Every finding on record at Richmond Healthcare & Rehab Center

The facility documented a census of 49 residents. The sample included three residents. Based on observation, interviews, and record review, the facility failed to respond to speech therapy recommendations for dietary changes and a swallow study result recommendation for Resident (R) 1.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses 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), Alzheimer's Disease with late onset (progressive mental deterioration characterized by confusion and memory failure), generalized muscle weakness, dementia (progressive mental disorder characterized by failing memory, and confusion), and dysphagia (swallowing difficulty).R1's admission Minimum Data Set (MDS) dated [DATE] noted the Brief Interview for Mental Status (BIMS) assessment was documented as not assessed. The MDS recorded R1's short-term and long-term memory was not assessed. The MDS further documented R1's decision-making abilities were not assessed. The MDS documented R1 required partial to moderate assistance with eating, oral hygiene, upper body dressing, personal hygiene, transferring from seated to standing position, and chair to bed transfers.The Nutritional Status Care Area Assessment (CAA) dated 01/02/26 documented R1 was recently hospitalized with a primary diagnosis of cerebral infarction. The CAA documented R1 was prescribed a Consistent Carbohydrate Diet (CCHO - a diet plan designed to manage blood sugar levels by keeping the amount of carbohydrates consumed at each meal consistent) and a Low Concentrated Sweets (LCS - a nutritional plan designed to manage blood sugar levels) diet of regular texture and consistency. The CAA documented R1 had poor appetite, but it was improving. The CAA documented R1 required partial to moderate assistance with eating. The CAA documented staff would monitor and document oral intake and nutritional changes. The CAA recorded any changes would be addressed with the dietician and physician.R1's 12/31/25 Care Plan documented R1 needed assistance with activities of daily living (ADL). R1's 12/31/25 Care Plan included the following fall interventions:12/31/25 - R1 required setup or clean-up assistance for eating.01/02/2026 - may crush medications and give together, except those on the do not crush list, unless authorized by the primary care provider (PCP).R1's 01/02/26 Care Plan documented R1 had a cerebral vascular accident that affected vision, mobility, and strength. The 01/02/26 Care Plan included the following fall interventions for R1:01/02/26 - directed staff to monitor intake to assure an adequate fluid intake to prevent dehydration. The intervention recorded If R1 was unable to eat, make sure diet was the correct consistency to facilitate safe swallowing. The intervention further recorded if R1 was unable to swallow, give enteral feeding (a medical method of delivering nutrition directly into the stomach or small intestine when a person cannot eat or drink enough by mouth) as ordered by the physician.01/02/26 - directed staff to monitor and document R1's ability to chew and swallow. If R1 presented problems, obtain order for speech therapy to evaluate and treat.R1's 01/02/26 Care Plan documented R1 had potential for diet and nutrition changes due to the new environment and recent admission to the center. The Care Plan documented R1 was at risk for weight loss, risk for swallowing problems, risk for chewing problems, and had recent acute hospital stay due to cerebral infarction. The 01/02/26 Care Plan included the following fall interventions for R1:01/02/26 - R1 had a diet order for a controlled carbohydrate/low concentrated sweet (CCHO/LCS) diet with regular texture and regular consistency.A Physician's Order with a start date of 12/30/25 and discontinue date of 02/12/26, documented a diet order of CCHO/LCS diet with regular texture and regular consistency for R1.R1's EMR lacked evidence of any other diet orders, or dietary changes for R1 during her stay in the facility from 12/30/25 to 02/04/26.A Speech Therapy Treatment Encounter Note dated 01/07/26 documented Speech language pathology (SLP) addressed dysphagia. R1 was seen at noon meal. The note documented R1 had an episode earlier in the week with significant coughing and difficulty swallowing meat. The note further documented nursing downgraded R1's diet to mechanical soft (foods that are physically altered to require minimal chewing, to assist those with swallowing issues). The note documented R1 demonstrated coughing and throat clearing with the ham and beans which were a mixed consistency. The note further documented R1 had no coughing with thin liquids or mechanical soft solids. The note documented R1 had a Flexible Endoscopic Evaluation of Swallowing (FEES - procedure used to evaluate how well a person swallows) study tomorrow (01/08/26).A Speech Therapy Treatment Encounter Note dated 01/08/26 documented R1 demonstrated some difficulty with thin liquids and did aspirate (when food, liquid, or saliva moves into the airway and lungs instead of being swallowed) a tic tac when she swallowed it whole with thin liquids and multiple pills at a time. The note documented SLP recommended R1's medications be crushed in puree (food blended into a smooth, pudding-like consistency that requires no chewing), until an official report was received and further review of the information was completed. A Flexible Endoscopic Evaluation of Swallowing (FEES) report for R1, dated 01/08/26, documented R1's current diet was mechanical soft solids and thin liquids. The report listed a recommendation of a Minced and Moist (modified diet with soft, moist, or finely minced food that requires minimal chewing) mechanical soft diet with thin liquids. The report recommended medications taken whole or cut in puree. The report recommended swallow strategies to keep R1 upright 90 degrees during and 60 minutes or more after meals and snacks. The report documented R1 required cues for double swallow for every bite and drink.A Speech Therapy Treatment Encounter Note, dated 01/15/26, documented R1 was discharged from all therapies due to unexpected exhaustion of insurance benefits. The note documented R1 had an altered diet of mechanical soft and thin liquids with pills crushed in puree. The note documented R1 required total supervision at meals for safety.Review of R1's EMR under the Misc tab revealed Licensed Nurse (LN) G uploaded R1's swallow study results into R1's EMR on 01/09/26. R1's EMR lacked evidence that R1's provider was notified of the results of the swallow study. R1's EMR lacked evidence of a physician's response to the swallow study results for R1.On 03/23/26 at 03:04 PM, Administrative Nurse D stated R1 typically ate by herself but needed prompting from staff. She stated staff helped R1 with her meals some, but did not recall any staff ever having to feed R1. Administrative Nurse D stated she was unsure what happened with the swallow study recommendations and speech therapy recommendations. She stated she was unsure if the family or provider declined the recommendations. Administrative Nurse D stated normally when a recommendation or result comes in, the nurse reviews it, then medical records (LN G) would transcribe it and put in a note. She stated once it goes through the process, the end results would come to her for review to ensure everyone did what they were required along the way, so nothing was missed. She stated she did not recall reviewing the recommendations for R1's swallow study or the speech therapy recommendations otherwise she would have looked into it to find out why it did not go through.On 03/23/26 at 05:59 PM Administrative Nurse D stated normally, when a video swallow result came back, and there was a recommendation sent to the facility, the physician would have reviewed it and given an answer as to why they would make an order change or not. She stated sometimes the physician would sign the result directly and it would have been scanned in after. Administrative Nurse D stated LN G would have been the staff member who would have scanned the results into R1's EMR. She stated speech therapy may have scanned or sent it directly to LN G for her to upload. She stated speech therapy should have followed through and asked if LN G got the order or recommendation for the diet change. Administrative Nurse D stated any order documentation would be forwarded to her as well so she could review them. Administrative Nurse D stated if any changes were made to R1's diet during her stay it would have shown up under the orders tab, even if it had been discontinued. Administrative Nurse D stated she did an in-service last month for issues like this with the nurses about documentation and orders. She stated floor nurses do not put in orders frequently and it was mostly done by LN G. She stated they covered in the in-service what residents are on antibiotics, orders, and expectations for better documentation. She stated she was unable to provide a sign-in sheet with LN G's signature for the in-service. She stated LN G did not attend the in-service and believed she was on vacation during that time. She stated the facility did not have a policy that was relevant to this situation and she was working on getting a policy put into place related to orders and recommendations.On 03/23/26 at 06:19 PM LN H stated orders, results, or recommendations make it to her, she would review them and then LN G scans them into the resident's EMR. She stated the nurses and the DON would have received a copy as well to ensure nothing was missed. She stated she was not sure but believed speech therapy notes with recommendations went to LN G as well. LN H stated the swallow study results would have been scanned by LN G and if there were any order changes the nurses and the DON would have received a copy of what had been changed. LN H stated the facility had an in-service about putting orders in the system. She stated she worked as an as-needed employee and was not at the in-service. She stated she was filled in when she returned by Administrative Nurse D. LN H stated if the swallow study results and recommendations were scanned into a resident's EMR under the Misc tab, she was unsure that there would have been any alert for her to know they came back. She stated if LN G uploaded the results, and did not tell the nurses about it, they would not have known if it needed to be reviewed. On 03/24/26 at 11:03 AM LN G stated she ensured physicians reviewed test results and that test results were uploaded or entered into the resident's EMRs. LN G stated if the speech therapist recommended dietary changes, then they would fill out a diet communication form as to what diet they recommend. She stated that form is then reviewed with or by the physician and the physician would then give the okay for the diet order. LN G stated she was not able to access any notes from the speech therapist, and the therapy director was good about communicating any changes that needed to be made. She stated the diet communication form would have been filed out by speech therapy and given to a nurse and dietary staff. She stated she would have then uploaded it under the miscellaneous (Misc) section of the resident's EMR. LN G stated after a physician was notified of a result or recommendation, she would have put in a progress note documenting the physician was notified. LN G stated she uploaded the swallow study for R1 on 01/09/26 and read the current diet was listed as mechanical soft on the swallow study report. She stated after she scanned the results in, she reviewed R1's orders and found R1's diet was entered as regular and not mechanical soft. LN G stated she contacted the provider and was told to continue R1's regular diet and he did not want to make any changes. LN G stated during that time there was no Director of Nursing (DON) or Assistant Director of Nursing (ADON) and she was interrupted before she put a response or notification progress note in R1's EMR. LN G stated she did not put the progress note in after contacting the provider about R1's swallow study results, or his response to the recommendations. LN G stated the provider did not give a rationale as to why he did not wish to make changes after she discussed the swallow study results with him. LN G stated she was unsure if the provider had seen or was aware of the information in the speech therapy notes and the speech therapist's recommendations. She stated she did not have access to that information and was not sure if the provider did either. LN G stated she did go over the swallow study results over the phone with the provider but was unsure if the provider had reviewed the results himself.No policy provided by the facility upon request.

The facility identified a census of 47 residents. The sample included 12 residents and five Certified Nurse Aides (CNA) reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure one of the five CNA staff reviewed had yearly performance evaluations completed. This deficient practice placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNA was employed with the facility for more than 12 months: CNA O, hired 03/06/23, had no yearly performance evaluation upon request. On 02/26/25 at 11:31 AM, Administrative Nurse D stated she was responsible for completing the nursing staff's yearly performance reviews. Administrative Nurse D stated CNA O worked nights. Administrative Nurse D stated she had not completed CNA O's yearly performance review. The facility's Required Training, Certification and Continuing Education of Nurse Aides policy dated 03/01/24 documented it was the policy of the facility to comply with State and Federal regulations and requirements as they pertained to the training, certification, and continuing education of its nurse aides. In-service training would be provided by qualified personnel and be based on the needs of the residents in the facility and any areas of weakness as determined in the nurse aide's performance reviews and facility assessment. The facility failed to ensure one of the five CNA staff reviewed had the required yearly performance evaluations completed. This deficient practice placed the residents at risk for inadequate care.

The facility identified a census of 47 residents and one kitchen. Based on record review and interviews, the facility failed to provide the services of a full-time certified dietary manager for the 47 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 02/25/25 at 02:30 PM, Administrative Staff A reported the facility currently did not have a certified dietary manager. On 02/26/25 at 11:00 AM, Dietary Staff BB stated she had been with the facility for over a year but was not certified. She stated the dietary manager came monthly. She stated she had not started classes but was looking into them. The facility's Dietitian policy last revised 04/2024 indicated the facility was to ensure a qualified, competent, and skilled dietary manager would help oversee the food and nutrition services in the facility. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparation, and storage of food for the 47 residents in the facility. This placed the residents at risk for inadequate nutrition.

The facility identified a census of 47 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to storage, preparation, and meal service. This deficient practice placed the residents at risk for food-borne illnesses and food safety concerns. Findings Included: - On 02/24/25 at 07:00 AM, a walkthrough of the facility was completed. An inspection of the dining hall revealed the dining room was closed off to the residents. The dining room ceiling fixtures hung from the ceiling. Dust covered the tables and floor of the dining room. No barriers were in place between the construction area and the food preparation areas. On 02/24/25 between 07:00 AM and 04:00 PM the door between the dining room, leading directly into the kitchen's cooking area remained propped open during meal preparation for breakfast, lunch, and dinner services. The dining room was cleaned and reopened on 02/25/25 for breakfast. On 02/24/25 at 07:30 AM, an inspection of the Memory Care Unit's kitchenette revealed opened/undated ice cream in the freezer unit. On 02/24/25 at 07:09 AM, Certified Nursing Aide (CNA) N stated the dining room was closed due to the roof caving in during the recent ice storm. She stated the dining room was under construction and off-limits to the resident. On 02/25/25 at 03:39 PM, CNA OO assisted with positioning several residents for breakfast, passed several food trays out, and began to provide assistive feeding to three residents for breakfast. CNA OO failed to complete hand hygiene during the entire breakfast service or during assistive feedings. On 02/26/25 at 10:15 AM, CNA N stated staff were expected to complete hand hygiene in between assisting residents or after touching soiled surfaces. She stated hand hygiene should be completed when switching between assisting different resident's meals. CNA N stated staff were expected to check and clean out the refrigerators outside the kitchen area. On 02/26/25 at 11:06 AM, Dietary Staff BB stated staff were expected to complete hand hygiene before, during, and after assisting residents or passing meals. She stated the facility had a verbal agreement for the memory care staff to clean the refrigerator. She stated the facility was to ensure plastic was placed to prevent contamination from the dining room construction if the doors were propped open. A review of the facility's Food Services and Nutrition policy (undated) indicated the facility would promote a system that identified proper service, cleaning, and food storage. The policy noted all surfaces within the dining room and kitchen were to be cleaned and sanitized per professional standards. The policy indicated food would be labeled/dated and stored in a manner that is safe and maintains nutritional value. The policy indicated staff were to ensure safe food handling practices to prevent cross-contamination and food-borne illness. The policy indicated staff should complete hand hygiene in between touching surfaces related to direct food preparation, handling, and serving. The policy noted all kitchen and dining equipment would be stored in a manner that prevented soiling or contamination of clean items. The facility failed to follow sanitary dietary standards related to food storage, preparation, and meal service. This deficient practice placed the residents at risk related to food-borne illnesses and food safety concerns.

The facility had a census of 47 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included: - A review of the information facility's in-service records revealed the following CNAs were employed with the facility for more than 12 months: CNA O, hired 09/02/14, had not completed the required in-services in the past 12 months. CNA NN, hired 11/08/18, had not completed the required in-services in the past 12 months. CNA Q, hired 08/03/21, had not completed the required in-services in the past 12 months. CNA P, hired 03/06/23, had not completed the required in-services in the past 12 months. CNA MM, hired 04/12/23, had not completed the required in-services in the past 12 months. On 02/26/25 at 11:31 AM, Administrative Nurse D stated she was responsible for ensuring the direct care staff received their required 12 hours of in-service education. The facility's Required Training, Certification and Continuing Education of Nurse Aides policy dated 03/01/24 documented the facility would provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. The facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care.

The facility identified a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to develop and implement individualized activities programming based on resident preferences for the residents on weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings Included: - A review of the facility's Activity Calendars for December 2024, January 2025, and February 2025 was completed. The calendars revealed church services, coloring, puzzles, and movies were provided on Sundays. The calendars revealed reminiscing, coloring, puzzles, and independent activities were provided on Saturday. On 02/25/25 at 10:30 AM the facility's Resident Council reported activities on the weekends were inconsistent compared to weekdays. The council reported the facility lacked staff-led activities on Saturdays and Sundays when direct care staff got busy. The council reported the facility would provide coloring pages and puzzles. The council reported weekends were slow without staff-led activities to keep the residents busy. The council reported staff would often turn on the television for the residents on the weekends when staff-led activities were not held. On 02/26/25 at 10:30 AM the facility held a bowling activity in the dining hall. On 02/26/25 at 10:06 AM, Certified Nurse's Aide (CNA) N stated staff were expected to provide the activities on weekends. She stated the activities schedules were posted on the wall and staff could provide direct activities if they chose. She stated there was no staff assigned to provide activities on the weekends, but the Activities Coordinator (AC) was responsible for planning and ensuring they were completed. On 02/26/25 at 10:15 AM, Licensed Nurse (LN) G stated the kitchen staff often held the activities on weekends. She stated the residents were provided movies, coloring pages, puzzles, and sometimes played games on the weekend. On 02/26/25 at 11:14 AM, Activity Staff Z stated the unit staff were expected to complete the weekend activities for the residents. She stated staff could provide activities not on the calendars if they wanted to including finger painting, music therapy, and going outside. The facility was unable to provide a policy related to activities as requested on 02/26/25. The facility failed to develop and implement individualized activities programming based on residents' interests and preferences. This placed the affected residents at risk for boredom, isolation, and decreased quality of life.

The facility identified a census of 47 residents. The sample included 12 residents, with one medication room and four medication carts. Based on observation, record review, and interviews, the facility failed to ensure controlled substances were accounted for and reconciled between shifts. This deficient practice placed the residents at risk for misappropriation and/or diversion of controlled substances. Findings included: - On 02/25/25 at 07:14 AM a review of the December 2024, January, and February 2025 Narcotic Count Sheet on the 100, 200, and 300 halls revealed a missing signature for Nurse On for the dates of 2024 were 12/22 and 12/31. The missing signatures for Nurse On for 2025 were 01/01, 01/08, 01/12, 01/13, 01/16, 01/17, 01/18, 01/19, 01/22, 01/23, 01/24, 01/27, 01/28, 01/29, 01/30, 02/19, 02/20, 02/22, and 02/23. On 02/25/25 at 07:14 PM, a review of the December 2024, January, and February 2025 Narcotic Count Sheet on the 100, 200, and 300 halls revealed a missing signature for the Nurse Off for the dates of 2024 were 12/22, 12/23, 12/25, 12/30, and 12/31. The missing signatures for Nurse Off for 2025 were 01/01, 01/02, 01/03, 01/04, 01/05, 01/06, 01/07, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15, 01/16, 01/17, 01/18, 01/19, 01/20, 01/21, 01/22, 01/24, 01/25, 01/26, 02/17, 02/18, 02/19, 02/20, 02/21, 02/22, 02/23, and 02/24. On 02/25/24 at 07:14 AM, Certified Medication Aide (CMA) stated the facility's policy was nurses or a CMA were to count with the oncoming CMA and the off-going CMA, to ensure the narcotic count was correct. On 02/26/25 at 07:14 AM, Licensed Nurse (LN) G stated each nurse or Certified Medication Aide (CMA) was to count with the on-coming and off-going nurse daily. She stated nursing staff were not supposed to leave the facility until the narcotic count was correct. On 02/26/24 at 02:26 PM, Administrative Nurse D said she expected anyone on the medication carts to count with the oncoming nurse each shift. The facility's Medication Storage dated 04/16/24 documented that the facility was to ensure all medications housed on the premises would be stored in medication rooms or medication carts. The facility would store medications according to the manufacturer's recommendation and sufficient to ensure proper sanitation, temperature, light ventilation, moisture control, segregation, and security. All narcotics are stored under a double lock and key. Any discrepancies that cannot be resolved must be reported immediately to the Director of Nursing, charge nurse, or designee. Staff were to complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted. Nursing staff must not leave the area until discrepancies are resolved or reported as unresolved discrepancies. The facility failed to ensure an accurate reconciliation of controlled medications was completed. This deficient practice placed residents at risk of medication misappropriation and diversion.

The facility identified a census of 47 residents. The sample included 12 residents, with one medication room and four medication carts. Based on observation, record review, and interviews, the facility failed to appropriately store medications and biologicals when staff failed to ensure the tuberculin (a sterile liquid used to diagnose tuberculosis) test serum was dated after the vial was opened. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - On [DATE] at 07:51 AM, the facility's medication room refrigerator contained two vials of tuberculin test serum that were undated. The tuberculin serum was opened, and the vials were undated. On [DATE] at 07:53 AM, Licensed Nurse (LN) G stated all tuberculin should have an opened date, either on the box or on the vial. LN G was unsure how long the vial was good for after the vial was opened. LN G verified the vials of tuberculin were undated. On [DATE] at 11:23 AM, Administrative Nurse D stated the tuberculin test serum should be dated with an open date or an expired date when the vials were opened. The facility's Medication Storage policy dated [DATE] documented all medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. The pharmacy and the medication room would be routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible missing labels. These medications are destroyed in accordance with our destruction of unused drugs policy. The facility failed to ensure the tuberculin test serum was dated when the vials were opened. This placed the residents at risk for adverse outcomes or ineffective medication regimens.

The facility identified a census of 47 residents. The facility identified eight residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure the linen cart was covered, and wash clothes were not stuffed in the guard rails outside of resident's rooms, and further failed to ensure all oxygen cannulas and nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks were stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 02/24/25 at 07:07 AM on the initial walk-through of the facility, wash clothes were placed in the handrails outside residents' rooms on the 100, 200, and 300 halls. On the 300 hall, the linen cart with towels, washcloths, and bedding was left uncovered. On 02/24/25 at 07:35 AM, R15's nebulizer mask laid directly on her bedside table. At the bottom of R15's bed sat an oxygen tank. The green oxygen tank sat on a stand, and a nasal cannula was wrapped around the handle. R15's nebulizer mask and nasal cannula were not stored in a sanitary manner. On 02/26/25 at 10:14 AM, Licensed Nurse (LN) G stated all respiratory equipment should be placed in an appropriate bag labeled with the resident's name when the resident was not using the equipment. LN G stated washcloths should not be stored outside residents' rooms on side rails. LN G stated the linen cart should always have the flap down. On 02/26/25 at 11:23 AM, Administrative Nurse D stated all staff were responsible for ensuring the respiratory equipment not in use was contained in a sanitary bag. Administrative Nurse D stated the linen cart should always be covered in a sanitary manner. She stated washcloths should not be on the guardrail outside residents' rooms. The facility's Oxygen Administration policy dated 01/08/24 documented oxygen was administered to residents who needed it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Staff would perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Staff would follow manufacturer recommendations for the frequency of cleaning equipment filters, and change oxygen/mask weekly and as needed. Staff were to keep delivery devices covered in plastic bags when not in use. The facility did not provide a policy for the storage of linens in a linen cart, or proper storage of washcloths. The facility failed to ensure the linen cart was covered, and wash clothes were not stuffed in the guard rails outside resident rooms. The facility further failed to ensure all oxygen cannulas and nebulizer masks were stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Resident (R) 35 and R43. This deficient practice placed the residents at risk for impaired dignity and quality of life. Findings Included: - On 02/24/25 at 07:23 AM, Certified Nurse Aide (CNA) PP stood over R35 during the breakfast meal service. CNA PP fed R35 her breakfast standing over her for the entirety of her meal. On 02/24/25 at 12:20 PM, R43 sat in her electric wheelchair with her lunch. An unidentified staff member stood over R43 several times during meal service to assist by feeding her meal due to R43's difficulty using the silverware. On 02/26/25 at 10:03 AM, CNA N stated staff should never stand over the residents while assisting them with their meals. CNA N stated staff should be seated next to them. On 02/26/25 at 10:15 AM, Licensed Nurse (LN) G stated staff were to sit next to the residents while assisting them with their meals during meal service. She stated staff were to sit at the residents' level to help assist them and provide dignity. On 02/26/25 at 11:30 AM, Administrative Nurse D stated staff were expected to sit next to the residents while assisting them with the meals. The facility's Resident's Rights policy revised 02/2024 indicated the facility was to ensure a care environment that promotes dignity, choice, and respect for all residents. The facility failed to provide a dignified care environment for R35 and R43. This deficient practice placed the residents at risk for impaired dignity and quality of life.

The facility identified a census of 47 residents. The sample included 12 residents, with two residents reviewed for accommodation of needs. Based on observation, record review, and interviews, the facility failed to provide wheelchair foot pedals for Resident (R) 16's wheelchair while pushing her in the hall. This placed R16 at an increased risk for preventable falls and injuries. Findings included: - R16's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin was made, or the body cannot respond to the insulin), sleep apnea (a disorder of sleep characterized by periods without respirations), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), muscle weakness, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R16 was impaired on both sides of her body in her upper extremities. The MDS documented R16 was dependent on staff for toileting and needed substantial to maximum assistance with bathing. The Annual MDS dated [DATE] documented a BIMS score of 14 which indicated intact cognition. The MDS documented R16 was impaired on both sides of her body in her upper extremities. The MDS documented R16 was dependent on staff for toileting and showers and required setup for eating and oral hygiene. R16's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 07/19/24 documented staff were to continue to assist R16 with activities of daily living (ADL) and her mobility. The CAA documented staff were to ensure R16 was under standard fall precautions and were to monitor for decline in functional abilities and report to the physician immediately. Staff were to ensure R16 had breaks while performing ADLs. The CAA documented staff were to ensure R16's call light was within her reach. The Care Plan dated 08/30/21 documented staff were to ensure R16 was wearing appropriate non-skid footwear when ambulating or mobilizing in a wheelchair. R16's plan of care dated 12/26/23 documented R16 required assistance with ADLs related to her diagnosis. On 02/24/25 at 07:34 AM, R16 was pushed to her room from breakfast by Licensed Nurse (LN) G without foot pedals. LN G asks R16 to hold her feet up. On 02/24/25 at 12:43 PM, R16 was pushed up hall 300 to eat lunch without her foot pedals on her wheelchair by Certified Nurse's Aide (CNA) S. On 02/26/25 at 09:56 AM, CNA M stated some of the residents do not like having the foot pedals applied to their wheelchairs. CNA M stated staff should let the residents pedal themselves if they wish to not have pedals placed on their chairs. On 02/26/25 at 10:14 AM, LN G stated residents should have foot pedals on wheelchairs if staff are pushing the wheelchair. She stated pushing residents with pedals would be the safest. On 02/26/25 at 11:23 AM, Administrative Nurse D stated that many of our residents do not like having foot pedals on their wheelchairs. She stated that this should be care planned if residents do not want the foot pedals and staff are pushing the wheelchair. The facility's Accidents and Supervision policy, dated 02/01/20, documented that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistive devices to prevent accidents. The facility failed to provide wheelchair foot pedals for R16's wheelchair while pushing her in the hall. This placed R16 at increased risk for preventable falls and injuries.

The facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R ) 7. This deficient practice placed R7 at risk of delayed care or uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of muscle weakness, type two diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), repeated falls, insomnia (difficulty sleeping), and dysphagia (difficulty swallowing). R7's Annual Minimum Data Set (MDS) completed 01/07/25 noted a Brief Interview for Mental Status (BIMS) score of nine indicating mild cognitive impairment. The MDS noted she had bilateral upper and lower extremity impairment. The MDS noted she required total staff assistance for bathing, toileting, dressing, bed mobility, and personal hygiene. R7's EMR recorded a Discharge Assessment-Return Anticipated MDS which recorded R7's discharge to the acute hospital on [DATE]. R7's Entry Tracking Record MDS documented that R7 returned to the facility on [DATE]. R7's Care Plan initiated on 01/04/23 indicated her goal was to remain at her long-term care facility. The plan noted she participated in rehabilitation therapy to improve her ability to complete her activities of daily living (ADL). R7's EMR under Progress Notes revealed a General Note complete on 01/11/25. The note revealed that R7 exhibited severe vomiting and was sent out to an acute care facility. R7's EMR under Progress Notes revealed a General Note completed on 01/14/25. The note revealed she returned to the facility. The EMR lacked documentation showing a written notification of transfer was provided to R7 or her representative. On 02/26/25 the facility was unable to provide written notification of transfer related to R7's hospitalization on 01/11/25. On 02/26/25 at 11:30 AM, Administrative Nurse D stated all residents were provided a bed-hold upon hospitalizations. She stated the facility used electronic forms and could provide the forms per the request of the resident or their representative. The facility failed to provide a policy related to notification of transfers as requested on 02/26/25. The facility failed to provide written notification of the reason and location for the facility-initiated transfer for R7. This deficient practice placed R7 at risk of delayed care or uncommunicated care needs.

The facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for hospitalization. Based on observations, interviews, and record review, the facility failed to provide a copy of the facility bed hold policy to Resident (R) 7 and/or their representative, with a written notice specifying the duration and cost of the bed hold, at the time of R7's transfer to the hospital. This placed the resident at risk for impaired rights. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of muscle weakness, type two diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), repeated falls, insomnia (difficulty sleeping), and dysphagia (difficulty swallowing). R7's Annual Minimum Data Set (MDS) completed 01/07/25 noted a Brief Interview for Mental Status (BIMS) score of nine indicating mild cognitive impairment. The MDS noted she had bilateral upper and lower extremity impairment. The MDS noted she required total staff assistance for bathing, toileting, dressing, bed mobility, and personal hygiene. R7's EMR recorded a Discharge Assessment-Return Anticipated MDS which recorded R7's discharge to the acute hospital on [DATE]. R7's Entry Tracking Record MDS documented that R7 returned to the facility on [DATE]. R7's Care Plan initiated on 01/04/23 indicated her goal was to remain at her long-term care facility. The plan noted she participated in rehabilitation therapy to improve her ability to complete her activities of daily living (ADL). R7's EMR under Progress Notes revealed a General Note complete on 01/11/25. The note documented that R7 exhibited severe vomiting and was sent out to an acute care facility. R7's EMR under Progress Notes revealed a General Note completed on 01/14/25. The note documented she returned to the facility. R7's clinical record lacked documentation for the completed bed hold related to her hospitalization on 01/11/25. On 02/26/25 the facility was unable to provide the bed-hold related to R7's hospitalization on 01/11/25. On 02/26/25 at 11:30 AM, Administrative Nurse D stated all residents were provided a bed-hold upon hospitalizations. She stated the facility used electronic forms and could provide the forms per the request of the resident or their representative. The facility's Bed Hold Notice policy revised 02/2024 indicated the facility would provide a written bed hold to each resident and/or representative regardless of the payment source. The facility failed to provide a copy of the facility bed hold policy to R7 and/or their representative, with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's two transfers to the hospital. This placed the resident at risk for impaired rights.

The facility identified a census of 47 residents. The sample included 12 residents, with 12 residents whose Minimum Data Set (MDS) were reviewed. Based on observation, record review, and interviews, the facility failed to complete an accurate MDS assessment for Resident (R) 35's status regarding admission to hospice services. This deficient practice placed R35 at risk for inappropriate care planning and care needs. Findings included: - R35's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Significant Change MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented R35 was dependent on staff assistance for her activities of daily living (ADL). R35's MDS lacked indication she had received hospice services during the observation period. R35's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 12/20/24 documented she was dependent on staff assistance for ADLs. R35's Care Plan dated 11/19/24 documented staff would consult with hospice if her pain was not controlled with the present medication regimen. R35's EMR under the Orders tab revealed the following physician orders: Admit to hospice services on 11/14/24. On 02/25/25 at 01:10 PM, R35 sat upright in her Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining room table after lunch. On 02/26/25 at 11:31 AM, Administrative Nurse D stated the person who completed the MDS nurse worked remotely. Administrative Nurse D stated the facility would notify the MDS nurse after a resident was admitted to a hospice provider. Administrative Nurse D stated she would have expected a modification would have been completed for the Significant Change MDS dated [DATE] which would have R35 had received hospice services during the observation period. The facility's MDS 3.0 Completion policy dated 03/24/23 documented the residents are assessed, using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. Significant Change in Status Assessment is required when a resident enrolls in a hospice program or changes hospice providers and remains in the facility, or a resident in the facility receiving hospice services discontinues those services (known as revocation of hospice care) and remains in the facility. The facility failed to accurately document R35's status on the MDS for her admission to hospice services. This deficiency placed R35 at risk for inappropriate care planning and care needs.

The facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 16 with grooming and face shaving. This deficient practice placed R16 at risk for impaired dignity, comfort, and a further decline in ADLs. Findings Included: - R16's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), sleep apnea (a disorder of sleep characterized by periods without respirations), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), muscle weakness, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R16 was impaired on both sides of her body in her upper extremities. The MDS documented R16 was dependent on staff for toileting and needed substantial to maximum assistance with bathing. The Annual MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R16 was impaired on both sides of her body, in her upper extremities. The MDS documented R16 was dependent on staff for toileting and showers and required setup for eating and oral hygiene. R16's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 07/19/24 documented staff were to continue to assist R16 with ADLs and her mobility. The CAA documented staff were to ensure R16 was using the standard fall precautions and were to monitor for decline in functional abilities and report to the physician immediately. Staff were to ensure R16 had breaks while performing ADLs. The CAA documented staff were to ensure R16's call light was within her reach. R16's Care Plan dated 12/26/23 documented R16 required assistance with ADLs related to her diagnosis. R16's plan of care documented she often refuses a bath or shower, and staff were to remind her of the importance of hygiene. Staff were to offer R16 a washcloth and soapy water for a sponge bath. R16's EMR lacked documentation of refusals for bathing or shaving her face. On 02/24/25 at 08:55 AM, R16 sat in the hallway waiting to go back to her room. R16's hair was matted to the right side of her head, her blue shirt had food on the front of it. R16's face had long gray whiskers. On 02/24/25 at 11:44 AM, R16 sat in her room in her wheelchair, R16's face remained with food on her shirt and face, and her face remained unshaven. On 02/26/24 at 09:56 AM, Certified Nurse Aide (CNA) M stated all residents should have clean clothes, their hair combed, and their face shaved. She stated it was the CNAs who ensured residents had clean clothes and shaved. CNA M stated if a resident refused care the CNA M would inform the nurse. On 02/26/25 at 10:14 AM, Licensed Nurse (LN) G stated all residents should be clean, and shaven and have their hair combed. LN G stated it was all staff duty to ensure residents were well groomed. LN G stated the CNAs have bathing sheets, if a resident refused grooming or bathing, the CNA would put that on the sheet and turn the sheet in to the Director of Nursing. On 02/26/25 at 11:23 AM, Administrative Nurse D stated it was all nursing staff's duties to ensure all residents were clean, were offered bathing, and the resident's faces were shaven. Administrative Nurse D stated residents' preferences to have their face shaved should be placed on the care plan, and refusals for bathing or care should be documented. The facility's Activities of Daily Living (ADL) dated 12/24/24 documented that the facility would ensure a resident's abilities in ADLs would not deteriorate unless deterioration was unavoidable. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility would maintain the individual objectives of the care plan and would review the care plan as needed. The facility failed to ensure staff assisted R16 with grooming and facial shaving. This deficient practice placed R16 at risk for impaired dignity and a further decline in ADLs.

The facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for weekly weights to monitor Resident (R) 17 for fluid overload. This deficient practice placed R17 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R17's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), muscle weakness, obesity (excessive body fat), hypoxia (inadequate supply of oxygen), unsteadiness on feet, fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 12 which indicated moderately impaired cognition. The MDS documented R17 had impairment on both sides of her body. The MDS documented R17 required partial to moderate assistance with toileting. The MDS documented R17 received a diuretic (medication to promote the formation and excretion of urine) during the observation period. The Significant Change MDS dated [DATE] documented R17 had a BIMS of 14 which indicated intact cognition. The MDS documented R17 was impaired on both sides of her body. The MDS documented R17 required clean-up assistance with toileting. The MDS documented R17 received a diuretic during the observation period. R17's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/06/24 documented R17 was monitored for complications associated with incontinence, toileting hygiene, and toileting transfers. The CAA documented the physician would be notified of any changes in patient skin and activities of daily living (ADL). The CAA documented peri care and brief changes would be administered by staff. R17's Care Plan dated 05/02/24 documented R17 had CHF, and desired to lose weight through diuretics. R17's plan of care documented staff would monitor R17's weight. R17's plan of care documented staff would weigh R17 weekly, per the recommendation of the physician related to diuretic use. R17's plan of care dated 07/19/23 documented staff would administer diuretic medications as ordered by the physician and monitor for side effects and effectiveness every shift. R17's EMR under the Orders tab dated 04/27/21 revealed the following physician orders: Torsemide (diuretic) tablet 40 milligrams (mg); give one tablet by mouth in the morning for CHF dated 01/16/24. Weekly weights every Thursday dated 11/7/24. Review of R17's Medication Administration Record (MAR) from 11/07/24 to 02/25/24 (15 weeks) lacked evidence staff measured and recorded R17's weight on the following dates 12/19, 12/26, 01/09, 01/23, 01/30, 02/20. R17's clinical record lacked documentation of physician notification the weekly weights were not obtained and lacked evidence R17 refused to be weighed. On 02/25/25 at 08:19 AM R17 sat on the side of her bed, waiting for her breakfast to arrive in her room. On 02/26/24 at 09:56 AM, Certified Nursing Aide (CNA) M stated nursing would let the CNA staff know if a resident needed to be weighed. CNA M stated the nurses usually made a list of residents who needed to be weighed. CNA M stated if the resident was not weighed on the date scheduled, the CNA would try to get the weight the following day. On 02/26/25 at 10:14 AM, Licensed Nurse (LN) G stated the weights for residents are on the nursing Treatment Administration Record (TAR). She stated the nurse would let the CNAs know what residents needed to be weighed each morning. LN G stated she would not notify the physician of non-completed or refusal of weights. On 02/26/25 at 11:23 AM, Administrative Nurse D stated the CNAs got the residents' weight as each resident would get up in the morning. She stated the weights were given to the nurse to put in the resident's EMR. Administrative Nurse D stated if a nurse was unable to obtain the weight, the physician would be notified. The facility's Provision of Physician Ordered Services dated 12/12/24 documented that this policy was to provide a reliable process for the proper and consistent provision of physician-ordered services according to professional standards of quality. The facility failed to follow a physician's order for weekly weights to monitor R17 for fluid overload. This deficient practice placed R17 at risk for a delay in treatment related to fluid overload and untreated illness.

The facility reported a census of 47 residents. The sample included 12 residents, with 5 reviewed for accidents. Based on observations, record reviews, and interviews, the facility failed to ensure a safe care environment related to the following Residents (R) 29, R33, and R32. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - The Medical Diagnosis section within R29's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), type two diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), cognitive-communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), weakness, and history of falls. R29's Quarterly Minimum Data Set (MDS) completed 02/03/25 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS noted she had bilateral lower extremity impairment. The MDS noted she used a wheelchair for mobility. The MDS noted she required total staff assistance for bathing, toileting, bed mobility, dressing, transfers, and personal hygiene. The MDS noted she was at risk for falls and had one minor injury fall. R29's Falls Care Area Assessment (CAA) completed 12/27/24 noted she was at risk for falls related to her medical diagnoses, medications, and a recent fall. The CAA noted a plan was created to minimize the risk. R29's Care Plan initiated on 10/14/21 indicated she was dependent on staff assistance for meals, oral hygiene, toileting, bathing, dressing, personal hygiene, transfers, and wheelchair mobility. The plan noted she was at risk for falls related to her impaired mobility and gait problems. The plan noted she had a history of unwitnessed non-injury falls. The plan instructed staff to ensure her call light was within reach and her room remained clutter-free. The plan noted she had a non-skid strip placed on the floor next to her bed and used a fall mat while in bed. The plan noted she had a non-injury fall from her bed on 01/31/25 and was to have a perimeter mattress to reduce the risks of further falls. On 02/25/25 at 08:30 AM, an inspection of R29's room was completed. R29's bed was in a low position with her fall mat against the wall. Her room had a non-skid strip on the floor next to her bed. R29's bed lacked a perimeter mattress. On 02/26/25 at 09:08 AM, an inspection of R29's bed revealed no perimeter mattress. On 02/26/25 at 09:10 AM, Certified Nurse Aide (CNA) Q stated staff should inspect each resident's room to ensure the fall interventions were in place. On 02/26/25 at 10:14 AM, Licensed Nurse (LN) G stated staff were expected to ensure all fall interventions were in place during each shift. She stated all direct care staff had access to the care plans and were expected to follow the interventions. On 02/26/25 at 11:23 AM, Administrative Nurse D stated staff were expected to review each resident's care plans and ensure the implemented interventions were in place. The facility's Accident and Supervision policy revised 01/2024 indicated the facility provided an environment free from potential accidents. The policy indicated that at-risk residents would be provided with individualized care plan interventions. The policy indicated staff would ensure the interventions were implemented correctly and consistently. The facility failed to ensure a safe care environment related to following R29's preventative fall interventions. This deficient practice placed R29 at risk for preventable falls and injuries. - The Medical Diagnosis section within R33's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), insomnia (difficulty sleeping), and repeated falls. R33's Quarterly Minimum Data Set (MDS) completed 12/02/24 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS noted she had bilateral upper and lower extremity impairments. The MDS noted she used a wheelchair. The MDS noted she was totally dependent on staff assistance for bathing, dressing, bed mobility, transfers, personal hygiene, and toileting. The MDS noted no falls since her last assessment. R33's Falls Care Area Assessment (CAA) completed 11/18/24 indicated she was at high risk for falls related to her medical diagnoses, medications, and history of falls. The CAA indicated that a care plan was completed to reduce the risks related to falls. R33's Care Plan initiated on 10/18/22 indicated she was dependent on staff assistance for meals, oral hygiene, toileting, bathing, dressing, personal hygiene, transfers, and wheelchair mobility. The plan noted she transferred with a Sit-to-Stand lift. The plan noted she was at risk for falls related to her impaired mobility and gait problems. The plan instructed staff to anticipate her needs, ensure her room was free from clutter, and have a fall mat next to her bed. The plan noted she was to keep a Dycem (non-slip mat used for stabilization and grip to prevent slipping) mat in her wheelchair related to an unwitnessed fall on 11/22/22. The plan noted her wheelchair was switched to a Broda chair (specialized wheelchair with the ability to tilt and recline) on 10/18/23. On 02/25/25 at 08:02 AM, R33 sat in her Broda chair in front of the television in the main lobby area. R33's chair had no Dycem underneath her. On 02/26/25 at 09:08 AM, R33 was moved from her Broda chair to her bed. R33 had no Dycem in her chair. On 02/26/25 at 09:10 AM, Certified Nurse Aide (CNA) Q stated sometimes the Dycem didn't get transferred or put back in place after moving her from her bed. On 02/26/25 at 10:14 AM, Licensed Nurse (LN) G stated staff were expected to ensure all fall interventions were in place during each shift. She stated all direct care staff had access to the care plans and were expected to follow the interventions. She stated that R33's chair was switched to a broad chair and may not have needed the Dycem. On 02/26/25 at 11:23 AM, Administrative Nurse D stated staff were expected to review each resident's care plans and ensure the implemented interventions were in place. The facility's Accident and Supervision policy revised 01/2024 indicated the facility provided an environment free from potential accidents. The policy indicated that at-risk residents will be provided with individualized care plan interventions. The policy indicated staff will ensure the interventions were implemented correctly and consistently. The facility failed to ensure a safe care environment related to following R33's preventative fall interventions. This deficient practice placed R33 at risk for preventable falls and injuries. 41037 - R32's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of unsteadiness on feet, muscle weakness, fractured right femur (broken thigh bone), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R32 had severely impaired cognition. The MDS documented R32 had no falls since admission or the previous MDS. The MDS documented R32 was dependent on staff assistance for transfers and bed mobility during the observation period. The MDS documented R32 had no limitation in her functional range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). The Quarterly MDS dated [DATE] documented R32 had severely impaired cognition. The MDS documented that R32 had no falls since admission or the previous MDS. The MDS documented R32 had limited ROM in her bilateral extremities. The MDS documented R32 was dependent on staff for transfers and bed mobility. R32's Falls Care Area Assessment (CAA) dated 03/25/24 documented she was a high fall risk, and she was unaware of safety issues. R32 had not had a fall since 05/01/23. R32's Care Plan dated 08/05/22 documented she had an unwitnessed fall and directed the nursing staff to place a fall mat on the floor beside her bed and place the bed in the lowest position. The plan of care directed the nursing staff to be sure her call light was within her reach and to respond promptly to all requests for assistance. The plan of care dated 11/08/22 documented R32 had an unwitnessed fall and had obtained laboratory work. The plan of care dated 04/18/23 documented R32 had an unwitnessed fall and her antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication was restarted. The plan of care dated 05/11/23 documented R32 had an unwitnessed non-injury fall and directed staff to assist her to the bathroom immediately after meals and before bedtime. The plan of care dated 01/03/25 R32 had a witnessed fall and directed the nursing staff to use foot pedals on her wheelchair when staff pushed her wheelchair. R32's EMR under the Progress Notes tab revealed the following Einteract Situation, Background, Assessment, Recommendation (SBAR) summary for providers situation note dated 01/03/25 at 10:20 AM documented R32 had a fall, and the intervention was to use foot pedals when pushing her in the wheelchair. On 02/24/25 at 11:53 AM, R32 sat asleep in her wheelchair, in her room. R32's two call lights were pinned onto the call light cords on the other side of her bed, out of her reach. On 02/25/25 at 07:36 AM, Certified Nurse Aide (CNA) M pushed R32 from her room to the dining room in her wheelchair without foot pedals on the wheelchair. R32's feet slid on the floor as CNA M pushed her to the dining room. On 02/26/25 at 09:55 AM, CNA N stated a resident's call light should always be within their reach. CNA N stated everyone had access to the resident's care plan. CNA N stated the fall interventions could be found on the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA N stated some residents were able to propel themselves in their wheelchairs and did not use foot pedals. CNA N stated the nursing staff should use foot pedals when pushing the resident in their wheelchair if a resident cannot lift their feet. On 02/26/25 at 10:14 AM, Licensed Nurse (LN) G stated the residents should have foot pedals on their wheelchairs when staff pushed the residents. LN G stated a resident's call light should always be within their reach. LN G stated it was the nurse's responsibility to ensure the fall interventions were in place. On 02/26/25 at 11:31 AM, Administrative Nurse D stated she would expect R32 to have foot pedals on her wheelchair when staff pushed the chair. Administrative Nurse D stated that R32 had fallen out of her wheelchair on 01/03/25 when hospice staff was pushing R32 to the shower room. Administrative Nurse D stated that R32 had put her feet down and fell forward out of her wheelchair. Administrative Nurse D stated call lights should always be placed within a resident's reach. The facility's Accidents and Supervision policy dated 02/02/20 documented that the resident environment remained as free of accident hazards as possible. Each resident received adequate supervision and assistive devices to prevent accidents. These included: identifying hazards and risks, evaluating, and analyzing hazards, implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions when necessary. The facility failed to ensure R32's foot pedals were placed on her wheelchair when pushed her to the dining room. The facility further failed to ensure R32's call light was within her reach. These deficient practices placed R32 at risk of falls and possible injuries.

The facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 15's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask and nasal cannula were stored in a sanitary manner. This placed R15 at an increased risk for respiratory infection and complications. Findings included: - R15's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), myocardial infarction (heart attack), rhabdomyolysis (breakdown of damaged skeletal tissue), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), dysphagia (swallowing difficulty), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), assistance with personal care, muscle weakness, hypertension (high blood pressure), unsteadiness of feet, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R15 was impaired on both sides of her body. The MDS documented R15 was dependent on staff for bathing and needed substantial to maximum assistance for toileting and oral hygiene. The Annual MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R15 required set-up and clean-up assistance for eating, bathing, and dressing. R15 required substantial to maximum assistance for toileting. R15's The Functional Abilities (Self-care and Mobility) Care Area Assessment (CAA) dated 04/09/24 documented staff would continue to assist R15 with care. R15's Care Plan dated 12/04/22 documented R15 required the use of supplemental oxygen and was at risk for complications. R15 would maintain adequate oxygenation daily. R15's plan of care documented staff were to change oxygen tubing and rinse filters weekly. R15's plan of care lacked documentation for storing the nebulizer when not in use. R15's EMR under the Orders tab revealed the following physician orders: Nursing was to change oxygen (O2) or nebulizer tubing and rinse the filter weekly, every Sunday night shift, and date each component. For oxygen use, nursing was to date tubing when changed and to add the number of liters ordered for the resident to the sticker on the tank, dated 04/09/23. Ipratropium-Albuterol inhalation solution (medication inhaled to open airways) 2.5-3.0 give 3 milligrams (mg)per 3 milliliters (ml) nursing to give one vial nebulizer every six hours for wheezing as needed and shortness of breath, dated 04/19/24. On 02/24/25 at 07:35 AM, R15 laid on her bed asleep, with her nasal cannula in place. R15's nebulizer mask laid directly on her bedside table. At the bottom of R15's bed sat an oxygen tank. The green oxygen tank sat on a stand, and a nasal cannula was wrapped around the handle. R15's nebulizer mask and nasal cannula were not stored in a sanitary manner. On 02/26/25 at 09:56 AM, Certified Nurse Aide (CNA) M stated staff should place the nebulizer and nasal cannula, when not in use, in a bag labeled with the resident's name. On 02/26/25 at 10:14 AM, Licensed Nurse (LN) G stated all respiratory equipment should be placed in an appropriate bag, labeled with the resident's name when the resident was not using the equipment. On 02/26/25 at 11:23 AM, Administrative Nurse D stated all staff were responsible for ensuring the respiratory equipment not in use was contained in a sanitary bag. The facility's Oxygen Administration policy dated 01/08/24 documented oxygen was administered to residents who needed it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Staff would perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Staff would follow manufacturer recommendations for the frequency of cleaning equipment filters, and change oxygen/mask weekly and as needed. Staff were to keep delivery devices covered in plastic bags when not in use. The facility failed to ensure R15's nebulizer mask and nasal cannula were stored in a sanitary manner. This deficient practice placed R15 at an increased risk for respiratory infection and complications.

The facility identified a census of 47 residents. The sample included 12 residents, with four reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record reviews, and observations, the facility failed to provide dementia-related care services for Resident (R) 91 to promote the resident's highest practicable level of well-being. This deficient practice placed R91 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R91's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), thrombocytopenia (abnormally low number of platelets, the parts of the blood that help blood to clot, sometimes associated with abnormal bleeding), kidney disease (damage to the kidneys that impairs their ability to filter waste products from the blood and produce urine), hypokalemia (low level of potassium in the blood), hyperlipidemia (condition of elevated blood lipid levels), muscle weakness, difficulty in walking, unsteadiness on feet, lack of coordination, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). R91's EMR indicated she was admitted on [DATE]. R91's EMR indicated Admission Minimum Data Set (MDS) was in process. R91's EMR indicated the Care Area Assessments (CAA) were not completed due to her new admission. R91's Care Plan initiated 02/11/25 indicated she resided on the Memory Care Unit related to her severe cognitive impairment. The plan noted she had poor safety judgment and was a risk for elopement. The plan noted she wore a Wander Guard (a bracelet that helps monitor residents who are at risk of wandering) bracelet due to her elopement risk. The plan instructed staff to provide meaningful activities, directional cues, and activities to distract the resident from elopement behaviors. On 02/24/25 at 07:00 AM, R91 wandered around the secured Memory Care Unit. R91 went into R32's room and began digging through R32's personal items in the room. Staff directed R91 to come out of R32's room and sit at the table for breakfast. On 02/25/25 at 08:30 PM, R91 was left unsupervised by the Memory Care close to the patio exit doors. Upon hearing the facility's fire alarm, R91 attempted multiple times to open the patio door without staff intervention. On 02/25/25 at 09:07 AM, R91 was left alone to push on the patio doors without staff intervention. On 02/25/25 at 01:14 PM, R91 attempted to push through the dining room exit doors. On 02/26/25 at 10:13 AM, Certified Nurse Aide (CNA) M stated staff were expected to keep the cognitively impaired residents out of other resident's rooms. She stated staff were to provide supervision, activities, and redirection to help prevent wandering or elopement attempts. On 02/26/25 at 10:30 AM, Licensed Nurse G stated staff were expected to closely monitor wandering residents and ensure the were safe. She stated staff were expected to provide ongoing supervision to prevent potential elopement from the rear doors. On 02/26/25 at 11:30 AM, Administrative Nurse D stated the direct care staff were expected to monitor the exit doors in case they became unlocked, or the memory care residents attempt to exit. She stated the residents should not be entering other resident's room and staff were expected to redirect them from entering other rooms. The facility was unable to provide a policy related to dementia care as requested on 02/26/25. The facility failed to provide dementia-related care services for R91 to promote the resident's highest practicable level of well-being. This deficient practice placed R91 at risk for decreased quality of life, isolation, and impaired dignity.

The facility identified a census of 47 residents. The sample included 12 residents, with three residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 15. This placed the resident at risk for inappropriate end-of-life care. Finding Included: - R15's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), myocardial infarction (heart attack), rhabdomyolysis (breakdown of damaged skeletal tissue), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), dysphagia (swallowing difficulty), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), assistance with personal care, muscle weakness, hypertension (high blood pressure), unsteadiness of feet, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R15 was impaired on both sides of her body. The MDS documented R15 was dependent on staff for bathing and needed substantial to maximum assistance for toileting and oral hygiene. The Annual MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented R15 required assistance with set-up and clean-up for eating, bathing, and dressing. R15 required substantial to maximum assistance for toileting. R15's The Functional Abilities (Self-care and Mobility) Care Area Assessment (CAA) dated 04/09/24 documented staff would continue to assist R15 with care. R15's Care Plan dated 01/29/25 documented R15 was admitted to hospice with a terminal illness. R15's plan of care documented her symptoms would be managed by interventions throughout the end of life. Staff would assess for pain, restlessness, agitation, constipation, and other symptoms of discomfort. Staff would medicate as ordered and evaluate effectiveness. R15's plan of care documented staff would provide nonpharmacological approaches to aid in decreasing discomfort. Bereavement services would be provided by hospice and the facility staff would notify hospice of any significant changes. R15's plan of care documented staff would provide medications per hospice and physician orders. On 02/24/25 at 07:35 AM, R15 laid on her bed asleep, with her nasal cannula in place. On 02/25/25 at 08:50 AM, R15 laid on her bed asleep, with her nasal cannula in place. On 02/26/25 at 09:56 AM, Certified Nursing Aide (CNA) M stated she was unsure what hospice provided for the residents. She stated the hospice aides would let the staff know if the hospice provider left any supplies. CNA M stated the facility provided showers on opposite days of hospice. She stated the hospice aide had scheduled days to give showers. CNA M stated she did not think what supplies or equipment, nor when the aide or nurse would be in the facility were on the resident's care plan. On 02/26/25 at 10:14 AM, Licensed Nurse (LN) G stated she was unsure what hospice provided. LN G stated she did not think what hospice provided would need to be on the facility's care plan, as it was on the hospice plan of care. LN G stated hospice aides and nurses were good at telling the facility what equipment and supplies they had brought to the resident. On 02/27/25 at 11:23 AM, Administrated Nurse D said she knew what supplies hospice provided were on the detailed care plan hospice provided. She stated the aides and nurses were good at reporting to staff when supplies were left and showers were given to the resident. She stated it would probably benefit the facility and the staff if the care plan was more detailed and matched the hospice providers. The facility's Coordination of Hospice Services dated 02/22/24 documented when a resident chooses to receive hospice care and services, the facility would coordinate and provide care in cooperation with hospice staff to promote the resident's highest practicable physical, mental, and psychosocial well-being. The facility and hospice provider would coordinate a plan of care and would implement the intervention according to the resident's needs, foals, and recognized standards of practice in consultation with the resident's attending physician and resident representative to the extent possible. The care plan would identify the care and services that each entity would provide to meet the needs of the resident and his expressed desire for hospice care. The facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for R15. This placed the resident at risk for inappropriate end-of-life care.

The facility reported a census of 39 residents. Based on interview and record review, the facility failed to protect the residents of the facility from an alleged perpetrator (AP) when staff allowed the AP to work after they received notification of alleged abuse on 12/24/20. The facility received notification from a nursing staffing agency on 12/24/20 at 03:30 PM that a Certified Nurse Aide (CNA) M witnessed the alleged perpetrator, Temporary Nurse Aide (TNA- staff member that has completed a shortened training course to be able to do the duties of a CNA during the COVID-19 pandemic) LL hit Resident (R)4 in the mouth multiple times. TNA LL was on duty at the time of the allegation and remained on duty until 12/25/20 at 06:50 AM, 15 hours and 20 minutes after the facility received the notification of the alleged abuse. Failure to remove the alleged perpetrator from the facility pending an investigation placed all of the residents in the facility at risk for staff to resident abuse. Findings included: - The Physician Orders, located in the electronic medical record (EMR), dated 11/02/20, included [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], assessed R4 as having clear speech, she could sometimes make herself understood, and she could sometimes understand others. Her Brief Interview for Mental Status score (BIMS) had an answer of not applicable on the MDS due to her being rarely/never able to make herself understood. The staff assessment for mental status indicated R4 had short and long-term memory problems, no memory/recall ability, and severely impaired decision-making skills. She had no behaviors, but did wander four to six of the seven days in the assessment period. She required supervision and set-up for bed mobility, walking in room and corridor, locomotion on and off the unit, and eating. She required limited assistance of one staff member for transfers and extensive assistance of one staff for dressing, toilet use, and personal hygiene. The Cognitive Care Area Assessment (CAA), dated 04/22/20, indicated she admitted with a [DIAGNOSES REDACTED]. She would nod her head to yes or no questions and was alert and oriented to her name only. The Communication CAA, dated 04/22/20, indicated that R4 spoke very little and did follow cues and instructions. The Quarterly MDS, dated [DATE], matched the prior MDS with these changes: wandering occurred daily, she required limited assist of one for bed mobility, and required extensive assistance of two or more staff for toilet use. The Care Plan, dated 10/08/20, revealed that R4 had impaired cognitive function, impaired thought process, and directed the staff to ask yes or no questions in order to determine needs. The staff were to identify themselves at each interaction, face her when speaking, and make eye contact. Staff should reduce distractions such as turning off the television, radio, closing the door, etc., and know she understood consistent, simple, directive sentences. The staff were to provide her with necessary cues and stop and return if agitated. R4 should have one thought, idea, question, or command presented to her at a time. The care plan also included that R4 needed assistance with her care needs, she could ambulate through the memory care unit, and staff were to supervise for safety. Two staff were needed to assist with dressing, one staff for personal hygiene and transfers, and one to two staff were required to assist with toilet use. Review of the facility's Investigation Summary, undated, indicated on 12/24/20 at approximately 03:30 PM Administrative Nurse D received a call from Agency Staff OO reporting that CNA M observed TNA LL smack a resident five or six times on 12/23/20. The investigation summary revealed Administrative Nurse D dismissed CNA M's allegations. On 12/30/20 CNA M reported to Administrative Nurse D that she observed TNA LL pop R4 on the face multiple times on 12/23/20. Also, during an interview on 12/30/20, CNA P reported to Administrative Nurse D that she witnessed TNA LL pop R4 in the mouth on 12/24/20. The facility failed on 12/24/20 to complete a thorough investigation of the alleged violation and dismissed the allegation until 12/30/20, when interviews were being conducted and the allegations were brought to the attention of Administrative Nurse D again. Review of the Timecard Detail Report, dated 12/20/20 through 01/02/21, indicated TNA LL clocked in on 12/23/20 at 02:00 PM and clocked out at 10:35 PM. On 12/24/20 at 10:00 AM she clocked in, then clocked out at 07:30 PM, clocked back in at 08:00 PM, and remained clocked in until 12/25/20 at 06:50 AM. The facility failed to remove TNA LL from access to residents when notified of the allegation of abuse. Review of the Complaint Investigation Witness Statement, revealed statements were collected on 12/30/20, including from CNA M, CNA P, and TNA LL, six days after receiving notification of the allegation on 12/24/20. On 01/04/21 at 07:28 PM, CNA M reported she worked the night shift at the facility from 06:00 PM to 06:00 AM and was in the room with TNA LL while providing cares to R4 and saw TNA LL pop the resident in the mouth six times or more. CNA M reported to the charge nurse what she had seen, and the charge nurse shrugged her shoulders. The next morning, she contacted the agency she worked for and informed them of what she had seen. On 01/05/21 at 04:10 PM, Administrative Nurse D reported there was an investigation for R4, but she felt like nothing happened, and that administrative staff did not call the allegation into the state. Furthermore, she revealed that administrative staff did not suspend TNA LL because she was PRN (as needed) and not on the schedule. On 01/06/21 at 11:55 AM, Administrative Nurse F revealed that CNA M reported to her on 12/25/20 at the beginning of her 06:00 PM to 06:00 AM shift that TNA LL had moved her hand back and forth lightly over R4's mouth, and that it had also happened a few days prior. Administrative Nurse F revealed that she texted Administrative Nurse D after CMA M told her what CNA M reported. On 01/06/21 at 01:11 PM Administrative Staff A revealed an internal investigation was done and determined the abuse did not happen, so they did not suspend TNA LL. On 01/07/21 at 09:37 AM, Agency Staff OO confirmed CNA M reported to her on 12/24/20 that she had seen another staff slap a resident four to five times. Agency Staff OO revealed she notified the facility the same day and reported the allegation to Administrative Nurse D. The facility policy Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 2017, that included Addendum A, undated directed that in response to allegations of abuse, neglect, exploitation or mistreatment, staff shall: 1. Have evidence that all alleged violations are thoroughly investigated. 2. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process. a. Means of prevention shall include but are not limited to: suspension of employment, removal from the building and/or premises, removal from work assignment, prohibition from entering the building or premises, restraining order separation of residents, 1:1 observation or other means as necessary to the situation. 3. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to ensure the residents of the facility remained free from contact from the TNA LL from the time the facility received the allegation of abuse on 12/24/20 at 3:30 PM, when they allowed TNA LL to work on 12/24/20 from 10:00 AM to 7:30 PM, and then from 8:00 PM until 6:50 AM on 12/25/20. This placed all of the residents in the facility at risk for staff to resident abuse. On 01/07/21 at 04:08 PM, Administrative staff A was informed the residents were in immediate jeopardy and was provided the Immediate Jeopardy Template for failure to protect the residents of the facility when staff allowed the alleged perpetrator to remain on duty at the time of the allegation, placing all of the residents of the facility at risk for staff to resident abuse. The facility abated the immediate jeopardy on 01/08/21 at 09:30 AM when they completed the following: 1. The last day TNA LL worked was 12/25/20 at 06:50 AM. 2. Provided education to the facility staff regarding Abuse, Neglect, and Exploitation including the need to provide protection to the residents of the facility until competition of the investigation and the outcome was determined. Completed 01/07/21 at 10:00 PM. 3. Developed a system where the administrator will monitor compliance weekly for four weeks and then monthly for six months. 4. Held a QAPI meeting with all required disciplines on 01/08/21 at 9:30 AM to discuss and develop a plan for compliance of the identified deficient practice. Following validation of the removal of the immediate jeopardy, on 01/08/21 at 9:30 AM, the deficienct practice remained at a scope and severity of an F.

The facility reported a census of 43 residents. Based on record review and interview, the facility failed to provide appropriate catheter care to ensure a functioning catheter for 1 (#3) of the 3 residents sampled for urinary tract infections. The resident admitted to the hospital with [REDACTED]. Furthermore the facility failed to identify the inadequacy of the antibiotic to treat resident (#3's) infection, and notify the physician for and alternate treatment. Findings included: - The facility admission record evidenced the facility admitted resident #03 on 6/20/11, and was re-admitted on [DATE]. [DIAGNOSES REDACTED]., hypertension (elevated blood pressure) and dysphagia (difficulty in swallowing). The resident was readmitted back into the locked Traditions unit. The MDS (minimum data set) assessment, dated 2/10/14, identified the resident with severe cognitive deficit, with indwelling urinary catheter, in need of extensive assist with transfers, walking, dressing and toilet use. The care plan, dated 1/30/14, included, requires indwelling catheter due to [MEDICAL CONDITION] (urine held in the bladder). May irrigate with 100 cc (cubic centimeters) of sterile water. Catheter care every shift using soap and water. Use a leg strap to anchor the catheter. Ongoing assessment of color, clarity and character of urine. Encourage fluid intake. Ongoing assessment for UTI (urinary tract infection). A physician's orders [REDACTED]. The treatment record and nurses notes lacked documentation of any catheter irrigation provided. On 7/3/14 at 3:10 P.M., licensed nursing staff D reported, irrigating it in the past but couldn't remember when and indicated it would be in the notes. Urinary output documented for this resident, on 2/9/14 included 500 cc on the day shift and 200 cc on the evening shift with zero documented on the night shift, for a total of 700 cc output for the 24 hour period. On 2/10/14 the day shift documented 600 cc output, the evening shift documented the output of 200 cc and 100 cc documented on the night shift, for a total of 900 cc for the 24 hour period. The nurses notes, dated 2/3/14 to 2/10/14, lacked documentation of any problem identified with the resident's output. On 2/10/14 at 2330 (11:30 P.M.), the nurses notes included, Entered residents room [ROOM NUMBER] (7:30 P.M.) to assess O2 (oxygen) sat (saturation) 95% room air. He/She was laying flat in his/her bed with normal color et respirations watching TV and speaking to this RN (licensed nursing staff F). At 2145 (9:45 P.M.) (certified staff E) notified this RN (licensed nursing staff F) resident hollered out help and was having difficulty breathing O2 sat 82% and inhalation weak and moist. Elevated HOB (head of bed) and applied O2, 3L/NC. O2 sat initially increased to 90%. 2200 (10:00 P.M.) called urgently to residents room, (Resident) was sweating profoundly, color pale with cyanosis around lips and fingertips. O2 decreased to 81% on O2 and now using accessory muscles. 2205 (10:05 P.M.) 911 notified of need for transport. EMS (emergency medical service) arrived at 2220 (10:20 P.M.), (Resident) still alert but unable to speak more than 1 word with pausing in-between. EMS applied non rebreather mask and EKG (recording of heartbeat) initially abnormal. EMS left at 2225 (10:25 P.M.) in route to (Hospital). The hospital history and physical, dated 2/11/14, documented the facility sent the resident to the emergency room , with a sudden shortness of breath, with an oxygen saturation level at 82%. The hospital evaluated the resident, then transferred the resident to another hospital for admission into an intensive care unit. The second hospital intensive care admission assessment, dated 2/11/14, documentation included, "Shortness of breath with hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood) and [MEDICAL CONDITION] (condition when the heart output is low and the body becomes congested with fluid), probably as a result of [MEDICAL CONDITION] from plugging of indwelling Foley catheter. He/She is dramatically improved with changing of the Foley catheter and significant urine (1600 milliliters) output." The resident used the Foley urinary catheter for [MEDICAL CONDITION] (non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections)/[MEDICAL CONDITION]. Furthermore, the resident returned to the facility on [DATE], with a physician's orders [REDACTED]. (milligrams) daily, for 7 days, for the urinary tract infection. On 2/13/14, the facility received a laboratory culture and sensitivity report from the hospital which included the identified organism of proteus mirabilis with resistance to [MEDICATION NAME]. (The antibiotic used would not resolve this infection). The facility Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. (milligrams), twice a day. The facility 24 hour report sheets and nurses notes included the following: 2/18/14, very dark urine on night shift. 2/19/14, no output on night shift. Doctor made rounds at 3:30 P.M. The resident complained of pain voiced upon touch. Urology consult ordered. Nurses notes, on 2/20/14 at 8:00 P.M., documented following the [MEDICATION NAME] administered, licensed nursing staff D reviewed the culture and sensitivity report and noted the proteus mirabilis not sensitive to the Cipro. Following notification of the physician, the physician ordered a different antibiotic sensitive to the proteus mirabilis. On 2/20/14 at 8:00 P.M., nurses notes documented the resident c/o abdominal pain upon touch. Noted to have dark amber urine in the foley bag with 100 cc output. Completed Cipro/ABT this day. On 7/1/14 at 5:30 A.M., licensed nursing staff D reviewed the medical record and noted the lab results related to resistance to Cipro. Staff D explained this had not been reported to the physician when he/she visited the resident on 2/19/14, and that the resident's urine continued to display hematuria (blood in the urine). On 7/1/14 at 11:40 A.M., the physician per phone interview, reported a lack of any memory of being notified of the proteus mirabilis resistance to [MEDICATION NAME] for this resident. The physician acknowledged a progress note would be in the resident's chart, if he/she had been notified. On 7/1/14 at 2:00 P.M., licensed nursing staff C failed to find a physician progress notes [REDACTED]. The facility failed to provide appropriate catheter care to ensure a functioning catheter for this resident. The resident admitted to the hospital with [REDACTED]. Furthermore the facility failed to identify the inadequacy of the antibiotic to treat this resident's urinary tract infection, and to notify the physician for an alternate treatment.

The facility reported a census of 44 resident's with 4 residents reviewed for dental status and services. Based on observation, record review, and interview, the facility failed to provide these 4 resident's (#1, #2, #3, and #4 with appropriate oral care to maintain healthy dental hygiene. Resident #1 required professional dental services to regain appropriate oral status due to plaque build-up and bleeding gums. Findings included: - Resident ' s #1 face sheet documented the resident admitted to the facility on [DATE], with the following Diagnosis: [REDACTED]. The admission MDS (minimum data set), dated 10/8/12, revealed the resident will sometimes understand others. The resident had short/long term memory problem, and severely impaired decision making. For ADL ' s (activities of daily living), the resident required extensive staff assistance of 1 for personal hygiene. The resident oral/dental status without issue. The CAA'S (care area assessment summary), dated 10/8/12, did not trigger for oral care or ADL's (activities of daily living). For cognition documented, " The resident has a cognitive impairment related to a [DIAGNOSES REDACTED]. The resident has decreased cognition and impaired his/her ability to make self understood at times and impaired his/her ability to follow a conversation with appropriate understanding of what is being said. " The admission assessment dated [DATE], documented the resident without oral issues. The Resident Data Set, dated 2/21/13, for Oral Health Status, documented the following: -Condition of teeth: Some/all natural teeth -Presence of: Staining/erosion Condition of oral Cavity: Normal appearance of Tongue -No inflamed gums The quarterly MDS, dated [DATE], revealed the residents usually understands. The resident with short/long term memory problem, and severely impaired decision making. For ADL ' s the resident required extensive staff assistance of 1 for personal hygiene. The resident without oral/dental issues. The care plan reviewed on 3/28/13, for altered thought process documented the following; -Give one instruction at a time to the resident. -Explain each activity/care procedure prior to beginning it -Give resident two choices when presenting decisions. The resident is a potential for weight loss related to impaired mobility and decreased cognition. -Provide the resident with verbal encouragement/cueing and assistance with meals -Oral care: teeth brushed 2 times a day and mouth rinsed out after each meal. The care plan had a sheet for additional approaches: On 3/1/13, [MEDICATION NAME] 400 mg (milligrams), 1 by mouth three times daily for 7 days for [MEDICAL CONDITION] simplex. -Daily oral hygiene. -dental appointment. The Resident Data Set, dated 5/21/13, for Oral Health Status unchanged from 2/21/13. The CNA ' s (certified nurses aides) Daily Care Guide, dated 6/2/13 documented the following: 1.) Oral care twice a day and as needed. Rinse mouth out after each meal. 2.) Rinse mouth with water after each meal. The Social Work Progress Notes, dated 3/4/13, documented, " The DPOA (durable power of attorney) called Friday after resident ' s doctor appointment and voiced a complaint. He/she was upset that oral care didn ' t appear to be done on the resident ... Phone conference held on this date with DPOA, myself, MDS coordinator and the DON (director of nursing). We discussed oral care and educated staff on this issue ... " The Social Worker Progress Notes, dated 3/15/13 documented, " Spoke with DPOA spouse regarding the resident ' s oral care. The DPOA spouse would like additional oral care to be done and added to care plan. I informed him/her I would speak with DON and contact him/her Monday with an update. " The Social Worker Progress Notes, dated 3/18/13 documented, " I called the DPOA at 1:45 PM and left a voice mail. I let him/her know the residents care plan had been updated with request and that we were also doing monitoring regards to oral care ... " The Physician A Progress Notes, dated 5/10/13, documented, " The resident was a new patient to our office. Arrived with generalized heavy plaque and calculus, food impaction, and bleeding of tissue. We performed a gross debridement today and plan on bringing him/her back in 2 weeks to do a fine scaling. The resident definitely needs help with brushing, flossing, dental, and oral hygiene. I would highly recommend that a designated person from the nursing staff would help the resident to brush and floss after breakfast, lunch and dinner. Also before night/bedtime. I would recommend brushing, flossing, and rinsing of [MEDICATION NAME] (a prescription mouth rinse to decrease gum tissue inflammation). Please, use a tablespoon of [MEDICATION NAME], and swish around for about 30 seconds; spit, do not rinse. I will be reevaluating the resident home care, and customizing a treatment plan for him/her in 2 weeks. Review of the pictures, taken by physician A on 5/10/13, prior to cleaning of the resident ' s teeth, revealed massive food build-up in and around the resident's teeth (both upper and lower), throughout. The gums appeared inflamed, and in one area, bleeding of the gums noted. The resident has several gold crowns, which were severely discolored. The letter, dated 5/28/13, from physician A , documented the following: " ...The resident came to our office, as a new patient on May 10, 2013, accompanied by his/her family. Upon examination of the resident's oral cavity, I found extremely heavy plaque and food debris ...It was clear to me that his/her teeth hadn ' t been brushed or rinsed for several days ...In the course of my career, I have worked with several patients who are living in a nursing or assisted living facility. I have seen many cases where patient ' s oral care is very poor, but this resident's case is definitely one of the most severe cases I have encountered. After a two hour appointment, I was able to clean the resident's teeth, and take another set of intra-oral photographs to compare the before and after results ...Before releasing the resident, we gave the family member, a written general dental care routine to be given to his/her health care providers. " The February 2013 CNA (certified medication aide) ADL record lacked documentation the resident received oral care twice daily for 6-2 shift, 3 out of 30 days. On the 2-10 shift, lacked documentation for 19 out of 30 days. The March 2013 CNA ADL record lacked documentation the resident received oral care twice daily for 6-2 shift 4 out of 31 days, and on 2-10 shift, 19 out of 31 days. The April 2013 CNA ADL record lacked documentation the resident received oral care on 2-10 shift for 25 out of 30 days. The 6-2 shift documented the resident received oral care for 30 out of 30 days. The May 2013 CNA ADL record lacked documentation the resident received oral care on the 6-2 shift 5 out of 31 days. On the 2-10 shift, lacked documentation for 14 out of 31 days. Review of the April 2013 Treatment Administration record documented the resident received daily oral hygiene. Review of the May 2013 Treatment Administration Record documented: Brush and floss teeth after each meal and before bedtime: 9:00 AM, 1:00 PM, 7:00 PM, and 9:00 PM. Review of the June 2013 Treatment Administration record documented the resident received Brush and floss teeth after breakfast, lunch, and dinner: 9:00 PM, 1:00 PM, and 7:00 PM. The record lacked documentation of the 9:00 PM brush/floss completed. Observation, on 6/13/13 at 6:50 AM, revealed the resident sitting in his/her wheelchair. Is alert and oriented to self, able to answer simple yes no questions. Direct care staff C in the room with the resident, with an emesis basin, tooth paste, gloves on, and a tooth brush. Direct care staff C explained to the resident regarding brushing his/her teeth. Gave the resident simple 1 step instructions. The resident did open his/her mouth, and direct care staff C proceeded to brush the resident ' s upper teeth, moving the tooth brush in an up and down motion. Staff continued cleaning the resident teeth in this manor until completed, and asked the resident to rinse then spit into the emesis basin, the resident swallowed instead. Direct care staff C cleansed the resident ' s mouth/face off with a wash cloth. The resident denied any pain or discomfort. Direct care staff C did not floss the resident ' s teeth. On 6/13/13 at 8:10 AM, the resident sitting in a wheelchair in the dining room, being fed breakfast by direct care staff D. The resident eating breakfast without difficulty. Reports breakfast taste good. On 6/13/13 at 8:45 AM, direct care staff D gathered supplies to brush the resident ' s teeth, washed his/her hands and put on gloves. Explained to the resident he/she (CNA) going to brush the resident teeth, and then proceeded with the left side, in an up down motion, on the sides and underneath until completed. Direct care staff D asked the resident to rinse and spit, the resident rinsed and swallowed. Direct care staff D cleansed the resident ' s face with a wash cloth. The resident denied any pain or discomfort. The CNA did not floss the resident ' s teeth. On 6/13/13 at 12:10 PM, the resident sitting in the dining room being fed lunch by direct care staff C. The resident eating meal without any difficulty. On 6/13/13 at 1:40 PM, licensed nursing staff E searching treatment cart for dental floss, took a couple of minutes to find. Licensed nursing staff E to the resident ' s room, washed hands, and set up oral care supplies and put on gloves. The resident in bed, in the upright position. Licensed nursing staff E explained to the resident he/she going to brush the resident ' s teeth, and asked the resident to open his/her mouth, licensed nursing staff E proceeded to brush the resident ' s teeth. Then asked the resident to take a sip of water and rinse mouth and spit into the emesis basin. The resident swallowed instead. Licensed nursing staff E used dental floss to floss the resident ' s teeth. The resident needed frequent reminders to keep mouth open to floss. The resident reported, " This takes too long. " Procedure done correctly. On 6/13/13 at 7:00 AM, direct care staff C reported, " The resident receives oral care when he/she gets up, after meals, and at bedtime. We know what to do for the resident because we have a mini care plan up at the desk we can refer too. We chart that we do oral care in the ADL book, and we are to chart before we leave. " On 6/13/13 at 9:04 AM, licensed administrative staff B reported, " We were aware it was a problem, so I have been auditing the residents charts, and it has improved. They (the CNA) are to do oral care in the AM and PM. I kind of knew we had a problem with oral care. " On 6/13/13 at 10:00 AM activity/social service staff F reported " They (DPOA) didn ' t attend the meeting, instead I did a phone conference. The family wanted his/her teeth brushed two times a day. The family member sent me a picture of his/her teeth. " On 6/13/13 at 10:30 AM, licensed nursing staff E reported, "The resident's oral care is done by either the nurse or the aide. Usually the CNA does oral care in the morning." On 6/13/13 at 12:12 PM, physician A reported, " The resident's teeth were in terrible shape. Had plaque build up and food in his/her teeth. The resident came back on May 23, 2013 and his/her teeth had improved a lot since the first time. The resident is too be seen in 3 months." On 6/13/13 at 12:30 PM, during a confidential interview on this date, an interested party stated, " I just get upset when we ask for basic care and he/she doesn ' t receive it. We have looked at the ADL sheets they (the CNA ' s) chart on, which documents the (resident ' s) teeth have been brushed. But the proof is in the look of his/her teeth. " On 6/13/13 at 1:45 PM, licensed nursing staff E reported, " I try to monitor the CNA's charting in the ADL Book, but it is busy sometimes and I don ' t check. I will ask them sometimes if they have charted all their ADL ' s, they are to chart daily. The family never voiced a concerns to me when they come in regarding the resident ' s teeth. I head about the family concerns when they called a couple of days later and talked with the Administrator or the DON (director of nursing)." On 6/13/13 2:22 PM, direct care staff G reported, " I do oral care after meals, bedtime and as needed. I do oral care when we get here, medication gets stuck in his/her teeth, and then after meals. I document in the ADL book. We (the CNA ' s) have a mini care plan sheet which tells us what to do." On 6/13/13 at 2:30 PM, direct care staff H reported, " The resident is total assist, and can ' t feed self. I give oral care before and after meals and when I lay the resident down. I document in the ADL book. When I get the resident up I clean his/her face, and I usually use a toothette, After supper I will brush his/her teeth, and if his/her lips are chapped will use chap stick. " On 6/13/13 at 4:00 PM, licensed administrative staff B reported, " I don ' t know how the resident ' s teeth became so bad. " The undated facility policy and procedure for Oral Care documented the following; "Standard: All resident receive appropriate oral care, including denture care if applicable, daily... 8. If resident is unable to perform self-oral care, provide privacy, place emesis basin in front of resident, and proceed to brush teeth... 9. Observe mouth for any adverse conditions such as bleeding, swelling, unusual mouth odor or any complaint of pain or discomfort. This also includes any adverse conditions that may result from poor fitting dentures. Note any such conditions in resident chart and report problem to the charge nurse. 10. Document oral care on ADL Sheet." The facility failed to provide appropriate oral care for this resident which resulted in bleeding gums prior to and after a long dental procedure, necessary to reach proper oral hygiene status for this resident. - The facility face sheet documented resident #2 readmitted to the facility on [DATE], with the following Diagnosis: [REDACTED]. The annual MDS (minimum data set), dated 1/10/13, documented the resident has unclear speech, understands others, and is usually understood. The resident with a BIMS (brief interview for mental status) score of 15, indicating intact cognition. The resident required total dependence of 1 staff for personal hygiene. The resident's oral/dental status without issue. The CAA'S (care area assessment summary), dated 1/10/13, documented for ADL ' s (Activities of daily living): The resident is a total assist due to ALS (amyotrophic lateral [MEDICAL CONDITION]) and weakness. The quarterly MDS dated [DATE], identified no change from the above MDS. The care plan, reviewed on 3/28/13, for ADL ' s documented the following: --Bathe 2 times a week and as needed. Requires assist of two. Provide oral care twice daily and as needed. The Resident data set, dated 5/19/13, documented the residents Oral Health Status as follows: Some/all natural teeth; without dentures; staining/erosion; normal appearance of tongue; and without inflamed gums, oral mucosal [MEDICAL CONDITION], ulcerations/abscess or complaints oral pain. Daily oral care. The ADL flow record for April 2013, documented the resident to receive oral care twice daily and as needed on 6-2 and 2-10. The record lacked documentation for 2-10 shift 9 out of 31 days. The ADL flow record for May 2013, documented the resident to receive oral care twice daily and as needed on 6-2 and 2-10. The record lacked documentation for day 6-2 1 out of 31 days. For the 2-10 shift, 7 out of 31 days. The ADL flow record for June 2013, documented the resident to receive oral care twice daily and as needed for on and 2-10. The record lacked documentation for 2-10 shifts, 2 out of 13 days. On 6/13/13 at 7:10 AM, the resident is sitting in his/her wheelchair in his/her room. Direct care staff D, washed his/her hands, and gathered supplies to brush the resident ' s teeth, and placed a towel over the resident ' s chest area to protect clothing. Direct care staff D, explained what he/she is going to do, put on gloves, asked the resident to open his/her mouth, and proceeded to brush the resident ' s teeth. Direct Care Staff D then gave the resident a sip of water and asked the resident to rinse and spit into the emesis basin. The resident followed the instructions and direct care staff D washed and dried the resident ' s mouth off. The residents upper and bottom teeth cleaned, and the resident without any complaints. On 6/13/13 at 8:10 AM, the resident sitting in a wheelchair in the dining room being fed breakfast. The resident ate breakfast without difficulty. On 6/13/13 at 12:10 PM, the resident sitting in a wheelchair in the dining room being fed lunch by direct care staff I. The resident eating/chewing without difficulty. On 6/13/13 at 3:30 PM, the resident in bed with the head elevated to a sitting position watching television. Direct care staff H asked the resident if he/she could brush his/her teeth now, and the resident gave permission. Direct care staff H washed his/her hand, gathered the supplies, put on gloves and placed a towel over the resident ' s chest area. Direct care staff H proceeded to brush the resident ' s teeth, upper and lower, front and back. Instructed the resident to take a sip of water, rinse and spit into the emesis basin. The resident followed the instructions and direct care staff H washed and dried the resident ' s face. The resident did not voice any complaints. On 6/13/13 at 7:10 AM, direct care staff D reported, " Oral care is to be done twice a day. We (CNA ' s) brush the resident ' s teeth when we get them up. We know who is to receive oral care by the care plans. " On 6/13/13 at 9:04 AM, administrative nursing staff B reported, " We were aware (oral hygiene) was a problem, so I have been auditing oral care and it has improved. They are to do oral care is AM and PM. I kind of knew we had a problem with oral care. " On 6/13/13 at 9:15 AM, the resident reported, " The staff is very good at doing oral care for me. They are good to me. " On 6/13/13 at 1:45 PM, licensed nursing staff E reported, " The CNA ' s (certified nurses aides) are to do oral care twice a day. Usually when the resident gets up and goes to bed. If I have time I check the ADL sheets to make sure the CNAs are documenting oral care. " On 6/13/13 2:22 PM, direct care staff G reported, " The resident usually only eats breakfast and lunch. We (the CNA ' s) brush the resident ' s teeth when he/she turns on the call light. Will brush his/her teeth a couple of times some nights. We (the CNA ' s) document in the ADL book. " On 6/13/13 at 2:30 PM, direct care staff H reported, " The resident will ask to have his/her teeth brushed anytime during the evening. We (the CNA ' s) document in the ADL book. " The undated facility policy and procedure for Oral Care documented the following; "Standard: All resident receive appropriate oral care, including denture care if applicable, daily... 8. If resident is unable to perform self-oral care, provide privacy, place emesis basin in front of resident, and proceed to brush teeth... 9. Observe mouth for any adverse conditions such as bleeding, swelling, unusual mouth odor or any complaint of pain or discomfort. This also includes any adverse conditions that may result from poor fitting dentures. Note any such conditions in resident chart and report problem to the charge nurse. 10. Document oral care on ADL Sheet." The facility failed to provide consistent oral hygiene for this dependent resident. - The facility face sheet documented resident #3 readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Annual MDS (minimum data set) dated 12/6/12, documented the resident had rarely/never understands others. The resident with short/long term memory problem and severely impaired decision making. The resident required for ADL ' s (activities of daily living) extensive staff assistance of 2 for personal hygiene. The resident without oral/dental issues. The CAA's (care area assessment summary), dated 12/11/12, failed to trigger the ADL care area. For cognition: I identified the resident with severe confusion related to late state Alzheimer ' s disease. Unable to make decisions for self. .. The quarterly MDS, dated [DATE], the MDS remained unchanged from the prior MDS. The May 2013, Resident data set documented for Oral Health Status the following: Some/all natural teeth lost, staining/erosion noted, normal appearance of tongue, no further issues documented. The care plan reviewed on 5/30/13, documented, Cognition: --anticipate needs an ensure needs are met for him/her. --try to use verbal and visual cues with the resident in effort to get him/her to comprehend. ADL ' s: --Requires extensive assist with all self cares, personal hygiene, grooming, etc. The care plan lacked documentation of oral care. The ADL record flow sheet for April 2013, lacked documentation for oral care twice daily and as needed for the 6-2 shift, 6 out of 30 days. and for 2-10 shift, 7 out of 30 days. The ADL record flow sheet for May 2013, lacked documentation for oral care twice daily and as needed for 6-2 shift, 1 out of 31 days; and for 2-10 shift, 1 out of 31 days. The ADL record flow sheet for June 2013, lacked documentation for oral care twice daily and as needed for 2-10 shift, 1 out of 13 days. On 6/13/13 at 8:10 AM, the resident being fed breakfast by direct care staff I. The resident chewing and swallowing without difficulty. On 6/13/13 at 8:55 AM, the resident in his/her wheelchair in room. Direct care staff I gathered supplies, washed his/her hands, and then put gloves on. Direct care staff I explained to the resident he/she is going to brush the resident ' s teeth, then proceeded to brush his/her teeth. The resident did not initially want to open his/her mouth. Direct care staff I instructed the resident to take a sip of water, rinse his/her mouth and then spit into the emesis basin. The resident followed instructions. Direct care staff I washed and dried the resident ' s face. The resident without signs and symptoms of pain or discomfort during the procedure. On 6/13/13 at 12:10 PM, direct care staff D feeding the resident lunch. The resident eating without difficulty. On 6/13/13 at 9:00 AM, direct care staff I reported, " I do oral care when I get a resident up in the morning and as needed. I chart in the ADL book incontinence and oral care every day. " On 6/13/13 at 9:04 AM, administrative nursing staff B reported, " We were aware (oral hygiene) was a problem, so I have been auditing oral care and it has improved. They are to do oral care is AM and PM. I kind of knew we had a problem with oral care. " On 6/13/13 at 1:45 PM, licensed nursing staff E reported, " I try to monitor the CNA (certified nurse aide) charting in the ADL Book, but it is busy sometimes and I don ' t check. I will ask them sometimes if they have charted all their ADL ' s. On 6/13/13 2:22 PM, direct care staff G reported, " I do oral care after meals, bedtime and as needed. I document in the ADL book. We (the CNA ' s) have a mini care plan sheet which tells us what to do. We start getting people up anywhere between 4:30 and 5:00 PM. When I work, I do oral care when the resident gets up and at bedtime. The undated facility policy and procedure for Oral Care documented the following; "Standard: All resident receive appropriate oral care, including denture care if applicable, daily... 8. If resident is unable to perform self-oral care, provide privacy, place emesis basin in front of resident, and proceed to brush teeth... 9. Observe mouth for any adverse conditions such as bleeding, swelling, unusual mouth odor or any complaint of pain or discomfort. This also includes any adverse conditions that may result from poor fitting dentures. Note any such conditions in resident chart and report problem to the charge nurse. 10. Document oral care on ADL Sheet." The facility failed to provide consistent oral hygiene for this dependent resident. - Resident #4 admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. The annual MDS (minimum data set) dated 5/20/13, revealed the resident usually understands others. The resident has a BIMS (brief interview for mental status) score of 9, indicating moderately impaired cognition. The resident required extensive staff assistance of 1 for personal hygiene and set up assistance for eating. The resident without oral/dental issues. The CAA'S (care area assessment summary), dated 5/21/13, documented for cognition: Resident has some cognitive deficit which requires him/her to need cueing and to be redirected. Also needs help with decision making. Staff to assist resident as needed. The CAA'S for ADL ' s (activities of daily living), documented: Resident requires extensive assist at all times with all ADL ' s. Requires supervision/set up for meal due to dementia and [MEDICAL CONDITION] diagnosis. Staff to assist resident as needed. The resident Data Set, dated 5/14/13, documented the following for oral health status: some/ all natural teeth lost, staining/erosion, normal appearance of tongue. Plan for oral health needs not documented. The April ADL flow record for 2013, documented " oral care twice daily and as needed " . Lacked documentation for the 2-10 shift, 8 out of 30 days. The May 2013 ADL flow record lacked documentation or oral care, for 2-10 shift 6 out of 31 days. The June 2013 ADL flow record lacked documentation for oral care, 2-10 shift 2 out of 13 days. The care plan, reviewed on 5/23/13, documented for self-care deficit; Assist of one or two...personal hygiene. --Give the resident verbal cues to help prompt her. --Praise him/her when a grooming or hygiene task is successfully completed The care plan lacked documentation for oral care. On 6/13/13 at 8:05 AM, the resident feeding self breakfast in the dining room. No signs or symptoms of difficulty chewing or swallowing. On 6/13/13 at 8:35 AM, direct care staff C gathered supplies to brush the resident ' s teeth. Direct care staff C washed his/her hands and put on gloves. He/she explained to the resident what he/she going to do, and then proceeded to brush the residents 4 lower front teeth. Direct care staff C instructed the resident to take a sip of water, rinse mouth, and then spit into the emesis basin. The resident followed the directions. Direct care staff C washed and dried the residents face. The resident denied any pain or discomfort. On 6/13/13 at 12:10 PM, the resident in the dining room, feeding self lunch. The resident chewing without difficulty. On 6/13/13 at 7:00 AM, direct care staff C reported, " The resident receives oral care when he/she gets up, and at bedtime. We know what to do for the resident because we have a mini care plan up at the desk we can refer too. We chart that we do oral care in the ADL book, and we are to chart before we leave. " On 6/13/13 at 9:04 AM, administrative nursing staff B reported, " We were aware (oral hygiene) was a problem, so I have been auditing oral care and it has improved. They are to do oral care is AM and PM. I kind of knew we had a problem with oral care. " On 6/13/13 at 1:45 PM, licensed nursing staff E reported, " I try to monitor the CNA's (certified nurses aides) charting in the ADL book, but it is busy sometimes and I don ' t check. I will ask them sometimes if they have charted all their ADL ' s. They are to chart daily." On 6/13/13 2:22 PM, direct care staff G reported, " I do oral care after meals, bedtime and as needed. I document in the ADL book. We (the CNA ' s) have a mini care plan sheet which tells us what to do. I use a toothette with mouth wash, the tooth brush hurts him/her. We start getting people up anywhere between 4:30 and 5:00 PM." The undated facility policy and procedure for Oral Care documented the following; "Standard: All resident receive appropriate oral care, including denture care if applicable, daily... 8. If resident is unable to perform self-oral care, provide privacy, place emesis basin in front of resident, and proceed to brush teeth... 9. Observe mouth for any adverse conditions such as bleeding, swelling, unusual mouth odor or any complaint of pain or discomfort. This also includes any adverse conditions that may result from poor fitting dentures. Note any such conditions in resident chart and report problem to the charge nurse. 10. Document oral care on ADL Sheet." The facility failed to provide consistent oral hygiene for this dependent resident.

The facility identified a census of 48 residents, with 19 residents sampled, including 3 sampled residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to ensure that 2 of 3 residents with cognitive impairment, reviewed for nutrition (#19 and #65) received nutritional supplements, dietary interventions, and consistent monitoring to prevent significant unplanned weight loss. Findings included: - Resident # 19 admitted to the facility on [DATE]. The April 2012, physician orders [REDACTED]. The 1/4/12 admission MDS (minimum data set) identified the resident with a BIMS (brief interview for mental status) score of 6 (0-7 indicated severely impaired cognition), and required extensive assistance with most activities of daily living. It further documented the resident received a mechanically altered, therapeutic diet, lacked any dental concerns, and with a weight of 216 pounds. The nutrition CAA (care area assessment) from the 1/4/12 MDS documented, "Resident's appetite good, able to feed self with set up, has dentures. Requires mechanical soft diet/cardiac diet. Currently working with ST(speech therapy) for cognition and swallowing techniques, is at risk for choking, weight loss, and aspiration." The 3/22/12 quarterly MDS identified the resident with a BIMS score of 1, lacked any changes with activities of daily living and a weight of 205 pounds. The 2/28/12 care plan instructed staff the resident had potential for weight loss, to provide verbal encouragement, cueing, and assistance as needed with meals. To offer food alternatives for meals served, provide between meal snacks, and to monitor and record meal intake. The dietician to evaluate nutritional status as needed. The 4/10/12 nutritional progress notes documented, " Current weight is 187 pounds (4/5/12) which reveals a 8.81 % weight loss in past 33 days, (a significant weight loss.) The resident's BMI (body mass index) is 24, which signify's overweight. the current diet is pureed with ground meat/gravy. The dietician recommended adding 1 can of Ensure (liquid dietary supplement) and adding to the FFP (fortified food program) to prevent further loss. Review of the medical record revealed a physician order [REDACTED]." However, the clinical record lacked documentation of the Ensure ever given until 5/1/12, after facility staff C, questioned by surveyor AA. Review of the meal intake sheets for March 2012, revealed the resident;s breakfast and lunch intake 75-100% with 6 days blank and the dinner intake revealed 5 blanks, 1 day of 25 % the rest showed 75-100% intake. The April 2012, meal intake sheets revealed the resident's intake for breakfast 1 day with 10 %, the rest with 75-100 % with 9 blank days. Lunch documented 18 blank days, 2 days with intake of 50 %, 2 days with 60%, and rest with 75-100 %. Dinner documented 1 day refused, 4 days intake of 10-25 %, 1 day with 50% intake, rest with intake % of 75-100% with 15 days blank. Review of the February - April 2012 snack record revealed the resident accepted a snack twice daily in February. From March 1-8 2012, the record documented a snack accepted 6 times and sleeping 3 times, the remaining days of March withoutdocumentation. The April documentation revealed the resident accepted 1 day, sleeping 2 days with the remaining days without documentation. Observation, on 4/26/12 at 12:00 PM, revealed the resident in the assisted dining room served pureed meal of 3 items on a plate, assisted by direct care staff L, and observed to feed self some. Intake of the meal consumed, 100% with 120 cc (cubic centimeters of fluids.) On 5/1/12 at 8:45 AM, observation revealed resident in the assistant dining room, served pureed meal, pancakes, meat with gravy, and a bowl with pureed bananas, 2 four ounce glasses of apple juice, assisted by direct care staff L. Staff L, reported the resident would take occasional bites, but usually required staff to feed him/her. The resident consumed 100% of meal and 180 cc. fluids. On 5/1/12 at 2:30 PM, direct care staff M, reported he/she did not remember if the resident received a magic cup supplement with the noon meal. " We don't give the magic cups all the time it depends on if the resident ate the meal, if he/she liked and ate the desert we don't give it." On 5/1/12 at 3:45 PM, dietary staff D stated, " The facility has no specific foods they use for the FFP plan. Nothing particular is identified to be given to individual residents, we usually use power milk or give magic cup supplements." On 5/2/12 at 7:50 AM, dietary staff N reported the kitchen adds nothing extra to the pureed diets for residents on the FFP plan. "If they are on that program they get magic cups or power milk." On 5/2/12 at 7:58 AM, dietary staff D stated," I called the dietician last night and we discussed the FFP plan. I have devised a plan to note on each resident 's meal card on the FFP plan the type of fortified food they are to be served, either power milk, power pudding,power cookies,etc. I think this will make it better for the staff to know what to serve the residents." She verified this plan not in place prior to the survey. On 5/2/12 at 10:55 AM, Administrative nursing staff B, verified the resident weighed 205 pounds on 3/1/12 and on 4/5/12, weighed 187 lbs. (a loss of 18 pounds), "The resident was referred to the dietician, I'm not sure what the recommendation was. we put the resident on weekly weights when identified as a weight loss." Staff B, checked and reported ,"Yes it was a significant loss, but he/she was not put on weekly weights until today, 'He/she was put on weekly weights today, but has not been weighed since 4/5/12" On 5/2/12 at 11:10 AM, administrative nursing staff C, verified the resident did have a physician order [REDACTED]." On 5/2/12 at 12:08 PM, direct care staff M, weighed resident reveled a weight of 183 pounds, 4 lbs less than the weight on 4/5/12, resulting in a loss of 22 pounds (10.7%) since 3/22/2012. The facility failed to provide the resident the physician ordered dietary supplement to prevent further weight loss and failed to have a system to provide supplements when the resident consumed less than 75% of the meal served. The resident experienced a 22 pound/10.7 % weight loss from 3/22/12 through 5/2/12, 1 month and 10 days. - According to the clinical record, the facility admitted resident #65, on 2/1/12. The resident's nutritional history/assessment, dated 2/1/12, recorded the resident's as 126 pounds, with the resident's usual body weight of 100 pounds. Review of the physician's orders [REDACTED]. Review of the admission Medicare 5-day Minimum Data Set 3.0 (MD'S) assessment, dated 2/7/12, documented the resident with a Brief Interview for Mental Status (BIMS) score of 3 (that indicated severe cognitive impairment), inattention, [MEDICAL CONDITION], preferred snacks between meals, required supervision and set-up for eating, upper extremity mobility impairment, obvious cavity or broken teeth and a weight of 126 pounds. Review of the Care Area Assessment (Camas), dated 2/13/12, documented severe cognitive deficit related to [MEDICAL CONDITION], unable to make own decisions regarding activities of daily living, pain from a fractured wrist, and staff needed to anticipate the resident's needs and ensure the resident's needs met. This same CAA recorded the resident needed to see a dentist with natural teeth with some broken teeth and apparent dental caries. Review of the significant change Minimum Data Set 3.0 (MD'S) assessment, dated 3/31/12, short and long-term memory impairments, severely impaired decision-making skills, rarely/never understood or made self understood, [MEDICAL CONDITION], extensive assistance of 1 staff member for eating, functional limitation of range of motion to one side of the body, weight of 120 pounds, received a mechanically altered diet, and no weight loss indicated. Review of the Care Area Assessment summary (CAAs), dated 4/3/12, triggered for nutrition and documented a potential for weight loss related to confusion, anxiety, and to continue with the plan of care to monitor weights and assist the resident with meals. Review of the resident's plan of care, dated 2/16/12, documented a potential for weight loss related to confusion,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), and poor dentition. The plan of care included the following interventions: - The dietician to evaluate current nutritional status. - Maintain current listing of food likes and dislikes - Offer food alternatives when appropriate for any meal served - Provide the resident with verbal encouragement/cueing - Weekly weight x 4 then monthly if stable - Refer to speech therapy as needed - Provide between meal snacks - Monitor for changes in resident's condition that may warrant increased supervision/assistance with nutritional intake and notify the resident's physician. The care plan had an intervention, dated 4/9/12, for speech therapy for dysphagia management and include diet analysis. The care plan had an intervention, dated 4/10/12, to place the resident on the fortified food program and to receive 1 can of Ensure, daily The care plan had an intervention, dated 4/23/12, for the resident to receive a pureed diet. The care plan had an intervention, dated 4/29/12, for staff to administer Vitamin B12 and vitamin D, as ordered. The care plan had an intervention, dated 4/30/12, for staff to serve the resident magic cup with lunch. Review of the resident's weights revealed the following: Review of the nursing admission assessment, dated 2/1/12, recorded an admission weight of 126 pounds, with height of 63 inches. Review of the weekly weight list provided by the facility recorded a weight of 122 pounds, on 2/22/12. The clinical record revealed the facility discharged the resident to an acute psychiatric facility on 2/25/12. Review of the nursing readmission assessment, dated 3/7/12, recorded a weight of 119 pounds. Review of the resident's weekly weights, obtained from the facility's weekly weight record, recorded the following: On 3/14/12, the resident's weight was 115 pounds On 3/21/12, the resident's weight was 115 pounds. The clinical record revealed the facility discharged the resident on 3/21/12 and readmitted the resident on 3/26/12, with a weight of 119.75 pounds, as recorded on the nursing reassessment form. On 3/30/12, staff recorded in the dietary nutritional note to add FFP (Fortified Food Program) to the resident's diet and 1 can Ensure plus, daily, secondary to weight loss. This dietary note recorded a brief hospitalization following a [MEDICAL CONDITION] with surgical intervention, the resident's diet remained a mechanical soft diet with fair oral intake, a weight of 119.75 pounds, revealed a 5.5% significant weight loss per 30 days. The nutritional note included laboratory tests reviewed of hemoglobin/hematocrit of 10.2/3.15, indicated low readings, glucose 150, elevated reading. bun (blood urea nitrogen)16, Sodium 144. The dietary note recorded the resident at nutritional risk secondary to age, [DIAGNOSES REDACTED]. The dietary note recommended to add FFP to the resident's diet order and 1 can Ensure Plus each day to prevent further weight loss. On 4/5/12, staff recorded the resident weighed 113 pounds. On 4/11/12, staff recorded the resident weighed 118 pounds. Review of the clinical record revealed the resident went to the hospital for nausea and vomiting on 4/16/12 and readmitted the resident to the facility on [DATE]. The resident's weight upon readmission to the facility was 106 pounds. Upon readmission to the facility, the physician ordered a mechanical soft diet and 1 can of Ensure plus, orally, each day. Review of the 4/17/12 laboratory work, revealed the resident's serum protein tested at 7.2 (within normal limits) and serum [MEDICATION NAME] tested at 3.7 (within normal limits). On 4/23/12, the physician changed the resident's diet to a pureed diet. On 4/25/12, staff recorded on the weekly weight record, the resident weighed 105 pounds. On 4/26/12 11:41 AM, observation revealed staff prepared the Ensure for the resident. During the meal observation, staff had to feed the resident, as the resident kept their head down most of the time. Observation revealed the resident needed encouragement to eat during the meal and ate only 25 % of meal. On 4/30/12, the resident's physician ordered Magic cup (nutritional supplement) served with the noon meal. Review of the 4/12 MAR (Medication Administration Record) lacked evidence of documentation of the physician ordered Ensure, ordered on [DATE], offered until 4/25/12, with documentation of 0% taken by the resident, on 4/26, the resident refused the supplement, and dates of 4/27, 4/28 and 4/29/12 revealed no amounts recorded as taken, and on 4/30/12, 5% of the supplement taken. Review of the resident's meal intake record from 4/18/12 through 4/30/12 (37 meals) revealed staff recorded the resident refused 5 meals, slept through 18 meals, and intake recorded on 13 meals of one meal intake of 80%, 2 meal intakes of 50%, other meal intake of 5-25%. On 4/30/12 at 1:35 PM, direct care staff V stated, "(The resident) has gone downhill recently. Is total care...Mostly dependent including eating now..." Review of the resident's 5/12 meal intake record revealed staff recorded on 5/1/12, the resident consumed 10% of the breakfast, 5% of lunch, and amount of dinner consumption not recorded. On 5/2/12, staff recorded the resident consumed 25% of the breakfast and lunch. On 5/1/12 at 8:07 AM, observation revealed the resident required assistance of staff to consume the morning meal. Observation revealed the resident ate 50% of the pureed breakfast of cream of wheat, eggs, and drank 100% of the milk. Observation during the meal revealed the resident required staff to encourage resident to feed their self. On 5/1/12 at 3:45 PM, dietary staff D stated, "There is nothing different with the diets, pureed, etc. There is no specific foods that (the facility) uses for the FFP program, nothing identified for individual residents." On 5/2/12 at 8:00 A.M., licensed staff I transferred the resident to the dining room chair and served the resident breakfast of pureed biscuits and gravy, eggs, sausage, cream of wheat, Vitamin D whole milk and water. Observation revealed the resident intermittently looked out the window and occasionally took a bite. At the end of the meal, observation revealed the resident drank 1/2 milk of the milk (approximately 4 ounces), but did not eat the cream of wheat cereal. On 5/2/12 at 9:45 AM, dietary staff N stated residents on the fortified food program get whole milk, magic cup, cream of wheat cereal, and added, "The mashed potatoes have stuff in them." On 5/2/12 at 12:00 PM, observation revealed therapy staff assisted the resident with the noon meal. At 12:34 PM, observation revealed the resident only drank 1/2 of the glass of milk. Observation revealed staff failed to provide the Magic cup supplement, as ordered, with the noon meal. On 5/2/12, at 1:24 PM, direct care staff M weighed the resident in the wheelchair and recorded the resident's weight of 98 pounds, an 8 pounds loss (7.5%) since readmission to the facility on [DATE]. On 5/2/12 at 2:45, administrative licensed staff B verified staff failed to initiate the 4/18/12 physician's orders [REDACTED]. At that time, this administrative licensed staff acknowledged this resident with weight loss. On 5/2/12 at 7:58 AM. dietary staff D stated, "I called the dietician last night and discussed the FFP plan. I have devised a plan for each resident, to note the type of FFP they are to be served. Power milk, power pudding, power cookies, etc. I think it would make it better for the staff to know what to serve them. This plan not put into place until during the survey." Review of the facility's 4/04 policy for Nutrition Protocols for Weight loss recorded, "POLICY: The dietitian will assess each resident with an identified weight loss...Interventions in increments may include the following: - Review meal intake, medications, [DIAGNOSES REDACTED]. - Fortify meals with fortified meal plans..." The facility failed to provide the resident the physician ordered dietary supplement to prevent further weight loss and failed to have a system to provide supplements when the resident consumed less than 75% of the meal served. Staff admitted the resident to the facility on [DATE] at a weight of 126 pounds. Upon return from a 10 day hospital stay on 3/7/12, the resident returned to the facility at a weight of 119 pounds. Upon return from a 5 day hospital stay on 3/26/12, the resident returned to the facility at a weight of 119.75 pounds. Upon return from a 2 day hospital stay on 4/18/12, the resident returned to the facility at a weight of 106 pounds. On 4/18/12, the resident's physician ordered staff to provide one can of Ensure plus, daily. The facility failed to provide this physician's orders [REDACTED]. In addition, on 5/2/12, staff failed to provide an additional physician ordered supplement, Magic Cup, during the noon meal. Also, the facility lacked written direction to ensure dietary staff served residents fortified food products when on the fortified food program. On 4/18/12, the resident weighed 106 pounds and on 5/2/12, the resident weighed 98 pounds, an 8 pounds loss (7.5%) since readmission to the facility on [DATE] (14 days).