Every finding on record at North Oaks Communities

Based on observation during the initial tour of the main kitchen with facility staff it was determined that the facility staff failed to store food items in a manner that maintains professional standards of food service safety and prepare food under sanitary conditions. The findings include: On 11/17/25 at 8AM, a tour of the kitchen with the Food and Beverage Director revealed the following: 1. Grease was layered on the tiled baseboards and on every wall edge in the kitchen. 2. The freezer and refrigerator floors with blacken areas and the area was littered with debris. 3. The handwashing sinks were blocked with trash cans. 4. The ceiling tiles were noted with areas of brown stains throughout the kitchen. 5. Tiles missing from the floor at the door entrances and noted to be filled with dirt and debride. 6. The dishwasher aide had long shoulder length hair and no hair net. 7. The freezer had ice buildup on the ceiling and on an unopen box of food. 8. The Jell-O was uncovered in the refrigerator and undated. 9. Shredded mozzarella cheese in a container covered with plastic wrap with black specks throughout and undated. 10. Chicken patties in a bag open and exposed to the air in the freezer and undated as to when it was open. 11. The dishwasher area had a pool of water coming from the dishwasher machine. 11/20/25 at 10 AM, the Administrator made aware of the kitchen findings and acknowledged the surveyor's concerns.

Based on a revisit of previous annual surveys and deficient practices identified during this survey, it was determined that the facility failed to have an effective Quality Assurance Program as evidenced by the identification of repeat deficiency. The failure to identify and develop appropriate plans of correction to correct quality deficiencies places all residents at risk.The findings include: The repeat deficiencies reviewed included area of store, preparation, distribute, and serve food in accordance with professional standards for food service safety. The repeated deficiencies were noted in 2019, 2024 and 2025 with Severity and Scope Grid listed as an F. On 11/20/25 at 10 AM, the concerns regarding repeat deficiencies and the failure of the previous plan of correction to address issues with the QA process were discussed with the Administrator, who acknowledged the surveyor's concerns. The Administrator stated that a surprise observation of the kitchen on 10/30/25, by the of the Certified Dietary Manager revealed the same repeated issue of undated, and uncovered food. The Administrated stated it was discussed in QA during the meeting on 11/16/2025. The plan is to educate the kitchen staff on food storage and labeling with the Food and Beverage Director. Cross Reference F 812

Based on medical record review and interview, the facility staff failed to assess a resident using the standardized Quarterly Review assessment tool at least once every three (3) months between comprehensive assessments (resident #18). This was evident for 1 out of 19 residents reviewed while completing the facility assessment facility task for the facility's annual survey. Findings include: The annual survey team reviewed resident #18's medical records on 11/19/25 at 12:45pm to complete the facility assessment facility task for the facility's annual survey. The medical record revealed that the resident was overdue for a quarterly assessment. The quarterly assessment was due on 10/14/2025. The annual survey team interviewed MDS Coordinator #5 on 11/20/25 at 8:45am regarding the facility's failure to complete resident #18's quarterly assessment on 10/14/2025. MDS Coordinator #5 acknowledged that the facility failed to complete the quarterly assessment timely. MDS Coordinator #5 stated that he/she started the position on 10/13/2025 and he/she was unaware that resident #18 would have an overdue quarterly assessment by 10/14/25. The surveyor reviewed resident #18's medical record on 11/20/25 at 9:30am. The resident's medical record revealed that MDS Coordinator #5 started the quarterly assessment for the resident. Surveyor interview with the Administrator and Regional Nurse #3 on 11/20/25 at 11:30am confirmed that the facility's MDS team failed to update the MDS record correctly.

Based on observations and staff interview, it was determined that the facility failed to store cold foods in a safe manner and failed to ensure staff had access to proper hand washing facilities. This practice was evident for multiple areas of the main kitchen during the initial kitchen tour and had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: During observation rounds of kitchen on 7/18/24 at 8:15 AM, the initial kitchen tour was conducted by Dietary Manager (Staff #5). During initial observation, the kitchen was noted to have a stream of clear drainage coming from the dishwashing area. Upon closer observation, a pipe from underneath the manual dishwashing station was leaking. Both handwashing stations in the main kitchen did not have working paper towel and soap dispensers. One freezer temperature was not at an appropriate temperature at 8:30 AM on 7/18/2024. The freezer next to stoves and ovens closer to the dishwashing station was at 42 degrees F. This freezer contained a 3 of bags of what appeared to be breaded foods that were soft to the touch. Upon inspection of dates on foods throughout all refrigeration and freezers, only one date was written and/or posted visible on all foods both in the refrigerator and the freezer. Frozen food boxes were stored on the floor of the freezer and there was ice build up on the back walls of the freezer. During interview with the Food and Beverage Director (Staff #8) at 10:30 AM on 7/18/24, A more in-depth tour of the kitchen was conducted. When he was asked what was being done about the leak in the dishwashing area he stated, I did not know of a leak, but I will take a look into it now. At this time both hand wash stations' paper towel and soap dispensers were still not functional. When asked where the kitchen staff are supposed to wash their hands properly if both handwashing stations were not functional, he stated that there were other sinks outside of the main kitchen employees could go to. When asked what the dates on the food in the refrigerator and freezer represented, he stated, The dates on them are the dates those foods were used and stored in the fridge. Staff #8 clarified that no foods other than some packaged refrigerator and frozen foods had use by dates on them. After surveyor intervention, Staff #8 had fixed both hand washing stations' paper towel and soap dispensers.

Based on medical record review and staff interview, it was determined that the facility failed to maintain accurate medical records on each resident. This was evident for 1 (resident #19) out of 8 residents that were reviewed during the survey. The findings include: On 07/18/24 at 9:30 AM the facility submitted a Matrix Roster to the survey team for review. The matrix roster revealed that Resident #19 was not on palliative care. Review of Resident #19 medical record on 07/19/24 at 10:15 AM revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form dated 03/27/2024. The MOLST form stated that Resident #19 was a [name of hospice provider] patient. Further review of Resident #19's record revealed that [name of hospice provider] was a hospice company that provides palliative care. During an interview on 07/19/24 at 11:00 AM the Director of Nursing (DON), Staff #3, verified the Matrix Roster that was given to the survey team was incorrect, Resident #19 was on palliative care patient.

Based on observations and staff interviews, it was determined that the facility failed to have an effective pest control plan so that the facility is free of mice. This was evident on the [NAME] ridge unit of the facility. The findings include: During observation rounds on 07/19/2024 at approximately 9:15 AM the Director of Nursing (DON) was standing outside in the facility hallway in front of room [ROOM NUMBER], a resident's room. While the DON was standing in this location, a mouse was observed running on the floor out of room [ROOM NUMBER], stopped at the DON's feet, and ran back into room [ROOM NUMBER]. During an interview on 07/19/2024 at 9:25 AM resident #2 stated that there were mice in his/her room and there have been many mice in his/her room. During an interview on 07/19/2024 at 9:28 AM staff #14 stated that a mouse pad was placed down in room [ROOM NUMBER]'s floor, and this is what the facility had been doing for the mouse problem. During an interview on 07/19/2024 at approximately 9:39 AM staff #15 stated that the facility has had mice problems for some time and the facility has switched over to a new exterminator company about a year and half ago. When asked what was being done with based on recommendations that pest control company has provided, she stated that they had been continually fixing doors and patching holes that mice could come through as they are reported. The pest control Logs were provided from weekly treatments and recommendations for this year. The pest control logs were reviewed on 7/19/24 at 9:50 AM. On the report of the visit on 6/21/24 it stated, Inspected and service throughout areas Inspected and serviced tin cats no mouse activity. Inspected and service glue boards, no mouse activity Mice are getting in door into main kitchen. Mouse tail hanging out of door unable to remove door needs to be taken down and fixed. One request for gnats at 519 Went over everything with. On the report of the visit on 6/28/24 it stated, Inspected and service throughout areas. Inspected and serviced tin cats no mouse activity. Inspected and service glue boards, no mouse activity Mice are getting in door into main kitchen. Mouse tail hanging out of door unable to remove door needs to be taken down and fixed. One request for gnats at 519 Went over everything with [staff name]. On observation rounds on 7/19/24 at 10:12 AM, this surveyor observed the loading dock double door. The bottom of the right door where both doors meet from the inside had a 4 inch by 1 inch sized opening. Outside of door there were 5 large bags of trash sitting on the floor of the loading dock. An interview was conducted on 7/19/24 at 10:15 AM with the Plant Operations Director (Staff #16) . Staff #16 was asked about the dock door opening, he stated he did not know of the opening, but will fix it as soon as possible. During an interview on 07/19/2024 at approximately 10:50 AM, the Administrator stated that there was a mouse in room [ROOM NUMBER] alive and the facility was working on removing the mouse.

Based on review of facility documentation and interviews, the facility failed to provide the required 12-hour minimum yearly in-service training for nurses' aides. This was evident in 1 out of the 5 employee records that were reviewed during the survey. The findings include the following: Review of Geriatric Nursing Assistant (GNA) #20 employee record on 07/22/2024 at 09:45 AM revealed a hire date of 06/28/2022. The GNA #20 was still employed by facility and there was no documentation that the required 12-hour minimum yearly in-service training was completed by GNA #20 for the year 2023. During an interview on 07/22/2024 at 10:15 AM, the facility's Human Resource Director #19, stated that she was unable to provide documentation that GNA #20 completed the required 12-hour minimum yearly in-service training for the year 2023.

Based on observations of the facility's kitchen and food services, it was determined that the facility failed to maintain food service equipment in a manner that ensured sanitary food service operations and failed to utilize appropriate hair restraints for employees in accordance with professional standards for food service safety. Concerns were identified during multiple observations of the facility's kitchen and food services operation. The findings include. An initial tour of the kitchen was initiated on 10/8/19 at 8:50 AM. At 09:50 AM, observation of the dish wash machine revealed that the wash temperature was not reaching a minimum of 160 degrees Fahrenheit. The Director/Executive chef was alerted, and he confirmed that the wash temperature gauge was stuck at 137 degrees Fahrenheit. The Director/Executive chef had instructed the dishwasher person (Staff #6) to hand wash all dishware in the three-compartment sink. The executive chef had demonstrated and tested the sanitation level in the three-compartment sink to be incompliance of at least 200 parts per million. Review of the dish machine temp log revealed that the dish wash temperatures were all filled out for the rest of 10/8/19. It was observed that Staff #6 had filled out the Dish Machine Temp logs for all three meals for 7 of the 8 days in (MONTH) 2019. The wash temperature was always recorded at 160 degrees Fahrenheit. Staff #6 had also filled out the three compartment sink sanitation log for all three meals for 7 of the 8 days in October. There was not any recording of Dish machine temperatures or 3-compartment sink sanitation for all three meals for 10/6/19. It was reported that a repair service company had repaired the dish washing machine by 11:30 AM on 10/8/19. A follow-up observation of the dish machine temperature at 1:30 PM on 10/8/19 revealed a wash temperature above 160 degrees Fahrenheit. The facility failed to ensure that the manufactures specifications for wash water temperature of at least 160 degrees Fahrenheit was maintained. A follow-up tour of the kitchen was conducted on 10/9/19 at 10:45 AM. The executive chef had provided a copy of the invoice for emergency services to the dish machine. The service company indicated that the wash temperature was not maintain at 160 degrees as they found curtains between the wash tank and the rinse tank were worn out and needed replacement. The service company had increased the wash temp to 180 degrees at idle to maintain 165 degrees during operation. Tours of the kitchen on 10/8, 10/9, and 10/10/19 at 11:15 AM, revealed multiple male staff with uncovered facial hair (goatees, beards, and/or mustaches). The morning cook (staff #5) was observed handling exposed foods without appropriate hair restraint/beard guard, and a dishwasher (Staff #5) handling exposed food contact surfaces of dishware. A discussion was held with the Food & Beverage Director on 10/10/19 in reference to staff with exposed facial hair. The Food & Beverage Director acknowledge that the facility has beard guards. Upon surveyor intervention staff with facial hair were observed utilizing appropriate hair restraints.

Based on observation and staff interview during the survey it was determined the facility failed to maintain a clean and comfortable environment. The findings include: An environmental tour was conducted with the Plant Operations Manager and the Director of Housekeeping on 10/11/19 at 1:32 PM and the following concerns were pointed out and discussed: The shower room had broken and cracked tile on the left shower wall that was in the second shower stall. There was also a black, orange and pink substance in the tile grout in the second shower stall on the walls and floor. There was a mound of debris in the corner on the floor behind the door. There was a soiled plastic glove on the floor in the corner of the right alcove. In room [ROOM NUMBER] the under the sink cabinet was dirty with black debris inside on the bottom of the cabinet and the front doors on the corner were missing laminate in addition to the laminate peeling off the particle board. In room [ROOM NUMBER] and #25 the topcoat of drywall was missing from around the soap dispenser. The bracket/stand for over the toilet seat was rusted. In room [ROOM NUMBER] the radiator front cover was loose. In room [ROOM NUMBER] the plastic cover for the cable box wire was not attached to the wall and was laying on the wire. The cove base outside of room [ROOM NUMBER] was pulled away from the wall approximately 5 inches. The Plant Operations Manager was asked how maintenance and housekeeping issues were reported and he stated there was a system that issues were placed in and about 40 percent were maintenance. He stated the Nursing Home Administrator (NHA) and the Director of Nursing (DON) had the ability to put issues in and if the facility staff or family/resident had an issue they could tell the nurse and the nurse could either tell the DON/NHA or they could call maintenance directly. He also stated once a month they will do rounds and touch things up. On 10/8/19 at 9:19 AM, an observation was made of room [ROOM NUMBER]. The resident's upper bed was equipped with quarter length bed rails. Areas of the rails had a rubberized covering to facilitate the resident's grip. The rail to the residents right hand side had brown smears on the rubberized area. A split approximately 4 centimeters long was observed in the rubberized covering over the rail located on the resident's left hand side. The edges and interior of the split had a dark discoloration. On 10/8/19 at 10:08 AM the surveyor observed resident room [ROOM NUMBER]. The wall behind the resident's recliner had several deep scuffs into the wall board exposing the plaster core of the wall board.

Based on a medical record review, it was determined that a physician failed to fully evaluate a resident as related to facility acquired pressure ulcers. This is evident for 1 of 1 resident (Resident #19) reviewed for pressure ulcers. The findings include: Review of Resident #19's medical record on 10/9/19 revealed this resident had acquired pressure ulcers while in the facility. A nurse's progress note written on 9/16/19 stated: .a new open skin area was noticed on right buttock. The new open area is a stage 2 decubitus which measures 2 cm (centimeters) x 1.5 cm x 0.1 cm. The note indicated that the wound was cleansed and [MEDICATION NAME] cream was applied. Additionally, the nurse's note indicated that the resident's attending physician was at the facility to see the resident. There was not any documentation from the resident's attending physician related to seeing the resident on 9/16/19. There was not a physician order [REDACTED]. There was a visitation note from the resident's attending physician dated 10/7/19. The note did not reveal that the doctor had examined and assessed the wound on the resident's buttocks. The attending physician's review of systems for skin stated, per staff buttocks doing well, and there were not any new treatment orders. The physician had failed to respond to the first notification of change in medical status on 9/16/19 related to the facility acquired pressure ulcer. The physician failed to indicate a treatment for [REDACTED].

Based on medical record review, and staff interview it was determined the facility failed to thoroughly assess a pressure ulcer consistent with professional standards of practice and promote healing to a pressure ulcer. This was evident for 1 of 1 resident (Resident #19) reviewed for pressure ulcers. The findings include: Review of Resident #19's medical record on 10/9/19 revealed that on 9/16/19 a nurse documented in a progress note .a new open skin area was noticed on right buttock. The new open area is a stage 2 decubitus which measures 2 cm (centimeters) x 1.5 cm x 0.1 cm. The note indicated that the wound was cleansed and [MEDICATION NAME] cream was applied. Additionally, the nurse's note indicated that the resident's attending physician was at the facility to see the resident. There was not any documentation from the resident's attending physician related to seeing the resident on 9/16/19. There was not a physician order [REDACTED]. A wound assessment was initiated on 9/19/19 indicating new open area with the same measurements from the nurse's note of 9/16/19. The next wound assessment was done 13 days later 10/2/19. The 10/2/19 assessment revealed the wound was larger than 9/19/19 at 3 cm x 3 cm x 0.1 cm. The resident was care planned for having impaired skin integrity that was initiated on 5/6/19. An intervention was added on 9/16/19 as skin protectant to open areas. On 9/30/19 Apply treatment to pressure ulcers as ordered was an added intervention to Resident #19's plan of care. There was a visitation note from the resident's attending physician dated 10/7/19. The note did not reveal that the doctor had examined and assessed the wound on the resident's buttocks. The attending physician's review of systems for skin stated, per staff buttocks doing well, and there were not any new treatment orders. On 10/8/19 there was a handwritten telephone order from the attending physician written as Cleanse buttocks area with soap and water, pat dry and apply [MEDICATION NAME] skin protectant cream after each incontinent care. There were not any nursing progress notes written on 10/8/19. On 10/9/19 at 11:35 AM a discussion was held with the Director of Nursing with a request to print the treatment administrative record to show that the treatment was performed as ordered. The Charge Nurse, Staff #15 was interviewed at 11:58 AM. The Charge Nurse indicated that the aide applied cream and she would look at the wound later. At 12:45 PM the Director of Nursing reported that she was unable to find any evidence/documentation that the order of 10/8/19 was transcribed to the treatment administration record and/or that the treatment was performed as ordered. A nursing progress was written at 2:07 PM on 10/9/19 stating; Sacrum is stage 1 pink and measures 3 cm x 1 cm x 0.0 without drainage. Right buttock is stage 1 pink 1 cm x 1 cm x 0.0 without drainage. Skin is intact except for some scarring discoloration on sacrum and buttocks. The next nursing progress note was written 30 minutes later at 2:37 PM on 10/9/19 stating; .The right buttock was not open again and a stage 2 (1cm x 1cm x 0.2 deep). Patient was washed and skin protectant was applied to buttock. The sacrum is healed. The electronic medical record was reviewed again on 10/15/19 at 10:47 AM. Review of the wound section did not reveal an evaluation of the wound since 10/2/19. It is important that the facility have a system in place to monitor the pressure ulcer in order to know if it is improving or if alternative treatments should be provided. At a minimum the documentation should include location, staging, size, drainage (color, odor), pain and the wound bed description.

Based on medical record review, observation and staff interview, it was determined the facility failed to provide a physician order [REDACTED]. This was evident for 1 of 1 resident (Resident #6) reviewed for accidents. The findings include: Review of Resident #6's medical record on 10/9/19 revealed (MONTH) 2019 physician's orders [REDACTED]. This order was initiated on 4/9/19. A review of Resident #6's care plan, revealed that a care area for Fall risk was initiated on 3/20/19. On 4/11/19 the following intervention was added: Place fall mats next to right side of bed while resident in bed. An interview was conducted with Resident #6 on 10/9/19 at 8:51 AM while the resident was still in bed. A mattress was observed standing on end against a wall. The resident was asked about the mattress up against the wall and s/he responded that they usually put it down at night. On 10/10/19 at 8:55 AM, Resident #6 was observed to be in bed without a fall mattress on the floor next to the bed. At 9:06 AM the Director of Nursing was notified following the surveyor back to Resident #6's room and confirmed that the fall risk mattress was not on the floor next to resident's bed.

Based on medical record review it was determined the facility failed to ensure Certified Registered Nurse Practitioner (CRNP) medical visit notes were in the resident medical record on the day the resident was seen. This was evident for 1 of 1 resident (Resident #19) reviewed for pressure ulcers. The findings include: A review of the medical record for Resident #19 on 10/9/19 revealed multiple occasions when the CRNP failed to document in the resident's medical record on the day of the visit. (A CRNP is an advanced practice nurse who performs the functions of a physician.) A CRNP note by (Staff #7) with 8/12/19 as the date of service (DOS) was shown to have been faxed to the facility on [DATE]. Another example of a late CRNP note with 8/16/19 as the DOS was shown to have been faxed to the facility on [DATE]. The last CRNP note in the resident's record on 10/9/19 had a date of service as 8/29/19 and the note was faxed to the facility on [DATE]. Copies of the late notes were obtained from the Director of Nursing as she was informed of the concern on 10/10/19.

Based on observation and resident interview it was determined that the facility staff failed to ensure that a resident had access to turn the over the bed light on and off. This was evident for 1 of 6 residents (Resident #15) interviewed during the initial phase of the survey. The findings include: An interview was conducted with Resident #15 on 10/8/19 at 9:55 AM. During the interview the over the bed light cord was observed hanging down behind the resident's bed. The resident was sitting upright in the bed and the light cord was approximately 4 feet away from the front of the resident. The resident was asked if he/she would like the ability to turn the light on and off the resident stated, Oh, I didn't realize that I could do that. The surveyor turned on the light and the resident stated, I am partially blind, but that makes it so much brighter in here. The surveyor asked the resident if he/she would like the surveyor to say something to Administration and the resident stated that he/she wanted to be able to have a longer cord. On 10/11/19 at 1:00 PM the surveyor toured the environment with the Plant Operations Manager. The surveyor showed the Plant Operations Manager the bed light cord and he said about 5 years ago they shortened the cords because one hit the prongs of a plug and it was a hazard. The resident told the Plant Operations Manager at that time that he/she wanted a longer cord. The Plant Operations Manager stated that he would get some type of string to attach to the cord so the resident would be able to turn the light on and off.

Based on review of facility documentation and interview with facility staff it was determined the facility failed to have evidence that an allegation of missing property was thoroughly investigated. This was evident for 1 of 2 residents (Resident #12) reviewed for Abuse. The findings include: A review was conducted of Facility reported incident #MD 2875 on 10/9/19 in which a family member reported that Resident #12 was missing a gold wedding band. The facility's investigative documentation included a statement from the resident's family member who felt someone must have forcefully removed the ring, review of a report from a bruise on the resident's hand from 7/8/19 and a search of the resident's room. The investigation indicated that security camera footage from 6/30/19 6:30 PM to 9:30 AM on 7/1/19 and from 7/7/19 6:30 PM to 9:30 AM on 7/8/19 was reviewed based on the time frame the resident's family member thought the ring may have gone missing. The facility was unable to reach a conclusion. Resident #12 had Private Duty Assistants (PDA's) during the day and evening however the investigation did not include statements from them or facility staff. The facility's administrator was interviewed on 10/11/19 at 11:26 AM. She was asked how she determined the time frame of video footage to review, she initially indicated a PDA had reported seeing the ring on a certain night, and she wanted to review the security video to see if it revealed anything conclusive, but it didn't. The Administrator later indicated that Resident #12's family member felt very certain the ring went missing on those dates but could not remember why they were so certain. The Administrator confirmed that the investigation documentation did not reflect this information. She also confirmed that no statements were obtained from the staff or PDA's in an attempt to determine the possible disposition of the resident's ring.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 of 15 residents (Resident #5, #15, and #6) reviewed during the survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) A review of the medical record for Resident #5 was conducted on 10/10/19 which included a review of Medication Administration Records (MAR). Review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of the MDS assessment with an assessment reference date (ARD) of 1/11/19, Section N Medications, failed to capture the use of [MEDICATION NAME] and [MEDICATION NAME] as there was 0 days used coded for anti-anxiety and opioid medications. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of the MDS assessment with an ARD of 4/10/19 failed to capture the use of [MEDICATION NAME] and [MEDICATION NAME] as evidenced by 0 days used coded in Section N, Medications for opioid, anti-anxiety and anti-psychotic. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of the MDS assessment with an ARD of 7/10/19 failed to capture the use of [MEDICATION NAME] in Section N, Medications as evidenced by a 0 days used coded for opioids. 2) Review of the medical record for Resident #15 on 10/8/19 documented that the resident had a history of [REDACTED]. Review of the MDS with an ARD of 7/25/19, Section N Medications, code 0 days used for antibiotic. The MDS should have been coded 3 for 3 days of antibiotic use during the 7 day lookback period. The findings were discussed with the MDS Coordinator on 10/10/19 at 3:00 PM. 3) An interview was conducted with resident #6 on 10/9/19 at 8:51 AM, while the resident was in bed with bilateral upper quarter bed side rails in the up position. During an interview with Resident #6 s/he acknowledged that the bed side rails assist him/her in bed mobility. A Review of the medical record for Resident #6 was conducted on 10/10/19. Review of the MDS assessment with an ARD of 7/22/19, Section P restraints, indicated that the use of bed side rails are a restraint. Further review of the medical record did not reveal any additional documentation to indicate that the use of bed side rails restrained the resident in any way. An interview was conducted with the MDS Coordinator Staff #4 on 10/10/19 at 11:39 AM. The MDS Coordinator acknowledged that resident #6 utilizes bed side rails to assist the resident in bed mobility and that the bed rails do not restrain the resident. The MDS Coordinator acknowledge the error in coding resident #6's previous quarterly MDS assessment.

Based on medical record review and staff interview it was determined that the facility staff failed to provide a resident centered dementia treatment and services plan by failing to create and implement resident centered care plans with achievable goals, measurable objectives and evaluations related to daily activities. This was evident for 1 of 2 residents (Resident #9) reviewed for dementia care. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Review of the medical record for Resident #9 on 10/11/19 documented that the resident had a BIMS (Brief Interview of Mental Status) of 8 on the most recent Minimum Data Set assessment with an assessment reference date of 8/15/19. A BIMS coded between 0 and 7 indicates severe cognitive impairment, scores between 8 and 12 indicate moderate impairment while scores above 13 shows little to no impairment. The evaluation is used to detect cognitive impairment and is a quick snapshot for that time. Further review of the medical record revealed the resident had [DIAGNOSES REDACTED]. Resident #9's care plans were reviewed and there was a care plan at risk for altered cognition with a goal, will be safe and have needs met. The interventions on the care plan were, monitor (resident name) every hour, repeat instructions as necessary, keep environmental stimuli to a minimum and maintain consistent routine as possible. The care plan did not address what specific interventions would be put in place for the resident. There was not a specific care plan to address individualized approaches to care and activities to accommodate the resident's loss of abilities. The facility failed to develop an activity care plan that would have addressed the resident's customary routines, interests, preferences and personal choices. An interview was conducted with the Activities Director on 10/11/19 at 1:00 PM and she confirmed there was no dementia care plan and wasn't aware they had to do one. The findings were discussed with the Director of Nursing on 10/11/19 at 1:26 PM.

Based on medical record review, observation and staff interview it was determined the facility failed to follow person-centered care plans. This was evident for 1 of 3 residents (Resident #5) reviewed for a skin condition and 1 of 1 resident (Resident #6) reviewed for accidents. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Review of Resident #5's medical record on 10/8/19 revealed (MONTH) 2019 physician's orders [REDACTED]. A review of Resident #5's care plan, Actual skin impaired had the intervention, skin sleeves as tolerated at all times and keep hand sleeve in place. Observation was made on 10/8/19 at 11:37 AM of Resident #5 in activities, sitting in a geriatric (geri) chair. The resident did not have geri-sleeves on. The resident was observed again on 10/8/19 at 2:37 PM in a music activity sleeping in the chair. The resident was wearing a yellow/mustard colored sweater with sleeves that were halfway up the arm, exposing the lower arms. The resident was not wearing geri-sleeves. Observation was made again on 10/9/19 at 9:30 AM of the resident sitting in the dining room. The resident was wearing a turtleneck and the sleeves were pushed up to the elbow. Observation made again on 10/9/19 at 10:45 AM while in activities and 10/9/19 at 12:50 PM while eating in the dining room. The resident was not wearing geri-sleeves. On 10/9/19 at 2:30 PM observation was made of Resident #5 lying in bed with geri-sleeves on. An interview was conducted with Geriatric Nursing Assistant (GNA) #1 at that time and the question was asked if she had just put the geri-sleeves on and she said, to be honest yes, don't tell because I don't want to get in trouble. I saw the sleeves sitting in the chair. They are new so the nurse probably just put them there. The Director of Nursing was made aware on 10/9/19 at 2:50 PM. 2) Review of Resident #6's medical record on 10/9/19 revealed (MONTH) 2019 physician's orders [REDACTED]. A review of Resident #6's care plan, Risk for Falls had the intervention, Place fall mats next to right side of bed while resident in bed An interview was conducted with Resident #6 on 10/9/19 at 8:51 AM while the resident was still in bed. A mattress was observed standing on end against a wall. The resident was asked about the mattress up against the wall and s/he responded that they usually put it down at night. The resident could not recall having any recent fall incidents. On 10/10/19 at 8:55 AM, Resident #6 was observed to be in bed without a fall mattress on the floor next to the bed. At 9:06 AM the Director of Nursing was notified following the surveyor back to Resident #6's room and confirmed that the fall risk mattress was not on the floor next to resident's bed.

Based on medical record review, and staff interview it was determined that the facility failed to show that a care plan was evaluated and revised by the interdisciplinary team after an assessment. This was evident for 1 of 1 resident (Resident #6) reviewed for accidents. The findings include. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Resident #6's medical record was reviewed on 10/9/19. A review of Resident #6's care plan, revealed that a care area for Fall risk was initiated on 3/20/19. The goal for this plan of care was written as; (name of resident) will maintain current level of mobility with no increase in the incidence of falls/inquires. The last quarterly Minimum Data Set (MDS) assessment had an assessment reference date of 7/22/19. A care plan meeting was held on 7/31/19 per a social worker note. An evaluation of the falls plan of care was not found in the medical record. On 10/10/19 at 4:57 PM an interview was held with the MDS coordinator, Staff #4 specifically asking: Where is the evaluation of the care plan related to fall? The MDS Coordinator was unable to show written documentation related to an evaluation/revision to the falls plan of care after the 7/22/19 quarterly MDS assessment.

Based on medical record review, observation and staff interview, it was determined the facility failed to render care in accordance with the resident's care plan and failed to apply an ordered treatment. This was evident for 1 of 3 residents (Resident #5) reviewed for a skin condition. The findings include: Review of Resident #5's medical record on 10/8/19 documented that the resident had frequent skin tears. A CRNP (Certified Registered Nurse Practitioner) note of 8/12/19 documented, Seen for ongoing medical follow-up. Nursing reports that pt (patient) has a skin tear to LLA (left lower arm) and is not healing well. A treatment was ordered. A review of Resident #5's care plan, Actual skin impaired had the intervention, skin sleeves as tolerated at all times and keep hand sleeve in place. The care plan evaluation that was done on 10/9/19 documented, resident had a skin tear to left lower arm in (MONTH) 2019. Area was treated with [MEDICATION NAME]. Treatment to arm was resolved and treatment was discontinued. Resident continues with Geri-sleeves. Staff applies Geri-sleeves and assist with resident's care as needed. Continue plan of care. The 7/18/19 care plan evaluation documented, staff continues to provide care as needed for resident's skin. Resident wears geri-sleeves to prevent skin tears to arms due to fragile skin. Review of Resident #5's (MONTH) 2019 physician's orders [REDACTED]. Observation was made on 10/8/19 at 11:37 AM of Resident #5 in activities, sitting in a geriatric (geri) chair. The resident did not have geri-sleeves on. The resident was observed again on 10/8/19 at 2:37 PM in a music activity sleeping in the chair. The resident was wearing a yellow/mustard colored sweater with sleeves that were halfway up the arm, exposing the lower arms. The resident was not wearing geri-sleeves. Observation was made again on 10/9/19 at 9:30 AM of the resident sitting in the dining room. The resident was wearing a turtleneck and the sleeves were pushed up to the elbow. Observation made again on 10/9/19 at 10:45 AM while in activities and 10/9/19 at 12:50 PM while eating in the dining room. The resident was not wearing geri-sleeves. Review of the Resident #5's (MONTH) 2019 Treatment Administration Record (TAR) on 10/8/19 at 2:38 PM revealed initials by the nurse which indicated the geri-sleeves were worn on 10/8/19. On 10/9/19 at 1:28 PM the nurse had signed off that the geri-sleeves were worn that day. On 10/9/19 at 2:30 PM observation was made of Resident #5 lying in bed with geri-sleeves on. An interview was conducted with Geriatric Nursing Assistant (GNA) #1 at that time and the question was asked if she had just put the geri-sleeves on and she said, to be honest yes, don't tell because I don't want to get in trouble. I saw the sleeves sitting in the chair. They are new so the nurse probably put them there. The Director of Nursing was made aware on 10/9/19 at 2:50 PM.