Every finding on record at Riderwood Village

Number of residents sampled: Number of residents cited: Based on observation, record review and interviews, it was determined that the facility staff failed to treat resident with dignity and care for resident's Activities of Daily Living (ADLs) /hygiene in a manner that promotes maintenance or enhancement of resident's quality of life. This was evident for 1 (Resident #69) out of 3 residents reviewed resident's dignity and ADLs/hygiene care during an annual survey.The findings include:Activities of Daily Livings (ADLs): Activities of daily living are activities related to personal care. They include bathing or showering, grooming, dressing, eating, using the toilet, getting in and out of bed or a chair and walking and more.On 09/15/2025 at 10:55 AM, Resident #69 was alert, and a Geriatric Nursing Assistant (GNA) earlier fed the resident. Surveyor observed this resident was in bed ungroomed; with disheveled hair, a dirty face, eye crust, and in a food-stained gown.On 09/16/2025 at 11:00 AM, The surveyor observed in the hallway and noted GNAs were in and out of Resident #69's room in past 2 hours. Further observed at 11:58 AM, this resident was still in bed not groomed, wearing a dirty gown, breakfast food above the lip. Additionally, their right eye was crusted shut with discharge. Resident #69 expressed a need for staff assistance with morning care and dressing.Record Review 9/16/2025 at 11:30 AM, Resident #69's was admitted to the facility on [DATE]. This resident had a history of moderate vascular dementia, chronic obstructive pulmonary disease, muscle wasting and atrophy. Their care plan indicated a request to honor preferences regarding hairstyle, nail care, makeup, and AM/PM rituals. Additionally, this resident required extensive assistance with ADLs.On 09/16/2025 at 12:15 PM, upon entering Resident #69's room the surveyor and Unit Manager Staff #11 noted that this resident was found still in a dirty gown, with uncombed hair, a greasy face, and food residue above the lip. In addition, eye discharge was preventing the right eye from opening. Staff #11 acknowledged these findings as unacceptable and promptly instructed staff to provide morning care and assist with dressing. Informed Staff #11 that above findings constitute a deficiency concern.During an interview, on 09/16/2025 at 12:25 PM, the Assistant Director of Nursing Staff #1 and the Administrator Trainer Staff #12 were made aware of the above findings as a deficiency concern regarding not treating the resident with dignity and the absence of morning ADLs/hygiene care. On 09/17/2025 at 2:25 PM, the Administrator reported to this surveyor that staff were re-educated.

Number of residents sampled: Number of residents cited: Based on observation and staff interview, it was determined that the facility staff failed to ensure that handrails were on all walls in resident areas including both resident's rooms and all resident common areas. This was evident for 2 of 2 nursing units and all common areas observed during the survey. This deficient practice had the potential to affect all residents, staff, and visitors on the units. The findings include: On Tuesday, 09/16/2025 at 9:16 AM during a tour of the facility, it was noted that there were no handrails near the elevator, an activities room (Garden Room), the hallway near the dining area (Grace's Table). On 9/16/2025 at 11:35 AM, met with the Administrator and employee #8 from the [NAME] Corporation. Employee #8 stated that they thought handrails only needed to be in the areas where resident rooms were located. He was shown the regulation on the surveyors laptop and it was also emailed to him that stated that handrails had to be on both sides of the hall in all areas were residents had access. On 9/16/2025 at 2:20 PM, a tour of the areas of concern in the facility was conducted with the Administrator and Employee #8 and the areas where there were no handrails were pointed out.

Number of residents sampled: Number of residents cited: Based on observation and interviews with staff, it was determined that the facility failed to ensure that the call system cord was accessible in the resident's bathroom. This was evident for 1 (Resident #57) of 1 resident's bathroom observed during the annual survey. The findings include:On 09/16/2025 11:40 AM, the surveyor visited room [ROOM NUMBER] to verify the call bell systems at the bed and the bathroom. The surveyor noted that the call bell cord was too short and tucked behind a trashcan that was placed directly next to the toilet. At 12:50 PM, a tour of room [ROOM NUMBER] was conducted with the Assistant Director of Nursing (ADON) 1 and ADON 2. They both confirmed the call bell cord was inaccessible to the residents due to its length and the placement of the call bell cord in the resident's bathroom. On 09/19/2025 at 4:13 PM, the Assistant Administrator, Assistant Director of Nursing (ADON) 1 and ADON 2 were made aware of these findings.

Number of residents sampled: Number of residents cited: Based on observation, interview, record review and facility policy review, it was determined that the facility failed to ensure meaningful activities to meet the needs/interests of the residents and to provide consistent resident centered/personalized activities for the dependent, confined residents in a manner that promotes maintenance or enhancement of residents' quality of life. This was evident for 2 (Resident #35 and Resident #69) out of 3 residents reviewed for ongoing resident centered activities program during an annual survey. The findings include-1) On 09/15/2025, at 10:09 AM, Resident #35 was observed in their room, awake and knee was contracted to chest. No TV, music or other activity was observed at these times. This resident was able to engage in a short conversation.Observation, on 09/16/2025 at 11:20 AM, Resident #35 was observed in bed, staff were in the room but not interacting with the resident at the time of the observation. This resident was not observed participating in or receiving visits from activity staff during the first two days of the survey.During an interview, on 09/16/2025 at 2:39 PM, the Activity Coordinator Staff #9 stated that most residents participate in two types of activity programs: group and individual activities. The calendar for group activities was provided and posted in advance. Noted the group activity schedule was from 9:00 AM and end around 4:30 PM. She continued to share that there was no set time for individual activities for those who were confined to their rooms. The Activity Director Staff #10 indicated that Resident #35 received one-to-one room visits from Staff #11. Staff #11 was not present for this interview. Surveyor requested copies of the individual Activity Log for recent 2 months of August and September.Record Review, on 09/19/2025 at 10:10 AM, Resident #35's was admitted on [DATE] to this facility with history of Parkinson's, osteoporosis, muscle wasting and atrophy, contracture of limbs, vascular moderate dementia. The care plan was examined that this resident was a Social Worker prior to retirement and interest/preferences were enjoying listening to music, spiritual/religious opportunity and family calling and visiting. This resident's assessment was dependent on staff for all Activity Daily Livings needs. The activity plan was to have one-to-one visit dramas on TV, listening to music and going outside when the weather was good, but the plan was not aligned with Resident #35's meaningful special interests/care plans. Furthermore, a review of the activity staff's Activity Log from August to September 2025 revealed that only dates were recorded i.e.: 8/4, 8/6, 8/11, 8/13, 8/18, 8/20, 8/22, 8/25, 8/27 and 8/29 as 10 days out of 31 days in August. Also, 9/1, 9/3, 9/8, 9/10 and 9/15 as 5 days out of 17 days in September. Again, no specific one-to-one activity was recorded on above those dates on the Activity Logs.Interview conducted on 09/19/2025, at 10:25 AM, Activity Staff #11 stated she was assigned to Resident 35's Unit, and her working hours were from 8:30 AM to 5:00 PM and she conducted all the group activities according to the group activity schedule. She mentioned visiting all dependent residents for one-to-one visit was not conducted consistently. She also confirmed that there was no activity recorded on the Activity Log including Resident #35.Record review, on 9/19/2025 at 11:20 AM, the facility Programming/Activity Policy under section 3 revealed that offered daily are based on the resident's holistic assessment, care/service plan and the preferences of each residentThe concern regarding the failure to provide one-to-one meaningful activities to meet dependent residents' needs/interests/preferences and be consistent with dependent residents' center/personalized activities based on assessments, care plans, the facility's policy and activity's log were reviewed with the Administrator on 09/22/2025 at 9:25AM. 2) On 09/15/2025, at 10:51 AM, Resident #69 was observed in bed awake, staring at the wall not able to move and with no apparent activity offered.Observation, on 09/16/2025 at 11:30 AM, Resident #69 was in bed. No TV, music or other activity was observed at these times, and this resident was not observed participating in or receiving visits from activity staff during the first two days of the survey.During an interview, on 09/16/2025 at 2:39 PM, the Activity Coordinator Staff #9 stated that most residents participate in two types of activity programs: group and individual activities. The calendar for group activities was provided and posted in advance. Noted the group activity schedule was from 9:00 AM and ended around 4:30 PM. She continued to share that there was no set time for individual activities for those who were confined to their rooms. The Activity Director Staff #10 indicated that Resident #69 received one-to-one room visits from Staff #11. Staff #11 was not present for this interview. Surveyor requested copies of the individual Activity Log for recent 2 months of August and September. On 9/16/25 at 3:20 PM, observed Resident #69 was dozing off while sitting in bed. During this observation, no individual activity was offered to this resident nor activity staff were present.Interview conducted on 09/19/2025, at 10:25 AM, Activity Staff #11 stated she was assigned to Resident 69's Unit, and her working hours were from 8:30 AM to 5:00 PM and she conducted all the group activities according to the group activity schedule. She mentioned visiting all dependent residents for one-to-one visit was not conducted consistently. She also confirmed that there was no activity recorded on the Activity Log.Record Review, on 09/19/2025 at 11:00 AM, Resident #69's was admitted on [DATE] to this facility with history of moderate vascular dementia, chronic obstructive pulmonary disease. and muscle wasting and atrophy. Reviewed Resident #69's care plan found that he/she enjoyed drawing, historical documentary activities, family visits and to be creative and simulated cognitively throughout the week. Additionally, she requested to honor the preferences for hairstyle, nail care makeup and AM/PM rituals. The care plan was examined but the planned activities were not aligned with Resident #69's specific meaningful interests/ preferences/care plans. Furthermore, a review of the activity staff's Activity Log from August to September 2025 revealed that only dates were recorded i.e.: 8/4, 8/6, 8/11, 8/13, 8/18, 8/20, 8/22, 8/25, 8/27 and 8/29 as 10 days out of 31 days in August. Also, 9/1, 9/3, 9/8, 9/10 and 9/15 as 5 days out of 17 days in September. Again, no specific one-to-one activity was recorded on above those dates on the Activity Logs.Record review, on 9/19/2025 at 11:20 AM, the facility Programming/Activity Policy under section 3 revealed that activities offered daily are based on the resident's holistic assessment, care/service plan and the preferences of each resident.The concern regarding the failure to provide one-to-one meaningful activities to meet dependent residents' needs/interests/preferences and be consistent with dependent residents' center/personalized activities based on assessments, care plans, the facility's policy and activity's log were reviewed with the Administrator on 09/22/2025 at 9:25AM.

Based on observations and interviews with staff, it was determined that the facility failed to ensure that the environment of 1) resident's rooms and 2) a resident's shower chair was maintained in a manner that minimized the potential for the spread of infection. This was evident for 3 of 4 areas reviewed during the annual recertification survey. The findings include: 1) On 09/15/2025, at 11:40 AM, during an initial tour of Resident #7's bathroom and room, a grey fall mat was observed on the bathroom floor, touching the toilet. A clear plastic bag containing a black object was also seen on the bathroom floor. In Resident #7's room, a clear plastic bag was found on the floor under the medicine cabinet, containing a light green and grey chuck and a gown. On 09/15/ 2025, at 11:54 AM Staff #7, a Licensed Practical Nurse (LPN), was shown the fall mat and the plastic bags in both the bathroom and the room. Staff #7, LPN was asked about the policy/procedure for floor mats in bathrooms and linens on the floor. Staff #7 explained that aides typically bathe residents, change bed linens, and then remove the linens from the room for laundering. Staff #7, LPN was then asked about the black object in the plastic bag on the bathroom floor. After putting on gloves, Staff #7, LPN, identified it as a wheelchair cushion for Resident #7. Staff #7, LPN was also shown the plastic bag on the floor in Resident #7's room with the gown and chuck inside. Staff #7, LPN, was asked about the handling of soiled linen. Staff #7, LPN, stated that aides place soiled linen in a clear plastic bag and take it to the soiled utility room to be put down the laundry chute. Staff #7, LPN acknowledged that the floor mat, wheelchair cushion, and linens should not have been on the floor and removed all items from the room. On 09/15/2025, at 12:09 PM, during the initial tour of Resident #73's bathroom, a Geri-chair was observed with a white sheet and a pink triangular abductor wedge were on the seat. A floor mat was also observed leaning against the toilet and trash can in the bathroom. On 09 /15/2025, at 12:13 PM Staff #7, LPN, was shown the Geri-chair, pink triangular abductor wedge, and the floor mat touching the toilet. When asked if these items should be in the resident's bathroom, Staff #7, LPN, stated that furniture should not be in the bathroom, and floor mats are generally placed against the bed when the resident is out of bed and out of the room. Staff #7, LPN verbalized understanding that these items could potentially spread infection. Staff #7 then removed the items from the room and took them to the soiled utility room to be cleaned 2) On 09/18/2025 at 11:10 AM, a tour of the second-floor Spa room revealed an unclean shower chair. An interview with Staff #17 verified that the shower chair should be cleaned by care associates before and after use. Staff #17 further explained that housekeeping provided deep cleaning of the spa room each morning. At 11:15 AM, an interview with Staff#19 and the second-floor clinical manager confirmed that the shower chair should be cleaned before and after use to minimize the potential spread of infectious diseases. At 12:45 PM, the surveyor verified that the housekeeping staff cleaned the spa room. On 09/19/2025 at 4:10 PM, the Assistant Administrator, Assistant Director of Nursing (ADON) 1 and ADON 2 were made aware of these findings.

Based on record review and staff interview, it was determined that the facility staff failed to ensure documentation of residents' Pneumococcal vaccination status in their medical records. This was evident for 1 (Resident #369) of 5 residents reviewed who were eligible for Pneumococcal vaccines during the survey. The findings include: Pneumococcal vaccine helps prevent Pneumococcal disease, any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a Pneumococcal vaccine for those age 65 and older and adults 19 through 64 with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) On 10/18/23 at 9:49 AM, randomly selected five residents' (eligible for the Pneumococcal, Flu, and COVID vaccination) vaccination statuses were reviewed. Reviewing Resident #369's paper medical chart revealed blank vaccination consent forms (for Influenza, Pneumococcal, and COVID-19) without any detailed information. During an interview with a Unit manager (Staff #3) on 10/18/23 at 10:22 AM, she stated Resident #369 had received Flu vaccine in the assisted living before being admitted to this facility on 10/03/23. Staff #3 also said that since the facility did not have Resident #369's COVID and Pneumococcal immunization status, she had emailed family members upon the resident's admission. On 10/18/23 at 10:50 AM, a review of the facility's electronic medical record vaccination survey section revealed that Resident #369's Flu and COVID vaccine was completed. However, the vaccination survey report showed the resident's Pneumococcal vaccination status as no record. In an interview with the Infection Control Preventionist (ICP) on 10/18/23 at 11:08 AM, she stated upon the resident's admission, the facility staff tracked their immunization status and updated them under medical records. The ICP said she expected the vaccination status to be updated within 2-3 days. The surveyor shared concerns about Resident #369's Pneumococcal vaccination status. The ICP verbalized she understood. During an interview with the Director of Nursing (DON), the ICP, and Staff #3 on 10/18/23 at 1:15 PM, Staff #3 insisted that since she did not receive any response from Resident #369's family member regarding his/her vaccination consent, she called them on 10/10/23. Resident #369 's family members confirmed that they would be at the facility on 10/18/23 for a care plan meeting and would sign the consent at that time. The surveyor asked the facility staff whether they had any documentation about this communication under the resident's medical record. Staff #3 confirmed that there was no documentation. On 10/18/23 at 1:25 PM, the facility staff submitted a Pneumococcal vaccine consent form for Resident #369 signed by a family member dated 10/18/23. The DON confirmed that the form was completed on 10/18/23. The surveyor informed the above issue about a Pneumococcal vaccination status that was not tracked for Resident #369 on 10/18/23 at 1:35 PM with the Nursing Home Administrator and the DON.

Based on observation, medical record review and interview it was determined the facility failed to follow physician's orders and the resident's care plan for the administration of oxygen. This was evident for 1 (#56) of 1 resident reviewed for the administration of oxygen. The findings include. Resident #56 was observed in bed on 10/10/23 at 1:40 PM receiving oxygen via nasal cannula (a tube worn in the nostrils to administer oxygen) that was attached to an oxygen concentrator (a machine that concentrates oxygen from room air). The flow meter scale with a metal ball was observed between the 4 and 5 lines to show an oxygen flow rate of 4.5 liters per minute. At 1:52 PM the facility's infection preventionist (staff #6) entered Resident #56's room to observe the oxygen concentrator. An interview followed and she indicated that she was documenting when the oxygen tubing was replaced. She was asked about the current oxygen flow rate, and she went back into the resident's room and upon exit she indicated that the metal ball was above the 4 line. On 10/10/23 at 2:50 PM the director of nursing assisted the surveyor in navigating Resident #56's electronic health record to locate the physician order for the administration of oxygen. The oxygen administration order of 8/3/23 indicated that a physician order for oxygen to be administered at 4 liters per minute. The director of nursing was informed of the observation of the flow meter rate set on 4.5 liters per minute and confirmed that the infection preventionist acknowledged that the rate was above 4 on the oxygen flow rate. Review of Resident #56's care plan on 10/18/23 revealed a care area indicating that the resident required oxygen therapy with a care intervention indicating that Resident #56 will need assistance in keeping O2 (oxygen) on and maintain prescribed liters of administration at all times daily. 4 LPM (liters per minute).

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (#52, #65, #218) of 3 residents reviewed for hospitalization . The findings include: 1.) Resident #52's medical record was reviewed on 10/11/23 at 11:20 AM. Review of a RN nursing note (staff #5) on 7/28/23 at 11:31 AM revealed Resident #52 was evaluated by a nurse practitioner and a doctor and an order for transfer to the emergency room via 911. Review of a nurses note of 8/1/22 effective for 6:30 PM revealed that after a nurse practitioner's skin wound assessment, the nurse practitioner ordered to transfer resident back to the hospital. Resident #52 was transferred to the hospital via 911. There was no written documentation in the medical record that the responsible party and/or resident was notified in writing of the 2 hospital transfers. The unit's clinical manager (staff #3) was interviewed on 10/13/23 at 12:43 PM. She was asked how the facility notifies the resident and/or the resident's representative in writing of the reason for transfer to the hospital in a language they. She indicated that the residents responsible party is notified and documented in progress notes. She indicated that administrative staff send a notice to the ombudsman. She adamantly indicated that the facility did not have a mechanism to inform the resident in writing when transferred to hospital. 42507 2.) On 10/11/2023 at 10:10 AM, Resident #218 was observed being taking out of the unit via stretcher by the paramedics. Per Licensed Practical Nurse, LPN #4, the resident was being taken to the hospital for treatment. Review of the medical record for Resident #218 on 10/17/2023 at 9:35 AM revealed documentation by nursing on 10/11/2023 at 11:42 AM that Resident #218 was transferred to an acute care facility on 10/11/2023 via 911: . Resident's son notified of the transfer to the hospital and also agreed to hold bed while resident is out at the hospital. However, there was no documentation and/or evidence in the record indicating that the facility staff notified the resident/resident's representative (RP) in writing of the reason for the transfer/discharge to the hospital. On 10/17/2023 at 10:12 AM, in an interview with LPN #4, she stated that Resident #218 was still in the hospital. Regarding resident/RP notification of transfers to the hospital, LPN #4 stated that the transferring nurse was responsible for notifying the resident and/or their RP about the bed hold policy. LPN #4 stated that communication regarding reasons for transfer of a resident was done verbally by phone and/or in person (when family was present at time of transfer) and documented in progress notes. LPN #4 confirmed that she did not notify Resident #218 and/or the resident's family/RP in writing of the reason for the transfer to the hospital. On 10/17/2023 at 10:34 AM, an interview was completed with the unit's Clinical Manager, Registered Nurse (RN #1) regarding notification of the resident/RP in writing of the reason for transfer to the hospital. RN#1 stated that they attempted to call Resident #218's spouse but s/he did not answer their phone, so the facility staff ended up calling/notifying the resident's son. RN #1 added that she later gave Resident #218's spouse the facility's Emergency transfer form and change in condition form that indicated the reason why the resident was transferred out. However, when asked to provide a copy/proof that she gave the resident's spouse in writing reason for the transfer to the hospital, RN #1 stated that the facility did not have any specific form that they give. RN #1 added that they did not give specific written notification regarding reason for transfers apart from the Emergency transfer form and change in condition form that were sent out with the resident. Surveyor noted and reviewed a copy of the Bed hold notification to Resident #218's son that was on file and dated 10/11/2023. However, there was no written documentation that the resident and/or resident representative was notified in writing of the reason for the transfer/discharge to the hospital. 43096 3) A review of Resident #65's medical record on 10/12/23 at 1:51 PM revealed that the resident's change in condition was documented on 9/14/23 at 7:50 AM about he/she noted unresponsive, congested with shallow breathing. The resident was evaluated by CRNP (Certified Registered Nurse Practitioner) with a new order to transfer the resident to the ER for further evaluation due to unresponsiveness. Further review of an electronic medical record revealed the Emergency Transfer to Hospital Form for Resident #65 documented that the resident was transferred to the hospital via ambulance on 9/14/23 at 8:12 AM. In an interview with the Director of Nursing (DON) on 10/12/23 at 2:42 PM, she stated that the facility staff documented a change in condition and emergency transfer to hospital form under assessment, but no additional note was required to document about the residents' transfer/discharge. During an interview with the DON on 10/17/23 at 1:29 PM, she confirmed that the facility staff called the residents' family members for their transfer/discharge, documented the emergency transfer form, and reported to the ombudsman.

Based on medical record review and interview of facility staff it was determined the facility staff failed to notify the physician when Resident #2's [MEDICAL CONDITION] machine malfunctioned. This was evident for 1 of 4 sampled residents reviewed. The findings include: Medical record review on 6/19/19 and 6/21/19 revealed that Resident #3 was admitted to the facility on [DATE] after being hospitalized and treated for [REDACTED]. Review of the hospital record revealed that a recommendation was made to keep the resident's oxygen saturation at 88% - 92% with the use of [MEDICAL CONDITION] as needed during the day and routinely at night. A [MEDICAL CONDITION] (bilevel or two-level positive airway pressure) is a non-invasive ventilation device that delivers an inhale pressure and an exhale pressure to support breathing in [MEDICAL CONDITION]. Medical record review revealed that on 4/16/19 at 12:24 a.m. the nurse documented the following entry in the progress note: . Resident scheduled for ([MEDICAL CONDITION]) every night, staff attempted to apply, but machine not working. The number written on the machine multiple times, but no response, will follow up in a.m. Resident remains in stable condition. No signs of distress noted . Medical record review revealed that on 4/16/19 at 6:35 a.m. the nurse documented the following entry in the progress note: . Bi pap machine remain(s) non functional from previous shift. (R)eport will be given to incoming nurse to follow up on the machine function. (R)esident slept most of the night but was awake periodically yelling and screaming for help . There was no documented evidence that the nurse notified the physician when the resident's [MEDICAL CONDITION] malfunctioned. Medical record review revealed the vendor for the [MEDICAL CONDITION] machine was notified on 4/16/19 at 8:23 a.m. and advised facility staff that a technician would come in to assess the machine or bring a new one. Interview of the Director of Nursing on 6/21/19 at 3:57 p.m. revealed that the nurse notified the supervisor, however, it was determined the nurse and the nursing supervisor failed to notify the physician when the resident's [MEDICAL CONDITION] malfunctioned.

Based on medical record review and interview of facility staff it was determined the facility staff failed initiate interventions to provide additional fluids when Resident #1 developed loose stools with suspected [MEDICAL CONDITIONS] infection. This was evident for 1 of 4 sampled residents selected for review. The findings include: Medical record review on 6/19/19 and 6/21/19 revealed that Resident #1 was admitted to the facility in (MONTH) 2019 for short-term rehabilitation following a hospitalization . The resident had a recent history of treatment with intravenous antibiotics for possible aspiration pneumonia. The resident had an indwelling urinary catheter. Medical record review revealed that Resident #1 had large to extra large loose stools on the following dates and times per the activities of daily living flow sheet: 5/22/19 3:17 p.m. 5/23/19 11:16 a.m. 5/23/19 4:14 p.m. 5/24/19 10:46 p.m. 5/25/19 7:19 a.m. 5/25/19 11:27 a.m. 5/25/19 9:57 p.m. Medical record review revealed that on 5/25/19 at 2:37 p.m. the nurse documented the following entry in the progress notes: Resident had 2 episode(s) of smelly loose stool this AM, and low grade fever of 99.2 . Dr. (name of physician) notified via clipboard, stool specimen for [MEDICAL CONDITION] collected . [MEDICAL CONDITIONS] is a bacterial infection of the colon. It typically occurs after the use of antibiotic medications. Symptoms include watery diarrhea 3 or more times per day. Diarrhea from [MEDICAL CONDITION] infections can result in dehydration. Although the resident was experiencing loose stools with suspected [MEDICAL CONDITION] infection 5/22/19 through 5/25/19, there was no documented evidence that nursing initiated interventions to ensure that the resident received additional fluids to attempt to prevent dehydration. Medical record review revealed that Resident #1 continued to have loose stools on the following dates and times per the activities of daily living flow sheet: 5/26/19 11:50 a.m. 5/26/19 3:13 p.m. 5/26/19 9:42 p.m. 5/26/19 9:50 p.m. 5/27/19 5:17 a.m. 5/27/19 7:13 a.m. 5/27/19 10:58 a.m. 5/27/19 8:02 p.m. Although the resident continued to have multiple loose stools 5/26/19 through 5/27/19, there was no documented evidence that nursing initiated interventions to ensure that the resident received additional fluids to attempt to prevent dehydration. Medical record review revealed that on 5/28/19 the resident was seen and examined by the nurse practitioner. The nurse practitioner documented that the resident was seen due to foul-smelling diarrhea and chronic Foley catheter use. The nurse practitioner documented that the resident complained of abdominal discomfort, his/her appetite was poor, had been weaned off of oxygen, but appeared slightly dyspneic. The nurse practitioner further documented that per discussion with the resident's spouse, awaiting results of stool for [MEDICAL CONDITION] and resident would be started on the antibiotic [MEDICATION NAME] 125 mg. by mouth 4 times per day x 10 days then every 8 hours x 3 days, then every 12 hours for 3 days. The nurse practitioner made no recommendation to increase fluids. Medical record review revealed that on 5/29/19 at 2:44 a.m. the nurse documented the following entry in the nursing progress notes: Alert and verbally responsive. Resident has an indwelling Foley catheter but it was not draining any urine. The foley was irrigated but returned very little. Resident has been having loose stool for days. v/s (vital signs) taken was (blood pressure) 71/48. (pulse) 98. (respirations) 22. (temperature) 97.7. MD on call notified and she ordered Nacl (sodium chloride solution) 0.9% at 100 (ml)/hr. x 1 liter. A (peripheral) line was inserted on the right hand. The IV is infusing without any IV complications. Will (continue) to (monitor). Medical record review revealed that on 5/29/19 the resident was seen and examined by the physician. The physician documented that the resident was acutely ill appearing with dry oral mucosa. The physician further documented: Completed 1 L of IV fluids, with minimal response - 200cc of (u)rine (output), B.P's still very low. With (his/her) severe dehydration, fluid loss with on going diarrhea and oliguria (he/she) need(s) higher level of care for aggressive IV hydration with close monitoring with labs and for nursing care as (he/she) is at high risk for decompensation. Discussed with the (spouse) and 2 daughters by the bedside with the current options of treatment and levels of care. They are agreeable for the hospital transfer. Review of the progress notes revealed that Resident #1 was transferred to the hospital via 911 on 5/29/19 at approximately 9:00 a.m. Interview of the Director of Nursing on 6/21/19 at 3:57 p.m. revealed that the nurses continued to monitor the resident's loose stools, monitored meal intake and offered fluids as needed. The Director of Nursing was unable to produce evidence that interventions were initiated to provide additional fluids to the resident in the presence of suspected [MEDICAL CONDITION] infection.

Based on medical record review it was determined the facility staff failed to develop a care plan for residents with impaired skin integrity. This was evident for 2 out of 4 resident's reviewed with non-pressure related skin conditions. Resident #8 and Resident #37 were affected by the deficient practice. The findings include: Resident #37's medical record was reviewed on 1/30/19 and 1/31/19. Medical record review revealed that on 1/16/19 the resident underwent [REDACTED]. Wound care instructions included: 1) Leave the original dressing in place for 24 hours; 2. Clean the wound once a day; allow water, shampoo and soap from the shower to wash over the wound; 3. Cover the wound with [MEDICATION NAME] or Vaseline and then apply a bandage for 1 - 2 weeks. Change the bandage daily. Additional instructions included reporting the following symptoms to the physician: increase in redness more than 1/4 inch on each side of the biopsy site; swelling; increasing or severe pain; drainage of pus; fever over 100.5 degrees; bleeding which cannot be stopped by firm pressure for 20 minutes. Medical record review revealed that on 1/17/19 at 11:03 P.M. the nurse documented the following entry in the progress notes: Biopsy site on the back intact, no s/s (signs/symptoms) of infection, c/o (complained of) pain, [MEDICATION NAME] given prn (as needed) with good effect, new order for dsg (dressing) change daily after washing with soap and water and applying vaseline. Medical record review revealed that on 1/30/19 the resident returned to the consultant physician for suture removal. The visit note stated that the wound was red and healing slowly. Instructions for wound care to the biopsy site included an antibiotic topical ointment, mupirocin 2% 2 times per day for 2 weeks. Medical record review revealed that the facility staff failed to develop a care plan with measurable goals and appropriate interventions related to the care and monitoring of the resident's biopsy site. 2. Resident #8's medical record was reviewed on 1/29/19, 1/30/19 and 1/31/19. Medical record review revealed that the resident has a history of multiple skin tears. The resident was treated for [REDACTED]. Review of the resident's skin sheet revealed that the resident's current active wounds are a pressure related wound of the sacrum, right posterior arm ecchymosis and a right posterior knee skin tear. Medical record review revealed that the resident has a care plan dated 10/23/18 for skin integrity related to a pressure related wound. Although the resident has been assessed with [REDACTED].

Based on facility staff interview, family interview, and observation of residents' records, the facility failed to individualize the care plan for Resident # 72. This was evident for 1 out of 32 residents investigated for care plan revision. The findings include: On 2/1/19 at 2:10 PM Resident # 72 was reviewed for unnecessary [MEDICAL CONDITION] medication, and dementia care. The resident has a history of [MEDICAL CONDITION], adjustment disorder, [MEDICAL CONDITION], anxiety, CAD (coronary [MEDICAL CONDITION]), Hypertension, diabetes 2, muscle weakness, gout, [MEDICAL CONDITION], hypercalcemia, [MEDICAL CONDITIONS] among other diagnoses. On 9/12/18 the resident was seen by Behavior Health to discuss gradual dose reduction of Klonopin and [MEDICATION NAME]. Record review revealed that the resident is alert and responsive on most days. Speech is soft, no anxiety present and the resident does not have acute distress. The behavior documentation sheet for the last 2 months indicated no behaviors present. Facility staff (# 6, 7, 8) were interviewed on 2/1/19 at approximately 1:30 PM with the federal surveyor present. Staff Members #6, 7 and 8 indicated that there were no targeted behaviors in the last couple of months That Resident # 72's family was present during the time of the behavior consult on 9/12/18 and did not want the resident to be taken off of any drugs as they believed this was the most stable that the resident has been in a long time. The family, daughter and husband, also, indicated to facility staff that they did not want the resident taken off any medication at this time. Also as revealed during this staff interview, the family are considering hospice soon for the resident. The plan is to continue medication and provide structure socialization. The Care Plan was completed but was not individualized to include the family wishes. The Care Plan did not include the family wishes to keep Resident #72 on Klonopin 0.5 mg, [MEDICATION NAME] 25 mg, and [MEDICATION NAME] 20 mg. The Brief Interview for Mental Status (BIMs) score was 3/15 for this resident.

Based on interviews with family and staff; and record review, the facility failed to individualize the care plan for 1 out of 32 residents investigated for individualized care plans. The findings include: On 02/01/19 at 11:53 AM record review revealed that Resident # 72 has a history of [MEDICAL CONDITION], adjustment disorder, [MEDICAL CONDITION], anxiety, CAD ([MEDICAL CONDITION],)[MEDICAL CONDITION](hypertension), DM2, (diabetes) muscle weakness, gout, [MEDICAL CONDITION], hypercalcemia, [MEDICAL CONDITIONS]. Review of the Social Worker's note completed on 1/30/19 indicated that the social worker spoke with family regarding hospice services. It was noted that Family agree with the hospice services but will look at the different hospice facilities and what they provide and then decide on the best option. The Family would let the social worker know. The resident is alert and responsive most days. She eats in the dining room with assistance. Family, husband and daughter very involved with mother. It was discussed with staff to not put Resident #72 back to bed unless she is with someone. Continued record review revealed that on 9/12/19 the resident was seen by Behavior Health to discuss GDR (gradual dose reduction) of Klonopin and [MEDICATION NAME]. Speech was soft, no anxiety present and the resident did not have acute distress. The Family was present during the time of the consult and did not want the resident to be taken off any drugs as they felt that this has been the most stable that the resident has been. The plan was to continue medication, provide structure socialization. The resident's Bims score was 3/15. According to medical record information the resident needs total assistance. A Care Plan was in place for non pharmacal interventions. The medical record revealed that on 1/7/19 the resident was referred to the Nurse Practitioner (NP) due to increased falls and agitation. as noted, the resident continues to hallucinate and have agitation. She needs constant redirection. Klonopin given as scheduled. The resident has had a change of condition since last week. The family believes that she has suffered a minor stroke. She/he is a no send to the hospital. Family will not agree to altering medication. Daughter and father are with resident every day. Any changes must go through daughter. The Family wishes were not included on the care plan. The care plan was not individualized. On (MONTH) 1, 2019 at 3:00 P.M. the surveyor interviewed the Geriatric Nursing Assistant (GNA) and nurse in charge of Resident #72 and they stated no behavior concerns about the resident.

Based on observation, medical record review and interviews of facility staff it was determined the facility failed to ensure that staff were transferring residents from bed to chair/chair to bed in accordance with the residents' care plans. This was evident for 2 of 7 sampled residents reviewed for accidents. Resident #1 and Resident #5 were affected by the deficient practice. The findings include: 1) On 1/29/19 at 1:07 P.M. the surveyor knocked on Resident #5's bedroom door. A Geriatric Nursing Assistant, GNA (Staff #11), answered the door. The resident was observed by the surveyor in the sit-to-stand mechanical lift. The resident had been left unattended in the sit-to-stand mechanical lift while Staff #11 answered the surveyor's knock on the door. Interview of the GNA, Staff #12, on 2/5/19 at 3:37 P.M. revealed that the care plans are located in the residents' rooms and provide information related to how a resident is transferred. Further interview of Staff #12 revealed that she utilizes the sit-to-stand mechanical lift to transfer Resident #5 and the resident is a 1 person assist. Interview of the Staff Development Coordinator, Staff #13, on 2/6/19 at 1:04 P.M. revealed that a resident that utilizes the sit-to-stand mechanical lift has to be able to bear some weight, have moderate upper body strength and be able to follow commands. Interview of the Unit Manager, Staff #14, on 2/6/19 at 2:20 P.M. revealed that Resident #5 requires the assistance of 2 staff for safe transfers. The Unit Manager, Staff #14, was unable to locate an assessment in the medical record indicating that the resident could be safely transferred with the sit-to-stand mechanical lift. Medical record review on 2/6/19 of Resident #5's Holistic Care Plan dated 1/12/19 revealed that the resident rarely/never understands and requires extensive assistance with the support of 2+ staff for transfers. Care plan approaches include using a gait belt during transfers. Review on 2/6/19 of Resident #5's quarterly Minimum Data Set (MDS), an assessment tool, revealed that Resident #5 was unable to complete the brief interview for mental status, has a short and long-term memory problem, has severe cognitive impairment, his/her ability to understand others is rarely/never and has functional range of motion impairment of the upper and lower extremities on both sides. Although staff are utilizing a sit-to-stand mechanical lift for transfers, there was no documented evidence in Resident #5's medical record that the resident was assessed for his/her ability to safely utilize the sit-to-stand mechanical lift for transfers. 2) Resident #1's medical record was reviewed on 1/29/18, 2/5/18 and 2/6/18. Medical record review revealed that Resident #1 has a history of skin tears and bruises. Review of nursing progress notes revealed that the resident sustained [REDACTED]. Review of the resident's holistic care plan, dated 10/10/18, revealed that the resident is totally dependent for transfers from chair to bed/bed to chair with the assistance of 2+ staff. Approaches include utilizing a gait belt during transfer assist. Medical record review and facility internal documents revealed that on 10/14/18 the Geriatric Nursing Assistant (GNA) was transferring the resident from the bed to the wheelchair, and the resident sustained [REDACTED]. x 1.5 cm. on the right shin. It was further documented that there were no new interventions at that time and staff would continue to use caution to prevent a reoccurrence. Interview of the Unit Manager, Staff #14, on 2/6/18 at 1:35 P.M. revealed that he was not aware of whether or not the gait belt was used during the transfer of 10/14/18 and whether or not 2 staff assisted the resident with the transfer. The Unit Manager contacted the GNA, Staff #15, and reported to the surveyor on 2/6/18 at 1:45 P.M. that the GNA, Staff #15, utilized the gait belt when transferring the resident on 10/14/18, and was alone when she transferred the resident.

Based on observations and staff interviews it was determined that required staff posting information was not in a prominent place readily accessible to residents and visitors. This was evident during the entire survey process. The findings include: On 2/1/19, 2/5/19, 2/6/19, 2/7/19, 2/8/19 the required nursing staffing information per this regulation was observed posted in the nursing administration area of the facility facing the interior wall not visible or readily assessible to residents and visitors. On 2/6/19 at 3:00 P.M. interview with the Administrator and Director of Nursing verified that the required staff posting was not available for resident or visitors during the survey process.

Based on the medical record and staff interviews, the facility staff failed to provide required written notice for Resident #69, or the resident's responsible party, of the bed hold policy during a transfer out of the facility. This was evident for 1 out of 2 residents investigated for hospitalization during the survey process. The findings include: On 01/31/19 around 12:07 PM while reviewing Resident #69's medical record for a recent hospitalization , it was noted that on 12/18/18 the resident was observed to be unresponsive with labored breathing. The doctor assessed the resident and ordered the resident to be transferred to the hospital for a [MEDICAL CONDITION](stroke). Review of the hospital transfer record and the resident's chart did not reveal that a bed hold policy was given to the resident or the resident's responsible party prior to the transfer. The bed hold policy educates the resident on whether a bed can be held during the resident's absence, and/or if not, the possibility of having to privately pay to hold the resident's bed, until the resident's return. This information was discussed by the surveyor with staff #6 who acknowledged the omissions.

Based on the medical record and staff interviews, the facility staff failed to provide necessary written notices for Resident #69, or the resident's responsible party, of a transfer out of the facility. This was evident for 1 out of 2 residents investigated for hospitalization during the survey process. The findings include: On 01/31/19 around 12:07 PM while reviewing Resident #69's medical record for a recent hospitalization , it was noted that on 12/18/18 the resident was observed to be unresponsive with labored breathing. The doctor assessed the resident and ordered the resident to be transferred to the hospital for a [MEDICAL CONDITION](stroke). Review of the hospital transfer record and the resident's chart did not reveal the below required information: 1. The name of the location where the resident was being sent. 2. Written notice to the resident or the resident's responsible party. 3. Notification to the Ombudsman of the hospital visit. This information was discussed with staff #6 who acknowledged the omissions.

Based on the medical record and staff interviews, the facility staff failed to provide a Care Plan for Resident #69's continuing care, to the hospital where the resident was being sent. This was evident for 1 out of 2 residents investigated for hospitalization during the survey process. The findings include: On 01/31/19, around 12:07 PM, while reviewing Resident #69's medical record for a recent hospitalization , it was noted that on 12/18/18 the resident was observed to be unresponsive with labored breathing. The doctor assessed the resident and ordered the resident to be transferred to the hospital for a [MEDICAL CONDITION](stroke). Review of the hospital transfer record and the resident's chart did not reveal the below required information: 1) A copy of Resident #69's Care Plan This information was discussed with staff #6 who acknowledged the omission.

Based on observation and staff interview it was determined that facility staff failed to ensure that residents' dignity was provided in 1) Providing personal grooming care, and 2) Long call light response times. This was evident for 2 out of 32 residents (R#63 and R#93) reviewed during the survey process. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The findings include: 1) On 01/30/19 at 2:13 P.M, during an interview with Resident # 93 in the resident's room the surveyor observed R#93 sitting in his/her wheel chair cluttered with food and fluid, wearing a soiled dirty shirt and pants, with long dirty fingernails and eyeglasses. Resident #93 asked this surveyor for help. The surveyor informed the Unit Clerk that R#93 needed care and assistance. 2) On 01/30/19 at 02:35 P.M. during an interview of Resident #63 and spouse, R#63 informed the surveyor (writer) that he/she must wait over 30 minutes for staff to respond to the call bells during the day, afternoon, night and weekend shifts. The resident stated, This is a nice place. I'm a Registered Nurse and they just need more help to assist us. During this same interview, the resident's spouse's main concern was regarding why the patients must wait such a long time for staff to answer the call lights. On 2/01/19 at 10:20 A.M., the Unit Manager, Staff member #3, was made aware of the concerns reported and verified the surveyor's concerns. The Administrator and Director of Nursing were made aware of the surveyor's findings prior to and during the survey exit.

Based on medical records review and interview with staff it was determined that the facility staff failed to ensure that the information used to complete the Minimum Data Set (MDS) significant change in condition assessment was accurate and complete when a [DIAGNOSES REDACTED]. This was evident for 1 of 32 residents (Resident #1) reviewed in the annual survey. The findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures that residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure that each resident's needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions (also referred to as MDS Items). Each triggered care area must then be assessed in order to determine if care planning is needed; and if so to drive an effective plan that will ensure that the assessed needs of each resident are met when care is delivered. Review on 02/06/19 of the significant change in condition MDS assessment for Resident #1, revealed that R#1 was admitted to the facility with multiple medical diagnoses, which included but was not limited to Alzheimer's. Resident #1 was admitted to a community hospice care center on 10/3/18. Continued record review revealed that on 10/10/18 the MDS significant change in condition coded revealed that the facility coded in Section J -Health Condition J-1400 the facility checked =Yes for chronic health condition which will result in end of life expectance less than 6 month. Reviewed in section O for same the MDS coding, dated 10/10/18, in Section O-1000 the Hospice Care was left blank. It was not coded in MDS assessment, as required. The facility must ensure that each resident's needs are clearly delivered as based on the accuracy of the MDS assessments.

Based on medical and administrative record review and staff and family interview, it was determined the facility failed to 1) clarify in the medical record the method of transfer needed to safely transfer a functionally impaired Resident who sustained a fracture of the left tibia and fibula during a manual transfer by 2 facility staff, 2) provide sufficient supporting documentation to support the discontinuance of a mechanical lift, and 3) document a clinical rationale for implementing a care plan that allowed facility staff to choose to transfer the resident with or without a lift without specific criteria for making the decision despite the results of a Lift Assessment that indicated a sit to stand lift was to be used to transfer the resident. These failures resulted in harm to Resident #4 when he/she was transferred without the aid of a mechanical lift. This was evident for 1 of 5 residents (#4) reviewed during this complaint survey. The findings include:Review of complaint #MD 145 revealed Resident #4 sustained a broken leg during a transfer from a shower chair to the bed on 7/14/16. The complainant expressed a concern that the resident was transferred by 2 staff without the aid of a mechanical lift.Resident #4 was a long-term care resident who had [DIAGNOSES REDACTED]. Review of the Activities of Daily Living (ADL; self-care activities such as bathing, grooming and dressing) Work Sheets for June 2016 and July 2016 revealed the following: 1) the resident was coded as being totally dependent and required the assistance of 1-2 staff during transfers 62/90 times in June 2016,2) staff coded the resident needed the extensive assistance of 2 staff during 22 of 90 transfers in June 2016,3) in July 2016 facility staff coded the resident as totally dependent requiring the assistance of 1-2 staff during 26 of 39 transfers, and4) facility staff provided the extensive assistance of 2 staff during 7 of 39 transfers in July 2016. Total dependence is defined as there being full staff performance of an activity with no participation by the resident. Extensive assistance is when the resident performs part of the activity.Review of the resident's ADL care plans revealed that a plan initiated on 7/21/14 and 7/6/15 indicated the resident was to be transferred with a Hoyer (brand of full mechanical lift used for transfers when a person requires 90-100% assistance to get into and out of bed). A Physical Therapy Evaluation and Plan of Care dated 2/12/15 noted a Sit-to-Stand lift was used for transfers, toileting, and showers. These lifts are designed to assist in raising weight-bearing patients to a standing position without the need for manual lifting. Review of the care plan update notes for 2014 and 2015, did not indicate the resident's transfer method was re-evaluated. A care plan initiated on 7/11/16 contained interventions to transfer the resident with 2 staff as tolerated and indicated staff, may use the sit to stand lift for transfers. Medical record review failed to reveal a documented clinical rationale for the changes, guidelines for determining the most appropriate method or identification of the staff responsible (licensed/unlicensed) for determining the method of transfer from day to day and shift to shift.According to the Lifting, Transfer and Bed Mobility Program policy and procedure a nurse would assess the level of physical assistance required for each resident on admission, readmission, annually, when there is a significant change in bed mobility or transfer status and when requested by a direct caregiver. Further medical record review revealed Lifting, Transfer and Bed Mobility Assessments dated 10/20/14, 7/1/15 and 7/9/16. The assessments dated 10/20/14 and 7/1/15 noted a sit to stand lift was needed for Resident #4. The assessment dated [DATE], post injury, also indicated a sit to stand lift was required, however there was a physician's orders [REDACTED]. Surveyor review of the nursing progress note and Change in Condition Note on 11/10/16 revealed that on the evening of 7/14/16 the resident was transferred from a shower chair to the bed using a 2-person lift and the resident, banged (his/her) left leg on the bed frame. This incident was not documented in the nursing notes dated 7/14/16. On 7/15/16 at 7:47 AM Staff #1 documented that swelling and discoloration were noted to the resident's left lower leg and foot and it was noted the resident complained of discomfort. In interview with the surveyor on 11/10/16 at 8:12 AM the Director of Nursing (DON) confirmed that the nursing staff are responsible for determining the method of transfer for residents. The Rehabilitation Department is not involved unless there is a special concern. Regarding the incident on 7/14/16, the DON stated when the assigned nursing assistant finished showering the resident the sit to stand lift was in use by another resident. He/she stated that the nursing assistant reported the resident began yelling that he/she wanted to go to bed. During an interview with the surveyor on 11/14/16 at 9:15 AM, the DON stated there were 2 sit to stand lifts assigned to the unit but one was out of service. He/she noted there are lifts available on other units. During an interview with the surveyor on 11/10/16 at 8:17 AM Staff #1 stated the resident could have been a 2 person transfer with gait belt or with a sit to stand lift (facility policy only requires 1 staff to operate the sit to stand). Staff #1 reported that when Staff #2 completed the resident's shower the lift was in use by another resident. When staff asked the resident to be patient he/she became verbally abusive and demanded to be transferred to the bed. The assigned nursing assistant asked another nursing assistant to assist in transferring the resident to the bed without the use of the lift. At the time the resident was transferred he/she bumped his/her leg on the bed but did not complain of pain. The assessment process for determining the safety of this transfer was not clear.In interview with the surveyor on 11/10/16 at 10:55 AM the family member stated he/she was surprised facility staff moved the resident without a lift as she/he was under the impression the lift was to be used with all transfers. The family member further stated that the resident had an episode of unsteadiness due to suffering a pulmonary embolism (blood clot in the lung) while in the bathroom in 2014 and thought it was decided then a lift was needed for transfers. Regarding the fracture he/she stated the resident told him his/her foot was caught on something during this transfer.