection data would be added to the Infection Control tracking log binder to review data in real time. The policy further indicated the data would be reviewed at Interdisciplinary Team Meetings.

Based on observation, interview and document review, the facility failed to immediately report allegations of abuse to the State Agency (SA) for 1 of 1 resident (R23) reviewed for abuse. Findings include: R23's Incident note dated 10/30/18, indicated at 4:30 p.m. a trained medication aide (TMA) went to feed R23 while family member (FM)-1 was present. R23 would not open her eyes or mouth at which time FM-1 told R23 to open your eyes and see who's here. R23 looked at the TMA who explained to R23 that she had her medicine and asked her to open her mouth. At first R23 would not open her mouth but then did and the TMA was able to give her half of her medicine when R23 again closed her eyes and clamped her mouth shut. The TMA asked R23 if she would look at her and showed her the spoonful of medicine. R23 again closed her eyes and FM-1 suggested to the TMA to put some yogurt on the spoon. The TMA tried this and R23 did open her eyes and mouth. The TMA asked R23 if she was hungry but once again she closed her eyes and mouth. In a louder voice, FM-1 said to R23, I know you're not sleeping open your eyes and eat. R23 opened her eyes and said, Why are you being so loud? FM-1 replied, Well if you would open your eyes and eat I wouldn't be so loud in which R23 responded by closing her eyes. The TMA proceeded to offer R23 some thickened breeze (liquid nutritional supplement) from a med cup, however, R23 had clamped her mouth closed at which time FM-1 kept saying to R23, Show me what you have in your mouth as FM-1 was trying to pry R23's mouth open with her finger. The TMA asked R23 if she was hungry, however, R23 did not respond. The TMA then offered R23 thickened water in which she had drank some twice, from a straw. Following this, the TMA told FM-1 that R23 was not hungry and offered to come back with a snack for R23 around 6:30 pm FM-1 stated, Let me try to feed her. The TMA Told FM-1 she could not do that as she could get into trouble, however, FM-1 stated, Don't tell anybody. The TMA again stated to FM-1, I can get in trouble. FM-1 proceeded to take the spoon, obtain a big spoonful of the breeze, put a washcloth up to R23's chin, forced R23's mouth open and put the spoonful of Breeze in her mouth. R23 opened her eyes and looked at the TMA as if she was about to cry when FM-1 forced R23's mouth open again and gave her another spoonful of the breeze. Following this, R23 clamped her mouth shut and turned her head away which made FM-1 unable to attempt to feed her again. FM-1 said to R23, You are being so damn stubborn! The TMA told FM-1 that R23 was not hungry, therefore should would go and get R23's eye drops in order to administer them. FM-1 asked the TMA to leave the tray of food in the room so she could feed R23 and that nobody would have to know, however, the TMA informed FM-1 she could not do that as she could lose her job and exited the room with the tray. On 1/15/19, at 7:18 a.m. R23 was observed from her room doorway, in bed, while FM-1 was at the bedside stating to R23, Here, Grandma, here's some water. You like water don't you? You're tired this morning, Grandma? Grandma, are you tired? Here's some water. FM-A proceeded to recite the Lord's prayer when R23 was heard coughing. From the doorway, FM-A was heard stating the following to R23: -At 7:25 a.m. FM-1 stated to R23, You need water grama. Good job followed by Here's water, dear and Here you go, here's water, do you like water? -At 7:29 a.m. FM-1 again stated, Here's water for you, honey. -At 7:33 a.m. FM-1 stated, Have some water. Grandma, I have your water. Do you like water? Grandma, I have your water. Here's some water. -At 7:37 a.m. FM-1 stated, Here's some water, Grandma. R23 was heard to state no when FM-1 stated, what are you talking about? Did you pray today? FM-1 again stated stated the Lord's prayer with R23. -At 7:38 a.m. FM-1 stated, Here, Grandma, here's some water for you. -At 7:40 a.m. FM-1 stated, Here's some water, Mom. Good job. -At 7:43 a.m. FM-1 stated, Here, Grandma, here's water. Good job. -At 7:44 a.m. FM-1 stated, Do you know what day it is today? Here's water. Good job and Drink some water, Grandma. Good job. Fantastic. On 1/15/19, at 8:54 a.m. nursing assistant (NA)-A stated she had observed FM-1 try to force feed R23 by pushing food into R23's mouth. NA-A also stated FM-1 had instructed her to put food in R23's mouth when R23 was yawning or talking, but NA-A told FM-1 no, she could not do that because R23 could choke. NA-A denied ever observing R23 choke, rather R23 did have episodes of coughing after swallowing. On 1/15/19, at 12:54 p.m. registered nurse (RN)-A stated she had recently starting working at the facility and was intimidated by FM-1 and confimred FM-1 would hold R23's mouth open and FM-1 would want staff to shove food in. RN-A also stated FM-1 was allowed only one glass of nectar thick water and one glass of ice chips at a time, but FM-1 would attempt to get more from staff, especially new employees. At 1:06 p.m. RN-A confirmed she would report suspected verbal or physical abuse by staff or family member immediately to the director of nursing (DON) or the unit manager, and also file a vulnerable adult report, immediately. On 1/15/19, at 1:10 p.m. Clinical Manager (CM)-A confirmed the aforementioned concerns with FM-1 force feeding R23. CM-A stated a vulnerable adult report was filed with the State agency in (MONTH) of (YEAR), but the facility had received a response by the SA of no further investigation needed therefore, the facility decided as a team to not file further reports related to this concern. On 1/15/19, at 1:29 p.m. the administrator confirmed the last vulnerable adult report related to this concern was filed in (MONTH) of (YEAR), and the whole situation with FM-1 had escalated. The administrator had confirmed FM-1 had been spoken too on many occasions but FM-1 continually denied anything that was brought to her attention and had a valid excuse for each time. The administrator stated the ethic's committee met quarterly and spoke about the situation with R23 and, further stated, the ethic's committee met the week prior for an emergency meeting to discuss. The administrator also stated she had spoken with the medical director on 12/24/18, and would be meeting with the facility's legal representative on 1/17/19. The administrator further stated the facility's ethic committee had decided to report any vulnerable adult concerns regarding R23 in the future. On 1/15/19, at 1:33 p.m. the administrator stated staff received mandatory abuse education within 72 hours of hire before performing duties on the floor and annually through the facility's online learning program. In addition, the administrator further stated staff would be receiving behavioral health education in the near future on how to address concerns with residents' family members. On 1/15/19, at 2:17 p.m. the administrator reviewed the facility's Vulnerable Adult policy dated 9/26/17, and confirmed the policy directed staff to report an incident or suspected incident of mistreatment or abuse by a non-staff member immediately for bodily harm and within 24 hours for non-bodily harm. The administrator confirmed a vulnerable adult report should have been filed in regards to the 10/30/18, incident and would file one at this time.

Based on observation, interview, and document review, the facilty failed to ensure standards of practice for documentation of medication administration were followed for 4 of 5 resident (R5, R41, R28 and R17) whose medications were not signed off at the time of administration. Findings include: On 11/13/17, at 5:47 p.m. licensed practical nurse (LPN)-A was observed to prepare medications for R5 which included [MEDICATION NAME] (antidepressant medication) and baby aspirin. LPN-A reviewed a paper print out entitled To Do List dated 11/13/17, as she dished each of the medications. At no time did LPN-A refer to the electronic medication administration record (EMAR) as she prepared the medications. LPN-A administered the medications to R5, returned to the medication cart and put a check mark next to R5's name on a piece of paper used for shift report. LPN-A was not observed to document the administration of the medications in the EMAR. - At 5:50 p.m. LPN-A prepared [MEDICATION NAME] for R41. LPN-A reviewed the To Do List and administered the [MEDICATION NAME] to R41. LPN-A then placed a check mark on the shift report. At no time did LPN-A review the EMAR or document on the EMAR that the medication was given. - At 5:55 p.m. LPN-A prepared R28's medications which included calcium, [MEDICATION NAME], potassium, [MEDICATION NAME] (blood pressure medication,) [MEDICATION NAME] (blood pressure medication), vitamin D, Tylenol and powervision (vitamin to increase vision). LPN-A reviewed the To Do List as she dished the medications. LPN-A did not review the EMAR prior to administering the medications to R28. LPN-A placed a check mark next to R28's name on the shift report paper. At no time did LPN-A document on the EMAR that R28 had received medications. - At 5:56 p.m. LPN-A stated she reviewed the To Do List as she administered medications. LPN-A stated she would sign off the medications when she had finished the evening medication pass. LPN-A then opened the computer and demonstrated how the medications would be signed off as she signed the EMAR for R5, R41 and R28. - At 7:36 p.m. consultant pharmacist - A stated medications were to be signed off in the EMAR as the medications were administered. On 11/14/17, at 1:26 p.m. LPN-C stated she printed a To Do List at the beginning of each shift and utilized the list for passing medications. LPN-C stated there were days that she would sign off the EMAR as she passed medications but it depended upon the day. LPN-C stated she did not consistently sign the EMAR at the time of the medication administration. - At 2:05 p.m. registered nurse (RN)-A stated each nurse printed off a To Do List at the beginning of their shift. The To Do List identified an accurate list of medications and treatments the nurse was to administer during their shift. RN-A explained that the wifi in the building was unreliable and for this reason, when the computers were away from the nurses station, the internet connection was lost causing the nurses to be unable to review the EMAR. RN-A stated she was aware the nurses signed off the EMAR at the end of their shifts and not while the medications were administered. - At 8:10 a.m. LPN-B was observed to set up medications for R17. The medications included [MEDICATION NAME] (blood pressure medication) [MEDICATION NAME] (stool softener), [MEDICATION NAME] powder (stool softener) potassium, [MEDICATION NAME] (treats [MEDICAL CONDITION]) and vitamin D. LPN-B referred to the To Do List as she dished each medications. LPN-B was not observed to review the EMAR prior to administering the medications. After R17 took the medications, LPN-B placed a check mark on the shift report next to R17's name. LPN-B stated she would sign the EMAR when she had finished administering medications to all of her assigned residents. - At 12:19 p.m. the director of nurses (DON) stated each nurse had their own system of how to sign out the medications on the EMAR. The DON explained the wifi connection did not hold a signal throughout the entire building, therefore, the nursing staff may or may not have connection at the end of the hallways. The To Do List was printed from the EMAR at the beginning of each shift and when there were changes, the charge nurse made the changes on the EMAR and informed the nurse on the unit to make changes to the To Do List. The DON stated the facility had not had any medication errors related use of the To Do List or the practice of documenting medication administration at the end of the shift. The Administration of Medication Policy dated March 2009, directed the staff to administer the medication according to the prescription. The policy did not direct the staff as to when the administration was to be documented on the EMAR. The facility's copy of The Really Big Book of Nursing Home Regulations Tenth Edition dated January 2014, directed: Documentation of administration must take place following the administration of the medication. On 11/14/17, at 12:25 p.m. the DON confirmed the facility policy did not direct the staff to document the administration of medications as they were given, however, the current acceptable standard of nursing practice was to document the administration of the medication directly after the medication was administered.

Based on observation, interview and document review, the facility failed to ensure decorative fireplaces were non heat producing per facility protocol in 1 of 4 dining rooms (Lady Slipper Drive) observed to have an electric fireplace which was producing heat resulting in an unsafe surface which was too hot to touch with a bare hand. Findings include: On 11/13/17, at 6:30 p.m. a decorative electric fireplace was observed located in the corner of the Lady Slipper Drive dining room in the Rosewood neighborhood. The fireplace consisted of a brick wall with a flat glass panel surrounded by a three inch metal frame. The fireplace was producing heat. The glass and metal frame were noted to be hot and untouchable with a bare hand. A 1/4 inch by three inch label affixed to the top of the metal frame read: Grill surface gets hot when heat is running. Although there were residents eating in the dining room and some were diagnosed with [REDACTED]. - At 6:50 p.m. the residents in the Lady Slipper Drive dining room were observed to finish their meal and left the dining room. None of the residents were observed to approach the fire place. The fireplace continued to be on and was very hot to touch. On 11/14/17, at 9:30 a.m. the Lady Slipper Drive dining room fireplace continued to be on. The metal frame and glass were hot to the touch. -At 10:20 a.m. the residents of the Rosewood neighborhood were observed to move about the unit, none of the residents attempted to approach the fireplace. -At 1:00 p.m. the fireplace continued to be on, the glass and the metal frame were too hot to touch. -At 1:05 p.m. nursing assistant (NA)-B stated she could not recall any of the Rosewood Neighborhood residents' sitting next to the fireplace. NA-B touched the glass and the metal frame and confirmed it was hot to touch. -At 1:08 p.m. NA-A touched the fireplace and confirmed it was hot to touch. NA-A stated she could not recall any of the residents attempting to touch the fireplace. -At 1:10 p.m. registered nurse (RN)-A stated each of the four dining areas in the facility were equipped with decorative fireplaces. RN-A stated none of the fireplaces were used to produce heat and could not recall them ever producing heat. RN-A approached the Lady Slipper Drive dining room and confirmed the fireplace was on and was producing heat. RN-A stated the fireplace was to be turned off. -At 1:15 p.m. the director of environmental services checked the temperature of the metal frame with a surface thermometer. The director reported the temperature of the frame was 140 degrees Fahrenheit and the temperature of the glass was 119 degrees Fahrenheit. The director of environmental services stated none of the fireplaces in the facility were used as heat sources as they were for decorative purposes only. The director confirmed the temperature of the glass and metal were hot enough to cause burns, if touched. He then removed the glass panel and turned the fireplace off. -At 1:25 p.m. the director of nursing (DON) stated the fireplaces were to be disabled and not were not to produce heat. The DON stated she was unaware any of the fireplaces in the facility had the ability to produce heat. -At 1:30 p.m. the facility incident reports were reviewed and no residents had sustained burns or other injuries from the fireplaces. -At 2:00 p.m. the director of environmental services reported the heating elements in all four fireplaces had been disconnected and were now unable to produce heat.

Based on observation, interview, and document review, the facility failed to provide adequate dining table height accommodations for 1 of 1 resident (R6) whose dining table was observed too high which prevented independent access to meals. Findings include: R6's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R6 had [DIAGNOSES REDACTED]. The MDS indicated R6 required extensive assistance for all activities of daily living which included eating. The MDS also indicated R6 was five foot, three inches tall. R6's Nutrition Care Area Assessment (CAA) dated 11/9/17, indicated R6's level of assistance with eating varied based on R6's level of alertness. Nursing would continue to provide and assistance and adaptive equipment if R6 continued to attempt to feed self. R6's Pressure Ulcer CAA dated 11/13/17, indicated R6 had a fair appetite, and overall was eating and drinking for meals, as she wanted. The CAA also indicated R6 was assisted with meals and was able to grab a cup, drink from a straw but was needing increased assistance with eating. R6 was also able to communicate through broken words, simple words or body language when she was done eating or not wanting to eat. R6's Care Planning Report dated 11/10/17, indicated R6 required varying levels of assistance, was somewhat independent at times, and at other times required total assistance. The care plan directed staff to have R6 sit in her wheelchair for meals, accompany to the table to eat and provide encouragement, cueing and redirection for eating, after tray set up. On 11/13/17, at 6:20 p.m. R6 was observed in the Rosewood dining room seated in a reclining wheelchair. While seated in the wheelchair, R6 was leaning forward and unable to sit up straight. Her feet were touching the floor. R6's eyes were level with the table height. Nursing assistant (NA)-A was observed to assist R6 with the evening meal. R6 was not able to reach the food items on the table on her own. On 11/15/17, at 9:45 a.m. R6 was observed to be seated in the dining room. R6's eye were level with the dining room table. R6 was not observed to attempt to feed herself. - At 11:53 a.m. registered nurse (RN)-A stated R6 had the ability to feed herself at times, depending on her mood. RN-A observed R6 while at the dining room table and confirmed the table height was level with R6's eyes and in order for R6 to reach her food independently, she would have to raise her arms over the level of her nose. RN-A handed R6 a covered cup with a straw in it. R6 was observed to be able to hold onto the cup and drink, however, she was unable to place the cup back onto the table as it was too high for her. RN-A confirmed the table was too high. On 11/15/17, at 12:05 p.m. the director of nursing confirmed the table height should accommodate the needs of the resident. - At 3:00 p.m. RN-A stated she had found a shorter table for R6 to use in the dinning room in order to attempt to increase her independence. A policy related to the accommodation of needs was requested and none was provided.

Based on observation, interview, and document review the facility failed to revise transfer care plan to include use of mechanical lift preferences for 1 of 1 residents (R16) observed connected to a mechanical lift while toileting. Findings include; R16's [DIAGNOSES REDACTED]. R16's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R16 had no cognitive impairment. R16's care plan dated 11/14/17 indicated R16 was totally dependent for toileting needs and required two persons physical assist for toileting. The plan directed staff to provide two plus staff physical assist with a sit to stand mechanical lift (EZ Stand). The care plan did not direct staff to leave the EZ Stand lift attached to R16 while seated on the toilet nor did it identify if R16 had requested the lift to remain attached to him. On 11/14/17, at 9:40 a.m. R16 observed seated on the toilet connected to the EZ stand lift by the harness. No staff members were present. At 10:00 a.m. R16 put his call light on nursing assistant (NA)-A and NA-B entered the room and used the mechanical lift to transfer R16 back to his wheelchair. R16 reported he did not know why the lift was not removed after he was transferred onto the toilet. On 11/14/17, at 1:29 p.m. R16 was again observed seated on the toilet connected to the EZ Stand lift. On 11/15/17, at 10:00 a.m. R16 indicated it was his preference to remain connected to the lift during toileting. R16's most recent Occupational Therapy (OT) evaluation dated 3/8/17, indicated R16 required maximum assist from two staff with a standing lift for transfer. The evaluation also indicated R16 had fair sitting balance and used the bed rail or standing lift with right upper extremity for support. The evaluation did not reflect an assessment and/or evaluation of R16's safety risks in order to remain connected to the lift unsupervised or R16's preferences. R16's record did not reflect a comprehensive safety assessment for the use of the EZ stand that would identify safety risks for R16 to remain connected to the EZ stand during toileting without staff present. Furthermore, the record did not reflect documented education of risks and benefits provided to R16 in order to make an informed decision to use the lift against manufacturer's guidelines. On 11/14/17, at 10:06 a.m. NA-A confirmed R16 was left alone in the bathroom connected to the EZ stand. When asked, NA-A stated she was unaware of a facility policy pertaining to leaving residents alone. NA-A stated registered nurse (RN)-A, indicated R16 could remain connected to the EZ stand without supervision while in the bathroom. NA-A verified the aide care guides and safety intervention logs did not reflect this directive. -At 1:45 p.m. RN-A stated it was R16's preference to remain attached to the lift while in the bathroom because it made him feel safe. RN-A confirmed the care plan did not direct staff to leave R16 connected to the lift nor did it address R16's preferences pertaining to the lift and toileting. -At 2:27 p.m. NA-G explained R16 could be left alone in the bathroom while connected to the lift. NA-G verified R16's ability to be left alone while connected to the EZ stand was not in the care plan but should be because of the safety and dignity concerns. -At 3:46 p.m. director of nursing (DON) explained R16 had variable levels of assistance related to weakness and could be transferred by two staff or use the mechanical lift. DON explained it was R16's preference to be left alone in the bathroom connected to the lift because it made him feel safe and it allowed for privacy and allowed aide staff to do other things while R16 was in the bathroom because he liked to sit for long periods of time. DON verified the care plan did not address safety risk considerations for leaving R16 connected to the lift unattended or R16's preferences to remain connected to the lift while toileting. On 11/15/17, at 11:03 a.m. occupational therapist (OT)-A explained therapy evaluated for transfer status on admission, every quarter, and with change of condition. OT-A stated it was her opinion it was safer to leave residents attached to a mechanical lift while they sat on the toilet unsupervised because it provided some stability and something to hang on to. OT-A indicated there was no documentation of other devices or modalities attempted that were offered to R16 to make him feel safe while he sat on the toilet. OT-A reported because of the layout of R16's bathroom and the location of the toilet, R16 required lift transfers to the toilet related to his left sided weakness (R16 had specifically requested his room despite the toilet placement). OT-A conceded the care plan should include the R16's ability to remain on the lift during toileting and/or his preferences. EZ Way Smart Stand manufacturer's operators manual included directions on lowering the patient after the transfer followed by instructions on how to unhook the harness after the resident was transferred to the desired location. The operator's manual did not include instructions on how to leave a resident connected to the stand while staff was not present. Facility policy Using Standing Lift last revised, 10/08 included: -When resident in desired spot and seated, remove sling, move lift out of way so cares can be accomplished. Facility policy Care Planning last revised 6/09, indicated the purpose was to provide mandated and essential information in an organized manner to develop and maintain a plan of care for each resident. The policy also included: -The comprehensive care plan has been designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. -The care plan shall be used in developing the resident's daily care routines.

Based on observation, interview, and document review, the facility failed to provide timely toileting and repositioning assistance for 1 of 3 residents (R6) and failed to provide oral cares for 2 of 3 residents (R6 and R29) as directed by the care plan. Findings include: R6 was not provided timely repositioning or toileting/incontinence care for approximately 5 hours on 11/13/17, or for 4 hours 30 minutes on 11/15/17. R6 was also not provided assistance with oral hygiene. R6's care plan dated 11/10/17, indicated R6 was to be assisted with toileting/incontinence cares and repositioning before and after meals/activities, upon rising and before bed. R6 was also to be encouraged to sit on the toilet. Additionally, the care plan indicated R6 required extensive assistance with oral cares. The care plan indicated R6 had an upper denture and a lower partial which she did not utilize. The plan directed the staff to provide oral cares twice a day. On 11/13/17, at 4:00 p.m. R6 was observed seated in a wheelchair by the Rosewood nurses station. -At 5:00 p.m. R6 was observed to wheel herself around the Rosewood nursing unit. -At 6:00 p.m. R6 was observed to be assisted to the dining room table for the evening meal. -At 7:10 p.m. R6 was assisted out of the dining room by nursing assistant (NA)-C. -At 7:15 p.m. R6 was observed seated in her wheelchair. R6 was observed to be edentulous on her top gum and had a few natural teeth on her lower gum. -At 7:24 p.m. NA-C stated she did not know when the last time R6 had been assisted with toileting or repositioning. -At 7:25 p.m. NA-D stated she had attempted to assist R6 with toileting/incontinence cares or repositioning at 4:45 p.m. but she had refused assistance. -At 7:28 p.m. NA-C and NA-D assisted R6 to transfer from her wheelchair to the toilet via a mechanical standing lift. R6's incontinence brief was observed to be saturated with urine. R6's skin was observed to be pink and intact. -At 7:35 p.m. NA-H stated R6 should have been assisted to the toilet at 4:30 p.m. however, she did not know if R6 was assisted or not. NA-H stated R6 had not been assisted repositioning or toileting since she arrived at the facility at 2:30 p.m. a total of five hours earlier. On 11/15/17, at from 7:00 a.m. until 9:00 a.m. R6 was continuously observed resting in bed on her right side. At no time were staff observed to assist her with repositioning, to the toilet or incontinence cares. -At 9:02 a.m. NA-E entered R6's room to assist her with morning cares. R6 was cued to sit up on the edge of the bed and NA-E and NA-F assisted R6 to transfer from the bed into a shower chair. R6's incontinent brief was observed to be saturated with urine. Once in the shower chair, R6 was observed to void. R6's skin was observed to be pink and intact. -At 9:15 a.m. NA-E approached R6 with her upper denture and attempted to place it in R6's mouth. R6 refused to open her mouth. Approximately 1 minute later, NA- E again approached R6 with her upper denture, R6 refused to open her mouth. NA-E was not observed to offer R6 the opportunity to brush her natural teeth or rinse her mouth before or after attempting to place the upper denture. NA-E stated R6 had last been assisted with incontinence cares on the night shift. - At 9:38 a.m. NA-E stated she had attempted to place the upper denture, but did not routinely offer oral cares with a toothbrush or oral swab because R6 would bite down on anything placed in her mouth. NA-E confirmed R6 had not been offered oral hygiene care. - At 11:20 a.m. registered nurse (RN)-A stated R6 was to be offered oral cares twice a day as directed by the care plan. - At 11:30 a.m. registered nurse (RN)-A reviewed the nursing assistant shift to shift report and stated R6 had last been assisted with repositioning and incontinence cares at 4:30 a.m. a total of 4 hours and 30 minutes earlier. RN-A stated R6 was to be assisted with repositioning and incontinence cares/toileting every 2-3 hours as directed by the care plan. R29 was not provided oral hygiene as directed by the care plan. R29's Care Planning Report dated 10/20/17, indicated R29 had her own teeth and an upper partial and required extensive assistance of one person for oral hygiene. The Care plan directed staff to prepare toothbrush and provide verbal/visual cueing for oral hygiene and to provide denture care, remove dentures at bedtime, and to clean and soak them overnight. On 11/15/17, at 8:58 a.m. NA-I was observed to wheel R29 into the bathroom and assist her to the toilet. After assisting R29 to wash up and get dressed, NA-I wheeled R29 into her room and combed her hair, applied her glasses and assisted R29 to apply lipstick. NA-I bagged the garbage and soiled linen, straightened up the room and made R29's bed. NA-I proceeded to gather the bagged garbage and linen and brought it to the soiled utility room. NA-I washed her hands and returned to R29's room. NA-I wheeled R29 to the dining room and served her breakfast. At no time during morning cares did NA-I offer R29 oral hygiene. A denture cup containing a partial plate and water was observed on the sink in R29's bathroom. On 11/15/17, at 11:38 a.m. NA-I verfied she had not provided oral hygiene for R29 and should have done so. On 11/15/17, at 4:06 p.m. the director of nursing confirmed staff should offer oral hygiene as part of am cares as directed by the care plan. Facility policy Care Planning last revised 6/09, indicated the purpose was to provide mandated and essential information in an organized manner to develop and maintain a plan of care for each resident. The policy also included: -The comprehensive care plan has been designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. -The care plan shall be used in developing the resident's daily care routines.

Based on observation, interview and document review the facility failed to ensure oral hygiene was provided for 2 of 2 residents (R29, R6) who were dependent upon staff for assistance with oral hygiene. Findings include: R29's annual Minimum Data Set ((MDS) dated [DATE], indicated R29 had moderate cognitive impairment and [DIAGNOSES REDACTED]. The MDS also indicated R29 required extensive assist of one person for dressing, toilet use and personal hygiene. R29's Activity of Daily Living (ADL)/Functional Care Area Assessment (CAA) dated 10/26/17, indicated R29 had varying cognitive status and was less alert and more tired on some days and would also be awake for long, extended periods of time. The CAA indicated R29 required extensive assistance with most ADLs due to advanced age and dementia. The CAA also indicated R29 was not safe to perform ADLs independently and would not remember to do so. R29's Care Planning Report dated 10/20/17, indicated R29 had her own teeth and an upper partial and required extensive assistance of one person for oral hygiene. The Care plan directed staff to prepare toothbrush and provide verbal/visual cueing for oral hygiene and to provide denture care, remove dentures at bedtime, and clean and soak them overnight. On 11/15/17, at 8:58 a.m. nursing assistant (NA)-I was observed to wheel R29 into the bathroom and assisted her to the toilet. After assisting R29 to wash up and get dressed, NA-I wheeled R29 into her room and combed her hair, applied her glasses and assisted R29 to apply lipstick. NA-I bagged the garbage and soiled linen, straightened up the room and made R29's bed. NA-I proceeded to gather the bagged garbage and linen and brought it to the soiled utility room. NA-I washed her hands and returned to R29's room. NA-I wheeled R29 to the dining room and served her breakfast. At no time during morning cares did NA-I offer R29 oral hygiene. A denture cup containing a partial plate and water was observed on the sink in R29's bathroom. On 11/15/17, at 11:38 a.m. NA-I verfied she had not provided oral hygiene for R29 and should have done so. On 11/15/17, at 4:06 p.m. the director of nursing (DON) confirmed staff should offer oral hygiene as part of a.m. cares as directed by the care plan. R6's quarterly MDS dated [DATE], indicated R6 had [DIAGNOSES REDACTED]. The MDS indicated R6 required extensive assistance for all activities of daily living. R6's care plan dated 11/10/17, indicated R6 required extensive assistance with oral cares. The care plan indicated R6 had an upper denture and a lower partial which she did not utilize. The plan directed the staff to provide oral cares twice a day, in the morning and in the evening. On 11/13/17, at 7:15 p.m. R6 was observed seated in her wheelchair. R6 was observed to be edentulous on her top gum and had a few natural teeth on her lower gum. On 11/15/17, at 9:15 a.m. R6 was observed to receive assistance with morning cares from nursing assistant NA-E and NA-F. NA-E approached R6 with her upper denture and attempted to place it in R6's mouth. R6 refused to open her mouth. Approximately one minute later, NA-E again approached R6 with her upper denture, R6 refused to open her mouth. NA-E was not observed to offer R6 the opportunity to brush her natural teeth or rinse her mouth before or after attempting to place the upper denture. -At 9:38 a.m. NA-E stated she had attempted to place the upper denture, but did not routinely offer oral cares with a toothbrush or oral swab because R6 would bite down on anything placed in her mouth. NA-E confirmed R6 had not been offered oral cares. -At 11:20 a.m. registered nurse (RN)-A stated R6 was to be offered oral cares twice a day as directed by the care plan. The Dental Care policy dated 3/2011, directed the staff to attempt to provide oral cares to prevent sores, odors, and coating of the tongue.

Based on observation, interview and document review, the facility failed to ensure timely repositioning was provided for 1 of 3 residents (R6) identified at risk for the development of pressure ulcers. Findings include: R6's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R6 had [DIAGNOSES REDACTED]. The MDS indicated R6 required extensive assistance for bed mobility, transfers and was unable to ambulate. The MDS also identified R6 at risk for the development of pressure ulcers. R6's Pressure Ulcer Care Area Assessment (CAA) dated 11/10/17, indicated R6 spent her time in her bed or chair and had a pressure relief device on the bed and wheelchair. The CAA indicated R6 was toileted and repositioned upon rising, before/after meals, activities, bedtime and /or as she indicated The CAA also indicated R6 was dependent upon two staff for bed mobility and transfers and had a history of [REDACTED]. R6's Braden Scale used for the prediction of pressure sore risk dated 11/10/17, indicated R6 was at moderate risk for the development of pressure ulcers. R6's Tissue Tolerance Assessment (tissue perfusion assessment) dated 11/10/17, indicated R6 required assistance to reposition every 2-3 hours while in bed or in the wheelchair. R6's care plan dated 11/10/17, indicated R6 was at risk for impaired skin integrity related to decreased mobility, cognitive deficits and incontinence. The plan directed staff to assist R6 with repositioning before and after meals, upon rising and before bed. On 11/13/17, at 4:00 p.m. R6 was observed seated in a wheelchair by the Rosewood nurses station. -At 5:00 p.m. R6 was observed to wheel herself around the Rosewood nursing unit. -At 6:00 p.m. R6 was observed to be assisted to the dining room table for the evening meal. -At 7:10 p.m. R6 was assisted out of the dining room by nursing assistant (NA)-C. -At 7:24 p.m. NA-C stated she did not know when the last time R6 had been assisted with repositioning. -At 7:25 p.m. NA-D stated she had last attempted to assist R6 with repositioning at 4:45 p.m. but R6 had refused to be assisted. -At 7:28 p.m. NA-C and NA-D assisted R6 to transfer from her wheelchair to the toilet via a mechanical standing lift. R6's wheelchair was equipped with a pressure redistribution cushion. R6's skin was observed to be pink and intact. -At 7:35 p.m. NA-H stated R6 should have been assisted at 4:30 p.m. with repositioning, however, she did not know if R6 had been or not. NA-H confirmed R6 had not been assisted with repositioning since she arrived at the facility at 2:30 p.m. a total of five hours earlier. On 11/15/17, from 7:00 a.m. until 9:00 a.m. R6 was continuously observed resting in bed on her right side. At no time were the staff observed to assist her with repositioning. -At 9:02 a.m. NA-E entered R6's room to assist R6 with morning cares. R6 was cued to sit up on the edge of the bed and NA-E and NA-F assisted R6 to transfer from the bed into a shower chair. R6's skin was observed to be pink and intact. -At 9:15 a.m. NA-E stated R6 had last been assisted with repositioning on the night shift. -At 11:30 a.m. registered nurse (RN)-A reviewed the nursing assistant shift to shift report and stated R6 was last assisted with repositioning at 4:30 a.m. a total of 4 hours and 30 minutes earlier. RN-A stated R6 was to be assisted with repositioning every 2-3 hours as directed by the care plan. The Resident Rounds policy dated June 2009, directed the staff to assist residents with repositioning every 2-3 hours.

Based on observation, interview and document review, the facility failed to provide timely assistance with toileting/incontinence care for 1 of 3 residents (R6) who were dependent on staff for toileting assistance and incontinence cares. Findings include: R6's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R6 had [DIAGNOSES REDACTED]. The MDS indicated R6 required extensive assistance for bed mobility, transfers and was unable to ambulate. The MDS indicated R6 was frequently incontinent of bladder and required assistance of two staff to transfer to the toilet. R6's Urinary Care Area assessment dated [DATE], indicated R6 had functional incontinence due to advancing dementia and indicated R6 was dependent on staff for toileting assistance and incontinence cares. R6's Bladder Reassessment dated [DATE], indicated R6 had periods of continent voiding and was to be encouraged to void upon waking, before and after meals and at bedtime. R6 was also to have her incontinent product checked and changed every 2-3 hours throughout the day and night. R6's care plan dated 11/10/17, indicated R6 was to be assisted with incontinence cares before and after meals, upon rising and before bed. R6 was also to be encouraged to sit on the toilet. On 11/13/17, at 4:00 p.m. R6 was observed seated in a wheelchair by the Rosewood nurses station. -At 5:00 p.m. R6 was observed to wheel herself around the Rosewood nursing unit. -At 6:00 p.m. R6 was observed to be assisted to the dining room table for the evening meal. -At 7:10 p.m. R6 was assisted out of the dining room by nursing assistant (NA)-C. -At 7:24 p.m. NA-C stated she did not know when the last time R6 had been assisted with incontinence cares. -At 7:25 p.m. NA-D stated she had attempted to assist R6 with incontinence cares at 4:45 p.m. but she had refused assistance. -At 7:28 p.m. NA-C and NA-D assisted R6 to transfer from her wheelchair to the toilet via a mechanical standing lift. R6's incontinence brief was observed saturated with urine. -At 7:35 p.m. NA-H stated R6 was to have been assisted to the toilet at 4:30 p.m. however, she did not know if R6 was assisted or not. NA-H stated R6 had not been assisted to the toilet since she arrived at the facility at 2:30 p.m. a total of five hours earlier. On 11/15/17, from 7:00 a.m. until 9:00 a.m. R6 was continuously observed resting in bed on her right side. At no time were the staff observed to assist her to the toilet or provide incontinence cares. -At 9:02 a.m. NA-E entered R6's room to assist her with morning cares. R6 was cued to sit up on the edge of the bed and NA-E and NA-F assisted R6 to transfer from the bed into a shower chair. R6's incontinent brief was observed to be saturated with urine. Once in the shower chair, R6 voided. -At 9:15 a.m. NA-E stated R6 had last been assisted with incontinence cares on the night shift. -At 11:30 a.m. registered nurse (RN)-A reviewed the nursing assistant shift to shift report and stated R6 had last been assisted with incontinence cares at 4:30 a.m. a total of 4 hours and 30 minutes earlier. RN-A stated R6 was to be assisted with incontinence cares/toileting every 2-3 hours as directed by the care plan. The Resident Rounds policy dated June 2009, directed the staff to assist residents with incontinence cares every 2-3 hours.

Based on observation, interview, and document review, the facility failed to ensure manufacturer's recommendations were followed for the cleaning of community blood glucose monitors for 1 of 1 resident (R35) observed to receive blood glucose monitoring. This had the potential to affect 3 residents who received blood glucose monitoring from the community glucometer on the Rosewood unit. Findings include: On 11/15/17, at 7:15 a.m. registered nurse (RN)-B was observed to obtain a community blood glucose monitor from the Rosewood nurses station and wipe it off with a Clorox Healthcare Bleach Germicidal Wipe. The glucometer was dampened by the wipe for approximately 10 seconds. RN-B proceeded to carry the glucometer, a glucometer strip, a retractable lancet (device used to obtain a finger stick blood sample, once engaged, the needle retracted into hard plastic sheath), a cotton ball and an alcohol wipe into R35's room. Once in the room, RN-B wiped off the end of R35's finger, pricked R35's finger with the lancet, and placed a drop of blood on the glucometer strip. Unfortunately, the glucometer did not read the strip and RN-B returned to the medication room for additional supplies. At 7:21 a.m., RN-B donned gloves, poked R35's finger again and obtained a blood glucose reading. - At 7:25 a.m. RN-B returned to the medication room, wiped the glucometer with a Clorox Healthcare Bleach Germicidal Wipe and returned the glucometer to glucometer stand. The glucometer was observed to be damped with the germicidal wipe for approximately 10 seconds. - At 7:27 a.m. RN-B reviewed the germicidal wipes container which directed the staff to ensure the surface cleansed with the wipe to be visibly wet for three minutes and allowed to air dry. RN-B stated she had never read the directions for the wipes before and was unaware any surface cleansed with the wipe was to be visibly wet for three minutes. - At 8:15 a.m. RN-A stated the staff were to wipe the glucometers off with the germicidal wipes according to the manufactures directions. - At 9:00 a.m. the director of nurses (DON) confirmed the glucometers were to cleansed according to the manufacturer of the cleansing wipes. A policy regarding glucometer cleaning was not provided.

Based on observation, interview, and document review, the facility failed to provide an odor free and sanitary environment in a personal room for 1 of 1 resident (R12) whose room had a pervasive urine odor. This also had the potential to affect all 10 residents who resided on the Lady Slipper Drive unit who passed R12's room when leaving the unit, as well as any visitors to the unit. Findings include: R12's quarterly Minimum (MDS) data set [DATE], indicated R12's [DIAGNOSES REDACTED]. The MDS indicated R12 had intact cognition and was independent in his ability to use the toilet with occasional incontinent episodes. R12's Urinary Care Area Assessment (CAA) dated 1/30/17, indicated R12 utilized incontinent briefs which he was able to change independently and was able to toilet himself independently. R12's care plan dated 10/7/17, indicated R12 had a history of [REDACTED]. On 11/13/17, at 4:17 p.m. upon entrance to the Rosewood unit, a strong pervasive urine odor was noted across from the Lady Slipper Drive dining room. Licensed practical nurse (LPN)-D was observed to be passing medications next to R12's room, however, LPN-D did not acknowledge the odor. - At 6:30 p.m. R12 was observed eating his evening meal in his room. The urine odor was noted to be extremely strong next to R12's bed and in the bathroom. A can of vanilla air freshener spray was noted on R12's television stand. - At 6:50 p.m. the hallway outside of R12's room was noted to have a strong pervasive vanilla air freshener odor. R12's room continued to have a strong urine odor. On 11/14/17, at 9:30 a.m. the hallway by R12's room was noted to have a strong, pungent urine odor. The odor lingered into the Lady Slipper Drive dining room. - At 10:20 a.m. housekeeper (HSKP)-A was observed cleaning the hallway next to R12's room and sprayed vanilla air freshener in the hallway. - At 12:51 p.m. R12's room continued to have a strong, offensive, urine odor. - At 1:00 p.m. R12 was observed to leave his room, R12 was not observed to have a urine odor, however, the room continued to have a pungent urine odor. - At 3:30 p.m. the director of environmental services entered R12's room and stated there was a strong vanilla air freshener odor in the hallway and in the room. Upon entering the bathroom, the director stated there appeared to be urine spilt on the floor in front of the toilet and the odor in the bathroom was quite strong. - At 3:35 p.m. NA-C stated R12's room frequently had a strong urine odor. NA-C stated R12 was independent with his personal cares and did not allow the staff members to assist with perineal cares. NA-C stated the urine odor was easily detected in the hallway next to R12's room. - At 3:40 p.m. licensed practical nurse (LPN)-C stated R12's room frequently had a strong urine odor. LPN-C explained R12 had occasional dribbling accidents and the staff attempted to assist him with cares, however, he would refused. LPN-C confirmed R12's room had a strong urine odor. - At 3:55 p.m. HSKP-A stated all of the residents rooms were mopped and cleaned on a weekly basis. The resident furniture was moved away from the walls and was cleaned on an every six month basis. HSKP-A stated R12's room frequently had a strong urine odor. HSKP-A stated she did not know if the odor was coming from the room or from R12 himself. HSKP-A stated the nursing staff kept air freshener sprays in R12's room in an attempt to cover the odor but it did not always help. HSKP-A stated she was aware of R12's room odor, she tried to clean the room, however, the odor continued to linger. - At 4:00 p.m. the director of environmental services stated he was in charge of the housekeeping and maintenance staff. The residents rooms were to be cleaned on a weekly basis and if a problem or odor was noted, the housekeeping staff were to clean and mop the room as needed. To his knowledge, R12's room was to be cleaned as needed. The director stated he would look for a stronger room deodorizer and set up R12's room to be cleaned on a daily basis or more frequently as needed. On 11/15/17, at 11:35 a.m. registered nurse (RN)-A stated she was aware R12's room frequently had an offensive urine odor. RN-A stated she had instructed the housekeeping staff to mop his room on a daily basis, however, indicated this had been a verbal direction and was not documented. R12 had been offered a urinal to assist with toileting and was offered assistance with personal cares on a daily basis, however, R12 had the ability to be independent with his cares and frequently refused assistance. RN-A confirmed R12's room had a urine odor issue. A policy related to room cleaning was requested and none was provided.