Every finding on record at Riverchase Health and Rehabilitation Center

Based on interviews and record review, the facility failed to protect 1 of 3 residents reviewed for neglect when staff failed to recognize, assess, and appropriately respond to injuries after the resident sustained a fall. (Resident #1)The findings include:Review of Resident #1's medical record revealed that on February 15, 2026, at 2:50 PM, Staff A, Licensed Practical Nurse (LPN), documented that Resident #1 fell during incontinence care and was found with abrasions, bruising, and redness to the right side and left upper back, a mark on the left forehead, and discoloration to the right knee, right arm, and right elbow.Review of Resident #1's medication orders revealed she was prescribed two daily anticoagulants: Clopidogrel and Aspirin. Documentation reflected that Resident #1 received Clopidogrel at bedtime on February 14, 2026, and Aspirin on the morning of February 15, 2026. The orders also directed staff to monitor for potential anticoagulant side effects and to notify the physician if the resident exhibited any of the following: sudden severe headache, nausea, vomiting, bruising, sudden changes in mental status, or shortness of breath.During an interview conducted on March 4, 2026, at approximately 4:00 PM, Resident #1's daughter reported that Staff A contacted her immediately after the fall on February 15. 2026. She further stated this phone call prompted her to report to the facility. She stated that she took photographs of the red marks on Resident #1's head and back and noticed she was in a lot of pain. Resident #1's daughter noted that she was acting different by talking louder than usual and stated that she is usually soft spoken and quiet. Resident #1's daughter shared her concerns about the injuries with Staff A. According to the daughter, Staff A assured her that the physician had been notified of the fall and that an X ray had been ordered and Tylenol was being administered for her complaint of pain. The daughter stated she assisted Resident #1 in eating dinner, and she left the facility while Resident #1 was sleeping at approximately 5:00 PM. About an hour later, she received a call informing her that Resident #1 was being transferred to the hospital. When she arrived at the hospital, the hospital staff informed her that Resident #1 had passed away.An interview conducted with the facility's Nurse Practitioner on March 5, 2026, at 10:11 AM revealed that Staff A had informed him that Resident #1 had fallen from the bed and was reporting pain in both legs. He recalled giving a verbal order for an X ray. He stated he was not made aware of the visible injuries and explained that, had he known the full extent of those injuries, he would have sent Resident #1 to the emergency room for further evaluation.A review of Resident #1's Change in Condition Note documented on February 15, 2026, at 7:47 PM showed that Staff B, LPN, had documented that Resident #1 was nauseated, vomiting, experiencing shortness of breath, and became unresponsive. Resident #1 was transferred to the local hospital at 9:15 PM. At 1:00 AM on February 16, 2026, it was documented that Resident #1's daughter notified the facility that Resident #1 had passed away. A review of Resident #1's Progress Notes revealed that Emergency Medical Services were called and arrived on February 15, 2026 at approximately 9:15 PM to transport Resident #1 to the local hospital after Resident #1 was found unresponsive and in respiratory distress. Documentation reflected that the first notation of a possible head injury occurred on February 15, 2026 at 2:50 PM. Review of the facility's Abuse and Neglect policy revealed that Neglect was defined as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based upon record reviews and interviews, the facility failed to follow physician orders to obtain urinalysis, adequately assess a resident for change in condition, and to prevent worsening of a urinary tract infection (UTI) that resulted in hospitalization . (Resident #1) The findings include: Resident #1 was admitted to the facility on [DATE] with a diagnosis of displaced posterior fracture of the first cervical vertebra. Skilled nursing assessments dated 1/9/25 thru 1/14/25 shows Resident #1 required setup assistance with meals, assistance with transfers, continent of bowel and bladder function, and alert and oriented. The skilled nursing assessment dated [DATE] thru 1/23/25 revealed the resident required dependent assistance with meals and eating and was incontinent of bowel and bladder. A review of Resident #1's care plan revealed she was care planned for self-care deficit, initiated on 1/13/25. Further review reveals resident A care plan was initiated on 1/23/25 for risk of complications related to incontinent episodes of bladder function. (photographic evidence). A review of physician orders dated 1/9/25 reveals labs were to be obtained including a urinalysis and Occult stool. Labs were obtained on 1/14/25. Upon reviewing the lab results provided by the facility, it was discovered that no urinalysis or occult stool lab was obtained. (photographic evidence obtained) An interview with Staff E, a Certified Nursing Assistant (CNA), on 2/12/25 at 2:15 pm revealed that she took care of Resident #1 during her stay at the facility, She stated that she saw a rapid decline as she was here, requiring more help to get up and eventually not wanting to get up at all. She stated she told the nurse about her concerns. Staff E stated she believed that Resident #1 went to the hospital on her discharge date due to her decline. An interview with Staff F, a Licensed Practical Nurse (LPN), on 2/12/25 at 3:30 pm revealed that after about 2-3 weeks being at the facility, she noticed a decline in functioning. I reported my concerns to the supervisor and let the family know about her decline. She stated she was not present when Resident #1 was discharged . An interview with the Nurse Practioner (NP) on 2/12/25 at 4:00 pm via telephone revealed. The NP recalled Resident #1 but states no one ever contacted him about any special concerns. He stated the facility orders routine urinalysis labs every week. He did not recall Resident #1 being treated for a UTI while at the facility. When asked about the lab result from the hospital, the NP stated, Urosepsis is a bad UTI with circulatory collapse. That's why we request that labs are done weekly so we can stay ahead of it and treat before it gets at that stage of a resident having to be hospitalized . Her urinary tract infection had to be brewing for several days and then she had an altered mental status, which can happen overnight in some cases. If we had gotten the Urinalysis done on admission we may have caught the infection early.

Based on observations, resident interviews, and staff interviews, the facility failed to provide a safe, clean and orderly environment for 8 of 22 rooms sampled. (Rooms 111, 114, 118, 201, 203, 205, 213 and 223) The findings include: On 12/27/23 at 11:05 AM, an observation of room [ROOM NUMBER]-2 revealed a fall mat with several rips and exposed padding. room [ROOM NUMBER]-2 was occupied by Resident #3 at the time of the survey. (Photographic evidence was obtained.) On 12/27/23 at 11:08 AM, an observation of room [ROOM NUMBER] -2 was conducted. The room was occupied by Resident #6 at the time of the survey. The trim on the wall by the head of the bed was detached from wall and fallen. Per resident interview, the trim had been detached for over 2 weeks. (Photographic evidence was obtained.) On 12/27/23 at 11:10 AM, an observation of room [ROOM NUMBER]-1 revealed a fall mat with several rips and exposed padding. room [ROOM NUMBER]-1 was occupied by Resident #4. (Photographic evidence was obtained.) On 12/27/23 at 11:18 AM, an observation of room [ROOM NUMBER] was conducted. room [ROOM NUMBER] was occupied by Resident #5 at the time of the survey. The air conditioner (AC) unit by the window had a blanket underneath. Per Resident #5, the blanket had been there since she was admitted weeks ago. The room also had exposed telephone wires and the overbed table was missing the outer border and had exposed particle board. (Photographic evidence was obtained.) On 12/27/23 at 11:19 AM, an observation of room [ROOM NUMBER] revealed a blanket underneath the AC unit. (Photographic evidence was obtained.) On 12/27/23 at 11:21 AM, an observation of room [ROOM NUMBER] revealed a blanket underneath the AC unit. (Photographic evidence was obtained.) On 12/27/23 at 11:27 AM, an observation of occupied room [ROOM NUMBER] was conducted. There were exposed wires underneath the AC unit. (Photographic evidence was obtained.) On 12/27/23 at 11:31 AM an observation of occupied room [ROOM NUMBER] revealed a blanket underneath the AC unit. (Photographic evidence was obtained.) On 12/27/23 at 2:03 PM, a tour was conducted with the Director of Nursing (DON) and the Maintenance Assistant. They verbally acknowledged all the above issues and stated they would remedy these issues immediately. On 12/27/23 at 4:05 PM, the DON provided the survey team invoices reflecting new orders for overbed tables and fall mats. These invoices stated orders were placed on 12/27/23 at 3:22 PM. The DON stated overbed tables and fall mats in disrepair would not be able to be replaced until the new ordered items arrived.

Based on observation, interviews, record reviews, and policy reviews, the facility failed to ensure that residents are free of any significant medication errors. 2 of 6 sampled nurses at the facility failed to obtain and administer the proper medication. (Staff G and H) The findings include: On 09/25/23 at approximately 12:30 PM, an interview was conducted with Resident #418. She explained that she was concerned because she had not received her Lovenox injection since last Friday. She explained that she notified the nurses, and she was told that the pharmacy had not sent the medication yet. On 09/26/23 at 2:43 PM, a review of the Medication Administration Record (MAR) was conducted for Resident #418 and revealed that current orders included Eliquis Oral Tablet 2.5 MG (Apixaban) 2.5 mg by mouth two times a day (an anticoagulant medication to treat deep vein thrombosis (DVT)) with a start date of 09/26/2023. Amongst the discontinued orders was Lovenox Injection Solution (a similar anticoagulant medicine used to treat DVT) Prefilled Syringe 100 MG/ML (Enoxaparin Sodium) Inject 1 application subcutaneously every 12 hours with a start date of 09/08/2023 and a discontinue date of 09/26/2023. On 9/26/23 at approximately 02:55 PM, a review of the progress notes was conducted for resident #418. There was a note dated 09/24/2023 that explained the nurse had placed a call to the pharmacy in reference to not receiving the Lovenox order. The pharmacy stated that the Lovenox was on back order with their supplier and they will send it soon as the medication is available. On 09/27/23 at approximately 09:31 AM, an interview was conducted with Nurse M, a Licensed Practical Nurse (LPN) and unit manager for the south unit. She was asked for clarification regarding if Resident #418 had been receiving her Lovenox injection. She indicated that the Lovenox has been on back order and she has not been getting it. She was asked for clarification on the MAR as it showed the Lovenox being administered as ordered twice a day since Friday and she suggested they must have had some left over and would follow up on it. On 09/27/2023 at approximately 10:30 AM, Nurse M provided copies of the packing slip from the facility's pharmacy that revealed a total number of 26 Lovenox injections had been ordered since 09/08/2023 through 09/18/2023. On 09/28/23 at approximately 09:41 AM, an interview was conducted with Nurse I, another LPN, She explained that, on Monday 09/25/2023, the evening dose of Lovenox was not in the cart so she went to pull it out of the Pyxis station, but it indicated the medication was not available. She went back to the floor and forgot to go back and fix her documentation from where she had already checked off that she administered it. She explained that she had already documented that she had administered the Lovenox and documented the site opposite from the last nurse's documentation. She reports calling the Advanced Practice Registered Nurse (APRN), but when he didn't answer the phone, she hung up without leaving a message. At approximately 09:59 AM, an interview was conducted with Nurse F, another LPN. She explained that when she worked on Friday 09/22/2023 on the 7:00 AM-7:00 PM shift that she administered the Lovenox to Resident #418 and that there were 2 or 3 doses left in the cart. At approximately 10:10 AM, an interview was conducted with Nurse H, another LPN. She explained that, on Monday 09/25/2023 during day shift, she didn't give the Lovenox medication because it wasn't available to give, but that she had already documented administering the Lovenox to Resident #418 prior to retrieving the medication. She reports faxing a written request over to the pharmacy to reorder it and notifying the resident that it was out and waiting for the pharmacy to bring it. She explained that she did not notify the doctor or anyone else at that time and that she forgot to go back and change her documentation. At approximately 10:25 AM, an interview was conducted with Nurse E, another LPN. She explained that she worked on the cart for Resident #418 on Friday 09/22/23, Saturday 09/23/23, Sunday 09/24/23 and Tuesday 09/26/23. She reports giving the resident her Lovenox injection on Thursday and noticed that it was running low, so she reordered it. On Saturday she reports there were three doses before she gave the prescribed morning dose and then there were 2 doses left after. She then administered the Lovenox on Sunday 09/24/2023 around 9:00 AM and noted there were no doses left in the cart. She called the pharmacy, and was told it was on back order, and they would send it as soon as it came in. She notified the APRN that the Lovenox was out and he verbalized to place the Lovenox on hold until it arrives from the pharmacy and resume it when it comes in. She reports calling the unit manager and notifying her of the medication Lovenox being out and speaking with Resident #418 to let her know it was on back order. She explained that when the APRN was in the facility on Tuesday 09/26/2023 that she advised him that Resident #418 was still out of Lovenox. At approximately 10:40 AM an interview was conducted with Nurse G, another LPN. She explained that on Saturday 09/23/23 during the night shift she administered the Lovenox injection to Resident #418 and there were two doses prior to her administering it. At approximately 11:03 AM an interview was conducted with Nurse M, the unit manager of the south wing. She explained that she received a call from Nurse E on Sunday 09/23/2023 stating that she talked to the APRN and called the pharmacy to notify of Resident #418 being out of Lovenox. The unit manager then spoke with the APRN on Tuesday 09/26/2023 when he came into the facility and told him that Resident #418 needed something because they still hadn't received the lovenox from the pharmacy. She explained that the APRN gave the order to discontinue the Lovenox and start on Eliquis. At approximately 11:22 AM, a telephone interview was conducted with the APRN. He explained that he received a call from Nurse E on Sunday 09/23/2023 regarding the Lovenox being out and that he gave her orders to hold the Lovenox until it came in. On Tuesday 09/26/2023, he reports that the unit manager notified him when he came into the facility that the Lovenox had still not come in, so he gave the order to discontinue it and start Resident #418 on Eliquis twice a day. A review of the facility policy for medication administration dated 11/2020 was conducted. The policy directed nurses to: #10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. c. If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.). 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 20. Correct any discrepancies and report to nurse manager.

Based on record reviews and staff interviews, the facility failed to ensure residents were free from accidents or injury by failing to ensure staff utilize appropriate assistive devices during showers for 1 of 5 residents reviewed for accidents. This failure resulted in emergent care and injury to Resident #55. The findings include: Review of Resident #55's record revealed a nurse progress note dated 1/19/22 at 4:11 PM, indicating the resident had bleeding and was being sent to the hospital for evaluation and treatment, per the primary care provider instructions. The hospital record dated 1/19/22 at 5:03 PM, stated the resident presented with a vaginal laceration after a slip and fall on a shower chair. The resident sustained a laceration to the left side vaginal labia majora measuring 1.5 cm, requiring 3 sutures, and a superficial laceration to the external labia majora measuring 4 cm. Review of the facility investigation of the incident revealed a statement from Employee I, Certified Nursing Assistant (CNA) dated 1/19/22, which reported that Employee H, an agency CNA, came to her after she had showered Resident #55 and asked for help to get her out of the shower chair. When Employee I entered the room, she found Resident #55 stuck in the shower chair seat. Employee I and two other staff assisted to release Resident #55 from the shower chair. One of the resident's legs had slipped and was lodged between the opening in the middle of the chair and the arm rest on the side of the chair. They were able to get the resident out of the chair. The Director of Nursing (DON) provided an additional investigation document, which stated on 1/19/22, Employee H, CNA, placed Resident #55 in a shower chair and performed a shower. After the shower, Employee H noticed the resident was stuck in the seat of the shower chair. Employee H requested the assistance of Employee I to remove the resident from the chair. Once the resident was removed from the chair, the staff noted she was bleeding. The staff alerted the nurse. The resident was transferred to the hospital for evaluation. The facility was unable to provide any other evidence of an investigation for the incident. Further review of the medical record for Resident #55 revealed a care plan dated 3/25/22, stating resident observed with vaginal laceration during transfer with bath. The care plan interventions included administer antibiotic as ordered, administer pain medications as indicated, keep vaginal area clean and leave sutures in place, sutures are dissolvable, monitor vaginal area every day for signs of infection and follow up with physician as indicated. The record did not describe the incident causing the vaginal laceration. The care plan nor the task menu items described the proper assistive device staff should use to safely shower the resident. The resident's weight was 171 pounds on 1/1/22. The resident's medical diagnoses included [CONDITION(S)] and flaccid (limp) [CONDITION(S)] ([CONDITION(S)]) affecting the left non-dominant side. An interview was conducted with the DON on 5/24/22 at 4:23 PM. She stated the agency staff did not know the shower bed would have been a better assistive device to use for showering Resident #55. The resident's care plan nor the task menu listed the shower bed was to be used. A telephone interview was conducted with Employee H, CNA, on 5/26/22 at 9:57 AM. Employee H stated, according to a verbal report from staff, the resident was permitted to use a shower chair. She reported that on 1/19/22, herself and another staff transferred Resident #55 to the shower chair. She showered the resident. She took the resident back to her room in the shower chair. She stated the resident moved in the shower chair which caused her groin area to get stuck under the seat of the shower chair. The resident was stuck in the chair. She obtained assistance from other staff to remove the resident from the chair. The resident verbalized she was in pain. She stated she did not see anything wrong with the shower chair. She was not aware of any written information to inform staff of the proper assistive device (shower chair or shower bed) to use when showering residents. An interview was conducted with Employee I, CNA, on 5/26/22 at 10:22 AM. She confirmed she assisted Employee H to get Resident #55 out of the shower chair on 1/19/22. She stated the resident's buttocks was stuck in the chair and her leg was stuck between the plastic in the middle of the chair. The resident is like spaghetti and does not have much control of her extremities. She stated she would not use the shower chair for Resident #55; she would use the shower bed. An interview was conducted with the Director of Rehabilitation on 5/26/22 at 11:32 AM. She stated Resident #55 was last seen by therapy in November 2021 for wheelchair positioning. The resident has [CONDITION(S)] with fixed positions, leaning to her side, and poor trunk control. She stated the facility has never requested a therapy evaluation to determine the safest device to shower the resident. An interview was conducted with Employee J, CNA, on 5/26/22 at 11:46 AM. She stated she provides care to Resident #55. The resident has limp upper and lower extremities. She stated the shower bed is safer to use for the resident because her body is limp, and she would lean over in the chair. She reviewed the resident's electronic record and confirmed the record did not indicate what device to use during resident showers. An interview was conducted with Employee K, CNA, on 5/26/22 at 12:07 PM. Employee K stated she cares for Resident #55. She stated the resident does not have good control of her limbs and body, and she leans. She uses the shower bed to shower Resident #55. She stated neither the care plan nor the task menu instruct which device to use during a shower. Agency staff ask other staff which device to use for showers. A policy regarding accident prevention was requested on 5/26/22 at approximately 1:00 PM. At the time of survey exit on 5/26/22 at approximately 3:30 PM, the policy had not been provided.

Based on record review, staff interviews and policy review, the facility failed to thoroughly investigate an accident resulting in injury and failed to develop and implement appropriate action plans to address the cause of the accident for 1 of 5 residents sampled for accidents. (Resident #55) The findings include: Review of Resident #55's record revealed a progress note dated 1/19/22 at 4:11 PM, indicating the resident had bleeding and was being sent to the hospital for evaluation and treatment, per the primary care provider instructions. The record revealed a care plan last reviewed 3/25/22 stating resident observed with vaginal laceration during transfer with bath. The care plan interventions stated administer antibiotic as ordered, administer pain medications as indicated, keep vaginal area clean and leave sutures in place, sutures are dissolvable, monitor vaginal area every day for signs of infection, and follow up with physician as indicated. The hospital record dated 1/19/22 5:03 PM, stated the resident presented with a vaginal laceration after a slip and fall on a shower chair. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The record did not describe the incident causing the vaginal laceration. Neither the care plan nor the task menu items described the proper assistive device staff should use to safely shower the resident. The resident's weight was 171 pounds on 1/1/22. The resident's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's internal investigation of the incident revealed a statement from Employee I, Certified Nursing Assistant (CNA) dated 1/19/22 who reported that Employee H, an agency CNA, came to her after showering Resident #55 and asked for help getting her out of the shower chair. When Employee I, CNA, entered the room, she found Resident #55 stuck in the shower chair seat. Employee I and two other staff assisted to release Resident #55 from the shower chair. One of the resident's legs had slipped and was lodged between the opening in the middle of the chair and the arm rest on the side of the chair. They were able to get the resident out of the chair. The Director of Nursing (DON) provided an additional investigation document which stated that on 1/19/22, Employee H, CNA, placed Resident #55 in a shower chair and performed a shower. After the shower, Employee H noticed the resident was stuck in the seat of the shower chair. Employee H requested the assistance of Employee I to remove the resident from the chair. Once the resident was removed from the chair, the staff noted she was bleeding. The staff alerted the nurse. The resident was transferred to the hospital for evaluation. The facility was unable to provide any other evidence of an investigation for the incident. An interview was conducted with the Administrator on 5/24/22 at 4:19 PM. He stated the shower chair used for Resident #55 broke and she fell inside the chair. He stated he purchased a new chair and removed the old chair from service. When asked why the facility did not document a thorough investigation of the incident on 1/19/22 involving Resident #55, he stated he was on vacation when the incident occurred. A follow-up interview was conducted with the Administrator on 5/25/22 at 9:45 AM. He then stated the shower chair used on 1/19/22 for Resident #55 was not broken or in disrepair. An interview was conducted with the DON on 5/24/22 at 4:23 PM. She stated the agency staff did not know the shower bed would have been a better assistive device to use for showering Resident #55. Neither tthe resident's care plan nor the task menu indicated the shower bed was to be used. A follow-up interview was conducted with the DON on 5/26/22 at 2:41 PM. She confirmed that if Resident #55 had been showered in the shower bed, the incident would not have occurred. A telephone interview was conducted with Employee H, CNA, on 5/26/22 at 9:57 AM. Employee H stated, according to a verbal report from staff, the resident was permitted to use a shower chair. She reported that on 1/19/22, herself and another staff transferred Resident #55 to the shower chair. She showered the resident. She took the resident back to her room in the shower chair. She stated the resident moved in the shower chair which caused her groin area to get stuck under the seat of the shower chair. The resident was stuck in the chair. She obtained assistance from other staff to remove the resident from the chair. The resident verbalized she was in pain. She stated she did not see anything wrong with the shower chair. She was not aware of any written information to instruct staff on the proper assistive device (shower chair or shower bed) to use when showering residents. An interview was conducted with Employee I, CNA, on 5/26/22 at 10:22 AM. She confirmed she assisted Employee H to get resident #55 out of the shower chair on 1/19/22. She stated the resident's buttocks was stuck in the chair and her leg was stuck between the plastic in the middle of the chair. The resident is like spaghetti and does not have much control of her extremities. She stated she would not use shower chair for Resident #55; she would use the shower bed. An interview was conducted with the Director of Rehabilitation on 5/26/22 at 11:32 AM. She stated Resident #55 was last seen by therapy in November 2021 for wheelchair positioning. The resident has [CONDITION(S)] with fixed positions, leaning to her side, and poor trunk control. She stated the facility has never requested a therapy evaluation to determine the safest device to shower the resident. An interview was conducted with Employee J, CNA, on 5/26/22 at 11:46 AM. She stated she provides care to Resident #55. The resident has limp upper and lower extremities. She stated the shower bed is safer to use for the resident because her body is limp, and she would lean over in the chair. She reviewed the resident's electronic record and confirmed the record did not indicate what device to use during resident showers. An interview was conducted with Employee K, CNA, on 5/26/22 at 12:07 PM. Employee K stated she cares for Resident #55. She stated the resident does not have good control of her limbs and body, and she leans. She uses the shower bed to shower Resident #55. She stated neither the care plan nor the task menu indicate which device to use during a shower. Agency staff ask other staff which device to use for showers. A follow-up interview was conducted with the Administrator on 5/26/22 at 12:59 PM. He stated he needs to do a better job of ensuring agency staff know the residents. He should have documented more of the investigation interviews. He confirmed the facility still employs agency certified nursing assistants who provide baths/showers to residents in the facility. He did not know if there was information to inform staff about how to safely shower residents, but stated it should be listed on the tasks or care plan. He confirmed that relying on staff to inform agency staff how to shower residents is not a good process to ensure resident safety. On 5/26/22 at 2:32 PM, the Administrator stated the facility did not develop a quality assurance performance improvement plan related to the incident involving Resident #55. Review of the facility's undated policy regarding incidents and accidents revealed it is the policy of this facility for staff to utilize Electronic Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. The purpose of incident reporting can include: assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care, ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences, alert risk management and/or administration of occurrences that could result in claims or further reporting requirements.

Based on record review, policy review and interview, the facility failed to create a discharge summary for 1 of 1 resident sampled for discharge. (Resident #103) The findings include: A closed record review for Resident #103 revealed the resident was discharged home as planned on 3/22/22. Further review revealed no documentation of a discharge summary. A review of the facility's undated policy and procedure, Discharge Summary and Care Plans, revealed the policy did not address completing a discharge summary for the resident record. On 5/24/22 at approximately 11:48 AM, an interview was conducted with the Director of Nursing (DON) who stated therapy had written a summary of the care but was still working on it. The DON confirmed there is no completed discharge summary at this time.

Based on observations, staff interviews, record review and policy review, the facility failed to ensure that proper Personal Protective Equipment (PPE) was worn for a resident on contact isolation precautions (#253); failed to ensure staff performed glucose blood monitoring in a manner to prevent cross-contamination for 2 of 2 observations (#57, #102), and failed to ensure that handwashing was performed during medication administration (#86). The findings include: PERSONAL PROTECTIVE EQUIPMENT On 5/24/22 at approximately 11:45 AM, an observation was made of a metal isolation PPE hanger on the door to Resident #253's room. The PPE observed in the hanger included gowns, gloves, hair, and shoe coverings. Upon entry into the resident's room, an observation was made of Resident #253 sitting in his wheelchair and Staff A, Certified Nursing Assistant (CNA), standing at the bedside pulling the bed sheets up. The bed sheets were observed coming into physical contact with Staff A's clothing. Staff A, CNA, was then observed pulling up the side rail of the bed, which was also coming into physical contact with Staff A's clothing. Staff A, CNA, did not have gloves or a gown on at the time of the observation. On 5/24/22 at approximately 11:55 AM, an interview was conducted with Staff A, CNA, who stated she was told a gown was not necessary because Resident #253's infection was contained. Staff A, CNA, was unable to recall who said the infection was contained. Staff A, CNA, stated she wore gloves when providing care, and confirmed she did not wear a gown for patient care and did not have PPE on to make up the bed. A review of Resident #253's medical record revealed the resident was on contact isolation precautions for [MEDICATION(S)] resistant enterococcus (VRE) bacteria in the urine. A review of Resident #253 Admission Minimum Data Set (MDS) dated [DATE] revealed under Section G that the resident requires extensive assistance with dressing and toilet use, and under Section H that the resident is frequently incontinent of urine. On 5/26/22 at approximately 10:00 AM, an interview was conducted with Staff B, Infection Preventionist, who stated if a resident has a VRE infection in the urine, and has a urinary catheter, the infection is considered contained. She further stated that if a resident is incontinent of urine, then the infection is considered not contained. Staff B confirmed the staff should wear a gown and gloves when providing direct care to Resident #253. Staff B further confirmed a gown and gloves should be worn when changing the sheets or making the bed for Resident #253. Review of the facility's undated policy, Isolation Precautions, revealed contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. Under the recommendations for PPE for contact isolation the policy revealed: gloves should be worn when touching the patient's intact skin or surfaces and article in close proximity to the patient (e.g. medical equipment, bed rails). Don gloves upon entry into the room or cubicle. Gowns are to be worn whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room or cubicle. GLUCOSE MONITORING and HAND WASHING On 5/25/22 at approximately 11:34 AM, an observation was made of Staff G, Licensed Practical Nurse (LPN), performing blood glucose monitoring for Resident #57. Further observation revealed Staff G entering Resident #57's room and placing the glucometer on Resident #57's bed. Staff G donned gloves and performed the procedure, then placed the glucometer back on the bed. Staff G, LPN, then picked up the glucometer from the resident's bed and carried it to the medication cart and placed the glucometer on top of the medication cart without placing a barrier on the medication cart. Staff G, LPN, then removed her gloves. Staff G, LPN, then pulled an insulin pen that was in a plastic bag from a drawer in the medication cart and placed it on the top of the medication cart. The plastic bag was touching the glucometer. Staff G, LPN, then placed a glove on her right hand, picked up the glucometer and pulled the used strip from the glucometer, then placed the glucometer in the top right drawer of the medication cart. Staff G, LPN, then prepared the insulin pen for Resident #86, and administered the insulin. Staff G, LPN, did not sanitize her hands after handling the dirty glucometer and picking up the insulin pen for Resident #86. After Staff G, LPN, administered the insulin to Resident #86, she retrieved the dirty glucometer and cleaned it with an alcohol prep pad and an alcohol wipe, and returned it to the top right drawer of the medication cart. An interview was conducted with Staff G at approximately 11:45 AM, who confirmed placing the glucometer on the bed without a barrier and then placing the glucometer on the medication cart without a barrier which could possibly lead to cross-contamination. On 5/25/22 at approximately 4:33 PM, an observation was made of Staff N, LPN, performing blood glucose monitoring for Resident #102. Further observation revealed Staff L place the glucometer and a bottle of test strips on the overbed table in Resident #102's room. Staff N, LPN, then picked up the glucometer and the test strips and placed a paper towel barrier under the items. Staff N, LPN, performed the procedure, then picked up the glucometer and the bottle of strips with the paper towel wrapped around the items, then placed them on top of the medication cart without using a clean barrier. Staff N, LPN, cleaned the glucometer with Clorox wipes and then placed the glucometer on the dirty paper towel. Staff N, LPN, stated she lets the glucometer dry naturally because there is a second glucometer in the medication cart. On 5/26/22 at approximately 10:00 AM, an interview was conducted with Staff B, Infection Preventionist, who stated the nurses should have a clean area set up in the resident room to place the glucometer, alcohol swabs, lancet and strip, and confirmed the nurses should not take the bottle of strips into the room. Staff B confirmed the nurses should place a barrier on the cart and stated the dirty glucometer should not be placed directly on the cart. Staff B stated the nurses should clean the glucometer with the bactericidal wipes that are on the cart. Staff B could not remember the name of the wipes and stated the glucometer should be allowed to dry. Staff B confirmed each cart has two glucometers. Review of the facility's undated policy, Glucometer Disinfection, revealed the purpose of the procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. The policy revealed the glucometers should be disinfected with a wipe pre-saturated with disinfectant that is effective against [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] B virus.

Based on observations, interviews and record reviews, the facility failed to provide necessary services for residents who require assistance with activities of daily living, specifically nail care, for 6 of 12 residents randomly sampled for nail care (Residents #2, #6, #7, #8, #13 and #14). The findings include: On 9/1/2020 at 10:23 AM, a telephone interview was obtained with Resident #2's daughter and representative who stated she was concerned by her mother's appearance when she saw her on a video call arranged by the facility after not seeing her face-to-face for several months due to the COVID-19 visitation restriction. She continued that she ended up seeing her mother in person while she was at the hospital and was concerned at the condition of her nails as they were long and filthy. She stated that the nurse at the hospital was also concerned about the condition of her mother's nails and assured her that they would be taken care of prior to her mother's discharge. She confirmed that the hospital trimmed and cleaned her mother's nails before sending her back to the facility. On 9/1/2020 a review of Resident #2's medical record was conducted. Review revealed that the resident was readmitted to the facility from the hospital approximately two weeks ago. Review of the plan of care which had an initiation date of 10/20/2019 and a scheduled review date of 9/8/2020 revealed that the resident required assistance with bathing, grooming and dressing daily related to impaired mobility. Care plan interventions revealed the following: provide oral care in the morning, evening, and as needed, assist with grooming and dressing daily, bath or shower three times per week, dress age appropriate and groom neatly daily and as needed. Review of the resident's daily task sheets, which are completed by the Certified Nursing Assistants (CNAs), revealed no fields related to nail care. On 9/1/2020 at 5:23 PM, an interview was conducted with CNA D, a CNA who works on the South Wing. The surveyor asked CNA D if nail care is scheduled to be completed on bath/shower days. CNA D informed the surveyor that there's no schedule for completing nail care, it's just completed as needed. The surveyor asked CNA D where the completion of nail care gets documented and she replied that it doesn't get documented anywhere. The surveyor asked what nail care should look like when it's being completed and she stated soak the residents' fingers in warm soapy water and use an orange stick to clean out from under the nails and then use a washcloth to clean around the nail bed and apply ointment to dry areas. The surveyor asked CNA D how residents' needs are being met while manicure activities have been suspended and the beauty shop is closed. CNA D hesitated and then shrugged. On 9/1/2020 at 5:27 PM, the surveyor and CNA D entered several South Wing rooms together to examine the condition of resident fingernails, beginning with the room that housed Resident #2. Resident #2's nails were observed to have a brown substance underneath the free edges of the nails on both hands. The surveyor and CNA D entered the room belonging to Resident #6 and Resident #7 next. When the surveyor asked to see Resident #6's nails, she stated that she she asked a staff member to clean under her nails and they said they would if they had time, but they never did. Resident #6 was also observed with a brown substance underneath the free edges of the nails on both hands. Resident #7 was observed with her right thumb nail extending approximately a centimeter beyond the end of the thumb. A brown substance was visible underneath the free edges of the nails on both Resident #7's hands. The surveyor asked if she'd allow staff to trim and clean her nails and she nodded her head and said yes. The surveyor and CNA D entered the room belonging to Resident #8. CNA D stated that Resident #8's toes were bad. She applied gloves and removed the resident's socks. The second toe on each foot overlapped onto the great toe. The great toenails were discolored with a black hue. Resident #8 shifted in her wheelchair and CNA D asked her if it was painful having her toes touched and she nodded her head yes. On 9/1/2020 at 5:45 PM, the surveyor inquired to the South Wing Assistant Director of Nursing (ADON) about Resident #8's toes. The ADON stated that she's had those hammer toes since before she arrived and the podiatrist hasn't been to the facility for some time due to COVID-19 but she was on the list to be seen when the podiatrist visits on 9/10/2020. The ADON continued that the previous treatments ordered including soaking and moisturizing them. On 9/1/2020 at 5:53 PM, the surveyor toured the facility's North Wing and observed a random sample of residents for fingernails. The surveyor entered the room belonging to Resident #12 and Resident #13. Resident #13 was using her left hand to eat rather than using a utensil. All nails on the left hand were excessively long and food was collecting underneath the nails. The surveyor asked Resident #13 if staff trim her nails and she replied, Yes, but it's been awhile. The surveyor asked if she'd like her nails trimmed and she replied, Yes. The surveyor entered the room belonging to Resident #14. A brown substance was visible underneath Resident #14's nails on both hands. Resident #14's nails were very short and he stated he bites his nails. On 9/1/2020 at 6:08 PM, an interview was conducted with CNA G who was working on the North Wing. The surveyor inquired about resident nail care and she stated that there's usually nail kits in the dayroom where residents can have their nails filed and painted. The surveyor stated that she was aware of manicures being a scheduled activity at many facilities prior to COVID-19 and asked about what alternatives have been offered since group activities have been canceled and residents are encouraged to stay in their rooms. CNA G replied, I really don't know. On 9/1/2020 at 6:40 PM, the surveyor met with the Nursing Home Administrator (NHA) and DON. The surveyor informed them of her concerns related to residents not being seen by the podiatrist for months, not documenting if and when nail care is provided, and not implementing an alternative to the pre-COVID scheduled manicure activities. The surveyor further informed them that residents were observed with excessively long nails and brown substances underneath the nails and that a resident had made a request for nail care earlier which went unanswered. The DON confirmed that the podiatrist had not been in the building since March or April and was scheduled to come for two days to address resident needs. The NHA and DON did not dispute the surveyor's concern regarding nail care not being adequately addressed.

Based on observation and staff interviews the facility failed to treat 2 of 11 residents dining in the south unit dining room with respect and dignity while feeding the residents (resident #23 and resident #34). The findings include: An observation was made on 10/29/2019 at approximately 12:10 PM, during lunch service on the South Unit day room. Staff member A, a Certified Nursing Assistant (CNA), was observed standing between resident #23 and resident #34; both residents were seated in wheelchairs. CNA A was observed feeding both residents at the same time while standing between them. CNA A was observed providing resident #23 a bite of food, then put the spoon down, and picked up resident #34 utensil and fed #34 a bite a food. Resident #23 was observed turning her head to the side in order to get the offered food into her mouth. An interview was conducted on 10/30/2019 at approximately 12:34 PM, with Assistant Director of Nursing (ADON) staff B. Staff B revealed staff are expected to sit while feeding residents and are expected to assist feeding only one resident at a time. Staff B revealed each staff assisting with feeding residents are expected to stay with the resident until the meal is completed. An interview was conducted on 10/31/2019 at approximately 10:56 AM, with CNA [NAME] CNA A confirmed on 10/29/2019 she fed the two residents (#23 and #34) at the same time while standing. CNA A confirmed she did not follow the correct practice while feeding the residents.

Based on record review and staff interview the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 25 sampled residents. (resident #82, 257 and 51) The findings include: Resident #82 Review of resident #82's quarterly Minimum Data Set (MDS) with an assessment reference date of 9/22/19 revealed the resident received an anticoagulant 7 out of 7 days. Review of the current physician orders [REDACTED]. The resident was receiving [MEDICATION NAME], an antiplatelet medication. The resident had a current care plan in place for receiving an anticoagulant. An interview was conducted with employee D, the Registered Nurse (RN) MDS Coordinator, on 10/31/19 at 12:19 PM. Employee D confirmed the 9/22/19 quarterly minimum data set was not coded correctly and the resident had not received an anticoagulant. Resident #257 A review was conducted of Resident #257's weights which revealed the following: 10/8/2019 - 104 10/9/2019 - 104 10/10/2019 - 103 10/11/2019 - 102 10/15/2019 - 98 10/22/2019 - 94 10/23/2019 - 94 10/29/2019 - 92 A review of MDS data from an annual assessment completed on 10/14/2019 was conducted which revealed that the weight documented in the assessment was 145 pounds. This weight was not reflected in the medical record. On 10/30/19 at 3:39 PM, an interview was conducted with the MDS Coordinator. At that time she looked through the resident's weights. After reviewing the data she stated, That must have been pulled from a previous stay. I'm not sure why it pulled a 145. So this was an erroneous weight. I will have to do a correction for that. Resident #51 A record review of the MDS assessment dated [DATE] was completed for Resident #51. The MDS, section J revealed the resident had two falls with major injury. An interview was conducted with the Prospective Payment System (PPS) Coordinator on 10/31/2019 at approximately 12:31 PM, she revealed the Assistant Director of Nursing was coding the MDS while the MDS Coordinator was on extended leave. The PPS Coordinator confirmed that Resident #51 did not have any falls and no major injury and the MDS was coded incorrectly.

Based on observations, interviews and record review, the facility failed to ensure residents were not physically restrained for 1 of 19 residents sampled (Resident #25). Findings: On 10/25/17 at approximately 9:15am resident #25 was observed sitting up in bed having breakfast with the right side of her bed pushed against the wall and the left side of her bed with a full siderail observed in the up position. The bed was also observed to be in a high position. Resident #25 was observed to be alert, but not able to make her needs known . Review of the physician orders [REDACTED]. On 10/25/2017 at approximately 9:30am an interview was conducted with the resident's nurse (Employee A). When asked if the resident was capable of getting out of bed, she stated yes, but she needs assistance as she had a prior fall that resulted in a fracture. On 10/25/17 at approximately 10:10am an interview conducted with the faciliy's Director of Nursing (DON) revealed resident #25 to be capable of getting out of the bed independently. On 10/25/17 at approximately 10:00am resident #25 was observed, in the presence of the DON, to be in bed with bilateral full siderails in the up position. The bed was observed to have been lowered to the low position. When resident #25 was asked if she could get out of the bed, she replied yes. When asked how she would get out of the bed with the siderails up, she stated I guess I would crawl over it. The DON confirmed the use of the full siderails to be a restraint, as resident #25 was capable of getting out of bed and the full siderails prevented the resident from getting out of bed without having to crawl over the rail. Review of the medical record for resident #25 showed a significant change in condition assessment, dated 9/27/17, that indicated resident #25 was severely cognitively impaired. The record also included a document, dated 9/5/17, titled side rail rationale screen. The screen documented resident #25 to be mobile and able to change position without assistance. The side rail screen documented no alternative interventions had been tried before the use of the side rails began. The screen documented the side rails were indicated as an enabler and at the resident's request. Interview conducted with resident's assigned Certified Nursing Assistant , Employee B, on 10/25/17 at approximately 10:50am revealed resident #25 was capable of getting out of bed and capable of ambulating.

Based on observation and interview the facility failed to thaw food safely, by completely submerging the item under cold water less than 70 degrees. Findings include: During the initial tour of the kitchen on 9/26/2016 at 09:14 AM, four packages of pre-cooked chopped chicken were observed to be stacked on top of one another in a sink with running water pouring onto the top package and running off on one side of the package. The meat was not fully submerged by water. The water, when checked by hand, was noticeably warm. The Certified Dietary Manager (CDM) then placed a thermometer into the running water. The thermometer read 83 degrees and the CDM verbally confirmed the temperature. The CDM stated at that time the water could be running with a temperature as high as 110 degrees.

Based on observations, staff interviews and clinical record review, the facility staff did not ensure one of two residents reviewed for restraint use (#134) did not have the restraint applied for staff convenience. Findings include: On 09/26/2016 at 11:17 AM Resident # 134 was first observed in day room in a group music activity. The resident was seated in geri chair with attached lap tray. The resident appeared confused, attempting to remove the lap tray and asking for staff to help her. At the time, Staff B (an aide) told the resident that someone will be in to help her. At 11:30 AM the resident remained in the day room and continuing to attempt to remove her lap tray. The same staff member continued to tell resident that someone will help her soon. The tray was not removed until 12:20 PM, over an hour after the resident was noted to start struggling with the restraint. During this entire observation of over an hour, there was only one staff member observed in the room with eight residents. On 09/26/2016 at 12:09 PM, Staff C (a Licensed Practical Nurse) stated in an interview the lap tray is for behaviors displayed by Resident 134. She stated it is in her care plan to have a geri chair with lap tray because she has behaviors related to her dementia. On 09/27/2016 at 2:33 PM Staff D (an aide) stated in an interview they have been using the geri chair with lap tray daily for a while, for agitation. On 09/27/2016 at 2:38 PM Staff E (a licensed practical nurse) stated the lap tray and geri chair has been used for over a year. She stated it is used daily because she gets agitated and to prevent falls. Per her orders she can have off if she is on one to one. She can't remove the tray. On 09/27/2016 at 3:03 PM Staff F (an assistant director of nursing) stated in an interview that the lap tray is not supposed to stay on for more than two hours and staff should get her up to walk around and do care. Sometimes they will put the tray on during meals but they do forget to take it off after meals and I have told them that they have to remember to remove the tray. On 09/28/2016 at 10:23 AM Staff G (a minimum data set coordinator) stated when resident #134 displays behaviors staff should try to redirect her, talk to her, give magazine or something to hold in her hands, or take her for a walk. If she attempts to remove the tray, staff should ask her if she needs to use the toilet or any other wants. If she does ask for it to be removed, staff should remove the tray. On 09/29/2016 at 8:53 AM the facility Director of Nursing was interviewed. She stated that during the time the resident was attempting to remove the lap tray, the Aide in the room could have opened the door and asked someone to come in to assist the resident, so that the tray could have been removed The Resident's treatment record, during the month of September 2016 indicated the resident was in the geri chair with lap tray 23 out of 28 days. During the month of August 2016, resident was in the geri chair with lap tray every day on 2 out of 3 shifts. During the month of July 2016, resident was in the geri chair with lap tray 30 out of 31 days.

Based on observation, record review and interview, the facility failed to appropriately code the dental status on the Minimum Data Set (MDS) assessment for 2 of 3 residents sampled for dental services (#63 and #44). The findings are: 1. On 09/26/2016 at 11:35AM an observation was conducted of resident #63 who was observed to be edentulous (without any teeth). An interview conducted with the resident at the time of the observation revealed that he had had all of his teeth pulled prior to being admitted to the facility. Resident's last comprehensive assessment was an annual with an assessment reference date (ARD) of 2/28/16. Review of Section L for Oral/Dental Status showed resident coded as No for section B: No Natural Teeth or Tooth Fragment(s) (edentulous). Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual steps for assessment for section L0200 gave the following coding instructions for L0200B No Natural Teeth or Tooth Fragment(s) (edentulous): if the resident is edentulous or lacks all natural teeth or parts of teeth you would indicate Yes. An interview conducted on 09/28/2016 at 1:36PM with the Director of Nursing revealed that all residents are assessed on admission for dental problems and are then referred if services are needed. She stated that edentulism is assessed but if there were no issues then no refferrals would be made. She stated that the unit managers are responsible for the coding of the dental section on the Minimum Data Set (MDS) for the residents on the units. A subsequent interview on 09/28/2016 at 3:00PM with the unit manager for the resident's unit confirmed that she was the person responsible for coding section L of the resident's MDS assessments.She was asked about the coding of the last comprehensive assessment for resident #63 in regards to the coding of the dental section and the resident being edentulous. She confirmed that the resident did not have any teeth at the time of his assessment in February 2016 and confirmed that she had improperly coded that section of the MDS. On 09/27/2016 resident #44 was observed during Stage One of the survey process. Resident #44 was observed to have no teeth (edentulous). On 09/28/2016 a record review related to Dental was conducted for resident #44. Resident #44 was admitted into the facility in July 2014. A review of her most recent Quarterly (08/16/2016) and annual MDS assessments (05/16/2016 and 05/16/2015) (Minimum Data Set) failed to identify the resident as edentulous. The MDS was coded incorrecty. The resident's July 2014 MDS assessment had been coded correctly. A review of the manual for Resident Assessment Indicator (RAI) indicated Coding instructions - Check L0200B, no natural teeth or tooth framents(s) (edentulous): if the resident is edentulous or lacks all natural teeth or parts of teeth. On 09/28/2016 at approximately 09:50am an interview ws conducted with the MDS Coordinator, she reviewed the entered MDS data and had misinterpreted the question related to dental and thought she was confirming that she did not have teeth. On 09/28/2016 at approximately 10:00am, the Unit Manager, along with the MDS Coordinator provided a copy of the resident's admitting MDS from 2014. The resident's admission MDS was coded correctly, but somehow it was misinterpreted and coded incorrectly on her 2015 and 2016 annual assessment. The Unit Manager stated she thought that question was referring to having dentures, in which the resident does not.

Based on observation, record review, and interview the facility failed to consistently implement care plan interventions related to pressure relief for 1 of 3 residents sampled for pressure ulcers (#20). The findings are: On 09/27/2016 at 10:45AM a staff interview was conducted with staff nurse H. She stated that resident #20 did have a Stage 3 pressure ulcer on her left buttock. A subsequent record review was conducted of resident #20s medical record. On 8/30/16 a physician's orders [REDACTED]. A review of the plan of care for resident #20 showed that the resident's skin impairment was planned for with interventions including float heels when in bed, and reposition resident every two hours for pressure relief and comfort. Observations of resident #20 were conducted at various times throughout the four day survey process and showed: 1. On 09/27/2016 at 1:16 PM Resident #20 was observed in her bed, lying on her back. Resident's heels were not elevated at the time of the observation. 2. On 09/27/2016 at 3:08 PM Resident was observed in her bed, lying flat on her back. The resident's feet were observed sticking out from under the sheet and there was nothing observed under them to ensure that her heels were floated. 3. On 09/28/2016 at 8:39 AM Resident was observed in her bed, lying on her back. The resident's feet were observed to be flat on the bed with her heels touching the sheet directly on top of her bed mattress, and not elevated. 4. On 09/28/2016 at 10:49 AM Resident was observed in her bed, lying flat on her back. Observation of the resident's feet showed her left heel to be directly laying on top of the sheet that was on the resident's mattress with her right foot propped on top of the left foot, adding more pressure to the left hell that was not observed to be floating off of the bed. 5. On 09/28/2016 at 12:38 PM Resident was observed in her room, lying in her bed flat on her back. Observation of the resident's feet under her bed spread showed that both feet were resting directly on the sheet covering the mattress. Feet were not elevated off the mattress for pressure relief. 6. On 09/28/2016 at 3:32 PM Resident was observed in her bed lying flat on her back. Observation of resident's feet under the cover showed both heels were resting directly on the sheet covering the mattress and not elevated for pressure relief. 7. On 09/29/2016 at 8:54 AM a wound care observation was conducted with the wound care nurse. Upon entering the resident's room, resident was observed in bed lying flat on her back. Resident 's entire body was visible at the time of this observation and both of her heels were observed on the bed and were not being floated. On 09/29/2016 at 9:22 AM an interview was conducted with the wound care nurse who confirmed that resident #20 is supposed to be turned every two hours, and that all of the facility's mattresses are pressure relieving. She also stated that the resident had a cushion that went in her chair when she would get up out of bed. On 09/29/2016 at 9:38 AM an interview was conducted with staff nurse I who stated that interventions for the resident include turning and repositioning every two hours and received an ordered supplement for wound healing. She stated that any interventions the residents have are entered into their computer system and that is how they are communicated to the certified nursing assistants. On 09/29/2016 at 9:41 AM an interview was conducted with staff member L who stated that the only intervention she was aware of for the resident was turning and repositioning every two hours. On 09/29/2016 at 9:43 AM an interview with facility staff J showed that she was aware that the resident had a place on her hip. She stated that staff go in her room to turn and reposition the resident every two hours, but stated that the resident refuses most often. She stated that they have tried using pillows behind her, but stated that the resident will remove the pillow sometimes as soon as they put it behind her. She also stated that the resident is supposed to have her heels floated and they have a cushion they use, but stated that the resident will normally kick it out. She stated that she had just tried to put the pillow under the resident's ankles and had asked the resident not to mess with it, but stated that as soon as she got to the resident's doorway, the resident had already kicked the pillow down to the foot of the bed. A subsequent observation conducted on 09/29/2016 at 9:52 AM showed resident #20 in her bed, lying on her back. Resident had her eyes closed and appeared to be sleeping. There were no extra pillows or cushions of any type observed in the room or around the resident's bed. Resident's feet were not floating and resident was positioned on her back.

Based on observation, record review, resident interview and staff interview the facility failed to provide all menu items of a therapeutic diet to 1 of 3 sampled residents sampled with significant weight loss. (#43) The findings include: An observation of the lunch meal for resident #43 was conducted on 9/27/2016 at approximately 12:18 PM. The resident was served meat loaf, mashed potatoes with gravy, peas and cake with a carton of fat free milk. The resident was not served a roll or any other bread except the cake. On 9/27/2016 at approximately 12:39 PM an interview was conducted with resident #43 and she confirmed she was not served a roll during the lunch meal. The resident did not request fat free milk, it was served with the meal tray. Review of resident #43's record revealed a current physician order [REDACTED]. The meal ticket for the resident indicated she was to receive a mechanical soft no added salt diet with 2% milk. The resident's dislikes indicated she did not like grits. Bread was not listed as a dislike. Review of the facility menu for 9/27/2016 indicated a resident on a mechanical soft no added salt diet should receive #8 scoop ground meatloaf, 1/2 cup mashed potatoes with 2 ounces of gravy, 1/2 cup green peas, bread of choice with margarine and a 2 x 3 square of red velvet cake. An interview was conducted with the Registered Dietician on 9/28/2016 at approximately 12:04 PM. She stated the resident should be served a roll and 2% milk unless the resident requested fat free milk. An interview was conducted with the Certified Dietary Manager (CDM) on 9/28/2016 at approximately 12:05 PM. The CDM confirmed the resident should have received 2% milk.

Based on observation, resident interview, staff interview and policy review the facility failed to ensure all medications were stored properly for 1 of 40 sampled residents. (#103) The findings include: An observation of resident #103 was conducted on 9/27/2016 at approximately 8:55 AM. The resident was in her room and in bed. An 8 ounce bottle of children's cold and cough syrup was observed on the dresser beside her bed. The resident stated she used the cough syrup if she had a cough in the middle of the night. An interview was conducted with employee A (Licensed Practical Nurse for resident #103) on 9/27/2016 at approximately 8:57 AM. She stated she thought the resident's daughter brought her the cough syrup and they have had previous concerns with the family bringing medications to the resident. She then removed the medications and informed the resident. Review of the facility policy for Storage of Medications revealed drugs and biologicals should be stored in a safe, secure and orderly manner. Compartments containing drugs and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended.

Based on observation and interview the facility failed to serve residents in room [ROOM NUMBER] and those residents seated at the same table in the North Unit Day/Dining Room at the same time as their tablemate's at one observation that took place at lunch on 04/10/12. Findings Include: A meal observation, which took place in the North Unit Day Room, began at 12:25 pm on 04/10/12. Residents were seated in the Day/Dining room at the start of this observation. There were 5 resident around a long rectangle table and 1 resident seated near the door with an over bed table as her dining table. Service of the food began with the arrival of the Unit Dining Cart at 12:25pm in which one CNA brought in one tray, set-up the tray and began feeding one of the residents seated at the table. The other residents seated at the table watched while this resident was being assisted. The last resident was served his meal at 12:41pm. On 04/13/2012 at 07:45am interview was conducted with the CNA assigned to the North Wing Day room, she stated that resident's who are assigned to the Day room for dining are listed on a chart. The chart, usually kept is the nourishment room was located with the assistance of the Unit Manager. The chart revealed the name of 6 residents assigned to the Day room for dining. The Unit Manager stated that sometimes they may have a few more residents, it just depends if those other resident are exhibiting behavior issues and require additional monitoring or supervision. On 04/10/12 @12:39pm a meal observation was conducted on the North Hall for lunch. This surveyor observed the resident in room [ROOM NUMBER] bed B being served and assisted with her meal and the resident in Bed A did not receive a meal tray. This surveyor asked the Certified Nursing Assistant(CNA) who was feeding the resident in bed B if the other resident was eating lunch today, she said, " yes but her tray has not came out yet " . 04/10/12 @ 12:51pm Resident in bed A was still observed without a meal tray. The CNA was observed still feeding the resident in Bed B. On 04/10/12 @1:08pm this surveyor observed the second meal cart come out on the floor. At that time the resident in room [ROOM NUMBER] bed A was served a meal tray. 04/13/12 @ 10:44am an interview was conducted with the Dietary Manager. She said that the meal trays go out according to the room order. She said that once the trays arrive on the floor the Certified Nursing Assistant (CNA) pass the trays. She said that they have an open dining and encourage residents to eat in the dining room, but sometimes residents change their minds about where they want to eat at the last minute. The Dietary Manager said that typically residents that are in the same room and in the dayroom are supposed to get their trays at the same time.

Based on observation and staff interview, the facility failed to provide housekeeping services necessary to maintain clean and sanitary handrails on the South Unit. The findings include: On April 11, 2012 at approximately 2:00pm, the handrails on each Wing of the South Unit were inspected for cleanliness and sanitation. Some of the handrails on each of the Wings were noted to feel sticky or tacky to touch. There were areas of visible dirt, hair and dust noted on some portions of the railings. . On the wall, on the underside of each railing, on various portions of each of the units, were a fuzzy substances with some debris noted. A housekeeper who was nearby stated that the rails are cleaned on a daily basis. The housekeeper did not know what the fuzzy substance was. On April 11, 2012 at approximately 2:15pm, an interview was conducted with the Housekeeping Supervisor. The sanitary concerns of the handrails were pointed out to the Supervisor. She stated that this was not acceptable and would be taken care of immediately. She thought the stickiness/tackiness of the handrails may have been related to the use of the cleaning agent, and suggested that they would possibly try using a different cleaning solution. On April 12, 2012 at approximately 10:45am during environmental tour with the Maintenance Director, he stated the fuzzy substance on the wall under the handrail was from the carpeting that use to be on the wall. During the tour, the Maintenance Department was in the process of removing portions of the handrail, so that the underlying fuzzy substance could be adequately removed and cleaned. The handrails were then re-secured.