Every finding on record at River Valley Rehabilitation Center

Based upon observations, interviews, and policy review, the facility failed to meet the requirements for resident council by not providing a private space for the resident council meetings. The findings include: An observation of the resident council meeting was made on 03/26/2025 at 11:00 AM. The meeting area designated by the facility was the dining room. Seven residents were in attendance for the meeting, including the resident council president and two staff members. Prior to the meeting beginning, the facility liaison, who is the Activities Director, asked what topics should be discussed and informed that she always conducts the meetings. The Activities Director was then asked to exit the meeting so they could discuss resident council topics without staff present. After the meeting began, a staff member from maintenance entered the meeting room without knocking, walked into the room for approximately 5 minutes, and looked around the room. The residents in attendance immediately stopped speaking while staff member was present. When the staff member was informed of the meeting taking place, he stopped, turned around, and left the meeting area. After approximately 20 minutes, another staff member entered the meeting room without knocking and spoke to a resident in attendance. The residents immediately stopped speaking while the staff member was present. The staff member assisted a resident from the meeting in progress. On 3/27/25 at 11:30 AM, an interview was conducted with the Activities Director (AD). The AD stated that she begins each meeting with welcoming the council members in attendance, discussing the activity calendar, and any new changes in the facility such as the rules and policies. The council members in attendance are given an opportunity to discuss any concerns they may have and are given the opportunity to suggest any activities they would like to see occur at the facility. The AD stated that the resident council has 10 residents all together, which includes the three officers. The AD stated that the council have never asked to meet without staff being present. She stated she usually leads the meetings. The Ad was asked if residents can express their concerns without fear of retaliation. The AD stated that no one has expressed their fear or concerns about staff getting back at them for voicing any concerns they may have. Usually, if a concern is brought up during the meeting, she will get the appropriate supervisory staff and their concerns are immediately heard and addressed during the meetings. The AD stated that the meetings are listed on the monthly calendar posted on all the units and they announce the meetings approximately fifteen minutes before the meeting begins. Staff will assist the residents who want to attend the meetings. The AD stated they hold the meetings in the dining room and there is always staff coming in and out of the meetings bringing things to the kitchen. Some of the staff will come and get the residents from the meeting to check and change them as needed. The AD acknowledged that there should not be any interruptions from the staff while the council meetings are in progress. The facility procedural guideline for resident council (effective date 1/2/2023) states, .the purpose of meetings is for the resident council provides a formal organized means of resident input into center operations. Under the general guidelines section states, the center will allow residents to organize into a council group without interference. The center will provide the group with space, privacy for meetings and staff support.

Based on observations, interviews and review of the maintenance request logs, the facility failed to maintain a comfortable and safe home like environment for 3 of 24 rooms investigated for environment (Rooms 106, 114 & 212). The findings include: room [ROOM NUMBER] On 03/24/25 at approximately 1:39 PM and on 3/27/25 at approximately 1:33 PM, observations of the bathroom door in Resident room [ROOM NUMBER] revealed peeling wood at the base of the door and the door dragging and scratching the floor. On 03/27/25 at approximately 2:26 PM, the Maintenance Director (MD) stated, we use a ledger system, each maintenance book is kept in the nurses station of that unit, any staff can write work orders in this book, the maintenance techs check theses logs daily, I follow behind to check for completion. I also do a monthly walkthrough of the entire facility and generate a report of work that needs to be completed. We do not have any outstanding work orders for room [ROOM NUMBER] at this time. The MD inspected the bathroom door in room [ROOM NUMBER]. He agreed that the wood was peeling at the bottom of the bathroom door and the hinge appeared to be loose at the top, causing the door to drag on the ground. On 03/27/25 at approximately 2:30 PM, the maintenance log was reviewed and no maintenance requests were found for room [ROOM NUMBER]. 28603 room [ROOM NUMBER] An observation of room [ROOM NUMBER] was conducted in the presence of the Maintenance Director on 3/27/25 at 2:40 PM. The windowsill was observed to be damaged with depressed areas in the wood and peeling paint. The Maintenance Director confirmed the windowsill was damaged with some rotten areas and the issue had not been reported to him. room [ROOM NUMBER] An observation of room [ROOM NUMBER] was conducted on 3/27/25 at 2:44 PM in the presence of the Maintenance Director. A hole in the wall was observed behind Bed A. The Maintenance Director estimated the hole in the wall to be approximately 8 inches long and 4 inches high. He stated he was not aware of the hole and the bed had probably been pushed into the wall. An interview was conducted with the Administrator on 3/27/25 at 2:49 PM. The Administrator stated the facility had a rounding program to check residents and rooms daily. Rooms are divided among management staff, and they check the rooms daily, then turn in a document weekly to him. If anything needs attention, they let maintenance know, place the item in the maintenance work order book and then check off the item once the repair is complete.

Based on observation, record review, and staff interview, the facility failed to provide or offer adequate grooming of facial hair for 1 of 3 residents sampled for activities of daily living (ADL). (Resident #75) The findings include: Observations of Resident #75 were conducted on 3/26/25 at 10:24 AM and 3/27/25 at 10:35 AM. The resident was observed to have gray facial hair to her chin approximately 1/2 cm long in some areas. On 3/27/25 at 10:35 AM, the resident was asked if staff ever offer to remove her facial hair. She could not recall. A review of Resident #75's electronic medical record revealed the resident had a diagnosis of dementia and was admitted to the facility on [DATE]. The admission minimum data set (MDS) with an assessment reference date of 2/7/25 revealed the resident required partial/moderate assistance with bathing and set-up or clean up assistance with personal hygiene. A review of the resident's care plan for ADL self- care performance deficit initiated 2/1/25 revealed the resident required set up or clean up assistance of one person for personal hygiene. A review of the ADL personal hygiene documentation from 3/18/25- 3/26/25 revealed no documented refusals of personal hygiene. An interview was conducted with Employee B (Certified Nursing Assistant) on 3/27/25 at 11:46 AM. Employee B stated she had worked with Resident #75 since she was admitted to the facility. She stated the resident was not capable of shaving herself and the resident had always had hair on her chin. She stated, when the resident was admitted in early February, she had asked a nurse to assist in removing the hair from the resident's chin because the resident had a bump on her chin and she was scared to use a razor. She did not know if the nurse removed any hair. She had not mentioned the chin hair to any other nurse since then. She stated when they shower residents they will attempt to remove any facial hair. If the resident refuses this service, they let the nurse know. An interview was conducted with the Director of Nursing (DON) on 3/27/25 at 11:57 AM. She stated staff should attempt to remove facial hair daily or when they observe it.

Based upon observations and interviews, the facility failed to report nurse staffing data at the beginning of each shift. The findings include: During observations of the nurse staffing data on 3/24/25, 3/25/25, and 3/27/25, it was observed that the facility had posted all staff for the entire day during the beginning of day shift, which included all staff for the day, evening, and night shifts. On 3/27/25 at approximately 02:20 PM, an interview was conducted with the Administrator and Regional Clinical Manager was conducted. They stated that they have always posted our nursing staffing data for a 24-hour period, then update it at the beginning of each shift and as needed when changes occur, such as call ins.

Based on observations, interview and resident care plan review the facility failed to ensure that resident's in the Sunshine Room were treated in a dignified manner as evidenced by failing to clean residents after consuming meals and by failing to create an environment that promoted social well-being for 5 of 7 residents observed. (#11, #12, #18, #77, and #112.) The findings include: On 12/02/2019 at approximately 2:30PM, Resident #12, was observed coming out of the Sunshine Room, the restorative dining hall, a staff member was pushing his wheelchair. The resident had food crumbs all over his mouth, on his shirt and pants. The staff member stated she was taking him to an activity in the main dining room. On 12/02/2019 at approximately 2:30PM, Resident #112, was observed in her wheelchair coming out of the Sunshine Room, she was being pushed by a staff member to the main dining room for an activity. Resident #112 had food on her face under her bottom lip. On 12/03/2019 at approximately 8:35AM, observations were made in the Sunshine Room during the breakfast time meal. There were a total of 7 residents in the dining room. The room was completely silent. There were three staff members present - all three staff members were seated, each feeding a resident. All seven residents were in wheelchairs. Three of those residents were at a long table, against the left side wall. The table was up against the wall; one resident was on either end and Resident #12 was seated facing the wall with his back to the room. Resident #112 was seated in a Broda chair (a tilt in place positioning chair which helps to prevent skin breakdown) turned away from the other residents facing the wall. The resident had a tablecloth draped over her chest to cover her clothes. The staff member stated they were out of clothing protectors. On 12/03/2019 at 2:10PM, residents were observed in the Sunshine Room. The television was on. Resident #112 was asleep in her chair. She had dried food under her lip. The Sunshine Room lunch time meal was served at 12:15PM. On 12/04/2019 at approximately 8:45AM, observations were made in the Sunshine Room during the breakfast time meal. Residents eat in the same place (dining chair location) for each meal. Resident #11, who was at the end of the long table, was sleeping with her head to her chin while her breakfast meal was in front of her. There was no conversation or cueing made with residents. The residents sat in complete silence. At 9:01AM, Resident #11 was approached by surveyor, the resident woke up and stated, Oh I forgot this was my dinner, and began to eat. On 12/05/2019 at approximately 8:40 AM, observations were made in the Sunshine Room during the breakfast time meal. There was one staff member present who was feeding a resident, and three residents feeding themselves. There were two residents waiting to be assisted with their breakfast. The room was silent. A few minutes later an additional staff member arrived. At approximately 8:50AM, the Director of Nursing and the Assistant Director of Nursing were asked to come to the Sunshine room to observe the ambience present during the resident's breakfast time meal. The room was quiet until the DON spoke with staff. Music was then turned on. The DON stated she would continue to monitor. An observation of the Sunshine Club Assisted Dining Room on 12/02/2019 at approximately 1:00PM revealed 7 residents and 3 staff. The room was observed to be quiet and stuffy. All tables except for a tray table were positioned against the wall. At the table located near the entrance, a resident sat at each head of the table and a third sat in the middle facing the wall. At a table located in the back of the room, a resident sat at one end of the table and restorative staff A sat at the other end with resident #112 who was positioned in her geri chair with her back to the table. Restorative staff C was seated at a table at the front of the room with resident #77 who was positioned to face the wall. Restorative staff B was also seated at the front of the room beside resident #18 who she was feeding from a tray table. No interaction between residents and little to no interaction between staff and residents was observed. Resident #112 was facing away from staff A in her geri chair with her eyes closed. Staff A was observed tapping spoonfuls of food against resident #112's closed mouth. No verbal interaction to include conversation, encouragement or cueing was observed. After resident #112 finished 100% of her meal, staff A positioned resident #112's geri chair in the middle of the room, activated the brakes, and asked staff C for permission to leave. Once staff C granted staff A permission, staff A left the room. A review of Resident #112's Activities, Cognitive Stimulation, Social Interaction Care Plan, dated 07/29/2019, indicated for All staff to converse with resident while providing care; attends Sunshine Club up to 5 x weekly for sensory stimulation; needs assistance during the activity

Based on observation and interview the facility failed to ensure the privacy and confidentiality of resident's medical information by posting the resident's name and level of supervision in a place visible to other residents and visitors for 2 of 2 sampled residents for privacy (resident #116 and #92). The findings include: On 12/2/2019 at approximately 11:00 AM, upon review of the staffing board posting in unit 2 it was observed to have the last names of residents #116 and #92 indicating they were on 1 to 1 supervision with a staff member assignment to each individual posted. The staff board was posted in a location readily visible to other residents and visitors. (Photographic evidence obtained) On 12/2/2019 at approximately 2:34 PM, observation of the staffing board posting showed resident's #116 and #92 names posted along with their level of supervision in the same manner and location as described above. On 12/3/2019 at approximately 2:44 PM in interview with the Unit 2 Manager staff D, the Assistant Director of Nursing, and the Director of Nursing it was confirmed that resident's #116 and #92's names and level of supervision were posted in a readily visible area to other residents and visitors. The Director of Nursing expressed that the resident's names should not be posted with their level of supervision in such a manner.

Based on interviews and record review, the facility failed to ensure that grievances voiced by family members were addressed and resolved for 1 of 1 resident (#38). Findings included: On 1/28/19 at approximately 10:45 AM, an interview was conducted with the spouse of resident #38. She stated that on (MONTH) 2, 2019 the resident was transferred to the 300 hall from the locked unit of the 200 hall without her knowledge. She stated the resident was admitted to the facility in (MONTH) (YEAR) to allow him to be on a secure unit, as he had a history of [REDACTED]. She stated she spoke with the nurse and had met with the administrator and voiced her frustration, but no one had followed up with her. She also revealed that the resident was moved back to the locked unit on (MONTH) 09, 2019, after wandering into other residents' rooms and attempting to get into their beds. A review of the grievance log for (MONTH) 2019 found there to be a lack of grievances related to resident #38. On 01/31/19 at approximately 12:07 PM, an interview was conducted with the administrator during which he revealed that he had met with the spouse of resident #38 to discuss her concerns related to the resident being transferred without her knowledge; however, he had mistaken the conversation to mean that she was upset with the resident being transferred back to the locked unit. He stated he had just assumed that the concerns were related to the most recent move since he had not been working in the facility when the first transfer had occurred. He stated a grievance report should have been completed, but this had not been done. Review of the facility's policy on grievances, dated 8/30/18, revealed the following: The resident, or anyone acting on their behalf filing the grievance, will be communicated with regarding the conclusion of the investigation and the corrective actions that will be taken.The resident, or anyone acting on their behalf, has the right to obtain a copy of the written conclusion. The administrator or designee will validate the completion of the process in a timely manner upon receipt of the completed grievance report.

Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program for of 2 sampled residents by failing to place residents with suspected contagious infections on proper isolation precautions (#40), and failing to follow contact isolaton precautions (#111). Findings include: On 1/29/19 a record review was conducted for resident #40, which revealed a physician order [REDACTED]. Further review of the chart found an order for [REDACTED].#77 who was reported to have loose stools on 1/16/19 and found to be negative for [MEDICAL CONDITION] on 1/17/19. On 1/31/19 at approximately 7:00 PM an interview was conducted with the Director of Nursing in which she stated that contact isolation should be ordered when the resident is suspected of having [MEDICAL CONDITION]. On 2/01/19 at approximately 8:09 AM an interview was conducted with the unit manager for the 200 hall in which she stated that the nurse should request an order for [REDACTED]. Review of the policy Isolation- Categories of Transmission-Based Precautions found that Contact Precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the residents environment. Resident #111: A care plan and physician order [REDACTED]. A contact isolation sign and equipment were hanging on the door outside the resident's room. On 1/30/2019 at approximately 3:23pm, 2 Certified Nursing Assistants, (CNAs), staff D and staff E, entered the room with surveyors to assist in observation of resident #111's heels. Resident #111 was on contact isolation precautions and is paraplegic. Neither of the CNAs washed hands nor put on gloves or any other personal protective equipment (PPE) prior to removing covers and mobilization devices and touching the feet and heels of resident #111. In an interview following the observation, the CNAs said that they washed hands after and acknowledged that they did not wear PPE and will wear PPE.

Based on observation, interview and record review, the facility failed to implement the comprehensive plan of care for 1 of 9 residents (#78) sampled for foot care, and for 1 of 3 residents (#85) sampled for nutrition. The Findings Included: Resident #78: An observation was made on 01/28/2019 at approximately 10:30 am of resident #78 while he was in his room, stretched out on his bed and laying on top of his covers. His feet were observed with no socks or shoes. His right, second toe was observed to be swollen and blackened on the tip with bands of skin pulled tightly due to swelling. An interview was conducted with the resident at the time of the observation in which he stated, The staff do not put a dressing on my toe, I think this happened when my toe nail was taken off last week by the person that cut my nails, but no staff have looked at my toe. An observation was made of resident #78 on 1/28/2019 at approximately 3:00 pm, when the resident was again laying on top of his bed. The resident then stated that nothing had been done about his toe and observation showed it remained swollen with areas of blackened tissue. An observation was made at approximately 10:00am on 1/29/2019 of resident #78 laying on top of his bed watching TV, feet exposed. His right second toe was observed to be purple in color with black at the tip of the toe. Again, the resident was interviewed at the time of this observation and stated, It really doesn't hurt unless something touches it, but no staff have looked at my foot. An observation was made on 1/29/2019 at 1:18 PM of resident #78 during which he was laying across his bed, no covers on and feet exposed to air. The resident's toe appeared more swollen and he stated, My toe does look swollen, nobody has said anything to me about it, but you. I think it happened last week. Review of the medical record for resident #78 revealed the resident was care planned, as of 12/21/18, for risk of impaired skin integrity related to diabetes and [MEDICAL CONDITION], with an intervention to Monitor/ document/ report any signs or symptoms of infection or any open areas. Resident #78 was also to have skin assessments completed weekly on Saturdays during the night shift. Review of the last skin assessment, completed by LPN staff F and dated 1/26/19, indicated the resident's skin was clear of any impairment. An interview was conducted, on 01/28/2019 at approximately 3:00am, with LPN staff F. During this interview, she stated she had completed documentation for the skin sweep but did not perform the sweep, but had marked the skin clear. An interview and observations were done with the wound care physician on 01/30/2019 at approximately 7:15AM. She stated the toe nail had been possibly cut off during the last podiatry visit and the toe had become infected. Her consultation report from this observation of resident 78's toes indicated patient was recently evaluated by podiatry and toe nail removed, now with scab on distal toe with pain, [DIAGNOSES REDACTED] and induration of the toe. Resident # 85: On 1/28/19 at approximately 12:10 PM, during an observation of the lunch meal, resident #85 was observed to gag, cough and spit up her food (was served regular diet). Staff were observed attending to the resident in her attempts to clear the food from her airway. After another coughing incident with resident #85, the unit manager was heard telling the resident, we are going to get you a different meat that will be easier to chew. review of the resident's medical record revealed [REDACTED]. On 1/31/19 at approximately 8:48 AM, an interview was conducted with the Speech Therapist. She stated that on the day the resident was observed to choke during lunch, she had been given a regular diet by mistake. She stated the resident was upgraded from a pureed diet to mechanical soft, but should never have received a regular diet. On 2/1/19 at approximately 8:09 AM, an interview was conducted with the unit manager for the 200 hall. She stated that the kitchen staff had delivered the wrong tray to the resident, but stated staff should have caught it when they set up the resident's tray for lunch. She reported once she realized the mistake, she ordered the correct meat right away.

Based on observation, interview and record review, the facility failed to provide monitoring and care of residents' feet, in accordance with professional standards of practice, for 1 of 9 residents (#78) observed for diabetic foot care. This lack of assessment and care resulted in the development of an acute toe infection for resident #78, who was diabetic. Findings include: An observation was made on 01/28/2019 at approximately 10:30 am of resident #78 while he was in his room, stretched out on his bed and laying on top of his covers. His feet were observed with no socks or shoes. His right, second toe was observed to be swollen and blackened on the tip with bands of skin pulled tightly due to swelling. An interview was conducted with the resident at the time of the observation in which he stated, The staff do not put a dressing on my toe, I think this happened when my toe nail was taken off last week by the person that cut my nails, but no staff have looked at my toe. An observation was made of resident #78 on 1/28/2019 at approximately 3:00 pm, when the resident was again laying on top of his bed. The resident then stated that nothing had been done about his toe and observation showed it remained swollen with areas of blackened tissue. An observation was made at approximately 10:00am on 1/29/2019 of resident #78 laying on top of his bed watching TV, feet exposed. His right second toe was observed to be purple in color with black at the tip of the toe. Again, the resident was interviewed at the time of this observation and stated, It really doesn't hurt unless something touches it, but no staff have looked at my foot. An observation was made on 1/29/2019 at 1:18 PM of resident #78 during which he was laying across his bed, no covers on and feet exposed to air. The resident's toe appeared more swollen and he stated, My toe does look swollen, nobody has said anything to me about it, but you. I think it happened last week. An interview was conducted on 1/29/2019 at 1:20 PM with Licensed Practical Nurse (LPN) staff H, in which she stated she did not know resident #78 had a hurt toe and confirmed she had been his nurse for the past two days and he was part of her regular hall. At the time of the interview, staff H conducted an observation of resident #78's toe with this surveyor. She again confirmed she had not known about his toe being swollen or discolored. A review of the medical record for resident #78 was also conducted with staff nurse H. During this review, no treatment orders were found to be in effect for the resident's injured toe. An interview was conducted with LPN staff C (wound care nurse) on 1/29/19 at approximately 1:30 PM. She stated she was currently not doing any treatments on resident #78's feet. At that time, another observation of the resident was conducted with the wound care nurse and staff H. After the wound care nurse inspected the resident's toe, and lifted the toe (which caused resident #78 pain), she stated, this thing is going to have to come off. Further review of the medical record for resident #78 revealed the resident was care planned, as of 12/21/18, for risk of impaired skin integrity related to diabetes and [MEDICAL CONDITION], with an intervention to Monitor/document/report any signs or symptoms of infection or any open areas. Resident #78 was also to have skin assessments completed weekly on Saturdays during the night shift. Review of the last skin assessment, completed by staff nurse F and dated 1/26/19, indicated the resident's skin was clear of any impairment. An interview was conducted, on 01/28/2019 at approximately 3:00am, with LPN staff F. During this interview, she stated she had completed documentation for the skin sweep but did not perform the sweep, but had marked the skin clear. A review was conducted of resident 78's activities of daily living documentation for 1/28/2019, which showed documentation that resident #78 had received a bath with staff supervision. The resident's last quarterly Minimum Data Set (MDS) assessment, dated 12/24/2018, showed no skin impairment for the resident; however, the resident was care planned as a risk for skin impairment related to decreased mobility, diabetes and [MEDICAL CONDITION]. A phone interview was conducted with the facility podiatrist on 1/30/2019 at approximately 2:00pm. Photographs were taken of the resident's toe and sent securely to the podiatrist, who stated the toe was swollen and possibly infected. He suggested antibiotics as treatment. An interview and observations were done with the wound care physician on 01/30/2019 at approximately 7:15AM. She stated the toe nail had been possibly cut off during the last podiatry visit and the toe had become infected. Her consultation report from this observation of resident 78's toes indicated patient was recently evaluated by podiatry and toe nail removed, now with scab on distal toe with pain, [DIAGNOSES REDACTED] and induration of the toe. After identification of this resident's toe concerns, the facility indicated they would be completing 100% audit of the residents' skin in the facility during the evening of 01/29/2019 to ensure no other residents had any unknown skin issues.

Based on observation, interview and record review, the facility failed to ensure residents received skin monitoring in accordance with professional standards of practice, by failing to assess and accurately document resident skin condition for 2 of 12 residents (#78 & #111) sampled for skin issues. Findings included: Resident #78: An observation was made on 01/28/2019 at approximately 10:30 am of resident #78 while he was in his room, stretched out on his bed and laying on top of his covers. His feet were observed with no socks or shoes. His right, second toe was observed to be swollen and blackened on the tip with bands of skin pulled tightly due to swelling. An interview was conducted with the resident at the time of the observation in which he stated, The staff do not put a dressing on my toe, I think this happened when my toe nail was taken off last week by the person that cut my nails, but no staff have looked at my toe. An observation was made of resident #78 on 1/28/2019 at approximately 3:00 pm, when the resident was again laying on top of his bed. The resident then stated that nothing had been done about his toe and observation showed it remained swollen with areas of blackened tissue. An observation was made at approximately 10:00am on 1/29/2019 of resident #78 laying on top of his bed watching TV, feet exposed. His right second toe was observed to be purple in color with black at the tip of the toe. Again, the resident was interviewed at the time of this observation and stated, It really doesn't hurt unless something touches it, but no staff have looked at my foot. An observation was made on 1/29/2019 at 1:18 PM of resident #78 during which he was laying across his bed, no covers on and feet exposed to air. The resident's toe appeared more swollen and he stated, My toe does look swollen, nobody has said anything to me about it, but you. I think it happened last week. An interview was conducted on 1/29/2019 at 1:20 PM with Licensed Practical Nurse (LPN) staff H, in which she stated she did not know resident #78 had a hurt toe and confirmed she had been his nurse for the past two days and he was part of her regular hall. At the time of the interview, staff H conducted an observation of resident #78's toe with this surveyor. She again confirmed she had not known about his toe being swollen or discolored. A review of the medical record for resident #78 was also conducted with staff nurse H. During this review, no treatment orders were found to be in effect for the resident's injured toe. An interview was conducted with LPN staff C (wound care nurse) on 1/29/19 at approximately 1:30 PM. She stated she was currently not doing any treatments on resident #78's feet. At that time, another observation of the resident was conducted with the wound care nurse and staff H. After the wound care nurse inspected the resident's toe, and lifted the toe (which caused resident #78 pain), she stated, this thing is going to have to come off. Further review of the medical record for resident #78 revealed the resident was care planned, as of 12/21/18, for risk of impaired skin integrity related to diabetes and [MEDICAL CONDITION], with an intervention to Monitor/document/report any signs or symptoms of infection or any open areas. Resident #78 was also to have skin assessments completed weekly on Saturdays during the night shift. Review of the last skin assessment, completed by staff nurse F and dated 1/26/19, indicated the resident's skin was clear of any impairment. An interview was conducted, on 01/28/2019 at approximately 3:00am, with LPN staff F. During this interview, she stated she had completed documentation for the skin sweep but did not perform the sweep, but had marked the skin clear. A review was conducted of resident 78's activities of daily living documentation for 1/28/2019, which showed documentation that resident #78 had received a bath with staff supervision. The resident's last quarterly Minimum Data Set (MDS) assessment, dated 12/24/2018, showed no skin impairment for the resident; however, the resident was care planned as a risk for skin impairment related to decreased mobility, diabetes and [MEDICAL CONDITION]. A phone interview was conducted with the facility podiatrist on 1/30/2019 at approximately 2:00pm. Photographs were taken of the resident's toe and sent securely to the podiatrist, who stated the toe was swollen and possibly infected. He suggested antibiotics as treatment. An interview and observations were done with the wound care physician on 01/30/2019 at approximately 7:15AM. She stated the toe nail had been possibly cut off during the last podiatry visit and the toe had become infected. Her consultation report from this observation of resident 78's toes indicated patient was recently evaluated by podiatry and toe nail removed, now with scab on distal toe with pain, [DIAGNOSES REDACTED] and induration of the toe. After identification of this resident's toe concerns, the facility indicated they would be completing 100% audit of the residents' skin in the facility during the evening of 01/29/2019 to ensure no other residents had any unknown skin issues. Resident #111 During an interview with resident #111 on 1/29/2019 at approximately 10:30am, resident #111 stated that he had developed some areas on his heels since being at the facility and the wound care nurse came in to take care of them. A review of the medical record for resident #111 did not reveal any progress notes or physician orders for treatment of [REDACTED]. A minimum data set (MDS) assessment, dated 1/11/2019, indicated the resident had no pressure ulcers; however, was at risk for developing them. It also indicated that he had moisture associated skin damage related to incontinence and indicated he was receiving application of ointments/ medications other than to the feet. Review of the resident's progress notes showed a note dated 1/27/2019 at 23:08 that read, skin dry and intact, no skin issues noted, and a note dated 1/29/2019 at 23:07 that read, residents feet inspected. Discolored toe nails noted. MD made aware. No orders at this time. On 1/30/2019 at approximately 3:23pm, 2 Certified Nursing Assistants (CNAs), Staff D & E, entered the room with surveyors to assist in observation of resident #111's heels. Observation revealed a reddened area with two small scabbed areas on the resident's left heel and dry, dark to black eschar covering the right heel as well as a dark purple area to the medial aspect of the right heel (photographic evidence obtained). On 1/30/2019 at approximately 4:00PM, the Director of Nursing (DON) and staff G accompanied surveyors to the resident's room to observe the areas on his heels. During observation, Registered Nurse (RN) Staff G indicated the skin on the resident's right heel appeared to have hardened as a result of application of ointment. There was no physician order or documentation of ointment being applied to the resident's feet. In an interview following the observation, the DON reviewed the electronic medical record for resident #111 and confirmed there was no documentation related to these areas on the resident's heels. An interview was conducted with the wound care nurse on 1/31/2019 at approximately 11:19am. She stated she was unable to find any documentation related to resident #111's heels. Review of the facility's policy on pressure ulcer sand skin care management (policy SHCRC .01), dated 04/25/2017, indicated staff would complete weekly skin checks on all residents.

Based on observation, interview and record review, the facility failed to ensure that 1 of 3 residents (#85) received food prepared in a form designed to meet their needs by providing a regular diet to a resident requiring mechanically soft food. Findings include: On 1/28/19 at approximately 12:10 PM, during an observation of the lunch meal, resident #85 was observed to gag, cough and spit up her food (was served regular diet). Staff were observed attending to the resident in her attempts to clear the food from her airway. After another coughing incident with resident #85, the unit manager was heard telling the resident, we are going to get you a different meat that will be easier to chew. review of the resident's medical record revealed [REDACTED]. On 1/31/19 at approximately 8:48 AM, an interview was conducted with the Speech Therapist. She stated that on the day the resident was observed to choke during lunch, she had been given a regular diet by mistake. She stated the resident was upgraded from a pureed diet to mechanical soft, but should never have received a regular diet. On 2/1/19 at approximately 8:09 AM, an interview was conducted with the unit manager for the 200 hall. She stated that the kitchen staff had delivered the wrong tray to the resident, but stated staff should have caught it when they set up the resident's tray for lunch. She reported once she realized the mistake, she ordered the correct meat right away. Review of the facility policy Diet Formulary dated as revised on 2/21/17, revealed: The facility provides each resident with a regular and therapeutic diet as ordered by the physician.

Based on observations, staff interviews, resident interview and record review, the facilty failed to accurately document skin assessments for 2 of 12 (#78 & #111) residents reviewed for skin issues. The findings are: An observation was made on 01/28/2019 at approximately 10:30 am of resident #78 while he was in his room, stretched out on his bed and laying on top of his covers. His feet were observed with no socks or shoes. His right, second toe was observed to be swollen and blackened on the tip with bands of skin pulled tightly due to swelling. An interview was conducted with the resident at the time of the observation in which he stated, The staff do not put a dressing on my toe, I think this happened when my toe nail was taken off last week by the person that cut my nails, but no staff have looked at my toe. An observation was made of resident #78 on 1/28/2019 at approximately 3:00 pm, when the resident was again laying on top of his bed. The resident then stated that nothing had been done about his toe and observation showed it remained swollen with areas of blackened tissue. An observation was made at approximately 10:00am on 1/29/2019 of resident #78 laying on top of his bed watching TV, feet exposed. His right second toe was observed to be purple in color with black at the tip of the toe. Again, the resident was interviewed at the time of this observation and stated, It really doesn't hurt unless something touches it, but no staff have looked at my foot. An observation was made on 1/29/2019 at 1:18 PM of resident #78 during which he was laying across his bed, no covers on and feet exposed to air. The resident's toe appeared more swollen and he stated, My toe does look swollen, nobody has said anything to me about it, but you. I think it happened last week. A review was conducted of the weekly skin assessment documentation for resident #78 and showed Licensed Practical Nurse (LPN) staff F had signed as the person who completed weekly skin assessments for resident #78 on 1/12/2019 and 1/26/2019. An interview was conducted, on 01/28/2019 at approximately 3:00am, with LPN staff F. During this interview, she stated she had completed documentation for the skin assessments on resident #78, but had not actually performed the skin assessments, but had marked the resident's skin as clear on the skin assessment forms. An interview was conducted with the Director of Nursing on 1/30/2019 at approximately 10:00am. She stated that the expectation was for staff to document after a treatment was completed, and if it is not completed, a progress note should be written and the treatment record should not be signed off. After identification of this resident's toe concerns, the facility indicated they would be completing 100% audit of the residents' skin in the facility during the evening of 01/29/2019 to ensure no other residents had any unknown skin issues. Resident #111 During an interview with resident #111 on 1/29/2019 at approximately 10:30am, resident #111 stated that he had developed some areas on his heels since being at the facility and the wound care nurse came in to take care of them. A review of the medical record for resident #111 did not reveal any progress notes or physician orders for treatment of [REDACTED]. A minimum data set (MDS) assessment, dated 1/11/2019, indicated the resident had no pressure ulcers; however, was at risk for developing them. It also indicated that he had moisture associated skin damage related to incontinence and indicated he was receiving application of ointments/ medications other than to the feet. Review of the resident's progress notes showed a note dated 1/27/2019 at 23:08 that read, skin dry and intact, no skin issues noted, and a note dated 1/29/2019 at 23:07 that read, residents feet inspected. Discolored toe nails noted. MD made aware. No orders at this time. On 1/30/2019 at approximately 3:23pm, 2 Certified Nursing Assistants (CNAs), Staff D & E, entered the room with surveyors to assist in observation of resident #111's heels. Resident #111 was on contact isolation precautions and was paraplegic. Observation revealed a reddened area with two small scabbed areas on the resident's left heel and dry, dark to black eschar covering the right heel as well as a dark purple area to the medial aspect of the right heel (photographic evidence obtained). On 1/30/2019 at approximately 4:00PM, the Director of Nursing (DON) and staff G accompanied surveyors to the resident's room to observe the areas on his heels. During observation, Registered Nurse (RN) Staff G indicated the skin on the resident's right heel appeared to have hardened as a result of application of ointment. There was no physician order or documentation of ointment being applied to the resident's feet. In an interview following the observation, the DON reviewed the electronic medical record for resident #111 and confirmed there was no documentation related to these areas on the resident's heels. An interview was conducted with the wound care nurse on 1/31/2019 at approximately 11:19am. She stated she was unable to find any documentation related to resident #111's heels. Review of the facility's policy on pressure ulcer sand skin care management (policy SHCRC .01), dated 04/25/2017, indicated staff would complete weekly skin checks on all residents.

Based on record review and interview, the facility failed to notify resident representatives in advance of room changes for 2 of 2 residents (#38 & #40). Findings include: On 1/28/19 at approximately 10:45 AM, an interview was conducted with the spouse of resident #38. She stated that on (MONTH) 2, 2019 the resident was transferred to the 300 hall from the locked unit of the 200 hall without her knowledge. She stated the resident was admitted to the facility in (MONTH) (YEAR) to allow for him to be on a secure unit, as he had a history of [REDACTED]. She also revealed that the resident was moved back to the locked unit on (MONTH) 09, 2019 after wandering into other residents' rooms and attempting to get into their beds. Record review for resident #40 revealed the resident was transferred to a private room for isolation precautions on 1/21/19. Review of the nursing notes found there to be no evidence that the resident's representative was notified of the transfer. On 1/31/19 at approximately 10:32 AM, an interview was conducted with the social services assistant. She stated that she was responsible for completing the Notification of Room Change form and for notifying families when a resident changed rooms. She also stated that when the family was notified, she made a note within the facility's electronic medical record. She was asked about resident #38's room change from the locked unit to the 300 hall, and stated she was unable to find evidence within the electronic system that the family was notified and was unable to find a completed Notification of Room Change in either the file cabinet or the stacks on her desk. During a follow-up interview conducted on 2/1/19 at approximately 8:23 AM, the social services assistant was asked about resident #40's room change, and stated I don't have it referring to both the form and family notification. Review of the facility policy for Room & Roommate Assignment Changes, dated 5/23/17, revealed the facility would promptly notify the residents and the residents' legal representatives or interested family members when there was a change in room. The policy also stated that representative notification had to be documented in the resident's medical record progress notes.

Based on observations, staff interview, and record review, the facility failed to implement the plan of care related to falls for 2 of 2 residents sampled for accidents, #6 and 50. The findings included: Resident #6's medical record was reviewed and revealed 6 falls for September and 3 falls for the month of October 2017. The fall care plan initiated on 3/28/2013 and last revised 9/26/2017, indicated an intervention for fall mats. Resident #6 was observed laying in bed asleep on 10/31/2017 at 1:53 PM and again at 3:08 PM. Each observation revealed no floor mats at the bedside. The resident was again observed on 11/1/2017 at 12:45 PM with no floor mats on either side of the bed. An interview was immediately conducted with the Unit Manager for Unit 1. She confirmed the resident had frequent falls and had multiple interventions in place to prevent falls. She confirmed the resident should have bilateral floor mats in place when in bed. She then walked to resident #6's room and confirmed the resident was in bed with no floor mats in place. She then removed them from their upright position between the wall and closet and placed on the floor on each side of the bed. Record review was conducted on resident #50's care plan. The resident's current care plan indicated that resident #50 is at risk for falls related to decreased mobility, decreased safety awareness and impaired cognition related to Dementia. Her care plan goals indicated resident #50 will minimize injuries related to falls until her next review. The care plan indicated interventions for the resident to have anti-rollbacks and anti-tippers on her wheelchair at all times. An interview was conducted on 10/31/2017 at 1:20PM with employee A and employee B and they both stated Resident #50 had fall interventions in place. Both staff confirmed resident #50 should have had anti-roll and anti-tipper devices on the resident's wheelchair at all times for preventative measures due to falls. During the interview, employee A observed resident #50's wheelchair and confirmed the resident did not have anti-rollbacks or anti-tippers on her wheelchair. Employee A confirmed the interventions were not in place and the resident's wheelchair had been washed the past Sunday.

Based on observations, record reviews, and staff interviews, the facility failed to ensure the environment was maintained free from accident hazards in 2 of 37 sampled resident rooms (314 and 317) and ensure assistive devices were in place as indicated in the plan of care for 2 of 2 residents reviewed for falls (#6 and 50). The findings included: An observation of room 314 was conducted on 10/30/17 at approximately 1:32 PM. The bathroom door was observed to have peeling wood on the outside and rough edges, the bedroom door had an area of wood that had peeled off and was rough to touch. An observation of room 317 was conducted on 10/31/17 at approximately 9:28 AM. The inside of the bathroom door had peeling, splintered wood. Further observation of the doors was conducted on 11/1/17 at approximately 11:29 AM in the presence of the Director of Nursing (DON). The DON observed the bathroom door and bedroom door in room 314 and the bathroom door in room 317 and confirmed the doors were in need of repair. Photographic evidence was obtained. On 11/1/17 at approximately 1:11 PM, the DON confirmed the vinyl covers placed at the bottom of some doors would not fix the peeling wood and the areas would have to be sanded down. These areas presented an accident hazard to residents. Resident #6's medical record was reviewed and revealed 6 falls for September and 3 falls for the month of October 2017. A physician's orders [REDACTED]. In addition, the fall care plan initiated on 3/28/2013 and last revised 9/26/2017, indicated an intervention for fall mats. Resident #6 was observed laying in bed asleep on 10/31/2017 at 1:53 PM and again at 3:08 PM. Each observation revealed no floor mats at the bedside. The resident was again observed on 11/1/2017 at 12:45 PM with no floor mats on either side of the bed. An interview was immediately conducted with the Unit Manager for Unit 1. She confirmed the resident had frequent falls and had multiple interventions in place to prevent falls. She confirmed the resident should have bilateral floor mats in place when in bed. She then walked to resident #6's room and confirmed the resident was in bed with no floor mats in place. She then removed them from their upright position between the wall and closet and placed on the floor on each side of the bed. Record review was conducted on resident #50's care plan. The resident's current care plan indicated that resident #50 is at risk for falls related to decreased mobility, decreased safety awareness and impaired cognition related to Dementia. Her care plan goals indicated resident #50 will minimize injuries related to falls until her next review. The care plan indicated interventions for the resident to have anti-rollbacks and anti-tippers on her wheelchair at all times. Upon further review on resident #50's medical record it showed she also had a MD order stating resident #50 should have had anti-roll back device and anti-rear tippers on wheelchair. It also stated nursing should be checking twice a day for preventions due to falls. An interview was conducted on 10/31/2017 at 1:20PM with employee A and employee B and they both stated Resident #50 had fall interventions in place. Both staff confirmed resident #50 should have had anti-roll and anti-tipper devices on the resident's wheelchair at all times for preventative measures due to falls. During the interview, employee A observed resident #50's wheelchair and confirmed the resident did not have anti-rollbacks or anti-tippers on her wheelchair. Employee A confirmed the interventions were not in place and the resident's wheelchair had been washed the past Sunday.

Based on observations, staff interviews, and record review, the facility failed to implement the plan of care for 1 of 4 sampled residents, by failing to keep the resident's call light within reach for resident #1. The findings include: An observation of resident #1 was conducted on 6/21/17 at approximately 10:33 AM. The resident was in her room sitting in her wheelchair next to the bed closest to the door. The resident was calling out and the surveyor could hear her in the hallway. Upon entering the room, the resident's call light was observed in a chair on the opposite side of her bed and not within her reach. The surveyor initiated the call light. Employee A (Certified Nursing Assistant) came to the resident room to answer the call light. Employee A confirmed the call light was not within reach for resident #1. Further observation of resident #1 was conducted on 6/22/17 at 9:27 AM. Resident #1 was observed in her room, sitting in her wheelchair next to the bed closest to the door. The resident's call light was clipped to her pillow on the other side of the bed. The resident asked the surveyor to hand her the call light and confirmed she could not reach it. Surveyor initiated the call light. Employee B (Registered Nurse Unit Manager) answered the call light and confirmed the call light was not within reach for resident #1. Review of the current plan of care for resident #1 revealed a care focus for resident #1 being at risk for falls dated 8/2/16. The interventions on the plan of care included placement of the call light cord to be within in easy reach of resident #1.

Based on observation and interview the facility failed to post accurate staffing on a daily basis for 56 of 56 residents on unit # 1. Findings include: A random observation on 9/14/16 at approximately 10:30 am showed a visitor questioning facility staff about which Certified Nursing Assistant (CNA) was working with their loved one. The person looked at the staffing posted and continued to question about staffing. An observation was made on unit #1 on 09/14/2016 at approximately 1:30 pm of facility posted staffing, which showed 2 Certified Nursing Assistants (CNAs) working the 7am to 3pm shift. An interview was conducted with unit manager C on 09/15/2016 at approximately 1:35 pm. She stated that the posted staff were not the same ones that had signed in for the shift and this posting was incorrect. Review of the CNA sign in sheets for that shift indicated that 5 staff members were working on unit #1 for the shift. At approximately 1:50 pm on 9/14/16 a replacement staff posting was posted indicating 5 CNA's were working on that shift. At approximately 2:30 pm that day, a third staffing sheet was produced by staff member C indicating 8 non-licensed staff working on that shift. At 2:45 PM on that date, there were four non-licensed staff observed working on the unit.

Based on observation and interview the facility failed to provide a safe, clean, comfortable, homelike environment for 25 of 25 residents on the locked unit (unit # 3). The findings include: An observation was made of the residents common area on unit #3 at approximately 12:30 pm on 09/13/2016. The common area was approximately a 20'x20' cove with 3 solid and 1 half size wall. The room was painted light cream with dark green carpet rising from the floor approx 4 feet high on the walls. In the right upper corner a tv was playing the news. The room contained two brown benches and one chair. (photographic evidence obtained) One resident was observed wandering in and out of room, occasionally stopping to look up at the tv. There were no paintings or decorations observed on walls causing a sterile looking environment. Residents were observed lined up in wheelchairs against the wall across from the nurses station. Some residents were eating snacks using their laps as tables. An interview was conducted with staff member A. She stated that she was unsure why there was nothing to make the area more homelike for the residents.

Based on record review, staff interviews and policy review the facility failed to assess and document pressure ulcers at least weekly in accordance with the facility policy for 1 of 3 sampled residents with pressure ulcers. (resident # 142) The findings include: Review of resident #142's record revealed the resident was admitted to the facility on [DATE]. The resident did not have any documented pressure ulcers at the time of admission. The nurse's note dated 5/18/2016 revealed the nurse found an area on the left heel and a new order for treatment was obtained from the physician. There was no description of the wound or measurements of the area documented on 5/18/2016. The wound was initially assessed and documented on 5/26/2016 to be an unstageable pressure ulcer with eschar (a dark area of dead tissue) measuring 2.5 cm x 1.5 cm. An interview was conducted with the unit 1 Registered Nurse (RN) manager on 9/14/2016 at approximately 3:20 PM. She stated the nurse who found the wound on 5/18/2016 should have measured the wound. An interview was conducted with the Director of Nursing (DON) on 9/14/2016 at approximately 4:52 PM. The DON confirmed the wound was not measured and assessed when it was found. The facility policy for pressure ulcer and skin care management was reviewed on 9/14/16. The policy stated when a pressure ulcer, wound or other skin condition is identified a licensed nurse completes a pressure ulcer or skin report weekly until healed. The report includes measurements and assessment of the wound.