Every finding on record at Montgomery General Hospital

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow proper personal protective equipment (PPE) requirements for a resident on enhanced barrier precautions. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Resident Identifier: #9. Facility Census: 36. Findings included:a) Resident #9 The facility's policy titled, Enhanced Barrier Precautions Policy, with no implementation given, stated changing linens was a high-contact resident care activity requiring a gown and gloves for residents on enhanced barrier precautions (EBP). Review of Resident #9's physician's orders showed an order written for enhanced barrier precautions due to a wound. On the door to Resident #9's room was a sign stating, Stop. Enhanced Barrier PrecautionsEveryone Must:Clean their hands, including before entering and when leaving the room.Providers and staff must also:Wear gloves and a gown for the following High-Contact Resident Care Activities.DressingBathing/ShoweringTransferringChanging LinensProviding Hygiene Changing briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressingOn 08/19/26 at 1:43 PM, Hospitality Aide (HA) #34 was observed making Resident #9's bed.Hospitality Aide #34 had removed the old linens and placed them in a plastic bag. He was putting the new linens on the bed when observed. HA #34 was wearing gloves but not a gown while making the bed. HA #34 was shown the sign outside Resident #9's room and agreed that he should have worn a gown when making the bed. On 08/19/26 at 1:51 PM, the Director of Nursing (DON) confirmed gowns should be worn while changing linens for residents with enhanced barrier precautions.

Based on observation, record review and staff interview, the facility failed to use appropriate alternatives prior to installing bed rails and failed to assess each resident for the risk of entrapment from bed rails prior to installation. This failed practice was a random opportunity for discovery and had the potential to affect all residents currently residing in the facility during the Long-Term Care Survey Process. Facility Census: 28. Findings Include: a) Facility Bed Rails An observation on 05/29/25 at 10:00 AM, revealed that all empty beds in the Long-Term Care Unit, and all 28 beds currently occupied by a resident had bed rails installed. The observation revealed that throughout the unit, 4 types of bed rails were being used. During an interview on 05/29/25 at 10:45 AM, The Maintenance Director (MD), stated, Prior to getting a new admit, we do not inspect the beds or anything. We just work on them if we have a work order for them. We do not have any policy that I know of, about inspecting the bed rails. During an interview and observation on 05/29/25 at 11:05 AM, of bed rails throughout the facility, the Director of Nursing (DON), stated, Everybody has bed rails the control to the beds is on them. These beds are so old. I have no idea where to find the manufacturer's guideline. As you can see, we have different types of beds and 3 or 4 different types of bed rails. A record review on 05/29/25 at 11:30 AM, revealed that all residents residing in the facility had a side rail assessment and consent completed and signed by the resident or Medical Power of Attorney (MPOA) upon admission. No side rail assessments had been completed since the admission of the resident. The side rail assessment and consent had no indication that the side rails were assessed for entrapment risk. During an interview on 05/29/25 at 12:30 PM, The Minimum Data Set Registered Nurse (MDSRN), stated, I do the assessments. I only do the one on admission. I did not know we were required to do anything different. The MDSRN further confirmed that nowhere on the side rail assessment does it mention checking for risk of entrapment. During an interview on 05/29/25 at 12:45 PM, The DON stated, I will look for the manufacturer's guideline and ask if we have that, but the beds are so old I doubt they are here. No further information was provided by the end of the survey.

Based on record review, and staff interview, the facility failed to notify the Medical Power of Attorney (MPOA) in writing of the transfer to the hospital, and did not provide the bed hold policy for Resident #28. Furthermore, the facility failed to notify the MPOA in writing of the transfer to the hospital, and did not provide the bed hold policy and no notification was sent to the ombudsman for Residents #18, and #10. This failed practice was found true for (3) three of (3) three residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifiers #28, #18, and #10. Facility census: 28. Findings include: a) Resident #28 A record review, on 05/29/25 at 12:00 PM, revealed that Resident #28 had been transferred to the hospital on [DATE]. Further record review found no transfer/discharge notifications, or the bed hold policy was sent to the MPOA. During an interview, on 05/29/25 at 12:38 AM, The Director of Nursing (DON), stated, I cannot find the transfer form, or the bed hold policy in the chart. The DON confirmed they were not sent. b) Resident 18 On 05/27/25 at 2:03 PM, a record review was completed for Resident #18. The review found the resident had been transferred to an acute care facility for a swollen knee on 04/23/25. The transfer form, bed hold policy and Ombudsman notification was requested from the facility. On 05/29/25 at 12:38 PM, the Director of Nursing (DON) was interviewed. The DON stated, I cannot find the transfer form, bed hold policy or the ombudsman notification.

Based on observation and staff interview, the facility failed to ensure the tray line milk cooler had proper seals to maintain safe temperatures for the milk/juice by holding it under 40 degrees Fahrenheit. This was a random opportunity for discovery and had the potential to affect a limited number of residents residing in the facility. Facility census: 28 Findings include: On 05/27/25 at approximately 11:30 PM the initial tour of the kitchen revealed a cooler that had a seal damaged causing a gap and making the cooler not seal correctly. Further observations of the cooler and milk that was being held inside showed the milk did not feel very cold to touch. An interview with Dietary Manager (DM) 05/27/25 at 11:40 AM who stated, I did not know the seal on the tray line milk cooler was like that. The DM took the temperature o placed a thermometer in the cooler and took the temperature of the milk. This temperature reading revealed the milk was 41.4 Fahrenheit and the cranberry juice was 57.6 Fahrenheit. When the DM checked the temperature of the inside of the cooler it was 51.0 degree Fahrenheit. The DM at this time confirmed the cooler was not properly holding temperatures due to the broken seal.

Based on observation, staff interview, resident interviews, and documentation review, the facility failed to maintain a proper infection prevention and control in the environment. Facility census 28. Findings include: a) On 05/28/25 at approximately 3:05 p.m., reviewed the facility's water management plan documentation. Upon review of the water management plan discovered that there was no water flow diagram readily available. Interview with employee #48 verified this at the time of discovery. The finding was also acknowledged by the Administrator that the facility does not have a water flow diagram. This finding was also acknowledged by the Administrator upon the exit on 05/29/25. b) Resident #15 On 05/27/25 at 1:14 PM, a soiled pink bath basin was observed sitting on floor under the sink in Resident #15's room. On 05/27/25 at 1:17 PM, Registered Nurse (RN) #9 was notified and stated, I thought maybe the sink was leaking but it's not. At this time, RN #9 removed the bath basin from the room. On 05/28/25 at 9:35 AM, the Director of Nursing (DON) was notified and confirmed the bath basin should not have been sitting under the sink in the floor. c) Resident #26 On 05/27/25 at 3:40 PM, an observation of oxygen tubing and cannula was found laying on the table and hanging into the floor. RN #9 was notified. RN #9 was asked, does the resident use oxygen? RN #9 confirmed the oxygen tubing and cannula did not belong to the resident. On 05/28/25 at 9:35 AM, the Director of Nursing (DON) was notified and confirmed the oxygen tubing and cannula should be stored properly; it should not be in the room if the resident does not use oxygen. d) Resident #11 On 05/27/25 at 1:10 PM, a urinal was observed hanging on the commode handle without being in an appropriate storage container. On 05/27/25 at 1:13 PM, Nurse Aide (NA) #16 removed the urinal from the commode handle. NA #16 stated, let me get this. On 05/28/25 at 9:35 AM, the Director of Nursing (DON) was notified and confirmed the urinal should be stored properly.

Based on observations and Staff interview the facility failed to ensure foods were probably labelled and discarded when out of date. This failed practice had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 28 Findings include a) On 05/27/25 at approximately 12:00 PM initial tour of the facility kitchen found the following; Two (2) salads were in the walk-in cooler with no dates/labels. One (1) carton of pasteurized eggs in the walk-in cooler with no dated/labels One (1) carton of heavy whipping cream in the walk-in cooler with no dates/labels One (1) carton of cream of wheat in the walk-in cooler with no dates/labels One bag of flour in the dry stock room with no open date One bag of cheesecake mix in dry stock with no open date One bag of Tostito corn chips in dry stock room with no open date An interview with the Dietary Manager (DM) on 05/27/25 at 12:10 PM regarding items not being labeled was completed. The DM stated, We will get this fixed, the staff should know better than this. confirming the items were not labeled correctly. Further observations during the initial tour of the kitchen on 05/27/25 revealed one (1) carton of milk with a use by date of 05/22/25. 05/27/25 at approximately 12:30 PM the DM stated, They must have missed that carton of milk when rotating the milk. On 05/27/25 at approximately 11:30 PM initial tour of the kitchen revealed a cooler that had a seal damaged causing a gap and making the cooler not seal correctly. Further observations of the cooler and milk that was being held inside showed the milk did not feel very cold to touch. An interview with DM on 05 /27/25 at 11:40 AM who stated, I did not know the seal on the tray line milk cooler was like that. An observation reveled the DM taking the temperature of the milk. The milk was 41.4 degrees Farenheit. The cranberry juice was 57.6 degrees Farenheit and the temperature inside the cooler was 51 degrees Farenheit. The DM at this time confirmed the cooler was not properly holding temperatures due to the broken seal on the cooler. When asked what the temperature of the milk and juice should be the DM stated, It (milk and juice) should be under 40 degrees Fahrenheit, but i think they just put that juice back in the cooler(but was not sure the juice were placed back in the cooler). confirming the milk and juice were above holding temperature.

Based on record review and staff interview, the facility failed to provide an accurate Pre-admission Screening and Resident Review (PASARR) containing all diagnoses for Resident #22 and #23. Resident identifiers: #22 and #23. Facility Census: 28. Findings include: a) Resident #22 On 05/27/25 at 3:17 PM, a record review was completed for Resident #22. The review found the PASARR dated 03/09/25 did not contain three (3) diagnoses. The following diagnoses were not included: Unspecified dementia, mild with anxiety, Bipolar disorder, in partial remission, most recent episode depressed and Depression, unspecified. On 05/28/25 at 3:06 PM, an interview was held with the Social Services Director (SSD). The SSD stated, thank you for letting me know. b) Resident #23 Review of PASARR on 05/27/25 at 1:42 PM revealed Bipolar disorder, Major depressive disorder was marked on the PASARR Further record review revealed the following Diagnoses: G20.C Parkinsonism, unspecified R45.851 Suicidal ideations (History of) F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features 05/28/25 2:56 PM DON confirmed Parkinsonism was not identified in the PASARR and Major Depressive disorder was identified on the PASARR when Resident #23 had no active diagnosis for Major Depressive Disorder.

Based on observation and staff interview, the facility failed to ensure privacy and confidentially during medication administration. Facility Census: 28. Findings Include: a) Computer on the Medication Cart On 05/28/25 at 4:34 PM, an observation of the medication cart sitting in the corridor by the elevators was unlocked and the computer screen was left unlocked. Licensed Practical Nurse (LPN) #34 was sitting in the employee lounge. There was no line of sight between LPN #34 and the medication cart. LPN #34 stated, I was just getting a drink. On 05/28/25 at 4:36 PM, the Director of Nursing (DON) was notified and stated, the medication cart and the computer should be locked.

Based on Record review and staff interview the facility failed to provide an accurate MDS diagnosis of Parkinsonism. This was found to be true for one (1) of 15 residents whose Minimum Data Set (MDS) was reviewed during the Long Term-Care Survey Process. Resident Identifier: #23 Facility census:28 Findings include: a) Resident #23 Record review completed on 05/27/25 03:42 PM revealed the following diagnosis Parkinsonism, unspecified Further record review of a consultation record completed by a neurologist on 12/14/23 revealed the neurologist had diagnosed Resident #23 to have Parkinsonism. Review of Resident #23's MDS section I (Active Diagnoses) that was completed on 03/14/24 revealed under the Neurological section that Parkinsonism was not marked. On 05/28/25 at 03:56 PM The Director of Nursing (DON) confirmed Parkinsonism was not identified in the MDS Completed on 3/14/24.

Based on resident interview, record review and staff interview, the facility failed to offer a pneumococcal vaccination to Resident #18. This was true for one (1) of five (5) residents reviewed under the care area of infection control. Resident Identifier: #18. Facility Census: 28. Findings Include: a) Resident #18 On 05/27/25 at 1:30 PM, Resident #18 asked, are you here to bring me my pneumonia shot? The resident was admitted to the facility on [DATE] and no documentation was found listing any immunizations the resident had received. On 05/29/25 at 11:25 AM, the Director of Nursing (DON) was interviewed regarding the pneumococcal vaccination for Resident #18. The DON stated, we have ordered them .but they haven't came in yet .the resident was not offered a pneumococcal vaccination since she has been here.

Based on observation and Staff interview the facility failed to ensure residents who room together were served lunch in a dignified manner, by not surveying meals at the same time. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Resident identifier: #2, #20 Facility Census: 28 Findings include: a) An observation during lunch tray pass on the hall on 05/28/25 at 4:21 PM revealed Resident #2 was served and had half his food eaten before Resident #20 was served. The residents were served approximately 15 minutes apart. During an interview on 05/28/25 with the Director of Nursing (DON) the DON stated, He (resident #20) gets his tray later because he requires staff to assist them. Confirming Resident #20 was not served and assisted when Resident #2 was given their lunch tray.

Based on record review, resident representative interview and staff interview, the facility failed to document all meal intake percentages for Resident #26, who was identified with weight loss. This was true for one (1) of two (2) residents reviewed under the care area of nutrition. Resident identifier: #26. Facility Census: 28. Findings Include: a) Resident 26 On 05/27/25 at 4:34 PM, an interview was held via telephone with Resident #26's representative. The representative stated, She is not eating well .I'm concerned. She dislikes eggs. On 05/28/25 at 7:56 PM, a record review was completed for Resident #26. The review of meal percentages from 04/08/25 through 05/28/25 found no documentation for the following dates: --04/17/25 dinner --04/19/25 dinner --04/20/25 breakfast --04/20/25 lunch --04/20/25 dinner --04/28/25 lunch --05/06/25 dinner A further review of the resident's weights found a 5.1% of weight loss from 04/08/25 through 05/08/25. The following is a list of the resident's weights: --04/08/25 163.60 --04/10/25 162.70 --04/17/25 159.00 --04/24/25 157.40 --05/01/25 157.80 --05/04/25 156.80 --05/08/25 155.30 No documentation from the facility physician or the registered dietician was found. On 05/29/25 at 9:05 AM, the Director of Nursing (DON) was notified of the weight loss of 5.1%. The DON stated, We don't have the food likes and dislikes .the dietary manager does that with the nursing home next door .if someone doesn't like something we usually find out over time.

Based on observation and staff interview, the facility failed to maintain the environment of which it had control over to remain free of accident hazards due to the medication cart being unlocked. Facility Census: 28. Findings Include: a) Medication Cart On 05/28/25 at 4:34 PM, an observation of the medication cart sitting in the corridor by the elevators was unlocked and the computer screen was left unlocked. Licensed Practical Nurse (LPN) #34 was sitting in the employee lounge. There was no line of sight between LPN #34 and the medication cart. LPN #34 stated, I was just getting a drink. On 05/28/25 at 4:36 PM, the Director of Nursing (DON) was notified and stated, The medication cart and the computer should be locked.

Based on record review, staff interview, and resident interview the facility failed to develop or implement a care plan related to nutrition and diagnoses. This failed practice was found true for toe (2) of 15 residents whose care plan were reviewed during the Long Term-Care Survey process. Resident identifiers: #23 and #26. Facility census: 28 Findings include: a) Resident #23 On 05/27/25 at 03:42 PM the following diagnoses was reviewed in Resident #23's medical record: Parkinsonism, unspecified Suicidal ideations (History of) Not marked on PASSR Further Record review of Resident #23's care plan showed neither diagnosis was identified in the resident person-centered care plan. 05/28/25 03:56 PM DON confirmed Parkinsonism and History of Suicidal Ideations was not identified in Resident #23's care plan. b) Resident #26 On 05/27/25 at 4:34 PM, an interview was held via telephone with Resident #26's representative. The representative stated, She is not eating well .I'm concerned. She dislikes eggs. On 05/28/25 at 7:56 PM, a record review was completed for Resident #26. The review found the care plan was not implemented under the focus area of potential for altered nutrition r/t (related to) no concentrated sweets diet. An intervention for the area of altered nutrition was for the facility to assess the residents likes/dislikes and provide diet as ordered with as many of resident's desired food choices. On 05/29/25 at 9:05 AM, an interview was held with the Director of Nursing (DON). The DON was asked, Will you provide a list of food likes/dislikes? The DON stated, We don't have the food likes and dislikes .the dietary manager does that with the nursing home next door .if someone doesn't like something we usually find out over time.

Based on observation and staff interview, the facility failed to ensure licensed nurse staffing information based on payroll information was accurately reported to the Centers for Medicare and Medicaid Services (CMS.) This has the potential to affect all residents at the facility. Facility census: 26. Findings included: a) Payroll Based Journal (PBJ) Review of the facility's Payroll Based Journal (PBJ) data from the Certification And Survey Provider Enhanced Reports (CASPER) found the facility did not have licensed nursing coverage 24 hours a day for 51 days during the third quarter of 2023: 04/01/23, 04/02/23, 04/05/23, 04/08/23, 04/09/23, 04/10/23, 04/12/23, 04/13/23, 04/14/23, 04/15/23, 04/16/23, 04/19/23, 04/20/23, 04/21/23, 04/22/23, 04/23/23, 04/26/23, 04/29/23, and 04/30/23. 05/01/23, 05/06/23, 05/07/23, 05/10/23, 05/11/23, 05/13/23, 05/14/23, 05/17/23, 05/18/23, 05/19/23, 05/20/23, 05/21/23, 05/24/23, 05/27/23, 05/28/23, 05/29/23, and 05/31/23. 06/03/23, 06/04/23, 06/07/23, 06/10/23, 06/11/23, 06/12/23, 06/14/23, 06/15/23, 06/16/23, 06/17/23, 06/18/23, 06/21/23, 06/24/23, 06/25/23, and 06/28/23. On 10/31/23 at 2:32 PM, the Director of Nursing (DON) reviewed the report and said, someone submitted the wrong information. The DON and the surveyor reviewed the payroll information of licensed nursing staff working and determined the facility did have nursing staff 24 hours a day as required. On 11/01/23 at 10:18 AM, the Administrator confirmed she had investigated the situation and had determined the facility made an error when entering and transmitting the licensed nurse staffing hours.

Based on observation and staff interview the facility failed to maintain proper infection control standards during wound care. This failed practice was a random opportunity for discovery and had the potential to affect only a limited number of fesidents. Resident identifier: #79. Facility census: 26. Findings included: a) Resident #79 Record review showed an order for Santyl ointment; 250 unit/gram for amount of a thin layer, topical. Special Instructions: Cleanse area to 5th right toe area with Normal Saline. Pat dry. Apply thin layer of Santyl, apply dry 4x4 gauze, wrap with Curlex daily. During observation of wound care on 10/31/23 at 11:22 AM, Licensed Practical Nurse (LPN) #43 did not disinfect the residents over bed table (OBT) or place a barrier down prior to initiating wound care. The Residents drink cup, half eaten cookie, and dirty napkin were left on the OBT. Dressing supplies were laid directly in a sticky substance on the table. LPN #43 laid the opened Santyl ointment tube directly down on the table. Ointment was protruding out of the tube opening and touched the table. LPN #43 proceeded to pick up the tube of ointment and scrap the ointment off the tube with a Q-tip. LPN #43 then applied the ointment the Resident's 5th toe wound. During an interview on 11/01/23 at 12:00 PM the Director of Nursing stated, You mean they didn't even use a Clorox wipe or anything? The DON verified the over the bed table should have been disinfected and a barrier placed prior to initiating the wound care.

Based on record review and staff interview the facility failed to ensure nurse staffing information was posted on a daily basis. This was a random opportunity for discovery and has the potential to affect all residents at the facility. Facility census: 26. Findings included: a) Staff posting At 10:40 AM on 10/30/23, observation revealed the nurse staffing information posted for public view at the nurses station was dated 10/27/23. The Director of Nursing (DON) confirmed the posting was not current for todays date - 10/30/23.

Based on record review and staff interview, the facility failed to have documentation to support ongoing communication, coordination and collaboration between the nursing home and the dialysis center for one (1) of one (1) Resident reviewed for the care area of dialysis. In addition, there was no evidence to support an ongoing assessment of the resident's condition and monitoring for possible complications before and after dialysis treatments received at a certified dialysis facility. Resident identifier: 23. Facility census: 26. Findings included: a) Resident #23 During the initial resident screening process of the survey on 10/30/23, observation of the Resident's room at 11:30 AM on 10/30/23 found the resident was not present. When asked where the resident might be, Registered Nurse (RN) #26 said the resident was at the dialysis center and should return to the facility around 4:00 PM. Review of the current medical record on the morning of 10/31/23, found no physician's orders for dialysis services. On 10/31/23 at 10:49 AM, the Director of Nursing (DON) reviewed the medical record and said there are no physician's orders for dialysis treatment. The DON confirmed the Resident does receive dialysis services and at an outpatient dialysis center three (3) times a week on Mondays, Wednesdays, and Fridays. On 10/31/23 at 10:56 AM, the DON and RN #26 were asked for evidence of communication between the facility and the dialysis center, such as dialysis pre and post dialysis weights, blood pressure, temperature, pulse, and any communication as to how the Resident tolerated dialysis. The DON said the facility tried sending a notebook with a report for the dialysis center to fill out but the dialysis center would never send it back. When asked who monitors and records the residents pre and post vital signs and pre and post weights on dialysis days, the DON said she guessed that was completed at the center. RN #26 said she had called the dialysis center herself to try to get the paper returned but was told by the dialysis center, providing information to the nursing home was a violation of HIPPA (Health Insurance Portability and Accountability Act) rights. When asked how the facility would know about the Resident's care at the dialysis center, the DON said, she figured the dialysis center would call the nursing home if the Resident had any problems. In addition, the DON was unable to provide documentation to verify the facility nursing staff monitor and documentation of the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. Review of the medical record supported the interviews from the DON and RN #26. For example, the Resident went out of the facility to the dialysis center on 10/30/23. No nurses notes were written in the medical record on 10/30/23 referencing the resident left the facility for dialysis. There was no mention of the Resident's condition before and after dialysis. Observation of the access site and condition upon return from dialysis was not recorded anywhere in the medical record. The only vital sign recorded on 10/30/23 was a blood pressure (108/60) obtained at 9:28 PM. On 11/01/23 at 8:35 AM, the Resident's physician said obtaining information from the dialysis had been a problem. She said the dialysis center has had some issues with their services. She said she would tell the medical director and maybe he could call the center. Review of the care plan found a dialysis care plan, updated on 08/04/23: The problem: Resident requires dialysis. The goal: Potential for excess fluid, port infection, tiredness from illness/transportation time. Approaches included: Monitor permacath site to right upper chest for signs and symptoms of pain or infection. Obtain vitals, weights and labs as ordered and communicate results to dialysis center as instructed. On 11/01/23 at 9:46 AM, the DON confirmed the care plan was not implemented.

Based on record review, Resident Council meeting and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 26 Findings Included: a) Activity Program During the Resident Council Meeting held on 10/31/22 1:16 PM, the residents group was asked the question, Are you satisfied with your involvement in group activities? The following concerns were voiced? The residents replied: -We only have group activities every other weekend. -We get packets to do on the weekends, they call that group activities. -Nothing to do in the evenings, we eat dinner and go to bed. -Sometimes they turn the TV on in the Dining Room for a ball game but no other weekend activities. During a review of three months of the monthly activity calendars revealed the following activities on weekends and evenings; October 2023: - Sunday, 10/01/23 11:30 AM Church on TV and Activity Packets - Saturday, 10/14/23 Activity Packets 2:00 Movie - Sunday, 10/15/23 11:30 AM Church on TV and Activity Packets - Friday, 10/20/23 6:30 PM Riverside Church of God -Saturday, 10/28/23 Activity Packets 2:00 Movie September 2023: Saturday, 09/02/23 Activity Packets 2:00 Movie Sunday, 09/03/23 11:30 AM Church on TV and Activity Packets Friday, 09/15/23 6:30 PM Riverside Church of God Saturday, 09/16/23 Activity Packets 2:00 Movie Friday, 09/17/23 11:30 AM Church on TV and Activity Packets Saturday, 09/23/23 Activity Packets 2:00 Movie Saturday, 09/30/23 Activity Packets 2:00 Movie August 2023: -Saturday, 08/12/23 Activity Packets 2:00 Movie -Sunday, 09/13/23 Activity Packets 11:30 Church on TV -Friday, 08/18/23 6:30 PM Riverside Church of God -Saturday,08/26/23 Activity Packets 2:00 Movie The Monthly Activity Calendars revealed only one (1) evening activity a month. It also revealed that every other weekend group activities were provided. During an interview on 11/01/23 at 3:16 PM, the Activity Director (AD) said she had two (2) assistants, but one had been used as a Nurse Aide (NA) because they were short staffed. The other assistant helps with laundry. We only have group activities every other weekend, the weekends with no groups gets an individualized activity packet. The weekend nurse gives out the packets for us when we are not here. The AD stated we have one evening activity a month, we can not get our volunteers to come back after COVID. The AD was asked, Why are your activity assistants not providing the evening activities? The AD stated, I share the one assistant with Laundry and I should be getting my other assistant back next month. The AD was informed of the information provided in the Resident Council meeting held on 10/31/23. During an interview on 11/01/23 at 3:42 PM, the Director of Nursing (DON) stated, one of the Activity Assistants did assist with laundry. The DON said, The other I have been utilizing because I have been short staffed and I pull her back to be a NA. I pulled her because a clean butt and being feed is more important than activities. The DON was asked, Are activities for mental, physical and psychosocial needs not important? The DON stated, Their care comes first, and when you short staffed I will pull wherever I can and wherever I want. During an interview on 11/01/23 at 4:05 PM, the DON stated the NA has been working since 02/03/23 as a Nurse Aide. I have been short staffed. This surveyor stated, You usually have four (4) to five (5) NA's on 7-3 shift, seven (7) to eight (8) NA's on evening and your census average is about 27 Residents, is that not enough staff for 27 residents? This surveyor informed the DON that Activities would be cited for lack of activities due to her utilizing the activity staff to do other jobs instead of providing the residents with the Activities of interest for evenings and weekends. The DON stated the NA would be back to activities in a few weeks after the four (4) new ones get trained.

Based on observation, policy review, resident council meeting and staff interview the facility failed to make grievances forms accessible to all residents and/or residents family/representatives residing in the facility. This had the potential to affect more than a limited number of residents living in the facility. Facility census: 26. Findings included: a) Grievance Forms A review of the facility policy titled Grievance/Concern with a revision date 03/21/18 and a reviewed date of 03/20 .PROCEDURE: A. Person making the complaint will notify the Charge Nurse on duty and ask for a complaint form. If present the charge Nurse will offer to all the Grievance Officer to speak with the patient/family/visitor. The federal guidelines indicate the following: 483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents ' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; a) Grievance Forms During the Long-Term Care Survey Process from 10/31/23 to 11/01/23 many observations throughout the facility revealed no evidence of grievance forms being accessible to the residents and/or resident representatives. During the Resident Council Meeting held on 10/31/23 at 1:18 PM, the residents as a group were asked the question, Do you know how to file a grievance? Do you know where to access your grievance forms? The residents as a group stated No, we don't. We just tell (Social Worker's name). During an interview, on 10/31/23 at 3:12 PM, the Social Worker (SW) stated the grievance forms are in a folder behind the nurse's desk. Anyone can ask us to fill it out. During an interview on 10/31/23 at 3:13 PM, Registered Nurse (RN) #26 stated the residents come to the desk, we get the form, and we fill it out for them. Then we fold it and put it under either the Director of Nursing's door or the SW's door. During an interview, on 10/31/23 at 3:14 PM, the SW acknowledged the grievance forms were not accessible to all residents or representatives. During an interview, on 10/31/23 at 3:14 PM, RN #26 acknowledged the grievance forms were not accessible to all residents or representatives. Then stated, We will have a folder put in the library for the residents and family to access the grievance forms.

Based on record review, resident interview, and staff interview, the facility failed, for two (2) of twenty-one (21) Stage II sample residents who were continent of urine when they entered the facility and became incontinent, to assure timely and appropriate assessment in an effort to possibly regain urinary continence. This resulted in actual harm, as both residents stated a desire to regain normal bladder function and no attempts were made by the facility to assist them with this goal. Resident identifiers: #32 and #31. Facility census: 34. Findings include: a) Resident #32 When reviewed on 05/12/10, the resident's medical record disclosed the resident had been admitted to the Extended Care Unit (ECU) on 12/21/09, following hospitalization for a broken pelvis. At the time of admission to the ECU from acute care, the resident had in place an indwelling Foley urinary catheter. The catheter was removed, according to nurse's notes on 01/12/10. An interview with a licensed practical nurse (LPN - Employee #28), on 05/12/10 at 9:52 a.m., disclosed that facility protocol was typically to remove catheters within twenty-four (24) hours of admission unless there was a [DIAGNOSES REDACTED]. The LPN further stated this resident had a broken pelvis and personally requested that the catheter remain in place. On 01/12/10, the resident agreed to have it removed. The medical record contained no physician's order for the removal of the catheter, no evidence of any attempt by staff to assess the resident's ability to regain continence, and no evidence of any attempt at bladder re-training prior to the removal of the catheter. The resident's minimum data set (MDS) assessments for the previous several months were reviewed. An admission MDS, with an assessment reference date of 10/18/09, stated in Section H that the resident was continent of bowel and bladder (both coded "0") with no devices or appliance (such as an indwelling catheter) present. A second admission MDS (with an ARD of 01/05/10) was identical as the above mentioned, although nurse's notes and staff interview stated the resident did have an indwelling catheter present between the dates of 12/21/09 and 01/12/10. A quarterly MDS (with an ARD of 04/05/10) stated the resident was continent of bowel (coded "0") and mostly incontinent of bladder (coded "4"). Although the MDSs inaccurately denied the presence of the indwelling catheter on any assessment, these findings would indicate the resident had been continent of urine prior to her hospitalization and placement of the indwelling catheter and that urinary continence may possibly have been attainable following the removal of the catheter. When interviewed on 05/13/10 at 9:45 am, the resident stated she feels the urge and tries to control it as much as possible. She stated she has "always had the desire to control it somehow. One thing for sure, I try to avoid the stuff that causes you to urinate. A person that has problems with urine control, they should not drink liquid before they go to bed, especially coffee." The resident's current care plan, when reviewed, contained no mention of urinary incontinence. The care plan / assessment nurse (Employee #25) confirmed, when interviewed on 05/12/10, that the resident's care plan did not reflect necessary services in the area of urinary incontinence or a plan to assist the resident in restoring as much normal bladder function as possible. b) Resident # 31 Medical record review, on 05/12/10, revealed this resident was incontinent of bladder when admitted on [DATE]. Review of the resident's care plan revealed no plan regarding an attempt at restoring normal bladder function. The resident's care plan regarding bladder incontinence, originating on 02/15/10 and updated on 04/22/10, was: "Will be clean and dry with use of incontinence products and prompt incontinence care through review date." The interventions were to check for incontinence and change clothing after incontinence, etc. There were no care plans to assist the resident in regaining bladder continence. This was confirmed by Employee #28 when interviewed at 1:00 p.m. on 05/12/10. At 11:00 a.m. on 05/13/10, the resident was interviewed regarding her incontinence. At that time, the resident stated she could feel the urge to urinate and would like to be continent if at all possible. .

Based on record review, observation, and staff interview, the facility failed, for one (1) of twenty-one (21) Stage II sample residents, to provide a resident environment as free of accident hazards as possible, by failing to ensure staff consistently secured and alarmed an exit door leading from the unit to a stairwell. This practice resulted in actual harm for Resident #30 when she exited the door unnoticed and fell down eight (8) steps in her wheelchair, sustaining an acromioclavicular joint separation (separated shoulder). Resident identifier: #30. Facility census: 34. Findings include: a) Resident #30 Review of the facility's incident / accident reports, on 05/11/10, revealed a report stating that, on 03/23/10 at 11:00 a.m., Resident #30 was found in a stairwell off the Extended Care Unit (ECU) at the bottom of eight (8) stairs. Further review of the document disclosed that, following investigation, it was determined a staff member had failed to utilize the proper method of securing the door and re-setting the door alarm after another resident had activated the alarm the day before. This information was confirmed in an interview with vice president of patient care services (Employee #32) on the morning of 05/13/10. The resident's medical record, when reviewed on 05/12/10, disclosed this [AGE] year old female was known to the facility to wander and to be at risk for falling. According to the resident's care plan, which was reviewed on 05/12/10, staff was aware the resident was a high risk for falls related to a history of falls. Interventions to assure the resident was free from falls included measures such as providing activities that minimize the potential for falls while providing diversion and distraction and applying a bed alarm and an EZ release seat belt while in wheelchair. The resident also wore a WanderGuard alarming device / bracelet, but this door was not equipped with the WanderGuard system. Review of the resident's minimum data set (MDS) assessments disclosed an MDS with an assessment reference date of 02/24/10. In Section E (Mood and Behavior), the assessor noted the resident exhibited wandering one (1) to three (3) days in the seven-day assessment reference period. The resident was noted in Section B (Cognitive Skills) to be moderately impaired in cognitive skills for daily decision-making, and in Section G (Physical Functioning), the resident was noted to range from needing extensive assistance to being totally dependent for completing most activities of daily living. When the resident was discovered following the fall, nurses' notes stated she was "lying on face / left side with wheelchair on back. Had to release EZ release seat belt to get w/c (wheelchair) off resident." The resident was secured to a back board and transferred to the emergency room (ER). The resident underwent [REDACTED]. There was acromioclavicular joint separation (separated shoulder), the resident returned to the ECU with a sling on the left arm, and the resident's pain medication was increased. .