Every finding on record at Mcintosh Senior Living

Based on interview and document review the facility failed to ensure residents were free from accidents for 1 of 3 residents (R1) when R1, who was care planned for the use of a mechanical lift, was transferred on multiple occasions using a pivot transfer by staff and the facility beautician. This resulted in actual harm for R1 who sustained a fracture related to improper transfers from staff. R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included Stroke, weakness and joint stiffness. Diagnosis added 8/15/25, included osteoporosis and fracture.R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. The MDS indicated R1 had not displayed rejection of care behaviors and was dependent on staff for transfers.R1's care plan dated 5/30/25, identified cognitive and communication impairments. The care plan identified impaired physical mobility related to a stroke with right sided hemiplegia (paralysis on one side of the body). The care plan directed staff to assist R1 to transfer using a mechanical stand device and two staff. The care plan was updated 8/12/25, to include a fracture of her left knee and directed staff to transfer using a mechanical stand and assist R1 with locomotion in wheelchair until she could use her left leg to self-propel again.R1's Progress Notes indicated the following:-8/8/25, R1 had been complaining of left knee pain since the previous evening. R1 had been guarding her knee, unable to manipulate it to a flat position and became upset when staff moved her leg. When asked if her pain was bad enough to make her cry, R1 shook her head yes. R1 had been moaning and grunting due to knee pain and shook her head yes when asked if it hurt when standing for transfer into bed the previous night.-8/9/25, R1 continued to have pain and swelling to her knee. -8/11/25, Physician updated due to continued knee pain. R1 had been tearful at times. Orders received for X-ray. Later in the shift, R1 left for CT (computed tomography) scan to knee. -8/11/25, R1 returned to the facility. Diagnosis of closed non-displaced fracture (a type of bone break where the bone cracks or breaks, but the pieces remain aligned and don't shift out of place) of condoyle (the two rounded prominences at the distal end of the thigh bone that articulate with the shin bone to form the knee joint) of left femur and had a splint in place. -8/12/25, Staff spoke with the physician who indicated R1 had severe osteoporosis that could have contributed to the fracture during the pivot transfers. R1 currently non-weight bearing and had a brace to be worn for six weeks. During interview on 8/19/25 at 12:02 p.m., the director of nursing (DON) stated their investigation identified five staff members identified to have transferred R1 without the use of the mechanical stand as care planned previous to her injury. During interview on 8/19/25 at 12:11 a.m., nursing assistant (NA)-A stated R1 needed to go to the beauty shop, and she and another staff member had performed a pivot transfer from R1's recliner to her wheelchair. NA-A said three total staff were in the room at the time. NA-A stated staff had a care sheet that identified how the residents were supposed to be transferred. During interview on 8/19/25 at 12:18 p.m., NA-B stated she had assisted NA-A to transfer R1 without following the care plan and stated it was not the first time she had performed a pivot transfer with R1. NA-B said R1's care plan indicated staff were to transfer using a mechanical stand. During interview on 8/19/25 at 12:30 p.m., NA-C stated staff, including herself, had been performing pivot transfers for R1 but not all the time. NA-C said she was not sure why but said they should not have. NA-C said R1's care plan directed staff to use a mechanical stand for transfers. During interview on 8/19/25, at 12:42 p.m., the facility beautician (B)-A stated R1 needed to get from her wheelchair to the salon chair and said NA-D came into the salon and attempted to transfer R1 by herself but said she was not strong enough. B-A stated she assisted NA-D to pivot transfer R1 to the chair. B-A said after she was finished with R1's hair, no staff were around so she placed her arms around R1, like a bear hug, under her arms and transferred her back into her wheelchair. B-A said after she got into the wheelchair R1 started to propel herself to the dining room but said another staff brought R1 back to use the bathroom before assisting her to the dining room. B-A said she thought since NA-D was going to transfer R1 by herself it was okay to assist with just one person.During interview on 8/19/25, at 3:02 p.m., the DON stated after they discovered staff had not been following the care plan for transfers with R1, they had immediately educated the NA's and B-A and initiated education with all staff that provide care and transfer residents. The DON stated they had also initiated audits of transfers and educated B-A she was not to perform any resident transfers. The DON said the physician said R1 had severe osteoporosis and felt the pivot transfers along with her diagnosis contributed to the fracture.Facility Policy Safet-patient-handling Program dated 3/19/23, indicated it was the policy of the facility that when residents required assistance to move residents, that assistance was provided in a manner safe for the residents. Specifically, mechanical lifting equipment and/or other patient moving aides.Facility Policy Providing Cares as Outlined in the Resident Care Plan dated 4/11/23, indicated all employees must follow each resident's plan of care exactly as written. Care must be delivered by the interventions, safety precautions, and restrictions listed in the plan of care.Prior to the start of the survey, on 8/12/25, the facility had initiated disciplinary action and education related to following the plan of care. Further, the facility had initiated compliance audits to ensure staff were following the plan of care. The education and audits were verified through interview and document review.

Based on observation, interview and document review, the facility failed to report an outbreak of nausea, vomiting and/or diarrhea for 6 of 6 residents (R38, R9, R36, R13, R35, R33) to the Minnesota Department of Health (MDH). This had the potential to affect all residents residing in the facility. Findings include: The facility provided undated and untitled symptom tracker identified the following: - 1/23/25, R38 developed symptoms of upset stomach and emesis and was immediately placed on contact precautions and attempted to keep the resident in her room. R38 was tested and negative for Influenza A and B, RSV, and COVID-19 (respiratory panel). - 1/25/25, R9 developed upset stomach, diarrhea and low grade temperature. R9 was immediately placed on contact precautions, tested and was negative for respiratory panel. - 1/25/25, R36 developed upset stomach, diarrhea and low grade temperature. R36 was immediately placed on contact precautions, tested and was negative for respiratory panel. - 1/26/25, R13 developed emesis, loose stools and low grade temperature. R13 was immediately placed on contact precautions, tested and was negative for respiratory panel. - 1/26/25, R33 developed dry heaves, vomiting and diarrhea. R33 was immediately placed on contact precautions, had a negative COVID-19 test and respiratory panel was pending. - 1/26/25, R35 developed symptoms of emesis and low grade fever. R35 was immediately placed on contact precautions, however, did not have a respiratory panel because she displayed the same symptoms of the other residents and they were negative On 1/27/25 at 3:36 p.m., the director of nursing (DON) stated there were several residents that developed symptoms of gastrointestinal (GI) illness over the weekend and were placed on contact precautions. The DON stated the facility follows MDH guidance for reporting communicable diseases. There were no staff that had developed symptoms. The DON further stated she had not reported the outbreak to MDH because she thought it was a simple GI illness because symptoms were resolving or resolved, and because the illness was in the community and was just the stomach flu. The facility Communicable Disease Reporting policy dated 8/26/24, identified communicable diseases shall be reported to the MDH and referred to the form Diseases Reportable to the MDH. The 2024-2025 MDH Norovirus Information for Long Term Care Facilities identified, individual cases of norovirus infection are not reportable in Minnesota. However, possible outbreaks of multiple cases with norovirus-like symptoms must be reported. They can be reported to the health department by phone or email.

Based on observation, interview and document review, the facility failed to ensure the restraint section of the Minimum Data Set (MDS) was accurately coded for 5 of 6 residents (R26, R37, R9, R25, R34) reviewed for MDS accuracy. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 was cognitively intact and required supervision with bed mobility. The bilateral bed rails/grab bars were identified to be used daily as a restraint. R26 Restraint/Assist Rail Evaluation dated 5/23/23, identified R26 used bilateral bed rails/grab bars for bed mobility and transfers. The bed rails/grab bars were not a restraint. On 6/6/23 at 9:10 a.m., R26's bed was observed to have bilateral bed rails/grab bars attached to their bed. R26 used the bilateral grab bars to turn and reposition during morning cares. During an interview on 6/6/23 at 9:10 a.m., nursing assistant (NA)-A identified R26 used the bed rails/grab bars for repositioning and turning in bed and they were not a restraint. R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 was cognitively intact and required extensive assistance with bed mobility. The bilateral bed rails/grab bars were identified to be used less than daily as a restraint. R37's Restraint/Assist Rail Evaluation dated 5/24/23, identified R37 used bilateral bed rails/grab bars for bed mobility and transfers. The bed rails/grab bars were not a restraint. On 6/7/23 at 10:30 a.m., bilateral bed rails/grab bars were observed to be secured to R37's bed. During an interview on 6/7/23 at 12:42 p.m., R37 stated he used the bed rails/grab bars when in bed for bed mobility and positioning. During an interview on 6/7/23 at 10:22 a.m., licensed practical nurse (LPN)-A stated the bed rails/grab bars on R37 and R26's beds were not a restraint. The bed rails/grab bars were used for bed mobility and turning/repositioning for both R37 and R26. 42075 R9's admission MDS dated [DATE], identified R9 was cognitively intact and required extensive assistance with bed mobility. The bilateral bed rails/grab bars were identified to be used less than daily as a restraint. R9's Restraint/Assist Rail Evaluation dated 4/26/23, identified R9's bilateral quarter assist rails were used to aid with bed mobility and were not a restraint. During interview on 6/7/23 at 7:37 a.m., R9 stated she used the grab bars every day to help get in/out of bed and to move around while in bed. During interview on 6/7/23 at 7:27 a.m., nursing assistant (NA)-B stated R9 had bilateral upper grab bars on the bed and used them daily to assist with turning side to side while in bed. R25's quarterly MDS dated [DATE], identified R25 was not cognitively intact and required extensive assistance with bed mobility. The bilateral bed rails/grab bars were identified to be used daily as a restraint. R25's Restraint/Assist Rail Evaluation dated 3/29/23, identified R25 utilized a quarter bed side rail to aide with mobility. The assessment identified the rail was not a restraint R34's annual MDS dated [DATE], identified R34 was cognitively intact and required extensive assistance with bed mobility. The bilateral bed rails/grab bars were identified to be used less than daily as a restraint. R34's Restraint/Assist Rail Evaluation dated 3/28/23, identified R34 used a left quarter assist rail to aid with bed mobility and transfers. The assessment identified the rail was used as an aide for R34 to reposition and transfer independently and was not a restraint. During an interview on 6/7/23 at 1:03 PM, the director of nursing (DON) stated the facility was coding bed rails/grab bars in the restraint section on the MDS. The DON was not aware that this section in the MDS was referring to the use of grab bars/bed rails in the capacity of them being a restraint. The DON would correct all the inaccurate MDS assessments as none of the residents who utilized grab bars were being restrained by the grab bars. The MDS3.0 RAI Manual Version 1.17.1 October 2019, identified bed rails included any combination of partial or full rails (e.g., one-side half-rail, one-side full rail, two-sided half-rails or quarter-rails, rails along the side of the bed that block three-quarters to the whole length of the mattress from top to bottom, etc.). Include in this category enclosed bed systems. Bed rails used as positioning devices should not be coded as a restraint. If the use of bed rails (quarter-, half- or three quarter, one or both, etc.) meet the definition of a physical restraint even though they may improve the resident's mobility in bed, the nursing home must code their use as a restraint at P0100A

Based on interview and document review the facility failed to ensure advance directives were readily available and included in the medical record for 1 of 18 (R18) residents reviewed for advance directives. Findings include: R18's Admission Record Printed [DATE], indicated she admitted to the facility [DATE]. R18's Admission Record did not identify a code status to indicated if she wanted cardio pulmonary resuscitation in the event she stopped breathing. R18's care plan identified impaired cognition and indicated she had a guardian to assist with decision making. R18's medical records lacked evidence of a resuscitation order. During interview on [DATE], at 1:08 p.m. licensed practical nurse (LPN)-A stated residents code status' were in the computer. LPN-A looked at R18's medical record in the computer and stated there was nothing in her record. LPN-A stated if the code status was not identified in the electronic record she would look in the paper chart. At 1:11 a.m. LPN-A went to retrieve the paper chart but was unable to locate it. LPN-A stated she would start CPR if R18 was found unresponsive. At 1:20 p.m. trained medication aide (TMA)-A stated if a resident was found unresponsive she would notify the charge nurse right away. TMA-A stated she was certified to perform CPR and stated she would look in the computer for the code status. TMA-A stated she had never looked at the paper chart for code status and said there was a list posted at the nurses station that identified residents who were a full code. TMA-A verified R18's name was not on the list. At 1:56 p.m. the social services designee (SSD) verified R18 did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The SSD stated typically she would fill out the POLST with the resident or family/guardian and put a copy in the paper chart. She stated R18's POLST was awaiting a signature and had not been put in the chart. The SSD stated medical records was responsible to put the code status in the electronic record and stated it had been missed. The facility policy CPR-Cardio Pulmonary Resuscitation dated [DATE], indicated nurses and other care staff were educated to initiate CPR unless a valid do not resuscitate order was in place or unless there were obvious signs of clinical death or if CPR could cause injury or peril to the rescuer. The policy further indicated each resident or their representative would complete a POLST form upon admission and a copy placed into the residents chart.

Based on observation, interview, and record review, the facility failed to ensure insulin vials for a personal insulin pen included a pharmacy label for 1 of 1 residents (R17) observed to receive insulin injection. In addition, the facility failed to ensure narcotic medications were controlled and stored in a manner to ensure limited access in order to prevent drug diversion. Findings include: R17's physician's orders [REDACTED]. On 4/3/18, at 5:18 p.m. registered nurse (RN)-C removed an insulin pen from an unmarked hinged box which was located in the medication cart. The pen was inscribed Free sample and Lilly company (manufacturer). The cartridge (which holds the insulin) contained the manufacturer's inscription identifying the medication name. Neither the pen nor the cartridge contained a pharmacy label which identified resident name, medication, and dosage to administer. RN-C confirmed the pen was not labeled with R17's name and stated it is a very unique pen that family supplied. RN-C also acknowledged that the insulin cartridge did not contain a label that identified it was intended for R17, or the prescribed dose. On 04/05/18, at 11:53 a.m. director of nursing (DON) acknowledged that R17's insulin was not labeled and indicated they had tried in the past but the labels fell off. The DON expected the pharmacy to label the individual vials for R17. During telephone interview with consulting pharmacist on 4/6/18, at 1:35 p.m. she acknowledged that there should be labeling on insulin cartridges. The facility policy was requested and not received. On 4/15/18 at 9:00 a.m. during medication storage and review of medication destruction, licensed practical nurse (LPN)-A indicated that any narcotic medication that was discontinued was to be put in the director of nursing (DON) office in a locked file cabinet. LPN-A proceeded to walk to the DON's office door which was noted to be left all the way open with the DON not present. Upon entering the unlocked DON's office, LPN-A retrieved keys from the unlocked top drawer of the DON's desk, and unlocked a long file cabinet drawer which contained medications which LPN-A stated needed to be destroyed with the pharmacist. LPN-A then indicated the narcotics in the drawer were not tracked or counted until destruction with the pharmacist, which was usually monthly. LPN-A verified there was no log sheet to identify which narcotics were supposed to be in the drawer and that information was tracked in the narcotic count books on each of the three medication carts. LPN-A stated that, to her knowledge, only she, (maybe one other nurse), and the DON accessed the file cabinet. LPN-A verified the DON's door was not always closed and locked when unoccupied. LPN-A verified narcotics needed to be double locked. LPN-A stated she had worked at the facility for 5 years in which this had been the process and there had been no discrepancy with counts or facility diversion that she was aware of. On 4/5/18, at 11:51 a.m. DON acknowledged narcotics were locked in a file drawer in her office and verified the door was not always locked when she was out of the office, and to her knowledge there had not been any discrepancy with counts or facility diversion. DON acknowledged that narcotics should have been double locked as required. During telephone interview on 4/6/18, at 1:35 p.m. consultant pharmacist verified that narcotics should have been double locked and confirmed the medications were only under single lock when the office door was left open. A Storage of Medications and Narcotics in Med Room policy dated 10/29/15, indicated medications put on hold/discontinued would be stored in a designated basket in locked med room/or locked cabinet in the DON's office until destruction by a registered nurse. A Counting of Narcotics policy dated 10/29/15, indicated when a schedule II, III, IV, V drug needed to be destroyed, medication was taken out of the locked med cart, counted by two licensed staff and placed in DON's office in a locked file cabinet awaiting destruction with Pharmacy.

Based on observation and interview the facility failed to maintain the kitchen and dish room in a clean and sanitary condition. This had the potential to affect all 41 residents who resided in the facility. Findings include: During the environmental tour with the dietary manager (DM) on 1/7/15, from 12:45 p.m. until 1:15 p.m. the following was observed in the dishwashing room and kitchen: - The wall behind the dishwasher had 10, quarter inch holes making the areas un-cleanable. The DM verified the finding and stated the holes were caused by a dishwasher that had been removed about a year ago and they would have maintenance repair. - An approximately 10 foot long area under the stainless steel counter top a laminated wall had cracked areas with rust and the edging of the ceramic tiles had a thick buildup of a black / gray greasy matter. The DM stated the laminated sheeting under the stainless steel counter top needed to be replaced and the edging of the ceramic tiles need to have a deep cleaning. - A 5 inch by 5 inch vent above the dishwasher was observed to have a thick coating of gray / back matter. The DM verified the vent needed to be cleaned and stated it was currently on the monthly cleaning schedule, however, thought it should be increased to a two times a month cleaning schedule. - All the ceramic tiles edging each wall in the kitchen were observed to have thick gray / black greasy matter on them. - Both the kitchen and dish room ceramic flooring which edged each door frame was observed to to have thick, greasy, gray / black matter on them. At that time of the tour, the DM verified the findings. The DM stated there was a cleaning schedule for the items to be cleaned but did not include a deep cleaning. Adding, the ceramic tile edging along with all the walls and door frames needed a deep cleaning to remove the greasy gray / black matter build up. The facility policy dated 10/15/2012, indicated the DM would create and monitor all cleaning and sanitation tasks needed for the dietary department.

Based on observation, interview and document review, the facility failed to provide a dignified, homelike dining experience for 11 of 11 (R1, R2, R5, R8, R19, R26, R29, R33, R35, R37, R42) residents who received their meals on trays in the south dining room (special care unit) for 3 of 3 meal observations. Findings include: On 1/5/15, at 5:35 p.m. the south dining room evening meals were observed to arrive in a dietary cart. The residents were observed seated at the dining room tables. Nursing assistant (NA)-C and the program coordinator (PC) were observed to deliver a meal tray to R1, R2, R5, R8, R26, R29, R35, R37 and R42. Each meal tray included an insulated plate, silverware, as well as cold items and beverages. Each resident was observed to eat their meal from the serving tray. On 1/6/15, at 11:30 a.m. the south dining room lunch meal was observed to arrive in a dietary cart. The residents were observed seated at the dining room tables. The activities assistant (AA) and NA-D were observed to deliver a meal tray to R1, R2, R5, R8, R19, R26, R29, R33, R35, R37 and R42. Each resident was observed to eat their meal from the serving tray. On 1/7/14, at 7:47 a.m. NA-A and NA-B were observed to deliver a breakfast tray to R2, R5, R8, R19, R26, R29, R33, R35 and R37 as the residents were seated at the dining room tables. Each resident in the south dining room was observed to eat their meal from the serving tray. During the aforementioned dining observations, at no time, were residents observed to take anything off of another resident's plate or interfere with each other's meal time. On 1/5/15, at 6:30 p.m. R29 stated he would prefer to have his plate placed directly on the dining room table and not left sitting on the serving tray. On 1/5/15, at 7:27 p.m. NA-C confirmed it was common practice to serve the meals on serving trays in the south dining room. On 1/7/15, at 7:09 a.m. cook (C)-A stated it was her expectation that unless there was a special reason for a resident to need to have their meal served on a tray, it would be better if the tray was removed and the dinnerware placed directly on the dining room table. On 1/7/15, at 12:51 p.m. the director of nursing (DON) stated the meals in the south dining room were served this way based off of a recommendation from the consulting registered dietician (RD) as the trays provided a boundary so the residents wouldn't take things off of each other's plate. The DON confirmed there were probably other ways to set these boundaries and they should be individualized for each resident. On 1/8/14, at 8:25 a.m. the consulting (RD) confirmed she was aware that in the south dining room the residents were being served and ate their meals on a serving tray which helped set boundaries for these residents so they wouldn't take things off of each other's plate. The RD was unable to identify the resident safety concerns mentioned in the facility's dietary department's philosophy policy dated 12/12/2013. The RD verified there had not been individual resident assessments completed which would have identified the need to provide the resident's their meals in this manner. The RD also confirmed there were probably other more dignified ways to provide place setting boundaries for the residents in the south dining room. The MCINTOSH SENIOR LIVING dietary department philosophy policy dated 12/12/2013, indicated the facility would provide quality dining that enhanced the residents dining experience. In addition, meals provided to the special care unit (south dining room) would be provided on trays due to resident safety issues.

Based on observation, interview and document review, the facility failed to ensure the most current state survey results were posted as required which had the potential for affect all 41 residents residing in the facility, family and visitors. Findings include: During the initial tour of the facility on 1/5/15, at 1:20 p.m. a laminated sign was observed posted outside the door of the director of nursing (DON)'s office and above a black plastic holder which read "Survey Results Posted Here." The black plastic holder contained a black three ring binder. The survey results in the binder were dated 11/08/2012, which was not the most current survey. A survey had been conducted on 10/25/2013. On 1/6/15, at 2:01 p.m. the DON confirmed the survey results for 10/25/13, were not in the survey binder. On 1/6/15, at 2:10 p.m. the administrator verified the most current survey results were not in the survey binder. On 1/7/15, at 7:12 a.m. observed posted on the wall in the common area by the main nursing station was a framed poster of the Resident Bill of Rights. Item #1 listed on the poster indicated the results of the most recent survey of the facility conducted by the state or federal surveyors would be posted in an accessible location. On 1/7/15, at 12:51 p.m. the DON stated the administrator was responsible for posting the survey results. The Your Rights Under The Combined Federal and Minnesota Resident Bill of Rights information packet dated 7/1/2007, which was provided to each resident, indicated under item #28 Examination of Survey Results - each resident had the right to examine the results of the most recent survey of the facility conducted by federal or state surveyors. No policy related to posting of state and/or federal survey results was provided. .

Based on observation, interview and document review, the facility failed to ensure the microwaves in the primary nourishment room on the east common corridor and on the special care unit (SCU) were clean which had the potential to affect 33 of 33 residents on the east corridor who utilized the microwave and 12 of 12 residents on the SCU which staff utilized for resident food. In addition, the facility failed to ensure toast was not prepared with bare hands for 1 of 12 residents (R3) who resided in the SCU. Findings include: On 10/21/13, at 5:20 p.m. the social service designee (SSD) was observed, with bare hands, preparing two 2 slices of toast for R3 on the SCU. The SSD was observed to touch the toast with her bare hands. On 10/22/13, at 8:43 a.m. the activity program coordinator (APD) was observed preparing toast for R3 on the SCU. With bare hands, the APD was observed to remove two slices of toast out of the toaster and hold the toast in place while she buttered them with a knife. On 10/24/13, at 9:46 a.m. the director of nursing (DON) stated staff had infection control training and were informed they could not touch toast with their bare hands. On 10/24/13, at 9:55 a.m. the SSD stated she knew she was not to touch the toast with her bare hands. In addition, the SSD stated she had training on this issue. On 10/24/13, at 10:07 a.m. the director of food services (DFS) stated the staff need to be reminded about the glove policy. On 10/24/13, at 10:19 a.m. the microwave in the nourishment room was observed to have dried food debris in it. The DFS verified the microwave was not clean. On 10/24/13, at 10:21 a.m. the microwave on the SCU unit had crumbs in it and the DFS verified the microwave was not clean. The DFS stated she did not know who was responsible for cleaning the microwave. On 10/24/13, at 10:27 a.m. the assistant director of nursing (ADON) stated she did not know who was responsible for cleaning the microwaves. On 10/24/13, at 10:34 a.m. the (APD) stated she knew she was supposed to wear gloves when touching food. On 10/24/13, at 11:02 a.m. the ADON stated the facility did not have a policy which addressed who would clean the microwaves. The undated glove usage policy indicated gloves would be worn when touching food.

Based on observation, interview and document review, the facility failed to ensure privacy was provided during insulin administration for 1 of 2 residents (R38) in the sample who were observed during insulin administration. Findings include: R38's [DIAGNOSES REDACTED]. R38's plan of care (POC) dated 6/5/13, indicated R38 had a memory deficit, was hard of hearing and rarely understood others. The POC also indicated R38 took medication with encouragement and directed staff to reapproach if R38 refused or became resistive. The POC also directed staff to explain all procedures step by step, giving direction and to repeat or demonstrate as needed for res understanding. In addition, the POC indicated staff could administer insulin when in the dining room to prevent further disruption and R38's need to be returned to own room. The POC indicated R38 would holler out during insulin injection and directed staff to attempt to distract R38 by encouraging card playing, piano, drawing, puzzles or visiting. On 10/21/13, at 5:15 p.m. R38 was observed in the day room near the main dining room, seated in a recliner. R38 was heard yelling out "no, don't do that." At this time, licensed practical nurse (LPN)-A was observed lifting R38's shirt up while holding an insulin syringe in the other hand. Another staff member was observed holding down R38's hands onto the arms of the chair. R38 continued to yell out "no, don't do that." LPN-A was observed to administer the insulin into R38's abdomen. During the administration of the insulin R38 yelled out "ouch," "don't do that," "ouch." LPN- A stated, "We have to do that to be able to give the insulin." There were eight other residents in the day room that observed the insulin administration. On 10/23/13, at 11:34 a.m. R38 was observed seated at a table in the activity room with two other male residents. Two female residents were also observed in the activity room. At this time, LPN-A was observed to draw up 13 units of [MEDICATION NAME] (insulin) into a syringe, carried the syringe into the activity room and gave R38 a cookie. When R38 picked up the cookie, LPN-A was observed to lift up R38's shirt and attempted to administered the insulin into R38's abdomen. R38 was observed to become instantly agitated, dropped the cookie and attempted to resist the insulin injection by grabbing the nurses hand, grabbing towards his shirt in an attempt to pull it back down over his abdomen. When R38 became resistive activity assistant (AA)-A took the resident's hands and held them down while the LPN-A quickly administered the resident the insulin into the abdomen. All four residents in the activity room observed the aforementioned insulin administration. After the insulin was administered to R38, the resident quickly calmed down and ate the cookie given to him. On 10/23/13, at 11:45 a.m. LPN-A confirmed she had tried to use the cookie as a diversion to distract R38 before she attempted to inject the insulin. LPN-A further stated sometimes distracting R38 on something other than the insulin injection made the administration of the insulin go more smoothly. LPN-A confirmed she had someone hold R38's arm so that she could get to the area she needed in order to inject the medication. LPN-A also confirmed all four of the other residents present in the activity room could clearly observe R38 resisting, being held down and given an injection in the abdomen. She stated all four of the other residents were not interviewable and could not comment if this practice bothered them. LPN-A stated R38 had a POC developed related to the insulin administration. On 10/25/13, at approximately 10:00 a.m. the director of nurses (DON) stated R38's family had given the facility consent to administer R38 insulin in a public area after the facility reviewed the risk versus the benefit of R38 not receiving the insulin injection. The DON stated the interdisciplinary team had considered how this practice may affect other residents or visitors who witnessed this procedure but felt it was more important R38 received the insulin injection. She confirmed the interdisciplinary team had not developed strategies to provide R38 insulin while maintaining his privacy and the privacy of others who may not wish to witness R38's administration of insulin.

Based on interview, and document review the facility failed to provide ambulation services according to the written plan of care (POC) for 2 of 3 residents (R14, R39) reviewed for ambulation. Findings include: R14 was not provided ambulation services as directed by the POC. R14 was diagnosed with [REDACTED]. R14 resided on the special care unit (SCU). R14's current POC initiated 9/20/13, indicated R14 had a nursing restorative program. The restorative care program dated 3/6/13, directed staff to ambulate R14 100-150 feet with the walker and a gait belt two-three times a day. The restorative ambulation records were as follows: -May 2013-ambulated 53 out of 62 opportunities. -June 2013-ambulated 55 out of 60 opportunities. -July- 2013-ambulated 45 out of 62 opportunities. -August 2013-ambulated 51 out of 62 opportunities. -September 2013-ambulated per the care plan. -October 2013-ambulated 26 out of 44 opportunities. On 10/24/13, at 1:29 p.m. the director of nursing (DON) reviewed the ambulation records with the surveyor for the months of May through October 2013, and verified the findings. The DON stated she was aware there was problems with the restorative ambulation program and she would be making changes. In addition, the DON verified the care plan was not followed and stated the policy would be revised. The Rehab Nursing Program policy dated 6/15/10, indicated nursing procedures were incorporated into charting guidelines to assure proper documentation. In addition, the policy indicated the registered nurse would review the program monthly and quarterly. R39 was not provided rehabilitation/restorative services as directed by the POC. R39's [DIAGNOSES REDACTED]. R39's POC revised on 6/17/13, indicated R39 was dependent on staff for all activities of daily living. The POC also indicated R39 had a left sided range of motion (ROM) deficit. The POC directed staff to walk R39 25-100 ft daily (with assistance of 2-3 staff), with a gait belt and forward wheeled walker, to follow behind R39 with a wheelchair and to allow rest periods as needed. In addition, the POC indicated R39 was to do 7-10 sit to stand exercises daily. For the sit to stand exercises, the POC directed staff to cue R39 to lean forward, head over toes and to push up from the wheelchair. The POC also directed staff to strongly encourage R39 to do more each day. Review of the REHABILITATION/RESTORATIVE SERVICE DELIVERY RECORD from 10/1/13, through 10/24/13, indicated R39 completed the sit to stand exercises on two out of 23 opportunities and ambulated eight out of 66 opportunities. On 10/24/13, at 10:03 a.m. the DON reviewed the residents REHABILITATION/RESTORATIVE SERVICE DELIVERY RECORD for October 2013, and confirmed that R39 had not received restorative rehabilitation services as directed by the POC.

Based on observation, interview and document review, the facility failed to provide ambulation services according to the assessed need for 2 of 3 residents (R14, R39) reviewed for ambulation. Findings include: R14 was diagnosed with [REDACTED]. R14 resided on the special care unit (SCU). The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R14 had a memory deficit with moderately impaired decision making skills. The MDS also indicated R14 required one staff limited assistance for ambulation. The Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 4/9/13, indicated R14 had memory impairment, ambulated with the use of a walker and was supervised when walking off of the unit. R14's current plan of care (POC) initiated 9/20/13, indicated R14 had a nursing restorative program for ambulation. The restorative care program form dated 3/6/13, directed staff to ambulate R14 100-150 feet with the walker and a gait belt two-three times a day. The restorative ambulation documentation records revealed the following: -May 2013-ambulated 53 out of 62 opportunities. -June 2013-ambulated 55 out of 60 opportunities. -July- 2013-ambulated 45 out of 62 opportunities. -August 2013-ambulated 51 out of 62 opportunities. -September 2013-ambulated as the POC directed. -October 2013-ambulated 26 out of 44 opportunities. On 10/23/13, at 12:42 p.m. nursing assistant (NA)-A stated R14 was to be ambulated with his walker by the NAs. She added, the activity staff and the nurses would also assist R14 with ambulation. At 12:47 p.m. NA-A reviewed the restorative ambulation record with the surveyor and stated R14 was to ambulate 100-150 feet two-three times a day and verified the ambulation was not consistently documented. NA-A stated she had not had time to ambulate R14 yet today. At 1:45 p.m. NA-A was observed to assist R14 to ambulate off the unit with a gait belt and the walker. R14 ambulated a total of 400 feet. On 10/24/13, at 9:32 a.m. the director of nursing (DON) stated the physical therapy evaluation dated 6/14/13, recommended R14 continue with the restorative nursing program dated 3/6/13. The DON verified R14 was to ambulate two-three times a day with the walker 100-150 feet. The DON also stated she reviewed the ambulation records at the end of each month. She added, she had left notes for the involved staff, and felt the ambulation was being done and not documented. On 10/24/13, at 1:29 p.m. the DON reviewed the ambulation records with the surveyor for the months of May through October 2013, and verified the findings. The DON stated she was aware there was problems with the restorative ambulation program and she would be making changes. In addition, the DON verified R14's POC was not followed and stated the policy would be revised. The Rehab Nursing Program policy dated 6/15/10, indicated nursing procedures were incorporated into charting guidelines to assure proper documentation. In addition, the policy indicated the registered nurse would review the program monthly and quarterly. R39 was not provided rehabilitation/restorative services according to the residents assessed need. R39 [DIAGNOSES REDACTED]. The annual MDS dated [DATE], indicated R39 required two staff assist for transfers and ambulation R39's POC revised 6/17/13, indicated R39 was dependent on staff for all activities of daily living due to a stroke with left sided deficit. The POC directed two-three staff to ambulate R39 25-100 feet with a forward wheeled walker, gait belt and rest periods two-three times a day. The POC also directed staff to provide seven to 10 sit to stand exercises by cueing R39 to lean forward, head over toes and push up from the wheelchair, daily. Additionally, the POC directed staff to strongly encourage R39 to do more each day. Review of the physical therapy progress notes revealed R39 had received formal physical therapy (PT) services twice daily following the left TKA on 5/21/13. The notes also indicated R39 was discharged from PT 8/2/13, and was started on a restorative rehabilitative program. The notes indicated R39 was again started on PT on 9/22/13, for increased strength and balance needs. On 10/23/13, R39 was discharged from PT as R39 had reached the maximum potential. The physical therapist had indicated in the physical therapy discharge summary that R39 was to continue with the previous restorative rehabilitative plan. Review of the resident's rehabilitation/restorative service delivery record for October 2013, revealed R39 had been provided formal physical and occupational therapy services from 9/20/13 until 10/18/13. Review of the physical therapy Therapy Nursing Communication Note dated 10/2/13, indicated the physical therapist had ordered staff to ambulate R39 two times a day with two staff, a front wheeled walker and a gait belt 20-50 feet every day in addition to the formal physical therapy being provided. The physical therapist also ordered R39's restorative program to include sit to stand exercises, at least 10 repetitions, one time a day. Review of the REHABILITATION/RESTORATIVE SERVICE DELIVERY RECORD revealed from October 1, 2013, through October 24, 2013, R39 completed the sit to stand program on 2 occasions out of 23 opportunities, and completed the ambulation program on 8 occasions out of 66 opportunities. On 10/23/13, from 7:00 a.m. to 2:30 p.m. R39 was observed to not have been been offered restorative rehabilitation ambulation or sit to stand exercises. On 10/24/13, at 9:12 a.m. NA-B verified she was responsible for providing care to R39. When asked what restorative rehabilitative services she was to provide R39, NA-B stated, "I don't know." NA-B confirmed she was responsible for the resident's care but then stated the certified occupational therapy assistant (COTA) was responsible for the resident's ambulation services. NA-B stated she was not aware R39 was also supposed to participate in sit to stand exercises, at least 10 repetitions, daily. On 10/24/13, at 9:14 a.m. the assistant director of nursing (ADON) stated the NA's were responsible for providing restorative or rehabilitative services including walking and transfer activities. The ADON further stated the COTA was also responsible for providing the ambulation services ordered for R39. On 10/24/13, at 10:10 a.m. the COTA stated she was only responsible for completing R39's walking program and not the sit to stand exercises program. The COTA stated that she was not aware physical therapy had recommended R39 be ambulated twice daily during the time the resident was getting formal physical therapy services twice a day, and confirmed she had not offered R39 ambulation services during the period of time R39 received formal physical therapy services (9/22/13-10/18/13). On 10/24/13, at 10:03 a.m. the DON stated "everyone" was supposed to help with restorative rehabilitative services. She also stated the nursing assistants, nurses and activity director, who was a COTA assisted with restorative rehabilitative services. Additionally, the DON stated the COTA provided rehabilitative services for some of the more challenging residents including R39. The DON reviewed R39's REHABILITATION/RESTORATIVE SERVICE DELIVERY RECORD for October 2013, and confirmed R39 had not received restorative rehabilitation services as recommended by physical therapy. On 10/24/13, at 11:23 a.m. R39 was observed ambulating 100 feet with a front wheeled walker, gait belt and two staff assistance. The sit to stand exercises was not offered during this observation.

Based on observation, interview and document review, the facility failed to ensure a resident identified at risk for pressure ulcers received a planned intervention related to the appropriate wheelchair with a pressure redistribution cushion to prevent the development of a pressure ulcer for 1 of 2 residents (R2) who had developed a Stage 3 pressure ulcer (PU) on the right buttock at the facility. R2 sustained actual harm from the development of the Stage 3 pressure ulcer (full thickness tissue loss). Findings include: R2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R2 was cognitively impaired and required extensive assistance of 2 staff for mobility. The MDS also indicated R2 had a Stage 3 (full thickness tissue loss) PU that measured 1.0 centimeters (cm) by 0.3 cm and 3.0 cm in depth. The current plan of care dated 10/4/12, indicated R2 utilized a pressure relief cushion (gel) in the wheelchair and a pressure relief alternating air mattress on the bed. Staff were directed to provide [MEDICATION NAME] 8 ounces three times a day for nutritional support, reposition every hour, and dressing changes per the doctor's orders. On 11/6/12, at 1:31 p.m. licensed practical nurse (LPN)-B and registered nurse (RN)-A were observed completing R2's PU wound treatment. LPN-B removed a 2 X 2 dressing that covered the wound along with Nu-gauze packing from within the wound. Drainage was observed on the packing and the dressing. LPN-B irrigated the wound with normal saline (NS). The wound was circular in appearance approximately .5 cm by .5 cm and there was also depth to the wound. LPN-B moistened clean Nu-gauze with NS prior to packing it into the wound with a sterile Q-tip. LPN-B applied skin prep around the wound followed by two 2 x 2 dressings with tape. Medical record revealed: The Skin Risk Factors and Interventions form dated 12/19/11, indicated R2 utilized pressure reduction devices in the bed and wheelchair. The Braden Scale (a tool for predicting PU development) dated 3/18/12, and 6/18/12, identified R2 at high risk for PU development. The nurses progress notes dated 5/22/12, indicated R2 had a red area on the right buttock measuring 8.0 cm by 6.0 cm, with an area of deep purple measuring 3.0 cm by 2.0 cm which was warmer than the other tissue. A [MEDICATION NAME] (a [MEDICATION NAME] dressing) was applied and staff were directed to reposition R2 every hour. However, interview on 11/8/12, at 10:03 a.m. with the director of nursing (DON), indicated the transport wheelchair which had a hard plate right under the seat of the wheelchair continued to be utilized for 8 more days for R2 until 5/30/12. The nurses progress notes dated 5/27/12, indicated the right buttock redness measured 6.0 cm by 5.0 cm, with a worsened deep purple inside that measured 3.7 cm by 2.8 cm. The nurses progress notes dated 5/30/12, indicated R2 had a Stage 3 PU that measured 4.0 cm by 3.0 cm open with a 2.0 cm by 2.0 cm area of eschar (black tissue), 40% of wound bed was eschar, the other 60% was red with no slough. R2 now had the correct wheelchair with pressure relief, and staff were to reposition R2 every hour. On 6/7/12, R2's primary care physician progress notes [REDACTED]. The wound clinic physician progress notes [REDACTED]. The chronic wound had now turned into a more acute wound and hopefully this would expedite healing. The significant change MDS dated [DATE], indicated R2 was cognitively impaired and required extensive staff assistance for mobility. The MDS also indicated R2 had a PU which measured 1.6 cm by 1.0 cm by 0.1 cm The Pressure Ulcer Care Area Assessment (CAA) dated 6/29/12, indicated R2 had an unstageable PU which had developed after R2 was placed in the wrong wheelchair. The wrong chair had an anti-roll back device which had a hard plate right under the seat of the wheelchair with no pressure redistribution cushion. The CAA also indicated on 6/20/12, the wound was debrided for healing purposes. Additionally, the CAA indicated R2 was being seen by the wound clinic and that the wound was being packed twice a day. On 7/9/12, R2 was seen at the wound clinic and was to return in one month. On 7/31/12, R2 was seen at the wound clinic and was to return on 8/9/12. On 8/9/12, R2 was seen at the wound clinic and was to return in three weeks. On 9/20/12, R2 was seen at the wound clinic and was to return in one month. On 10/22/12, R2 was seen at the wound clinic and was to return in one month. On 8/30/12, the wound clinic nurse practitioner (NP) ordered R2 to be up in the chair for meals only, limited to one hour at a time. R2 was to return to the wound clinic in three weeks. The weekly skin monitoring form dated 11/5/12, indicated the PU measured 0.5 cm by 0.8 cm by 2.2 cm. On 11/8/12, at 10:03 a.m. the DON stated they had a nightly cleaning schedule for wheelchairs and the wrong wheelchair was placed in R2's room after it was washed on Monday 5/21/12. The DON stated the other wheelchair had no cushion in it as it was a transport chair. In addition, the anti-roll back wheelchair had a plate under the seat that was hard. The DON stated on 5/22/12, when they noticed the redness on R2's buttock they placed a cushion in the wheelchair, but had not changed the wheelchair. On 11/8/12, at 2:54 p.m. the DON and LPN-A verified that on 5/21/12, R2 had been placed in a wrong wheelchair without a pressure redistribution device. LPN-A stated on 5/22/12, she had noticed the PU on the right buttock. LPN-A also stated she had witnessed RN-B placing a cushion in R2's wheelchair. LPN-A stated R2 would have sat in the wrong wheelchair without the cushion for breakfast and lunch on 5/22/12, prior to the cushion being placed, approximately 2 hours. LPN-A stated R2 sat in the recliner in his room after meals. The DON stated when she had returned to work on 5/30/12, she realized R2 was still using the transport wheelchair with the anti-roll back device and returned his correct wheelchair to him. The PU policy dated 4/09, indicated there would be adequate pressure relief in all aspects of the resident cares. Example-wheelchair.

Based on observation, interview and document review, the facility failed to store cooking utensils and maintain the convection ovens in a clean and sanitary manner. This practice had the potential to affect all 42 residents residing in the facility. Findings include: During the sanitation tour on 11/8/12, at 10:06 a.m. with the dietary manager (DM), the baking utensil and ladle/scoop storage drawers were observed to have removable, dried debris in them. The two convection ovens had dry, hard, thick, black removable debris in them. In addition, 3 plastic cereal container lids were observed to have thick layers of cereal like dust on them. The individual cereal scoops were observed to be resting on the dusty lids. The undated Cleaning Instructions: Cleaning and Cabinets and Drawers policy and procedure indicated the cabinet and drawers would be free from food particles and dirt and that they should be cleaned twice a month. The undated Cleaning Instructions: Cleaning Ovens policy and procedure indicated the ovens would be cleaned as needed and at least once every two weeks. At the time of the sanitation tour, the DM verified the findings and stated the policy and procedures had not been followed.

Based on observation, interview and document review, the facility failed to store and serve food under sanitary conditions in the kitchen related to undated frozen foods which were available for resident use and dust above the stove/cooking area which had the potential to affect all 43 residents residing in the facility. Findings include: Inspection of the walk-in freezer during the initial tour of the kitchen at 1:30 p.m. on 10/3/11, with the dietary manager (DM) revealed a bag of chicken breasts, a bag of diced chicken, and 3 bags of hot dog buns (one of which had ice crystals on them) which were not dated. Also noted at the time of the initial kitchen tour were dusty sprinkler heads under the hood vent above the stove/cooking area. At 11:11 a.m. on 10/5/11, during the tray line observation, the sprinklers were observed to be without dust or debris. At that time, cook-A stated maintenance comes to clean that area when she tells them it needs cleaning. Cook-A stated she did not believe sprinkler cleaning was on a regular cleaning schedule. At 11:33 a.m. the DM returned with a log dated 10/3/11, that indicated "kitchen hood and filters cleaned." At 11:55 a.m. the maintenance supervisor, (MS) stated they just cleaned the hood vent, filters, and sprinklers on 10/3/11. The MS stated the hood and filters were cleaned by maintenance quarterly, but they had not been cleaning the sprinklers quarterly. The MS stated he thought it was a good idea to clean the sprinklers as well and to do it monthly instead of quarterly as dust and debris could collect and fall into the food over the stove. At 9:40 a.m. on 10/6/11, during the follow-up sanitation tour, the DM stated the kitchen staff was aware of the need to date all food. He stated they had signs up ( to remind staff to date food) and they had all taken the Safe Serve course. In reference to the ice crystals on the bag of hot dog buns, the DM stated maybe those had not been rotated and added they should probably remain in another box while in the freezer to decrease the chance of freezer burn. The undated policy Food Storage indicated frozen foods should be dated and items placed in the freezer not in original container would be dated for rotation purposes. At 12:10 p.m. on 10/6/11, the DM brought in the undated form Sample Cleaning Schedule which listed stove hood and filters under the monthly cleaning schedule. The DM stated he would expect the sprinkler heads to be a part of that cleaning.

Based on interview and document review, the facility failed to immediately report allegations of misappropriation of funds to the administrator and to the appropriate State agency for 1 of 1 resident (R41) reviewed in the sample who had reported missing money. Findings include: R41 had reported missing money and staff failed to report the allegation immediately to the administrator and to the appropriate State agency. R41's quarterly Minimum Data Set ((MDS) dated [DATE], identified the resident with minor cognitive impairment that required cueing with recall. At 7:14 p.m. on 10/3/11, R41 stated he had reported $70.00 missing approximately 7 months ago to the social worker designee (SSD). R41 also stated he had never been told what the outcome of the missing money was. The 5/14/11, interdisciplinary progress note indicated R41 stated someone had stolen his bottle of Tylenol and $70.00 that his brother had brought him. The 5/6/11, social service progress note indicated R41 had reported $70.00 was missing. The progress note indicated R41's friend (F-1) who managed his finances and checkbook had not given him $70.00. The friend gave him small amounts of money periodically from his trust account. The progress note indicated R41 seemed to be more relaxed after R41's friend had explained the trust account to him. No additional documentation was noted in R41's medical record regarding missing money incidents. R41's trust account transaction history indicated periodic money was taken out of the account: on 2/4/11, $20.00, on 4/11/11, $33.12, on 5/2/11, $10.00, on 6/17/11, $70.00, and on 7/6/11, $50.00. The facility's Abuse Prevention Program Policies and Procedures dated 12/10/10, indicated: that upon identification of financial exploitation, the caregiver or staff member who identified the situation would immediately contact the charge nurse who would then contact the administrator immediately and that all incidents of alleged misappropriation must be reported to the state agency within 24 hours. The facility's undated policy, Missing Items indicated: - Once an item was reported missing it would be recorded in the missing item notebook in the social service office. -Pertinent facts such as time, date, item description would be recorded in the book. -Social service designee (SSD) would notify administration of the missing item. -An assessment would be made as to how reliable the person who reported lost item was. -An investigation would be done to pinpoint where the item could be or how it disappeared. -Documentation of missing items would be completed in the missing item notebook. At 12:00 p.m. on 10/5/11, F-1 stated she did not give R41 $70.00. She stated she could not recall what happened when R41 reported he lost $70.00. F-1 added R41 would periodically state he was losing his money. At 12:30 p.m. on 10/5/11, R41 stated he lost $70.00 and even remembered the bills that he had in his billfold at the time. He added, he had planned to pay a person who had helped him with something and the money was gone. He stated he had never been told what happened to the money. At 2:00 p.m. on 10/5/11, R41's brother (B-1) was contacted and stated R41 had told him that he was having money taken from him. B-1 stated he never gave R41 $70.00. B-1 stated the friend who managed his checking account may have given him the money. B-1 added R41 was able to take money out of his trust account whenever he wanted. B-1 stated he had never heard what had happened with the missing money issue. On 10/6/11 at 8:15 a.m. the SSD and the facility's bookkeeper were interviewed. The SSD stated an incident report or missing item report was never filled out regarding the $70.00. She added they had searched his room and checked down in the laundry department and had found R41's billfold with $25.00 in it. The SSD stated no documentation had been completed regarding the missing money. The bookkeeper stated R41's $8000.00 insurance check had been missing at the same time. The bookkeeper stated B-1 was now in charge of all of R41's finances. The SSD stated the staff searched R41's room and belongings and were unable to find the $8000.00 check. The SSD stated the facility contacted the insurance company and a new $8000.00 check was re-issued to R41. The SSD added the bookkeeper had contacted R41's brother to notify him of the missing $8000.00 check, however, never documented this in R41's medical record. The SSD stated no documentation of the missing money incidents or notification of the administrator had been documented.

Based on observation, interview, and document review, the facility failed to provide assistance with oral cares for 1 of 1 resident (R44) in the sample who required assistance with oral hygiene. Findings include: R44 did not receive assistance with oral care the morning of 10/5/11. R44 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R44 had memory problems, moderately impaired decision making skills, and required extensive assistance with personal hygiene which included brushing teeth. The current plan of care (POC) printed 7/13/11, directed staff to encourage or assist R44 to brush teeth twice daily. The POC also directed staff to encourage R44 to use the upper denture with adhesive if willing. On 10/5/11, at 8:15 a.m. nursing assistant (NA)-A and licensed practical nurse (LPN)-A assisted R44 with morning cares. However, NA-A and LPN-A did not offer oral cares or offer the upper denture to R44. At approximately 8:30 a.m. R44 was observed eating breakfast and had not been offered his upper denture. R44 was observed after breakfast and throughout the morning during random observations at 9:10 a.m., 9:30 a.m., and 10:00 a.m. R44 was not offered his upper denture or oral hygiene. At 10:36 a.m. NA-A shaved R44 but did not offer oral hygiene. On 10/5/11, at 10:40 a.m. NA-A stated he was aware that R44's POC directed staff to offer or perform morning oral cares. NA-A stated he normally offered oral hygiene to R44 but probably just forgot today. NA-A stated he had worked in the facility 7 months and had never offered R44 his upper denture. At that time, NA-A was asked if R44 had an upper denture in the facility and NA-A then showed the surveyor R44's upper denture in a cup at the nurse's station. On 10/5/11, at 12:20 p.m. LPN-A verified they had not offered oral care to R44 as directed on his POC. LPN-A stated they normally do provide oral care, or at least offer it, although R44 refused about half the time. LPN-A stated R44 did not allow staff to put in his top denture, so they no longer tried to put it in anymore. On 10/5/11, at 12:45 p.m. the assistant director of nursing (ADON) stated staff should always offer oral cares as directed on R44's plan of care On 10/6/11, at approximately 10:00 a.m. the ADON stated she would have to check to see if it was appropriate to try to put in R44's upper denture as she did not know if it would fit anymore since he had gone so long without it. The facility's Oral Cares policy dated 2/20/09, directed staff to offer to rinse, brush , or swab resident's oral cavity BID (twice daily) with morning and bedtime cares.

Based on observation, interview, and record review, the facility failed to provide services in accordance with the resident's written plan of care for 1 of 1 resident (R44) observed who required assistance with oral hygiene and 1 of 3 resident ( R37) in the sample who required assistance with repositioning. Findings include: R44's plan of care was not implemented related to oral hygiene on the morning of 10/5/11. R44's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R44 had memory problems, moderately impaired decision making skills, and required extensive assistance with personal hygiene which included brushing teeth. The current plan of care (POC) printed 7/13/11, directed staff to encourage or assist R44 to brush teeth twice daily and to encourage R44 to use his upper denture with adhesive if willing. On 10/5/11, at 8:15 a.m. nursing assistant (NA)-A and licensed practical nurse (LPN)-A assisted R44 with morning cares however, NA-A and LPN-A did not offer oral cares or offer the upper denture to R44. On 10/5/11, at 10:40 a.m. NA-A stated he was aware that R44's POC directed staff to offer or perform morning oral cares. NA-A stated he normally offered oral hygiene to R44 but probably just forgot today. NA-A stated he had worked in the facility 7 months and had never offered R44 his upper denture. On 10/5/11, at 12:20 p.m. LPN-A verified they had not offered oral care to R44 as directed on his POC. LPN-A stated R44 did not allow staff to put in his top denture, so they no longer tried to put it in anymore. On 10/5/11, at 12:45 p.m. the assistant director of nursing (ADON) stated staff should always offer oral cares as directed on R44's plan of care R37 did not receive timely assistance with repositioning according to the plan of care on the morning of 10/5/11, for 2 hours and 40 minutes. R37's significant change MDS dated [DATE], indicated R37 had memory problems and severely impaired decision making skills. The MDS identified R37 was dependent on 2 staff for transfers and mobility. The current plan of care (POC) revised 8/15/11, indicated R37's skin was intact and identified R37 was dependent on staff for mobility and positioning and required the assistance of 2 staff to reposition. The undated NAR (nursing assistant registered) Care Plan Sheet directed staff to reposition R37 every 1.5 hrs when in the chair. On 10/5/11, during constant observation from 7:10 a.m.- 8:00 a.m. R37 was seated in a wheelchair (w/c) at the dining room table. During constant observations from 8:30 a..m..-9:50 a.m. R37 remained in the same position. R37 was observed to be repositioned by NA-A and LPN-A at 9:51 a.m. On 10/5/11, at 10:50 a.m. NA-A stated he had not repositioned R37 since the resident had been brought out for breakfast around 7:00 a.m. NA-A verified R37's care plan identified he was on a 1.5 hour (hrs) repositioning schedule while sitting. On 10/5/11, at 12:25 p.m. LPN-A stated she was aware of R37's repositioning schedule of every 1.5 hrs while seated as directed on the NA sheet. On 10/5/11, at 12:50 p.m. the ADON stated staff should have repositioned R37 every hour and a half when sitting and although the repositioning schedule was not on the formal POC, staff were to follow the NA care plan which identified his repositioning schedule. On 10/6/11, at 9:20 a.m. the director of nursing (DON) stated the resident should have been repositioned as directed on the NA Care Guide.

Based on observation, interview, and document review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary condition for residents' personal room chairs for 1 of 1 resident (R32) in the sample with a soiled cloth recliner. Findings include: R32's personal cloth recliner was not maintained in a sanitary manner. R32's [DIAGNOSES REDACTED]. On 10/3/11, at 5:02 p.m. the cushion of the cloth recliner in the R32's room smelled of stool. On 10/6/11, at 10:05 a.m. R32 was not in the room, and the cushion of the cloth recliner smelled of stool. At 11:52 a.m. on 10/6/11, housekeeper (H)-A stated the recliner was R32's personal chair. H-A smelled the cushion of the chair and stated it had a musty odor. A covered pillow was in the chair and H-A stated that smelled of stool. She removed the pillow and pillowcase from the room as they both smelled of stool. She stated she would put them in the laundry. H-A stated about one month ago, she had cleaned the chair with foam cleaner as R32 had urinated in the chair. She stated normally if the chairs smell, maintenance will clean them. H-A stated the chair was not on a routine cleaning schedule. At 12:04 p.m. on 10/6/11, the housekeeping supervisor (HS) came to R32's room. She smelled the cushion of the recliner and stated it was "bad." She added, R32's personal chair was the facility's responsibility to clean. She stated she would have maintenance use the cleaning machine on the chair and put it on a routine cleaning schedule. In addition, she stated if they can't get chairs clean, they talk with the family and request vinyl cushioned chairs. At 12:09 a.m. on 10/6/11, the HS stated the facility's policy identified cleaning the lobby furniture on a daily basis. She stated she would update the policy to include furniture in resident rooms to be cleaned weekly when housekeeping staff do their thorough cleaning. At 12:45 p.m. NA-E stated R32 toilets independently and is never incontinent. The facility's undated policy and procedure for cleaning the lobby furniture identified the housekeeper that was responsible for cleaning the lobby, would also clean the furniture everyday.

Based on interview and document review, the facility failed to implement their policy regarding reporting allegations of misappropriation of funds to the administrator and the appropriate State agency for 1 of 1 resident (R41) in the sample who reported missing money. Findings include: R41 had reported missing money and staff failed to follow their policy and report the allegation immediately to the administrator and to the appropriate State agency. The facility's Abuse Prevention Program Policies and Procedures dated 12/10/10, indicated: that upon identification of financial exploitation, the caregiver or staff member who identified the situation would immediately contact the charge nurse who would then contact the administrator immediately and that all incidents of alleged misappropriation must be reported to the state agency within 24 hours. R41's quarterly Minimum Data Set ((MDS) dated [DATE], identified the resident with minor cognitive impairment that required cueing with recall. At 7:14 p.m. on 10/3/11, R41 stated he had reported $70.00 missing approximately 7 months ago to the social worker designee (SSD). R41 also stated he had never been told what the outcome of the missing money was. The 5/14/11, interdisciplinary progress note indicated R41 stated someone had stolen his bottle of Tylenol and $70.00 that his brother had brought him. The 5/6/11, social service progress note indicated R41 had reported $70.00 was missing. The progress note indicated R41's friend (F-1) who managed his finances and checkbook had not given him $70.00. The friend gave him small amounts of money periodically from his trust account. The progress note indicated R41 seemed to be more relaxed after R41's friend had explained the trust account to him. No additional documentation was noted in R41's medical record regarding missing money incidents. R41's trust account transaction history indicated periodic money was taken out of the account: on 2/4/11, $20.00, on 4/11/11, $33.12, on 5/2/11, $10.00, on 6/17/11, $70.00, and on 7/6/11, $50.00. At 12:00 p.m. on 10/5/11, F-1 stated she did not give R41 $70.00. She stated she could not recall what happened when R41 reported he lost $70.00. F-1 added R41 would periodically state he was losing his money. At 12:30 p.m. on 10/5/11, R41 stated he lost $70.00 and even remembered the bills that he had in his billfold at the time. He added, he had planned to pay a person who had helped him with something and the money was gone. He stated he had never been told what happened to the money. At 2:00 p.m. on 10/5/11, R41's brother (B-1) was contacted and stated R41 had told him that he was having money taken from him. B-1 stated he never gave R41 $70.00. B-1 stated the friend who managed his checking account may have given him the money. B-1 added R41 was able to take money out of his trust account whenever he wanted. B-1 stated he had never heard what had happened with the missing money issue. On 10/6/11 at 8:15 a.m. the SSD and the facility's bookkeeper were interviewed. The SSD stated an incident report was never filled out regarding the $70.00. She added they had searched his room and checked down in the laundry department and had found R41's billfold with $25.00 in it. The SSD stated no documentation had been completed regarding the missing money. The bookkeeper stated R41's $8000.00 insurance check had been missing at the same time. The bookkeeper stated B-1 was now in charge of all of R41's finances. The SSD stated the staff searched R41's room and belongings and were unable to find the $8000.00 check. The SSD stated the facility contacted the insurance company and a new $8000.00 check was re-issued to R41. The SSD added the bookkeeper had contacted R41's brother to notify him of the missing $8000.00 check, however, never documented this in R41's medical record. The SSD stated no documentation of the missing money incidents or notification of the administrator had been documented. On 10/6/11, at 9:45 a.m. the social service designee (SSD) verified the facility policy was not followed for R41's missing money incidents.