Every finding on record at Quaker Hill Manor

The facility reported a census of 47 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility, and to prevent the potential for food borne bacteria in one of one kitchen. Findings included: - During an initial tour of the resident kitchenette, on 12/02/25 at 09:37 AM, the following areas of concern were noted in the facility kitchen:1. The vent on the front of the ice machine had a build-up of dust and debris.2. A cart holding clean, plastic trays for serving residents' food contained food debris.3. Eight plastic containers holding cold cereal had a sticky, dusty substance on the lids.4. Two large, white, rolling plastic containers containing sugar and potatoes had a sticky, dusty substance on the lids.5. Four reach-in freezer doors had dried-on food. The handles of the reach-in freezers had a build-up of food debris and a sticky substance.6. An electric blender base had a thick, dried-on food substance.On 12/03/25 at 08:51 AM, Dietary Staff BB confirmed the above areas of concern needed to be addressed.The facility's kitchen cleaning schedule documented counters and carts would be cleaned daily, and the ice machine, refrigerators, and freezers would be cleaned weekly.

The facility reported a census of 47 residents with 12 residents sampled, including one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to one Resident (R)30, when the resident sat with her bare legs, including her upper thighs, exposed. Findings included:- R30's Electronic Medical Record (EMR) revealed a diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R30's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She had limited range of motion (ROM) on one side of her upper and lower extremities (UE/LE) and was dependent on staff for lower body dressing. The Activity of Daily Living (ADL)/Functional Abilities Care Area Assessment (CAA), dated 10/02/25, documented the resident required assistance from staff for activities of daily living (ADLs). R30's Quarterly MDS, dated [DATE], documented a BIMS score of 14, indicating intact cognition. She did not have any limitation in ROM and required substantial to maximal staff assistance with lower body dressing. R30's ADL Care Plan, revised 11/07/25, instructed staff the resident was dependent on staff for lower body dressing. R30's EMR under the Tasks tab, dated 11/03/25 through 12/01/25, revealed the resident required partial/moderate to dependent staff assistance for lower body dressing. On 12/01/25 at 10:03 AM, the resident sat in her room, with the door open, in her wheelchair. Her gown and blanket were pulled up to her waist, exposing her legs from her upper thighs to her feet. The resident was visible to any staff, visitors, or other residents in the hallway. On 12/02/25 at 09:15 AM, the resident sat in her room, with the door open, in her wheelchair. Her gown and blanket were pulled up to her waist, exposing her legs from her upper thighs to her feet. The resident was visible to any staff, visitors, or other residents in the hallway. On 12/01/25 at 10:03 AM, the resident stated she was unable to cover her legs with the blanket in her lap. On 12/03/25 at 09:40 AM, Certified Nurse Aide (CNA) N stated the resident was able to cover her legs with the blanket on her own, but at times would leave her legs uncovered. On 12/03/25 at 10:30 PM, Administrative Nurse D stated it was the expectation for staff to ensure residents were covered appropriately to ensure their dignity. The facility policy Resident Rights, implemented 01/01/25, included: The facility shall ensure all residents are treated with dignity, respect, and consideration.

The facility reported a census of 47 residents; the sample included 12 residents including two residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R)15 and R1, and/or their representative, a written notification explaining the purpose of the discharge.Findings included:-R15's Electronic Medical Record (EMR) documented a diagnosis of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). R15's admission Minimal Data Set (MDS), dated [DATE], documented the resident admitted to the facility from a short-term, acute hospital on [DATE]. He had a Brief Mental Status (BIMS) score of 15, indicating intact cognition. R15's Discharge MDS, dated [DATE], documented the resident discharged from the facility to a short-term, acute hospital on [DATE]. His BIMS was not assessed. R15's EMR lacked documentation of a written notification with the explanation of the purpose for the resident's transfer to the hospital. On 12/03/25 at 11:37 AM, Administrative Staff A stated that written notification of R15's emergency transport to the hospital had not been completed, as required. The facility policy for Emergency Transfer Notification Policy, dated 09/18, included: The resident and the resident representative shall be notified of hospital transfer in writing by the facility as soon as is practicable. - R1's Electronic Medical Record (EMR) revealed a diagnosis of lung cancer, respiratory failure, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R1's Nurse Note dated 11/20/25 at 02:16 AM documented R1was sitting on the side of the bed, wavering forward. R1's oxygen level was 79 percent (%) after breathing treatments were provided. R1 agreed to go to the hospital. The ambulance arrived and transported R1 to the hospital. R1's EMR lacked documentation of a written notification to the resident and/or her representative, which explained the reason for the transfer to the hospital. On 12/03/2025 at 10:55 AM, Social Services X stated that she was the person who went over the bed hold with the resident's representative. Social Services X said she was unaware of the regulation to notify the resident in writing and notify the ombudsman. On 12/03/2025 at 11:07 AM, Administrative Nurse D said she was unaware of the regulation to notify the resident's representative in writing of a discharge or transfer, and the facility had not been notifying the ombudsman. On 12/03/2025 at 11:07 AM, Consultant HH stated that there needed to be a written notification of transfer to the resident and/or his representative, and that usually the social service designee sent this. The facility's undated Emergency Transfer Notification Policy documented that the resident and representative will be notified of transfer in writing by the SSD as soon as is practicable.

The facility identified a census of 47 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to revise Resident (R) 1's Care Plan with the interventions to address a diagnosis of cancer or the cancerous lesions.Findings Included:- R1's Electronic Medical Record (EMR) revealed the following diagnoses of lung cancer, respiratory failure, and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing).R1's 10/09/2025 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R1 had dressing treatments. R1 had a diagnosis of cancer.R1's Care Plan dated 04/23/18 documented R1 was at risk for skin breakdown and documented that the nurse monitored skin daily and completed a monthly skin assessment. R1's Care Plan lacked documentation of cancerous skin lesions or lung cancer.R1's Physician's Orders documented an order to cleanse a wound to the thigh with Vashe (prescription wound cleanser), apply calcium alginate (highly absorbent dressing), then 4x4, cover with Xeroform (sterile non-adhering fine mesh gauze treated with a bacteriostatic agent), and apply ABD pad (large pad to absorb drainage). Wrap with ACE wrap. Change daily and as needed. Ordered 12/01/25.R1's telephone check-up on 09/03/25 with the pulmonologist (lung doctor) documented a diagnosis of squamous cell carcinoma (cancer) in R1's right lung.R1's Wound Care Plus Progress Note dated 10/23/25 documented the wound was six centimeters (cm) by 6.7cm. R1 went to an oncology appointment the previous day and was told the wound was cancerous.R1's Physician Progress Note dated 11/06/25 documented to start chemotherapy as soon as possible.R1's Physician Progress Note, dated 11/13/25, documented a port was placed. Keep the area clean and dry and watch for signs of infection. R1 was to carry a card at all times.R1's Physician Progress Note dated 11/18/25 documented metastatic squamous cell carcinoma (a type of advanced cancer where squamous cells-which are flat cells on the surface of the skin-have spread from their original location to other parts of the body) with ongoing bleeding from the left thigh, and severe anemia. Start Keytruda (an immunotherapy drug that works by blocking a protein, preventing cancer cells from hiding from the immune system, thereby empowering your body's T-cells to attack the cancer).R1's Nurses Note dated 11/29/2025 at 02:54 PM documented a dressing change to R1's left thigh with a copious amount of blood noted.On 12/01/2025 at 12:09 PM, R1 sat on her bed and stated she had cancer and she had a big cancer lesion on her left thigh. R1 reported she was going to have radiation on it.On 12/02/2025 at 8:53 AM, Licensed Nurse (LN) H stated she was going to dress the wound on R1's thigh, but she was waiting for another staff member to help due to the bleeding. During the dressing change, pressure was applied to keep the bleeding down.On 12/03/2025 at 10:52 AM, LN G stated that the MDS nurse updates the care plans.On 12/03/2025 at 11:07 AM, Administrative Nurse D stated that the wound and the cancer should have been documented in the care plan but were not documented in the care plan.The facility policy Care Plan Revisions Upon status Change, dated 01/01/25, documented the resident's care plan would be modified as needed.

The facility reported a census of 47 residents; there were 12 residents sampled, including one resident reviewed for activities of daily living (ADL). Based on observation, interview and record review, the facility failed to provide oral care for Resident (R)30, who was dependent on staff for oral hygiene.Findings included: - R30's Electronic Medical Record (EMR) revealed a diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).R30's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She required setup and clean-up assistance with oral hygiene.The Activity of Daily Living (ADL)/Functional Abilities Care Area Assessment (CAA), dated 10/02/25, documented the resident required assistance from staff for her ADLs.R30's Quarterly MDS, dated [DATE], documented a BIMS score of 14, indicating intact cognition. She required setup and clean-up assistance with oral hygiene.R30's ADL Care Plan, revised 11/07/25, instructed staff the resident was dependent on staff for oral hygiene.Review of R30's EMR under the Tasks tab, dated 11/03/25 through 12/01/25, revealed the resident required independent to dependent staff assistance with oral care.On 12/01/25 at 10:03 AM, the resident had dried-on food debris around her mouth. Her toothbrush and sink in her bathroom were dry.On 12/02/25 at 09:15 AM, the resident had dried-on food debris around her mouth. Her toothbrush and sink in her bathroom were dry.On 12/01/25 at 10:03 AM, the resident stated she was unable to brush her teeth on her own, and the staff did not assist her. She would like to have her teeth brushed every morning and before bed.On 12/02/25 at 09:17 AM, Consultant Staff GG stated the resident required staff assistance with oral hygiene.On 12/03/25 at 09:40 AM, Certified Nurse Aide (CNA) N stated the resident was able to brush her teeth on her own. CNA N confirmed she did not offer to brush the resident's teeth as part of her morning cares.On 12/03/25 at 10:30 PM, Administrative Nurse D stated it was the expectation for staff to assist residents with oral care when needed.The facility policy for Activities of Daily Living (ADL), implemented 01/01/25, included: Staff shall provide the necessary services to maintain oral hygiene for a resident who was unable to carry out ADLs independently.

The facility identified a census of 47 residents, with 12 residents sampled, including one resident reviewed for non-pressure skin issues, and one resident reviewed for constipation. Based on record review, interview and observation, the facility failed to monitor skin issues for Resident (R)30 and failed to administer as needed (PRN) medication and assess for constipation for R19.Findings included:- R30's Electronic Medical Record (EMR) revealed a diagnosis of cerebral infarction (CVA - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R30's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She was dependent on staff assistance with transfers. The Activity of Daily Living (ADL)/Functional Abilities Care Area Assessment (CAA), dated 10/02/25, documented the resident required assistance from staff for her ADLs. R30's Quarterly MDS, dated [DATE], documented a BIMS score of 14, indicating intact cognition. She required substantial/maximal staff assistance with transfers. R30's ADL Care Plan, revised 11/07/25, instructed staff the resident was dependent on staff for transfers and had a limited range of motion (ROM) on one side of her upper and lower extremities due to a history of a CVA. R30's EMR, dated 11/18/25, revealed documentation of a skin tear to the resident's left hand, measuring 1.0 X 0.1 centimeters (cm). The documentation lacked an explanation of which measurement was for the length (L) or the width (W) of the wound. The wound had minimal serosanguineous (semi-thick blood-tinged drainage) drainage. Staff were to cleanse the area with wound cleanser and apply a bordered gauze dressing. The resident reported no pain with the wound. R30's EMR, undated, revealed documentation of a skin tear to the resident's left hand, measuring 4.0 X 1.5 cm. The documentation lacked an explanation of which measurement was for the L or the W of the wound. The wound had minimal serosanguineous (semi-thick blood-tinged drainage) and serous (thin, clear) drainage. Staff were to cleanse the area with wound cleanser and apply a bordered gauze dressing. The resident reported no pain with the wound. R30's EMR lacked any further documentation of the wounds. On 12/01/25 at 10:03 AM, the resident had bandages, dated 12/01/25, on her left hand and forearm. On 12/01/25 at 10:03 AM, the resident stated she obtained skin tears to her left hand and wrist during transfers on two separate occasions. On 12/03/25 at 09:40 AM, Certified Nurse Aide (CNA) N stated the resident obtained skin tears to her left hand and wrist during transfers. On 12/02/25 at 11:09 AM, Licensed Nurse (LN) G stated that when a resident had a skin issue, staff would change the dressing, as ordered, and document the wound's appearance on a wound assessment; if the wound was worsening, the facility would notify the resident's physician. On 12/02/25 at 01:18 PM, Administrative Nurse D stated the resident's left arm was completely flaccid due to a CVA. The skin tears occurred when staff transferred the resident from her wheelchair with a full-body lift, and her arm became caught between her body and the arm of the wheelchair. Administrative Nurse D confirmed documentation lacked weekly documentation of the wound's appearance, as required. The facility policy for Skin Tears, implemented 01/01/25, included: The facility shall utilize a systematic approach for the prevention and management of skin tears, including assessment, monitoring, and modification of interventions as appropriate. - R19's Electronic Medical Records (EMR) documented diagnoses, which included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R19's 10/07/25 Significant Change Minimum Data Set (MDS) documented R19 was rarely understood and had memory problems. The MDS noted R19 was frequently incontinent of bladder, but always continent of bowels. R1 did not have a toileting program, and/or constipation. R19's Care Plan dated 05/29/24, documented R19 was at risk for constipation related to medication use and directed staff to monitor and document bowel movements every shift. If R19 had no bowel movement in three days, the nurse was to perform a bowel assessment and initiate the bowel movement protocol. R19's Physician Orders in the EMR documented an order for Fleet Oil Enema rectally every 24 hours as needed for constipation, ordered 09/13/25. Review of R19's bowel movement frequency under the Tasks in the EMR dated 11/04/25 through 12/03/25 revealed the resident exceeded three days/72 hours without a bowel movement and/or treatment from 11/21/25 at 11:57 AM through 11/29/25 at 12:15 PM (eight consecutive days) with no medication given for constipation and no assessment documented. On 12/03/25 at 11:07 AM, Administrative Nurse D said the nurse monitored the residents for bowel movements. The nurse follows the standing orders for the bowel movement protocol. If there is no bowel movement, the nurse assesses the resident. Administrative Nurse D said if the resident does not have kidney impairment, the nurse proceeds with medications, and assessments would be completed and documented. The facility's Constipation Management Policy documents that the facility will monitor bowel patterns daily and intervene promptly when abnormalities are noted. No bowel movements for 72 hours trigger an assessment and intervention per the standing orders.

The facility reported a census of 47 residents; the sample included 12 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure Resident(R) 4's call light remained in reach to prevent falls for R4. The facility further failed to ensure R45 had wheelchair pedals when staff propelled him in the wheelchair. Findings included:- R4's Electronic Medical Records (EMR) documented the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R4's 09/23/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. R4 had no falls in the previous quarter.R4's 09/23/25 Falls Care Area Assessment (CAA) documented R4 had a history of falls prior to admission, used medications that may affect his level of alertness, and had weakness. R4 had a defect with balance, gait, strength, and endurance. R4's risk factors included falls and a potential for major or minor injuries related to falls.R4's Care Plan dated 10/30/19 documented R4 was at risk for falls related to having a catheter (a tube inserted into the bladder to drain urine), weakness, and decreased safety awareness. On 12/10/23, staff applied pink tape to R4's call light for a visual cue. An intervention dated 10/30/24 directed staff to encourage R4 to use the call light for assistance.On 12/01/2025 at 09:19 AM, observation revealed R4 laid in bed. There was a floor mat on the floor by his bed. The call light was on the floor along the wall at the head of the bed. There was a sign across the room on his wardrobe that read, Call us for help [R4].On 12/01/2025 at 10:03 AM, the call light remained on the floor.On 12/02/2025 at 8:57 AM, R4 was in bed, and the call light remained on the floor.On 12/02/2025 at 11:34 AM, R4 remained in bed with his call light on the floor. Certified Medication Aide (CMA) and Certified Nurse Aide (CNA) O entered the room and encouraged R4 to get up for lunch. R4 refused to get up but agreed to be changed. CMA R and CNA O changed R4's shirt and checked his brief. They covered him up and left the room with the call light still on the floor.During an interview on 12/02/2025 at 10:41 AM, CNA O stated that R4 calls for help using the call light and sometimes yells out for help when he wants to get up; staff check on him often.During an interview on 12/03/2025 at 11:07 AM, Administrative Nurse D stated that R4 should always have his call light within reach.The facility's Fall Prevention Program, dated 01/01/25, documented under the compliance guidelines that the call light and frequently used items will be placed within reach. - R45's Electronic Medical Records (EMR) documented the following diagnoses: traumatic brain injury (TBI- an injury to the brain caused by external forces) and epilepsy (brain disorder characterized by repeated seizures).R45's 09/17/2025 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score was not assessed; R45 had good memory per staff interview. R45 had no falls in the previous quarter.R45's Care Plan documented, on 12/21/2024, R45 had an actual self-care impairment related to a recent fall with fracture that resulted in a total left hip replacement. The plan documented R45 was dependent on staff assistance with wheelchair mobility.On 12/03/2025 at 08:45 AM, R45 sat in his wheelchair in the commons area. Licensed Nurse (LN) G talked to R45 and directed him to go to his room. R45 did not attempt to self-propel his wheelchair to his room. R45 remained leaning forward in his wheelchair with his eyes closed.On 12/03/2025 at 08:48 AM, Certified Medication Aide (CMA) S pushed R45 in his wheelchair to the room with no foot pedals. CMA S reminded R45 to raise his feet. R45 was able to hold his feet slightly above the floor. His feet were lightly touching the floor at times. Staff took R45 to the bathroom, then propelled him back to the common area without foot pedals.On 12/03/2025 at 9:14 AM, R45 still sat in the wheelchair with his head hung down and eyes closed. LN G approached R45 and placed the foot pedals on his wheelchair. LN G stated she looked, and R45 was not care planned to be pushed without wheelchair pedals.On 12/03/2025 at 09:04 AM, CMA S stated she thought it was care planned for him to be assisted in the wheelchair without foot pedals, but CMA S would check the care plan.During an interview on 12/03/2025 at 11:07 AM, Administrative Nurse D stated that staff should use wheelchair pedals when they pushed a resident in a wheelchair.On 12/03/25 at 03:56 PM, Administrative Staff A stated that staff know they are expected to use wheelchair pedals whenever a staff member pushed a resident in a wheelchair.The facility's Fall Prevention Program dated 01/01/25, documented each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The facility's undated Safe Transport of Residents in Wheelchairs documented leg rests must be attached and positioned appropriately whenever staff are pushing a resident in a wheelchair.

The facility identified a census of 47 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on interview and record review, the facility failed to follow physician orders regarding blood pressure monitoring for Resident (R) 5's blood pressure medication when staff administered the medication despite R5's blood pressure being lower than the ordered parameters. Findings included:- R5's Electronic Medical Record (EMR) revealed a diagnosis of hypertension (HTN-elevated blood pressure).R5's Significant Change Minimal Data Set (MDS), dated [DATE], documented she had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She had a diagnosis of HTN.The Psychotropic Medication Use Care Area Assessment (CAA), dated 02/23/25, documented the resident took multiple medications.R5's Quarterly MDS, dated [DATE], documented she had a BIMS score of 15, indicating intact cognition. She had a diagnosis of HTN.R5's HTN Care Plan, revised 11/07/25, instructed staff the resident received hypertensive medication (medication used to lower blood pressure). Staff were to hold the medication if the resident's systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 110.R5's EMR included the following physician's order:Metoprolol (a hypertensive medication) 50 milligrams (mg), by mouth (po), twice daily (BID), for a diagnosis of HTN, hold if the SBP was less than 110, ordered 07/01/25.Review of R5's Medication Administration Record, dated 11/01/25 through 11/30/25, revealed staff administered the medication on seven occasions with the resident's SBP less than 110.On 12/03/25 at 09:47 AM, Certified Medication Aide (CMA) R confirmed the medication had been given when the resident's SBP had been out of the ordered parameters.On 12/03/25 at 10:13 AM, Administrative Nurse D stated it was the expectation for staff to hold medications when the SBP was out of parameters.The facility policy for Medication Administration, implemented 01/01/25, included: The facility shall administer medications as ordered by the physician and in accordance with professional standards of practice.

The facility reported a census of 47 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to use adequate hand hygiene when caring for residents. Findings included:- Observation on 12/03/2025 at 12:56 PM, Certified Medication Aide (CMA) S and Licensed Nurse (LN) G, entered Resident (R) 2's room and donned gloves and gowns. CMA S placed the walker in front of R2 and performed a two-person stand-pivot transfer with the walker. R2 pivoted, sat on the edge of the bed, then laid down on the bed with assistance. LN G grabbed the trash at the top of the trash can and moved the trash to the other side of the bed. LN G did not change gloves after touching the trash can. CMA S removed R2's pants, and LN G obtained a brief and wipes from the bedside stand, wearing the same soiled gloves. CMA S removed her gloves and washed her hands, then CMA S applied clean gloves. Both staff members unattached the brief from their side of R2. LN G obtained wipes and wiped the front of R2's peri area, still wearing the soiled glove, and then applied cream to R2's peri area. CMA S opened the clean brief and handed it to LN G. LN G placed the brief under R2 and removed the dirty brief. CMA S washed her hands and applied clean gloves. LN G then removed the soiled gloves and applied clean gloves without performing hand hygiene. LN G cleaned the opening and the catheter tubing, cleaning away from the body. LN G dried the area and applied petroleum jelly to the opening of the urethra (tube by which urine is carried from the bladder out of the body). They attached the brief and made R2 comfortable. Both staff washed their hands and left the room.On 12/03/2025 at 01:19 PM, LN G verified she did not wash her hands when removing her gloves, prior to putting new gloves on, and confirmed that she had not completed hand hygiene between dirty and clean areas while assisting with R2's peri care.During an interview on 12/03/2025 at 01:36 PM, Administrative Nurse D stated she expected staff to perform adequate hand hygiene, which included completing hand hygiene when removing gloves prior to applying clean gloves.The facility's undated Infection Control Policy documented the facility will follow Standard Precautions for Infection Control and Prevention, including but not limited to hand hygiene, which referred to both washing with plain or anti-microbial soap and water and use of alcohol gel (when hands are not visibly soiled, alcohol gel is the preferred method of hand hygiene). Staff would perform hand hygiene before and after contact with a resident, immediately after touching blood, body fluids, non-intact skin, mucous membranes, or contaminated items (even when gloves are worn during contact), after removing gloves, and when moving from contaminated body sites to clean body sites during resident care.

The facility reported a census of 47 residents. Based on observation, record review and interview, the facility failed to display posted staffing information which contained the required data including the actual nursing hours worked for the 47 residents who resided in the facility. Findings included:- Review of the facility's Daily Staffing Sheets, from 11/03/25 through 12/03/25, revealed the actual hours worked had not been completed on the daily staffing sheets.On 12/03/25 at 10:30 AM, Administrative Nurse D confirmed the facility had not completed the actual hours on the nurse staffing sheets, as required.The facility policy Nurse Staffing Posting Information, implemented 12/03/25, included: The Nurse Staffing Sheet will be posted daily and will contain the total number and the actual hours worked by nursing staff.

The facility reported a census of 47 residents. The sample included 12 residents. Based on interviews, record reviews and observation, the facility failed to ensure a safe, homelike environment in all areas of the facility including those used by visitors and staff and the floor in one of one kitchen. This deficient practice created a risk for impaired safety and cleanliness.Findings included:- Observed on 12/02/25 at 09:20 AM, numerous ceiling tiles in the east residential hall had flaked areas and/or cracked or broken areas. Two ceiling tiles outside R12's room were damaged, and there was a ceiling tile track that was hanging down. Several ceiling tiles outside R13's room were damaged and required replacement or repair. Also observed were cracks from the top of the resident door frame to the ceiling of R12, R37, R25, R10, R5, and R30.Observed on 12/02/25 at 09:25 AM, numerous ceiling tiles were broken, cracked, and/or stained in the facility entrance common area and the south resident hall, and there were numerous ceiling tile tracks that were damaged and/or hanging down.An initial tour of the kitchen on 12/02/25 at 09:37 AM revealed the parameter of the kitchen floor had a build-up of food debris.On 12/02/25 at 09:45 AM, Maintenance U stated he observed and monitored he ceiling tiles throughout the building frequently; if they were damaged, looked bad, or had stains, he replaced them. On 12/02/25 at 10:23 AM, Administrative Staff A stated she expected the facility to be fresh and clean, and if anything was damaged, she expected it to get addressed and a plan made to repair whatever it was. She further stated that all staff were expected to be vigilant and identify any maintenance or environmental concerns and to turn in work orders. She said that if ceiling tiles or ceiling tracks were damaged, they should be replaced.On 12/03/25 at 08:51 AM, Dietary staff BB confirmed the kitchen floor was in poor condition and said it needed to be replaced.The facility policy Safe and Homelike Environment, dated 01/01/25, documented that the facility would provide a safe, clean, comfortable, and homelike environment. The policy further documented that housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

The facility reported a census of 44 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the resident kitchenette, on 02/12/24 at 01:12 PM, the following areas of concern were noted in the resident refrigerator/freezer: 1. One box of store-bought pizzas that were undated and unlabeled. 2. An opened can of soda, half full, was undated and unlabeled. 3. One resident's half-eaten meal tray which was undated and unlabeled. 4. One bowl of mixed fruit was undated and unlabeled. 5. One bowl of a dessert was undated and unlabeled. 6. The temperature log on the refrigerator was dated December 2023. During an initial tour of the resident kitchenette, on 02/12/24 at 01:12 PM, the following areas of concern were noted: 1. The inside of the microwave had dried on food substances. 2. The inside of the sink had a build-up of soap scum and dried on food. 3. A coffee maker had dried-on coffee. 4. A 15 ounce (oz) opened bottle of flavored powdered coffee creamer was undated and unlabeled. 5. The rubber shelf liners in three of the four cabinets had a build-up of food debris and dust. 6. Two drawers contained spilled coffee grounds and food debris. During an initial tour of the main kitchen on 02/12/24 at 01:22 PM, the following areas of concern were noted: 1. An ice machine had a heavy build-up of dust and debris in the air vents and a build-up of dust on top of the ice machine. 2. A coffee machine had a thick layer of dried on coffee. 3. A microwave had dried on food debris on the front and the inside. 4. Two of six cabinet doors had a dried-on food substance. 5. Eight of 10 drawers had a dried, sticky substance on the rim with food debris on the inside of the drawers which held plastic pitcher lids, plastic eating utensils and plastic trash bags. 6. Two cabinet doors beneath the microwave and coffee maker had a build-up of food debris on the inside of the cabinet drawers. 7. Four of the four cabinet doors beneath the microwave and coffee maker had dried-on food debris and a dried-on liquid substance. 8. One of the reach-in refrigerators had two bowls of mixed fruit and one bowl of a dessert which were undated and unlabeled. 9. A plastic bowl of chopped onions were undated and unlabeled in the reach-in refrigerator. 10. A 48 oz container of salsa was undated and unlabeled in the reach-in refrigerator. 11. A container of shredded cheese was undated and unlabeled in the reach-in refrigerator. 12. The four-doored reach-in freezer had a build-up of food debris on the bottom. The front of the freezer doors had dried-on food and liquid substances. 13. A shelf underneath one worktable with boxes of plastic eating utensils, fruit and onions had a heavy build-up of food debris, dust and a sticky substance. 14. A metal shelf used to hold clean bowls, lids and other dishes had a build-up of dust and dirt. 15. One food preparation table had a rubber mat on the bottom shelf which contained a build-up of food debris. 16. A stationary can opener had a dried on sticky substance. 17. A blue, plastic container which held the inverted blender was completely covered in a dried-on sticky substance and was discolored. 18. A trash can next to the three-holed sink, had dried on food and liquid substances. 19. Two shelves above the three-holed sink, used to store clean pots and pans, had a layer of dust. 20. Twelve half cookie sheets were put away wet and had water droplets in the sheets. 21. Two toasters had a heavy build-up of crumbs on the inside and a sticky substance covering the toasters. On 02/12/24 at 01:41 PM, Dietary Staff BB stated she did not know the cookie sheets could not be put away while they were still wet. On 02/14/24 at 01:24 PM, Dietary Staff CC stated the refrigerator and microwave in the kitchenette was for resident food. The food items should be dated and labeled. The kitchen staff was responsible for cleaning the bistro area. Dietary Staff CC confirmed the areas of concern in the kitchen needed to be addressed. The facility policy for Sanitization, revised 10/2008, included: All kitchen areas and dining areas shall be kept clean. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, cracks and chipped areas that may affect their use or proper cleaning. Food preparation equipment will be allowed to air dry whenever practical. Ice machines will be cleaned. Kitchen and dining room surfaces shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The facility failed to prepare and serve food under sanitary conditions for the residents of the facility appropriately to prevent the potential for food borne bacteria.

The resident reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff. Findings included: - During the initial tour of the kitchen on 02/12/24 at 01:22 PM, the following area of concern was noted: The floor throughout the kitchen floor had areas which contained a dried, liquid, sticky substance and the parameter of the floor had a heavy build-up of dirt and grime. On 02/14/24 at 01:24 PM, Dietary Staff CC confirmed the kitchen floor parameter had a heavy build-up of dirt and grime. Dietary Staff CC stated staff were to keep the kitchen floor clean. The Daily Cleaning List revealed the kitchen floor was to be swept and mopped daily. The facility lacked a policy regarding the cleaning of kitchen floors. The facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff.

The facility reported a census of 44 residents with 14 residents selected for review which included three residents reviewed for choices. Based on observation, interview, and record review, the facility failed to ensure bathing opportunities, per the residents' preferences, for two Residents (R)30 and R36, of the three residents reviewed for choices. Findings included: - Review of Resident (R)30's Physician Order Sheet dated 02/05/24, revealed diagnoses that included chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), lymphedema (swelling caused by accumulation of fluid when the lymph system is damaged or blocked), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required partial to moderate assistance for bathing. The Activities of Daily Living (ADL)Functional/Rehabilitation Care Area Assessment (CAA), dated 08/10/23 assessed the resident at risk for decline of ADL due to exacerbation (worsening) of COPD. The Quarterly MDS dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required substantial to maximum assistance for bathing. The Care Plan reviewed 11/06/23, instructed staff the resident required wound care for the lymphedema and to include washing his legs with soap and water and applying dressings. The resident was independent with bed mobility, dressing, toileting, and personal hygiene, but required assistance with bathing. On 02/07/24, the physician instructed staff to provide lymphedema wraps to R30's right lower extremity every Wednesday. Review of the Social Service Note dated 02/06/24, revealed the resident preferred a shower two to three times per week. Review of the Shower Schedule revealed the resident was scheduled for a shower on Wednesdays and Saturdays. Review of the Shower Sheets revealed the resident received a shower on 01/17/24, 01/20/24 (twice a week) and once a week on 01/24/24, 01/31/24, 02/07/24, and 02/14/24. Interview, on 02/12/24 at 01:45 PM, with the resident, revealed he did not receive bathing opportunities as frequently as he would like. Interview, on 02/14/24 at 12:47 PM with Licensed Nurse G, revealed the resident received a shower on Wednesdays at which time staff would remove the Unna boot (special gauze bandage) and then rewrap his right lower extremity after the shower. Interview, on 02/14/24 at 01:28 PM with Certified Nurse Aide (CNA) N, revealed if the bath aide was not working, other staff working the floor should provide bathing. Interview, on 02/14/24 at 12:24 PM with CNA M, revealed she provided bathing to the residents and works five days a week on Mondays through Fridays. Interview, on 02/15/24 at 10:30 AM with Administrative Nurse D, revealed the resident should receive bathing opportunities as per his preference as staff may wrap his lower extremities with a waterproof material during the shower. The facility Bathing Policy dated 01/01/20, instructed staff to provide bathing and grooming based on individual resident preferences. The facility failed to provide bathing opportunities to this resident two to three times a week as per his preference to promote wellbeing. - Review of Resident (R) 36's Physician Order Sheet dated 02/05/24, revealed diagnoses included multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord) and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive functioning. The Activities of Daily Living (ADL) Functional/Rehabilitation Care Area Assessment (CAA), dated 06/22/23, assessed the resident with impairment to perform ADL's due to MS and required staff assistance. The Quarterly MDS, dated [DATE], revealed the resident required substantial to maximum assistance with bathing. The Care Plan, reviewed 11/12/23, instructed staff to provide a shower two to three times per week. The Social Service Note dated 11/22/23, revealed the resident preferred a shower two to three times per week. Review of the Bathing Sheets revealed the resident received a bathing opportunity on 01/15/24 and 01/20/24 (twice a week), 01/29/24, 02/02/24 (twice a week), 02/05/24, 02/08/24 listed the resident as out of the facility) and on 02/12/24 (seven days later). Interview, on 02/12/24 at 02:00 PM the resident revealed he preferred to have more frequent bathing opportunities, but often went out of the facility for appointments and outings and missed bathing. Interview, on 02/14/24 at 01:28 PM with Certified Nurse Aide (CNA) N, revealed if the bath aide was not working, other staff working the floor should provide bathing. Interview, on 02/14/24 at 12:24 PM with CNA M, revealed she worked to provide bathing opportunities five days a week on Mondays through Fridays and would make up a missed bath the following day. Interview, on 02/15/24 at 10:30 AM, with Administrative Nurse D, revealed the resident should receive bathing opportunities as per his preference as staff. Administrative Nurse D stated the resident frequently went on outings, and this may contribute to his lack of showers, but she would expect staff to provide opportunities upon his return. The facility Bathing Policy dated 01/01/20, instructed staff to provide bathing and grooming based on individual resident preferences. The facility failed to provide bathing opportunities to this resident two to three times a week as per his preference to promote wellbeing.

The facility reported a census of 44 residents with 14 residents selected for review. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to include one Resident (R)26's use of Estrace (a female hormone) for inappropriate sexual behaviors. Findings included: - Review of Resident (R)26's Physician Order Sheet, dated 02/05/24, revealed diagnoses included hemiplegia/hemiparesis (weakness and paralysis on one side of the body),cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (condition with disordered or absent language function), and major depressive disorder (major mood disorder which causes persistent feelings of sadness), The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The resident had no behaviors. The Psychotropic Drug Use Care Area Assessment (CAA), dated 10/19/23, assessed the resident used psychotropic (medications to alter mood or thought) medications daily. The resident received Celexa (an antidepressant) for major depressive disorder. The Care Plan reviewed 01/23/24, instructed staff the resident received Celexa and Trazodone for depression. The resident understood and followed tasks and required staff assistance of one for activities of daily living. The care plan indicated the resident (male) received Estrace (a female hormone with a black box warning of increased risk of endometrial (lining of the uterus) cancer. On 11/12/22, the physician instructed staff to administer Estrace (a female hormone) 0.5 milligrams daily. Review of the Progress Notes dated 09/13/22, revealed the resident received treatment at a behavioral health facility for inappropriate sexual behavior. The practitioner added Estrace to his medication regime for inappropriate sexual behavior on 09/13/22. Observation, on 02/13/24 at 09:10 AM, revealed the resident participating in therapy. Interview on 02/14/24 at 11:40 AM, with Administrative Nurse F, confirmed the care plan included the black box warning for female use of Estrace and did not indicate why R 26 (male) received this medication. Administrative Nurse F stated the diagnoses populated from the electronic record system for hormone replacement. Interview, on 02/14/24 at 03:30 PM, with Administrative Nurse D, confirmed the lack of appropriate diagnosis for use of Estrace for R26 and lack of care plan for inappropriate sexual behavior for this resident although he did not display the behavior since admission to the facility on [DATE]. The facility policy Resident Centered Care Plan Process revised 11/20/17, instructed implement an individualized interdisciplinary plan of care appropriate to their needs, strengths, and limitations. The facility failed to develop a comprehensive care plan to include the resident's use of Estrace for inappropriate behaviors to provide interventions for this resident's potential behaviors.

The facility reported a census of 44 residents with 14 residents sampled, including two residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide oral care for one dependent Resident (R)35. Findings included: - Review of Resident (R)35's electronic medical record (EMR) revealed a diagnosis of COVID (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. She was dependent on staff for oral hygiene. The Activities of Daily Living (ADL)/Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 02/05/24, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 14. She was dependent on staff for oral hygiene. The ADL care plan, revised 01/16/24, instructed staff the resident was dependent on staff for oral hygiene. Review of the resident's EMR from 01/16/24 through 02/13/24, revealed the resident was mostly dependent on staff for oral hygiene. On 02/13/24 at 10:00 AM, Licensed Nurse (LN) I entered R35's room to provide cares. The resident had a build-up of a white substance on her lips and a build-up of a food on her teeth. LN I was unable to find any oral care supplies in the resident's room. LN I left the resident's room and returned with oral care supplies, LN I completed oral care using an oral swab. On 02/14/24 at 08:17 AM, the resident had a dried substance on her lips and her teeth were covered with a whitish substance. The resident had not yet had breakfast. On 02/14/24 at 11:49 AM, Certified Nurse Aide (CNA) P entered the resident's room to answer the call light. The resident continued to have dried food on her lips and a covering of food on her teeth. On 02/13/24 at 10:14 AM, CNA Q stated staff were to do oral care with the resident when she woke up in the morning and again after lunch. CNA Q confirmed he had not provided oral care to the resident that morning. On 02/13/24 at 10:49 AM, CNA P stated oral care should be done every time any cares are done with the resident. CNA P confirmed the resident's teeth had a layer of food/debris build-up on them. On 02/14/24 at 08:03 AM, LN I confirmed the resident's teeth were heavily soiled with food debris. On 02/15/24 at 08:58 AM, Administrative Nurse D stated it was the expectation for staff to complete oral care every morning and evening. The facility's policy for Oral Care, reviewed 01/01/24, included: It was the practice of the facility to provide oral care to residents in order to prevent and control plaque-associated oral diseases. The facility failed to provide adequate oral care for this dependent resident.

The facility reported a census of 44 residents with 14 residents selected for review which included five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to clarify the diagnoses for a medication for one Resident (R)26 of the five residents reviewed for medications. Findings included: - Review of Resident (R)26's Physician Order Sheet, dated 02/05/24, revealed diagnoses included hemiplegia/hemiparesis (weakness and paralysis on one side of the body), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (condition with disordered or absent language function), and major depressive disorder (major mood disorder which causes persistent feelings of sadness). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The resident had no behaviors. The Psychotropic Drug Use Care Area Assessment (CAA), dated 10/19/23, assessed the resident used psychotropic (medications to alter mood or thought) medications daily. The resident received Celexa (an antidepressant) for major depressive disorder. The Care Plan reviewed 01/23/24, instructed staff the resident received Celexa and Trazodone for depression. The resident understood and followed tasks and required staff assistance of one for activities of daily living. The care plan indicated the resident (male) received Estrace (a female hormone with a black box warning of increased risk of endometrial (lining of the uterus) cancer. On 11/12/22, the physician instructed staff to administer Estrace (a female hormone) 0.5 milligrams daily. Review of the Progress Notes dated 09/13/22, revealed the resident received treatment at a behavioral health facility for inappropriate sexual behavior. The practitioner added Estrace to his medication regime for inappropriate sexual behavior on 09/13/22. Interview on 02/14/24 at 11:40 AM, with Administrative Nurse F, confirmed the care plan included the black box warning for female use of Estrace and did not indicate why R 26 (male) received this medication. Administrative Nurse F stated the diagnoses populated from the electronic record system for hormone replacement. Interview, on 02/14/24 at 03:30 PM, with Administrative Nurse D, confirmed the lack of appropriate diagnosis for use of Estrace for R26 and lack of care plan for inappropriate sexual behavior for this resident although he did not display the behavior since admission to the facility on [DATE]. The facility policy Medication Orders revised February 2023 instructed staff to include the diagnosis or indication for use of medication. The facility failed to identify the diagnoses for this resident's use of Estrace and failed to develop a comprehensive care plan to provide interventions for this resident's potential behaviors.

The facility reported a census of 37 residents with 13 selected for review, including two residents reviewed for self-determination/choices. Based on observation, record review, and interview, the facility failed to honor one of the two residents bathing preferences, Resident (R)17, who requested baths on Saturdays so she was ready for church on Sundays. Findings included: - The electronic medical record (EMR), for Resident (R)17 included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], assessed R17 with clear speech and able to make her needs known. The Brief Interview of Mental Status (BIMS) score was 14, indicating she was cognitively intact. She required physical help in part of bathing activity with assistance of two staff. It was very important for her to participate in religious activities and choose what type of bathing she wanted to receive. The Activities of Daily Living [ADL] Care Area Assessment (CAA), dated 04/18/22, revealed R17 had an alteration in her ADL function related to recent surgery and health decline. The Care Plan, dated 04/12/22, revealed R17 had difficulty with bathing/showering and required assistance of one staff. Staff needed to encourage her to bathe at least weekly as her family reported she would not bathe as often as she should. The care plan lacked her preference for bathing. Review of the EMR for bathing preferences lacked R17's preference and the frequency as needed. The Skin Communication Form revealed the staff provided bathing to the resident on the following Saturdays: 05/28/22, 06/04/22, and 06/11/22. Bathing did not occur on 05/14/22 and 05/21/22. R17 missed two of six Saturday's reviewed for bathing. On 06/13/21 at 01:25 PM, R17 stated sometimes she has problems getting a shower on Saturdays. She had to call her family to call the facility because the staff would not listen to her. R17 stated she liked her shower on Saturday so that on Sunday all she had to do was to get dressed and put on her makeup so she would be ready for church that morning when her family came to get her. On 06/15/22 at 09:51 AM, Certified Nurse Aide (CNA) R stated there was a list of what baths are scheduled on what days. CNA R stated that R17 wanted her baths on Saturdays, and she was not typically on duty on Saturdays to assist with bathing. CNA M was at the facility on Saturdays to do her bathing. The EMR will have the residents' preferences for bathing and the staff filled out a skin sheet when the bathing was done. On 06/16/22 at 11:02 AM, an unidentified family member stated he has had to call the facility for the resident to get her shower done. He further explained that the resident wanted one done on Saturdays and at 09:15 AM on Sundays the family picks her up to take her to church. The family member stated he has called twice in the last month to request her shower to get done or have been in to visit and had to ask the staff to please be sure bathing gets done that day. I ask the staff that if she refused a shower to call me and I have not received a call to let me know she ever refused. On 06/16/22 at 11:17 AM, Licensed Nurse (LN) G stated that bathing preference was determined upon admission and placed on the care plan and the bath aide notified of the preference, then the bath aide will ask them what days they prefer bathing. The preference is put into the EMR and would alert the staff to the days of preferred bathing and would be on the care plan. R17 prefers a bath twice a week with definitely one being on Saturday because she goes to church on Sunday. There were times she has refused a shower and I notify the nephew and he will sometimes call her and reference her last shower and then she will take one after that. LN G confirmed the EMR and the care plan lacked R17's bathing preferences. On 06/16/22 at 11:28 AM, CNA M stated she works on Saturday's, usually works the floor and will give baths if CNA R was off. There was a list of everyone and their bath day and when bathed, documentation would be done on the skin assessment communication sheet and put in the EMR. R17 preferred to bathe on Saturdays always. If unable to assist her with bathing on the day shift then the evening shift would do it. CNA M stated her family was in several Saturday's ago around shift change at 02:00 PM and asked about her bathing and one of the staff said they would give her a shower. On 06/16/22 at 11:36 AM, Administrative Nurse D stated the EMR should have a resident's bathing preference and there is a schedule for bathing. The bathing preference should also be on the care plan. Generally, there is a bath aide here on Saturday's. R17 can be difficult to get to bathe, was not aware of her wanting one on Saturday, and did not know she went out on Sunday's. The facility policy Bathing Policy, dated 01/01/20, revealed it was the policy of the facility to provide bathing and grooming based on individual resident preference. The resident or their responsible party will be interviewed upon admission to the facility regarding bathing preferences. Bathing preferences will include time of day, type of bathing, frequency of bathing, and preference regarding shaving/facial hair. Preferences gleaned from this interview will be reflected on the comprehensive care plan. Preferences will be reviewed quarterly and as needed and updated accordingly. The facility failed to provide bathing per the resident's preference/choices on Saturdays for two of six opportunities.

The facility reported a census of 37 residents with 13 selected for review. Based on observation, record review, and interview, the facility failed to review and revise the care plan for two sampled residents, Resident (R)17 with bathing preferences/choices and R21 with interventions post falls to prevent further fall occurrences. Findings included: - The Admission Minimum Data Set (MDS), dated [DATE], assessed R17 with clear speech and able to make her needs known. The Brief Interview of Mental Status (BIMS) score was 14, indicating she was cognitively intact. She required physical help in part of bathing activity with assistance of two staff. It was very important for her to participate in religious activities and choose what type of bathing she wanted to receive. The Care Plan, dated 04/12/22, revealed R17 had difficulty with bathing/showering and required assistance of one staff. Staff needed to encourage her to bathe at least weekly as her family reported she would not bathe as often as she should. The care plan lacked her preference for bathing related to the choice of Saturdays so she would be ready for church sooner on Sundays. Review of the EMR for bathing preferences lacked R17's preference and the frequency as needed. The Skin Communication Form revealed the staff provided bathing to the resident on the following Saturdays: 05/28/22, 06/04/22, and 06/11/22. Bathing did not occur on 05/14/22 and 05/21/22. R17 missed two of six Saturday's reviewed for bathing. On 06/13/21 at 01:25 PM, R17 stated sometimes she has problems getting a shower on Saturdays. She had to call her family to call the facility because the staff would not listen to her. R17 stated she liked her shower on Saturday so that on Sunday all she had to do was to get dressed and put on her makeup so she would be ready for church that morning when her family came to get her. On 06/15/22 at 09:51 AM, Certified Nurse Aide (CNA) R stated there was a list of what baths are scheduled on what days. CNA R stated that R17 wanted her baths on Saturdays, and she was not typically on duty on Saturdays to assist with bathing. CNA M was at the facility on Saturdays to do her bathing. The EMR will have the residents' preferences for bathing and the staff filled out a skin sheet when the bathing was done. On 06/16/22 at 11:02 AM, an unidentified family member stated he has had to call the facility for the resident to get her shower done. He further explained that the resident wanted one done on Saturdays and at 09:15 AM on Sundays the family picks her up to take her to church. The family member stated he has called twice in the last month to request her shower to get done or have been in to visit and had to ask the staff to please be sure bathing gets done that day. I ask the staff that if she refused a shower to call me and I have not received a call to let me know she ever refused. On 06/16/22 at 11:17 AM, Licensed Nurse (LN) G stated that bathing preference was determined upon admission and placed on the care plan and the bath aide notified of the preference, then the bath aide will ask them what days they prefer bathing. The preference is put into the EMR and would alert the staff to the days of preferred bathing and would be on the care plan. R17 prefers a bath twice a week with definitely one being on Saturday because she goes to church on Sunday. There were times she has refused a shower and I notify the nephew and he will sometimes call her and reference her last shower and then she will take one after that. LN G confirmed the EMR and the care plan lacked R17's bathing preferences. On 06/16/22 at 11:28 AM, CNA M stated she works on Saturday's, usually works the floor and will give baths if CNA R was off. There was a list of everyone and their bath day and when bathed, documentation would be done on the skin assessment communication sheet and put in the EMR. R17 preferred to bathe on Saturdays always. If unable to assist her with bathing on the day shift then the evening shift would do it. CNA M stated her family was in several Saturday's ago around shift change at 02:00 PM and asked about her bathing and one of the staff said they would give her a shower. On 06/16/22 at 11:36 AM, Administrative Nurse D stated the EMR should have a resident's bathing preference and there is a schedule for bathing. The bathing preference should also be on the care plan. Generally, there is a bath aide here on Saturday's. R17 can be difficult to get to bathe, was not aware of her wanting one on Saturday, and did not know she went out on Sunday's. The facility policy Bathing Policy, dated 01/01/20, revealed it was the policy of the facility to provide bathing and grooming based on individual resident preference. The resident or their responsible party will be interviewed upon admission to the facility regarding bathing preferences. Bathing preferences will include time of day, type of bathing, frequency of bathing, and preference regarding shaving/facial hair. Preferences gleaned from this interview will be reflected on the comprehensive care plan. Preferences will be reviewed quarterly and as needed and updated accordingly. The facility failed to review and revise this resident's care plan to include her personal choices on when she wanted her baths related to her church outings on Sundays. - The electronic medical record (EMR), for Resident (R)21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS), dated [DATE], assessed R21 with a Brief Interview of Mental Status (BIMS) score of ten, indicating moderate cognitive impairment. She required extensive assistance of two staff for transfers, did not ambulate, had range of motion impairment to one side of her upper extremities, and used a wheelchair for locomotion. R21 had a fall in the past month prior to admission and had a fracture related fall in the past six months prior to admission. She had not had any falls since admission to the facility. The Significant Change MDS, dated [DATE], assessed R21 with a BIMS score of eight, indicating moderate cognitive impairment. She had no changes to her transfer or ambulation status and continued to use a wheelchair for mobility. She had an impairment of her range of motion to one side of her lower extremities and no impairment to her upper extremities. R21 had not had any falls since reentry to the facility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/03/21, revealed R21 had problems with both short and long term memory recall. The Activities of Daily Living [ADL] CAA. Dated 08/03/21, revealed R21 required extensive assist with ADL's and readmitted to the facility with a fracture to her right femur. She needed two staff to assist her with transfers, was not ambulating, and used a wheelchair for mobility. The Falls CAA, dated 08/03/21, revealed R21 was at risk for falls due to weakness and medication side effects. She required extensive assist of two staff for transfers and used a wheelchair for mobility needs. R21 sustained a femur fracture following a fall and required reminders not to get herself up. The Quarterly MDS, dated [DATE], assessed R21 with a BIMS score of seven, indicating severe cognitive impairment. There were no changes to her transfers, ambulation status, and method of mobility. She had no range of motion impairment to her upper for lower extremities and did not have any falls. The Care Plan, dated 05/05/21 revealed R21 was at risk for falls due to weakness and required extensive assistance from staff with transfers and ambulation. Staff were to keep frequently used items within reach and keep pathways free of clutter. The wheelchair was her primary mode of locomotion. The Baseline Care Plan, dated 07/22/21, revealed R21 was at risk for falls/had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She required assistance of two for transfers, did not ambulate, and was dependent on staff for locomotion. The Care Plan, dated 05/05/22, revealed R21 required extensive assistance of two staff members for transfers and continued to have a risk for falling. Staff were to assist with transfers, keep frequently used items within reach and keep pathways clear and free of clutter. On 07/17/21 additional intervention added for pink tape to be on her call light as a visual cue to use her call light. Additionally, the care plan included R21 had difficulty remembering and would become easily confused related to her long-term memory loss. The Progress Note, dated 07/12/21 at 02:44 AM, revealed R21 fell at 07:43 PM, and stated she was trying to get up and slid off the side of the bed. The Post Fall Evaluation, dated 07/12/21 lacked a post fall intervention to prevent further falls. The Progress Note, dated 07/15/21 at 12:06 AM, revealed R21 had a fall on the previous shift at approximately 03:30 PM. The staff placed R21 on every 30-minute visual checks at this time as an intervention to attempt to prevent fall risk. The staff failed to implement an immediate intervention post fall to prevent further falls. The Witness Statement from Certified Nurse Aide (CNA) P, dated 07/14/21, revealed R21 stated she was trying to get out of bed and the Stupid wheelchair moved. The Witness Statement from CNA Q, dated 07/14/21, revealed R21 was sitting against the wall on her bottom with the wheelchair next to her unlocked. The facility failed to put an appropriate intervention in place to keep the wheelchair from moving when the resident attempted to transfer herself. The Progress Note, dated 07/19/21 at 07:13 AM, revealed at approximately 04:10 AM, a scream was heard down the hall. R21 was in her room located between the beds by the counter with her wheelchair behind her screaming in pain. R21 complained of right leg and hip pain and had shortening of the leg at that time. The facility received an order to x-ray the right hip, then to send R21 to the emergency room after results received. The Witness Statement from CNA LL, dated 07/19/21, revealed she assisted R21 into dry pajamas and a clean brief a hour and a half before the fall. CNA LL left the wheelchair under the counter away from her so she would not get into it and be tempted to take a walk. She had clipped her call light to her shirt, but it was on the other bed when she arrived to the room. The Interdisciplinary Team [IDT] Review/Investigation for the fall on 07/19/21 included R21 stated she unlocked her wheelchair to take a walk and it slipped away from her and she fell . The IDT recommendation included a pink strip added to the call light to remind her to call out for assistance with transfers. The intervention was a repeat intervention from a fall R21 had on 06/09/21. The EMR revealed R21 had a right femur fracture that had been surgically repaired and returned to the facility on [DATE]. On 06/13/21 at 04:41 PM, a family member reported that R21 had fell at home and has fallen at the facility and broke her hip once, and the thought the first two times she fell the brakes were not set on the wheelchair. On 06/14/22 at 12:34 PM, CNA N and CNA O transferred R21 from her wheelchair to her bed. The call light lacked pink tape on it and the floor by the bed lacked the planned non-skid strips. On 06/14/22 at 12:47 PM, CNA N stated she had not seen any pink tape on her call light and that R21 has never turned her call light on when she has been on duty. On 06/16/22 at 04:10 PM, Administrative Staff A stated R21 had moved from another room and that her call light now had the pink tape on it. On 06/20/22 at 02:32 PM, Administrative Staff A stated a new intervention was not implemented following the fall on 07/11/21. She had thought non-skid strips by the bed was, but that was the intervention implemented for the resident's fall on 07/05/22. She would expect the staff to come up with a new intervention after each fall and update the care plan. When R21 returned from the hospital on 07/22/21, a low bed was put in place. The facility policy Accident/Incident Committee dated 11/20/20, revealed the purpose of the policy was to review post incident documentation to ensure that adequate interventions have been put into place to reduce the risk of future occurrences, including falls. A meeting would be held the morning after the incident occurred or within a reasonable time frame with the Administrator, Director of Nursing, Assistant Director of Nursing/Safety Nurse, and any other pertinent department managers, therapy personnel, or frontline staff. The meeting will include discussion, review and/or revision of the Post-Fall Assessment to ensure completion and review the care plan to ensure immediate interventions were put into place after the incident. The facility policy Resident Centered Care Plan Process, dated 03/28/18, revealed it was the policy of the facility to provide individualized, interdisciplinary plan of care for all residents that was appropriate to their needs, strengths, limitations, and goals based on initial, recurrent and continual needs. At 90-day intervals, or more frequently based on response to the resident's condition and request of the resident, the interdisciplinary care team will revise the plan for care, treatment, and services. The facility failed to review and revise the care plan for R21 with interventions implemented post falls to prevent further fall occurrences.

The facility reported a census of 37 residents with 13 selected for review including three residents reviewed for accidents. Based on observation, interview, and record review the facility failed to follow planned fall interventions and implement a new and/or appropriate intervention for one of the two residents, Resident (R)21, to prevent occurrence of additional falls for this resident with multiple falls. Findings included: - The electronic medical record (EMR), for Resident (R)21, included diagnoses of aftercare of fracture of right femur (thigh bone), fracture of left humerus (bone of the upper arm), and dementia (progressive mental disorder characterized by failing memory, confusion). She admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS), dated [DATE], assessed R21 with a Brief Interview of Mental Status (BIMS) score of ten, indicating moderate cognitive impairment. She required extensive assistance of two staff for transfers, did not ambulate, had range of motion impairment to one side of her upper extremities, and used a wheelchair for locomotion. R21 had a fall in the past month prior to admission and had a fracture related fall in the past six months prior to admission. She had not had any falls since admission to the facility. The Significant Change MDS, dated [DATE], assessed R21 with a BIMS score of eight, indicating moderate cognitive impairment. She had no changes to her transfer or ambulation status and continued to use a wheelchair for mobility. She had an impairment of her range of motion to one side of her lower extremities and no impairment to her upper extremities. R21 had not had any falls since reentry to the facility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/03/21, revealed R21 had problems with both short and long term memory recall. The Activities of Daily Living [ADL] CAA. Dated 08/03/21, revealed R21 required extensive assist with ADL's and readmitted to the facility with a fracture to her right femur. She needed two staff to assist her with transfers, was not ambulating, and used a wheelchair for mobility. The Falls CAA, dated 08/03/21, revealed R21 was at risk for falls due to weakness and medication side effects. She required extensive assist of two staff for transfers and used a wheelchair for mobility needs. R21 sustained a femur fracture following a fall and required reminders not to get herself up. The Quarterly MDS, dated [DATE], assessed R21 with a BIMS score of seven, indicating severe cognitive impairment. There were no changes to her transfers, ambulation status, and method of mobility. She had no range of motion impairment to her upper for lower extremities and did not have any falls. The Care Plan, dated 05/05/21 revealed R21 was at risk for falls due to weakness and required extensive assistance from staff with transfers and ambulation. Staff were to keep frequently used items within reach and keep pathways free of clutter. The wheelchair was her primary mode of locomotion. The Baseline Care Plan, dated 07/22/21, revealed R21 was at risk for falls/had a history of falls. Her bed was against the wall, call light with pink tape, non-skid socks, and non-skid strips. She required assistance of two for transfers, did not ambulate, and was dependent on staff for locomotion. The Care Plan, dated 05/05/22, revealed R21 required extensive assistance of two staff members for transfers and continued to have a risk for falling. Staff were to assist with transfers, keep frequently used items within reach and keep pathways clear and free of clutter. On 07/17/21 additional intervention added for pink tape to be on her call light as a visual cue to use her call light. Additionally, the care plan included R21 had difficulty remembering and would become easily confused related to her long-term memory loss. The Progress Note, dated 07/12/21 at 02:44 AM, revealed R21 fell at 07:43 PM, and stated she was trying to get up and slid off the side of the bed. The Post Fall Evaluation, dated 07/12/21 lacked a post fall intervention to prevent further falls. The Progress Note, dated 07/15/21 at 12:06 AM, revealed R21 had a fall on the previous shift at approximately 03:30 PM. The staff placed R21 on every 30-minute visual checks at this time as an intervention to attempt to prevent fall risk. The staff failed to implement an immediate intervention post fall to prevent further falls. The Witness Statement from Certified Nurse Aide (CNA) P, dated 07/14/21, revealed R21 stated she was trying to get out of bed and the Stupid wheelchair moved. The Witness Statement from CNA Q, dated 07/14/21, revealed R21 was sitting against the wall on her bottom with the wheelchair next to her unlocked. The facility failed to put an appropriate intervention in place to keep the wheelchair from moving when the resident attempted to transfer herself. The Progress Note, dated 07/19/21 at 07:13 AM, revealed at approximately 04:10 AM, a scream was heard down the hall. R21 was in her room located between the beds by the counter with her wheelchair behind her screaming in pain. R21 complained of right leg and hip pain and had shortening of the leg at that time. The facility received an order to x-ray the right hip, then to send R21 to the emergency room after results received. The Witness Statement from CNA LL, dated 07/19/21, revealed she assisted R21 into dry pajamas and a clean brief a hour and a half before the fall. CNA LL left the wheelchair under the counter away from her so she would not get into it and be tempted to take a walk. She had clipped her call light to her shirt, but it was on the other bed when she arrived to the room. The Interdisciplinary Team [IDT] Review/Investigation for the fall on 07/19/21 included R21 stated she unlocked her wheelchair to take a walk and it slipped away from her and she fell . The IDT recommendation included a pink strip added to the call light to remind her to call out for assistance with transfers. The intervention was a repeat intervention from a fall R21 had on 06/09/21. The EMR revealed R21 had a right femur fracture that had been surgically repaired and returned to the facility on [DATE]. On 06/13/21 at 04:41 PM, a family member reported that R21 had fell at home and has fallen at the facility and broke her hip once, and the thought the first two times she fell the brakes were not set on the wheelchair. On 06/14/22 at 12:34 PM, CNA N and CNA O transferred R21 from her wheelchair to her bed. The call light lacked pink tape on it and the floor by the bed lacked the planned non-skid strips. On 06/14/22 at 12:47 PM, CNA N stated she had not seen any pink tape on her call light and that R21 has never turned her call light on when she has been on duty. On 06/16/22 at 04:10 PM, Administrative Staff A stated R21 had moved from another room and that her call light now had the pink tape on it. On 06/20/22 at 02:32 PM, Administrative Staff A stated a new intervention was not implemented following the fall on 07/11/21. She had thought non-skid strips by the bed was, but that was the intervention implemented for the resident's fall on 07/05/22. She would expect the staff to come up with a new intervention after each fall and update the care plan. When R21 returned from the hospital on 07/22/21, a low bed was put in place. The facility policy Accident/Incident Committee dated 11/20/20, revealed the purpose of the policy was to review post incident documentation to ensure that adequate interventions have been put into place to reduce the risk of future occurrences, including falls. A meeting would be held the morning after the incident occurred or within a reasonable time frame with the Administrator, Director of Nursing, Assistant Director of Nursing/Safety Nurse, and any other pertinent department managers, therapy personnel, or frontline staff. The meeting will include discussion, review and/or revision of the Post-Fall Assessment to ensure completion and review the care plan to ensure immediate interventions were put into place after the incident. The facility failed to follow planned fall interventions and failed to implement a new and/or appropriate intervention for the resident, to prevent reoccurrence of additional falls for this resident with multiple falls.

The facility reported a census of 47 residents. The sample of 15 included 6 reviewed for nutrition. Based on observation, record review, and interview, the facility failed to develop and implement timely interventions to prevent weight loss for 1 (#16's) of the 6 residents sampled for nutrition. Resident #16 lost, from 1/21/19 through 2/20/19, 9 pounds or 6.52% weight loss in 29 days, with a total weight loss of 17 pounds/12.3% in less than 3 months, from 1/21/19 (138 pounds) to 4/3/19 (121 pounds). Findings included: - Resident #16's, signed physician orders, dated 3/5/19, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 1/28/19, revealed the resident had a BIMS (brief interview for mental status) score of 8, indicating moderately impaired cognition. The resident had a mood score of 4, indicating minimal depression. The resident required extensive staff assistance for transfers, locomotion, and eating. The resident required a wheelchair for mobility. The resident without swallowing issues, weighed 138 pounds, and the resident with obvious or likely cavity or broken natural teeth. The CAA (care area assessment), dated 1/29/19, for nutrition advised the resident weighed 138 pounds and without any weight loss. The 30-day MDS, dated [DATE], revealed the resident had a BIMS score of 7, indicating severely impaired cognition. The resident weighed 129 pounds (6.52%) with weight loss, however was not on a physician-prescribed weight-loss regimen. The 48 hours interim care plan, dated 1/22/19, lacked documentation for nutrition. The resident with dementia. The resident did not require assistance with eating. The resident was able to easily communicate with the staff. The care plan for nutrition, initiated on 1/29/19, advised the resident would maintain adequate nutritional status by maintaining his/her weight through the next review date. The interventions identified the resident would receive a regular diet, with regular texture, and regular liquids. The RD (registered dietician) was to evaluate and make diet change recommendations PRN (as needed). The physician ordered, on 1/22/19, the resident to receive a regular diet. The resident's electronic medical record (EMR), documented the resident weighed on admission (1/21/19) 138 pounds. The nutrient requirement calculations, by dietary staff K, dated 1/24/19, advised the resident had an IBW (ideal body weight) of 100 pounds, with an admit weight of 138 pounds. The recommended dietary intake identified the resident required 1,080 calories, 41 grams of protein, to maintain his/her weight, and for weight gain the resident required 1,580 calories. The nutrition risk assessment section, revealed the admission assessment documented the resident weighed 138 pounds, and without protein concerns. The resident received a regular diet, and thin (regular) liquids. The resident ate 53% of meals, with 1,405 calorie intake from meals, and 57 grams of protein intake from meals. The resident's nutrient needs were 1,227 cc (cubic centimeters) of fluids, 1,080 calories, and 41 grams of protein. The resident did not receive supplements and without additional recommendations, at that time. The resident made his/her own food choices, fed himself/herself, and liked to eat most meals in his/her room. The RD initial assessment, advised the resident weighed 133 pounds, on 1/30/19. The resident had a BMI of 26 (normal BMI 18-22). The resident received a regular diet with most of the meal intake of 76-100%. The resident without [MEDICAL CONDITION] and had a minor weight fluctuation of 131-138 pounds since admission with adequate meal intake. To continue with the current care plan and monitor weights and intakes and follow-up with the RD as needed. The resident's EMR, documented on 1/30/19, the resident weighed 133 pounds, down 5 pounds, since 1/21/19. The weekly skin, nutrition, and at-risk (SNAR) meeting, dated 1/30/19, documented the resident weighed 133 pounds. The resident required a regular diet, and texture with regular liquids consistency. The resident's intake of meals was 78%, and 57% for snacks. The resident had a [DIAGNOSES REDACTED]. The meeting notes did not indicate any further interventions to prevent further weight loss put in place. On 2/1/19, the resident's laboratory results identified the resident with a low [MEDICATION NAME] of 3.3. The normal range was 3.5 to 5.7. The Protein level of 6.2, which was also low with a normal range of 6.4 to 8.9. The resident's EMR, dated 2/6/19, documented the resident weighed 132 pounds, down 1 more pound, since 1/30/19. The weekly SNAR meeting, dated 2/6/19, documented the resident weighed 132 pounds. Received a regular diet with regular texture and liquids. The resident ate 79% of meals and 41% of snacks. The resident without any new orders for diet/supplement change. The physician aware. The resident's EMR, dated 2/12/19, documented the resident weighed 129 pounds, down 3 more pounds, since 2/6/19. The weekly SNAR meeting, dated 2/14/19, documented the resident weighed 129 pounds. Received a regular diet, with regular texture, and regular liquids consistency. The resident ate 82% of meals and 57% of snacks. The resident identified without significant weight change, and without any new diet/supplement changes. The resident's EMR, dated 2/20/19, documented the resident weighed 129 pounds. The resident remained at the same weight, since 2/12/19. However, the resident had a 6.52% weight loss in 30 days, and the facility staff failed to notify the RD of the resident's significant weight loss. The weekly SNAR meeting, dated 2/20/19, documented the resident weighed 129 pounds. Received a regular diet with regular texture, and regular liquids consistency. The resident ate 75% of meals and 32% of snacks. The resident without a weight change from the last week comparison weight. The resident with a -3% weight (loss, which was inaccurate as resident lost 9 pounds/6.52%) change over 30 days. The resident weighed on 1/21/19, 138 pounds. Continue to monitor the resident's weight weekly. The weekly SNAR meeting, dated 2/27/19, documented the resident weighed 130 pounds. The resident received a regular diet with regular texture, and regular liquids consistency. The resident consumed 82% of meals, and 57% of snacks. The resident without weight changes. Continued with a negative 3% (inaccurate)change over 30 days. The resident without change in diet or supplement. The resident's EMR, dated 2/28/19, documented the resident weighed 128 pounds. The resident had a 7.25% weight loss, from 1/21/19 through 2/28/19, (35 days). The resident's weight of 129 pounds, was down 1 pound from 2/20/19. The resident's EMR on 3/7/19, documented the resident weighed 130 pounds. The resident gained 2 pounds, since 2/28/19. The weekly SNAR meeting, dated 3/7/19, documented the resident's weight 130 pounds. The resident received a regular diet with a regular texture and regular liquids consistency. The resident ate 83% of meals, and 41% of snacks. The resident with a 2.2 pound weight gain from the last week comparison weight. The resident did not trigger for weight. The staff encouraged the resident to attend all meals. Changed the evening meal time to around 5:00 PM, for the resident and spouse's preferences. Continue to monitor the resident's weight weekly until stable. The resident's EMR on 3/13/19, documented the resident weighed 129 pounds. The resident lost 1 pound, since 3/7/19. The weekly SNAR meeting, dated 3/13/19, advised the resident weighed 129 pounds. The resident received a regular diet with a regular texture, and regular liquids consistency. The resident ate 62% of meals and 38% of snacks. The resident with a significant weight change of 1-pound loss from last week's comparison weight. The resident did not trigger for weight. The staff encouraged the resident to attend all meals. The evening meal time changed to around 5:00 PM, for the resident and spouse's preferences. (Also in the 3/7/19, SNAR notes) Continue to monitor the resident's weight weekly until stable. The resident's EMR on 3/20/19, documented the resident weighed 125 pounds. The resident lost 4 pounds, since 3/13/19 (in 7 days). The weekly SNAR meeting, dated 3/20/19, identified the resident weighed 125 pounds. The resident received a regular diet with regular texture and regular liquids consistency. The resident ate 90% of meals and 38% of snacks. The resident had a significant weight change of a 1 pound weight loss from last week's comparison weight. The resident did not trigger for weight. Encouraged resident to attend all meals. Changed the evening meal time to around 5:00 PM, for the resident and spouse's preferences. The resident without diet and supplement changes. The resident's EMR on 3/27/19, documented the resident weighed 126 pounds. The resident gained 1 pound, since 3/20/19. The weekly SNAR meeting, dated 3/27/19, advised the resident weighed 126 pounds. The resident received a regular diet with regular texture, and regular liquids consistency. The resident ate 83% of meals and 27% of snacks. The resident with a significant weight change of a 1 pound weight gain from last week comparison weight. The resident with a 7.5% weight loss. The comparison weight on 1/21/2019, of 138 pounds, identified an 8.7% weight loss, of 12 pounds. Staff encouraging the resident to attend all meals. Changed the evening meal time to around 5:00 PM, for the resident and spouse's preferences. The resident without changes to diet or supplement. Review of the facilities meal intake for the resident, from 3/3/19 through 4/2/19, identified the following: From 3/5/19 through 3/11/19, the resident averaged 67% of meal intake. From 3/13/19 through 3/18/19, the resident averaged 60% of meal intake. From 3/20/19 through 3/25/19, the resident averaged 70% of meals. From 3/27/19 through 4/2/19, the resident averaged 62% of meals. The resident's snack intake, for the last 30 days (3/5/19 through 4/3/19), identified the resident refused snacks 50% of the time and consumed approximately 51-75% of snacks he/she did take. On 4/1/19 at 8:05 AM, the resident was in his/her bed, awake and answered simple yes/no questions. At 9:06 AM, and 10:53 AM, the resident continued to be lying in bed. At 10:53 AM, direct care staff J stated the resident declined offered shakes on numerous times. On 4/1/19 at 12:10 PM, the resident in the dining room looking at his/her plate of food, which was biscuits and gravy. The resident was not feeding himself/herself currently. At 12:28 PM, the resident observed to push his/her food around on his/her plate and had taken a couple of bites of the meal. However, the resident was eating a brownie, at that time and stated it tasted good. The spouse sat beside the resident encouraging the resident to eat. The resident ate approximately 50% of the meal. On 4/2/19 at 8:15 AM, the resident sat at the dining room table and had eaten toast and coffee and a bowl of cereal. The resident stated he/she just was not hungry. On 4/2/19 at 12:53 PM, the resident sat at the dining room table with a plate of ham, scalloped potatoes, and corn bread with jelly, and a slice of apple pie. The resident was in good spirits and had eaten approximately 1/2 of his/her potato's, and the ham was cut up into bite size pieces. At 1:08 PM, the resident had eaten 1/2 slice of ham, and 3/4 of the scalloped potatoes, 1/2 of the cornbread with jelly and a few bites of the apple pie. Did not observe staff encouraging the resident to eat. On 4/3/19 at 10:15 AM, administrative nursing staff C and administrative nursing staff D took the resident to the bathing room to weigh. Staff D cleared the scales and weighed the resident in his/her wheelchair and the resident weighed 166 pounds. The resident then propelled to his/her room via wheelchair by staff D. Staff C and D transferred the resident from the wheelchair to the rocker. The staff brought the wheelchair and weighed it at 45 pounds. Subtracting the wheelchair from the first weight the resident weighed 122 pounds, a 4-pound weight loss from the previous week. On 4/3/19 at 11:00 AM, direct care staff J cleared the wheelchair/standing scale and then staff J and direct care M assisted the resident to stand on the scale then stepped back and the resident weighed 121 pounds. The staff re-weighed the resident because the earlier weight obtained was thought to be wrong by administrative nursing staff C. On 4/1/19 at 11:29 AM, dietary staff K stated the resident wanted biscuits and gravy for breakfast so the resident was sent a room tray of biscuits and gravy, but when the resident received his/her room tray he/she asked for the tray to be held. On 4/2/19 at 10:00 AM, dietary staff K stated the RD would be notified if the resident had a weight loss. Staff K did attend the SNAR weekly meetings. The committee reviewed every resident on the SNAR list and were very thorough. If the RD, that comes monthly, had recommendations, the RD would let staff C know. The resident did not always get up for meals. If the resident eats less than 50% of the meal, the staff would offer the resident a shake. On 4/2/19 at 2:48 PM, direct care staff L stated the resident did not eat well and he/she did not give the resident any type of supplements. The resident did not usually eat. The resident usually ate 25-50% of meals. The staff must encourage the resident to eat along with his/her spouse. Staff L would notify the nurse if the resident's weight was different from the last weight. On 4/2/19 at 3:17 PM, direct care staff M stated the resident required a lot of patience. If the resident was fighting the staff, he/she would get the nurse, and the nurse would help guide the resident's care. The resident could be sneaky and he/she was not quite sure what sets the resident off. The resident's fighting worsened over the last month, he/she did not want to eat, go to the bathroom, or anything. Staff M stated he/she tried not to let the resident eat in his/her room. Staff M would offer the resident a shake and keep going back to see if the resident would get up. The resident also liked to eat the Yogurt. Earlier, around 10:00 AM, the resident asked for a snack, a sandwich and his/her spouse gave the resident a cookie. On 4/3/19 at 8:25 AM, dietary staff K stated the 30-day MDS alerted him/her to the resident's weight loss, and he/she sent an E-mail to the RD who had not responded. The E-mail was unavailable for review upon request. On 4/2/19 at 9:37 AM, administrative nursing staff D verified the 30-day MDS documented the resident with weight loss of 5% and the resident was not on a physician ordered weight loss regimen. Staff D would not notify staff C or dietary the resident had lost weight. There were other measures in place for staff C and staff K to be notified if the resident had lost weight. On 4/2/19 at 1:05 PM, administrative staff C stated he/she had the list of the resident's weight with the amount lost and the weights and vitals summary did document a 3% weight loss, however it also identified the 30-day MDS with a 5% weight loss in the last 30 days since admission. Staff C would not expect staff D to notify him/her of any weight loss from the MDS, because there were other means of obtaining this information. On 4/8/19 at 9:03 AM, consultant staff P stated if a resident had weight loss, he/she would review the resident either when he/she would come in monthly or if the facility would like the resident reviewed sooner he/she would. Staff P would review the residents meal/snack intake, and if the resident was [MEDICATION NAME] (increased fluid output). If the staff would like to start a supplement, or fortified foods before he/she would reach the facility then that would also be good, and he/she would review when in the facility. Staff P was unable to verify if the facility notified him/her of the resident 6.2% weight loss on 2/20/19. His/her expectation would be the staff should have stepped up and implemented an intervention for the weight loss. On 4/8/19 at 9:20 AM, physician representative O stated the facility would send a fax with any concerns to the physician and then he/she would address the concern and fax back to the facility. The physician visits the facility at least every 2 weeks. Staff O believed the physician would expect the staff to notify the physician of any significant weight loss. The facility (SNAR) policy, dated 8/17, documented it was the intent of this facility to identify residents at risk, assess and as an interdisciplinary team (IDT) meet, review and revise plans of care. The facility would ensure that the resident maintains, to the extent possible, acceptable parameters of nutritional status to reduce risk of weight loss. After admission/re-admission, a resident would be weighed weekly for 4 weeks to establish a baseline or identify risks of weight loss/gain. If weight loss/gain of 5% in 30 days, 6% in 90 days, 8% in 180 days noted on monthly weights, the resident then would be added to the weekly SNAR meeting for review. The physician, responsible party and the resident would be notified of the unexpected weight gain or loss. The facility failed to monitor and implement timely effective interventions to address this resident who had a 6.52% weight loss in 29 days, from 1/21/19 through 2/20/19, and who continued to lose weight, with a total weight loss of 17 pounds/12.3% in less than 3 months, from 1/21/19 (138 pounds) to 4/3/19 (121 pounds).

The facility reported a census of 60 residents. Based on observations, record review and interview, the facility failed to develop and implement effective interventions to prevent repeated falls for 1 (#1) of 4 sampled residents with falls, who fell and sustained a right hip fracture. Findings included: - The medical record face sheet evidenced the facility admitted resident #1 on 8/8/13. [DIAGNOSES REDACTED]. The hospital discharge record, dated 8/8/13, documented the resident fell at home on 8/3/13 and sustained a fractured left hip and received a heniarthroplasty (a surgery which replaces only the ball portion of the hip), while in the hospital. On 8/8/13, the facility completed a fall risk assessment and scored the resident at 15, a total score of 16 or greater represented a high risk for falling. The admission MDS (minimum data set) assessment, dated 8/12/13, included the resident had severely impaired cognitive skills, extensive assist required for bed mobility, transfers, dressing, total dependence for toileting and a history of one fall prior to admission, (which resulted in a left hip fracture). The initial care plan, dated 8/8/13, included a need for 1 staff with transfers,..."Fall risk: Do not leave unattended in BR (bathroom)." Nurses notes, on 8/12/13 at 1:50 A.M., documented, "...pt.(patient) cont. (continued) to attempt to get up from bed and ambulate on own..." 8/12/13 at 2:15 A.M., "PRN (as needed) pain medication administration was ineffective. Cont. to attempt to get out of bed. One on one staff monitoring." 8/12/13 at 4:34 A.M., ..."pt. moaning with pain cont to get out of bed with ambulation holding onto furniture. Alert to person only. Staff sitting with pt. redirected back to bed with extensive assist x 2 staff..." On 8/12/13 at 12:15 P.M., nurses notes documented, "CNA (certified nurse aide) was walking past elders room and observed elder (#1) sitting on floor next to bed." The physician ordered xrays of the right hip after the staff noted the resident with new pain in the right hip area. The portable xray unit reported "R (right) hip intact, moderated degree of osteoarthritic changes within the right hip." The nurses notes continued to document, "Pain meds and anxiety meds given with relief noted. (Family) in facility and aware of incident. (Family) concerned that elder continues with pain." The physician was notified and ordered to send elder to ER (emergency room ). Elder transported to ER via EMS (emergency medical service). ..."Cat scan done at ER, showed new right intertrochanteric fracture of hip. Elder admitted to hospital with surgery pending." The 8/16/13 nurses notes documented the resident readmitted to the facility, following right hip repair. Observation, on 9/4/13 at 8:30 A.M., revealed the resident asleep in a low bed with a mat beside the bed. At 9:20 A.M., the resident worked with therapy, bearing full weight. At 9:45 A.M., the resident moved about the facility in a wheelchair with a lap buddy, (a device that acts as a reminder to residents to ask for assistance before getting out of the wheelchair), restraint in place. The resident continued to self propel the wheelchair with his/her feet, throughout the facility. On 9/4/13 at 11:00 A.M., licensed staff B reported, " (Resident) only had one fall so we didn't think about putting (him/her) in a low bed with the mat, although the fall risk assessment completed at admission documented 3-6 falls. (The resident's) (family member) reported only the one fall in the last 6 years while taking care of (him/her). (The resident) fractured the left hip at home and had the surgery." On 9/4/13 at 11:30 A.M., licensed nursing staff C acknowledged the resident was up most of the night on 8/12/13, (night before fall) so (he/she) advised the staff to allow the resident to sleep and not get (the resident) up for breakfast. On 9/4/13 at 12:25 P.M., certified staff D acknowledged staff checking, changing and putting the resident back to bed at 9:30 A.M., when the resident tried to crawl out of bed. Then at 12:15 P.M., staff D while pushing a resident back to their room after lunch, noted the resident on the floor, in front of his/her bed. Staff D then summoned licensed nursing staff to assess the resident. On 9/4/13 at 12:35 P.M., certified staff E reported, "(Resident) is always on the move. (He/she) was just like that when (the resident) came in." On 9/4/13 at 1:10 P.M., an alert and oriented resident stated, "(Resident #1) tried to get out of the bed a lot of the time." On 9/4/13 at 1:30 P.M., licensed nursing staff F reported, "We visited with the (family member) and (he/she) had only had the one fall and (the resident's) assessment was not high so we didn't feel like (he/she) needed a low bed and mat at the time of admission..." On 9/4/13 at 2:20 P.M., certified nursing staff reported, "We toilet (him/her) every 2 hours at least. (The resident) can stand. (He/she) doesn't always go to bed most of the night. We do all for (him/her) we can. (The resident) requires 2 assist most of the time." The facility failed to adequately assess this resident with potential for repeated falls and failed to develop and implement effective interventions to prevent this confused resident from additional falls and injury. The resident, admitted with a newly fractured left hip, fell 4 days after admission and sustained a fractured right hip.