Every finding on record at Riverside Health & Rehabilitation

Based on interview and record review, the facility failed to provide sufficient staffing, which contributed to ADLs not being completed for dependent residents for 4 (#s 1, 3, 6, and 8), low staffing concerns reported by residents for 4 (#s 1, 4, 5, and 9) of 9 sampled residents; and multiple staff concerns of not having enough time to complete assigned tasks or take their breaks. Findings include:During an interview on 6/15/26 at 1:26 p.m., resident #1 stated, I have a private bathroom, and I think they assume I can just walk in there and take my own shower. I need assistance, and my showers are often missed.During an interview on 6/15/26 at 4:54 p.m., staff member G stated, Evening shift showers are probably the task that gets missed the most.During an interview on 6/17/26 at 7:16 a.m., staff member P stated the person working the hall is responsible for doing the daily scheduled baths. Staff member P stated, It's hard when there is only one person on the hall; many of the staff don't feel comfortable leaving the hall long enough to complete a bath or shower.During an interview on 6/17/26 at 12:50 p.m., staff member K stated, Baths and showers are not consistent on Birch Hall because the staff does not feel comfortable leaving the hall for the amount of time it takes to complete a bath or shower.Review of resident #1's 30-day lookback for bathing showed three missed showers.Review of resident #3's 30-day lookback for bathing showed four missed showers.Review of resident #5's 30-day lookback for bathing showed two missed showers.Review of resident #6's 30-day lookback for bathing showed six missed showers.Review of resident #8's 30-day lookback for bathing showed six missed showers.2. During an interview on 6/15/26 at 1:26 p.m., resident #1 stated, There is not enough staff to meet our needs, and sometimes things like bathing get missed. I think the problem (low staffing/lack of care) is keeping quality people here.During an interview on 6/15/26 at 3:09 p.m., resident #4 stated, It seems like they are always short-staffed, and when they are short-staffed on other halls, they always pull the staff from this hall, and baths get missed. During an interview on 6/15/26 at 3:12 p.m., resident #5 stated, It seems like most of the time they are short-staffed. That is what we hear, and you can tell when there isn't enough staff. Our baths get missed.During an interview on 6/15/26 at 3:20 p.m., resident #9 stated, I don't feel like there is enough staff here. I know they could use more. During an interview on 6/15/26 at 4:02 p.m., staff member H stated CNA shifts are eight-hour shifts, but due to staff turnover, some have been working 12-16-hour shifts. Staff member H stated, You never know how many staff you are going to have on the evening shift. I think it is supposed to be two, but that rarely happens on Cedar Hall. During an interview on 6/15/26 at 4:17 p.m., staff member N stated tasks often get missed on the evening shift on Cedar Hall due to only one staff member being on shift. During an interview on 6/15/26 at 4:54 p.m., staff member G stated, I think I have taken one break the whole time I have worked here. Only one person is scheduled during the evening shift on Birch Hall, and it is hard to find the time to take them (breaks) and still meet the demands of the residents.During an interview on 6/17/26 at 7:16 a.m., staff member P stated the facility tried to get away with only one staff member on the Birch Hall when the census was low. Staff member P stated the capacity of Birch Hall is 14, and the hall currently had 13 residents. Staff member P stated staff missed their breaks all the time when there was only one person scheduled. Staff member P stated, I try to assist where I can. During an interview on 6/17/26 at 12:50 p.m., staff member K stated, There is usually only one person scheduled on Birch Hall during the day, but it depends because they (management) always pull staff from Birch Hall to assist with appointments. Staff member K stated there was always one person scheduled on Birch Hall for evenings and nights. Staff member K stated, Management is pushing for us to take our breaks, but there aren't enough staff to do so. Staff member K stated there were three residents on Birch Hall who were a two-person transfer, and it was hard to get extra help during the busy times, such as around mealtimes.Review of the facility's CNA schedule for the Birch Hall for the dates of 6/1/26 - 6/14/26, showed:Day shift: 6:00 a.m. to 2:30 p.m., 7 out of 14 days, one CNA scheduled.Evening shift: 2:00 p.m. to 10:30 p.m., 12 out of 14 days, one CNA scheduled.Night shift: 10:00 p.m. to 6:30 a.m., 14 out of 14 days, one CNA scheduled.Review of a facility document titled Part 4: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, undated, showed: .Staffing Plan: Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. The facility fills a complete schedule weeks in advance, taking into account resident census and needs. Nursing manager/ED review the schedule to confirm appropriate. This review includes weekends, evenings, and holidays. Position: Nurse aides, 142-145 hr/day.

Based on observation, interview, and record review, the facility failed to provide ADL care of bathing for dependent residents for 4 (#s 1, 3, 6, and 8) of 9 sampled residents. This caused resident #1 to feel unclean. Findings include: During an observation and interview on 6/15/26 at 1:29 p.m., resident #1 was lying in his bed, and his nails were long and had a brownish substance under them. Resident #1 had flakes of dry skin peeling off on his arms. Resident #1 stated, I need assistance with showers. I have a private room with a bathroom. I don't trust myself alone in there because the whole bathroom gets wet when I shower, and I might slip. I need assistance, and my showers are often missed. I feel dirty when I miss my showers.During an interview on 6/15/26 at 4:54 p.m., staff member G stated, Evening shift showers are probably the task that gets missed the most.During an interview on 6/17/26 at 7:16 a.m., staff member P stated the person working the hall is responsible for doing the daily scheduled baths. Staff member P stated, It's hard to complete showers when there is only one person on the hall; many of the staff don't feel comfortable leaving the hall long enough to complete a bath or shower when there is only one person working the hall.During an interview on 6/17/26 at 7:26 a.m., staff member L stated that whoever is working on a hall is responsible for doing baths and showers. Staff member L stated if a resident refuses to take a shower, they will offer them a bed bath, and that is documented in their medical record. Staff member L stated it can be difficult to get them all done when there is only one staff member working the hall. During an interview on 6/17/26 at 8:52 a.m., staff member B stated the unit manager scheduled the resident showers and tried to meet the residents' preferences. Staff member B stated that the unit manager spreads the showers out throughout the three shifts, so staff do not get overloaded. Staff member B stated that the staff who are working the hall are responsible for completing the showers on that hall. Staff member B stated the unit manager owns the process for bathing and is responsible for ensuring they (showers) are getting done. Staff member B stated that if they identify a resident who has continually refused showers, they will monitor and attempt to identify the reasoning for the refusals. Staff member B stated she needed to talk to the unit managers about their monitoring process for bathing to ensure they were identifying those residents who are not getting bathed/showered. During an interview on 6/17/26 at 12:50 p.m., staff member K stated that resident baths and showers are not consistently provided on Birch Hall because the staff did not feel comfortable leaving the hall for the amount of time it would take to complete a resident bath or shower.a. Review of resident #1's 30-day lookback for bathing showed: Bath Day Wednesday and Saturday Eve shift, two showers were completed in the 30-day lookback period of 5/23/26 - 6/13/26.Review of resident #1's care plan showed: Bathing: Bathing/Shower assistance requires physical help in part of bathing activity.b. Review of resident #3's 30-day lookback for bathing showed: Bath Days (Wed and Sunday - evening shift), two showers were completed in the 30-day lookback period of 5/24/26 -6/14/26.Review of resident #3's care plan showed: Bathing: Prefers to be showered once per week.Review of resident #6's 30-day lookback for bathing showed: Bath Day Thursday and Sunday Eve shift: No showers were completed in the 30-day lookback of 5/21/26 - 6/14/26.c. Review of resident #6's care plan showed: Bathing: Bathing/Shower assistance requires total assist from staff.d. Review of resident #8's 30-day lookback for bathing showed: Bath Day Thursday and Sunday Day shift: No showers were completed in the 30-day lookback of 5/21/26 - 6/7/26Review of resident #8's care plan showed: Bathing: Bathing/Shower assistance requires physical help in part of bathing activity.Review of a facility document titled Activities of Daily Living, with a reviewed date of 10/27/25, showed: Policy:The facility ensures that the resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.Definitions: Activities of Daily Living include the resident's ability to:1. Bathe. Procedure: .3. Provide necessary services for residents who are unable to carry out activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to complete a thorough investigation for an allegation of sexual abuse by a staff member for 1 (#1) of 9 sampled residents. This caused the resident to be frustrated that there was no resolution to the investigation. Findings include:Review of a facility-reported incident, dated 5/22/26, showed: Resident #1 reported to a staff member an incident of alleged sexual abuse by a staff member.Review of the facility's findings for this allegation, dated 5/29/26, showed: The investigation found that the allegations are unable to be verified. The witnessing CNA reports she was not in the room for all of the cares. The resident did not say anything at the time, but the witness reports that he was quiet. ED interviewed 5 other residents on the same hallway.During an interview on 6/15/26 at 1:26 p.m., resident #1 stated he reported the incident to the nurse on duty and later filed a police report. Resident #1 stated no one from the facility had followed up with him about the investigation or how he was doing. During an interview on 6/16/26 at 12:26 p.m., staff member B stated abuse investigations were a team effort, with staff member A reporting them and doing most of the investigation. Staff member B stated their process for investigating allegations of abuse was to ask the resident to describe the incident, interview other staff members, choose a sample of residents to interview, and to focus on the area of concern. Staff member B stated for the incident involving resident #1, she assisted by interviewing staff member J with staff member A present. Staff member B stated that staff member A conducted the rest of the investigation. Staff member B stated the last abuse training was conducted in March 2026, and she thought resident #1's care plan was updated to include care in pairs after the incident.During an interview on 6/16/26 at 12:40 p.m., staff member A stated she was the person responsible for reporting and investigating allegations of abuse. Staff member A stated she performed the following when she conducted the investigation of staff member M and resident #1: talked to the resident directly, immediately suspended staff member M, talked to other residents, and obtained the witness statement. Staff member A stated she filed a police report and contacted the family. Staff member A stated she did not document the interviews she conducted with other residents or staff, and she did not have a copy of the police report. Staff member A stated it would depend on what the police reports showed whether they would allow staff member M to return to work or not. Staff member A stated staff member M refused to write a statement. Staff member A stated social services did not follow up with resident #1 after the incident, but was aware of the incident. Staff member A stated there was no further information to provide for this investigation. During an interview on 6/16/26 at 12:09 p.m., staff member E stated her role when there is an allegation of resident abuse was to assist with interviewing other residents and follow up with the resident affected for any psychosocial outcomes. Staff member E stated staff member A was mostly in charge of investigating abuse allegations, but the Director of Nursing and Social Services would assist as needed. Staff member E stated she never followed up with resident #1 after the sexual abuse allegation, and she was not involved with that investigation at all due to a police report being filed, and it was still under investigation. During an interview on 6/16/26 at 2:38 p.m., resident #1 stated, Staff member A talked to me initially to file a police report and only came back to talk to me to see if the police had called me; no one has talked to me about the incident or the status of the investigation.During an interview on 6/17/26 at 9:25 a.m., staff member A stated she typed up a timeline of events for surveyor review, and there was no other documentation of staff member M's suspension or notification to the family of the incident. Review of the facility's investigation file for the incident dated 5/22/26 failed to show what other residents were interviewed, the questions that were asked, all staff who were interviewed, the details found in those interviews, the dates the interviews were conducted, follow-up with the resident for psychosocial outcome, and interventions for the resident if necessary. The investigation file consisted of the bounds report, a witness statement, a summary of steps taken, and a summary of notification to the family/POA. Review of resident #1's comprehensive care plan with an initiation date of 1/3/25 failed to show it was updated to reflect care in pairs and failed to show it was updated with any new interventions after the incident on 5/22/26 related to the resident's mental health and well-being as related to his feelings and the incident. Review of a facility document titled Abuse, Neglect & Exploitation with a last reviewed date of 1/9/26 showed: Policy: Each resident has the right to be free from abuse, including verbal, sexual, physical and mental abuse. VIII. Investigation of Alleged Abuse, Neglect, Exploitation, and MisappropriationWhen suspicion of abuse, neglect, exploitation, or misappropriation or reports of abuse, . an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation shall be conducted. Components of an investigation shall include when appropriate:-Interview the involved resident, if possible, and document all responses. If residents cognitively impaired, interview the resident several times to compare responses. -Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement.-Document the entire investigation chronologically.

Based on interview and record review, the facility failed to protect a resident's right to be free from non-consensual sexual contact by a staff member and ensure the resident had necessary social services following the alleged event for sexual abuse, and the resident was bothered, embarrassed, and felt humiliated after the event, for 1 (#1) of 9 sampled residents. This deficient practice did not allow the resident the opportunity to heal from the alleged event, which still bothered him as of the survey, and he was reportedly self-isolating due to his fear. Findings include: Review of a facility-reported incident, dated 5/22/26, showed: Resident (resident #1) reported to Unit Manager at 1615 (4:15 p.m.) that while 2 CNAs were changing his brief earlier in the day, (staff member M), CNA inserted her finger in his rectum. ED interviewed him and he states (staff member M) was checking his buttocks for open areas and was spreading his anus and he felt her finger enter his rectum. He believes she inserted it up to the 'second knuckle'. [sic]Review of findings for this allegation, dated 5/29/26, showed: The investigation found that the allegations are unable to be verified. The witnessing CNA reports she was not in the room for all of the cares. The resident did not say anything at the time, but the witness reports that he was quiet. ED interviewed 5 other residents on the same hallway.During an observation and interview on 6/15/26 at 1:26 p.m., resident #1's door was shut to his room, and he was lying on his bed. Resident #1 stated staff member M stuck her finger in his rectum past the second knuckle and moved it around. Resident #1 demonstrated a circular motion with his hand. Resident #1 stated he reported the incident to the nurse and later reported it to the police. Resident #1 stated staff member J was in the room and may have witnessed the incident. Resident #1 stated that staff member M does not take care of him anymore. Resident #1 stated he has declined his baths because of the incident and is scared it will happen again. Resident #1 stated he requested that staff member M not care for him anymore. Resident #1 stated nobody from the facility had followed up with him or had provided him with an outcome of the investigation. Resident #1 stated that no staff members had followed up with him to see how he was doing after the incident.During an interview on 6/16/26 at 8:55 a.m., staff member M stated, I don't know what incident you are referring to. The facility did not tell me anything before putting me on suspension. They accused me of sexual abuse and wouldn't even let me know who the resident was. I was cleaning his (resident #1's) bottom, and I can't do that without another CNA in the room because of his size. I didn't do anything wrong.During an interview on 6/16/26 at 10:10 a.m., NF1 stated the facility did not alert her when the incident with resident #1 occurred. NF1 stated that resident #1 was lucid sometimes and was hard to understand at times. NF1 stated, He (resident #1) told me about the incident, but I didn't really follow what he was saying at the time. NF1 stated the facility didn't let her know until a couple of days later. NF1 stated, He (resident #1) was quite upset about it; He (resident #1) even wanted to be in a private area to tell me about the incident so no one would hear him because he was embarrassed. NF1 stated that resident #1 had never had issues with any of the staff before this incident. NF1 stated, I do think he is still concerned about it. I want to see things come to a just conclusion. It has been weeks without resolution.During an interview on 6/16/26 at 12:09 p.m., staff member E stated she would usually follow up with residents after an abuse allegation had occurred. Staff member E stated she was not involved in this specific investigation, and she had not followed up with resident #1 to see how he was feeling after the incident.During an interview on 6/16/26 at 12:40 p.m., staff member A stated she was the one who investigated the incident with resident #1. Staff member A stated she talked to resident #1, suspended staff member M, interviewed other residents, obtained a written statement from the witness, filed the police report, and contacted the family. Staff member A stated, Staff member E is aware of the incident, but she probably hasn't followed up with the resident. Staff member A stated she would have to check the electronic medical record for any further information.During an interview on 6/16/26 at 12:55 p.m., staff member J stated, I am not sure exactly what happened to resident #1. I was assisting in cleaning him up after he had a bowel movement, and had to pop my head out the door to check on other call lights, and when I came back to assist with cleaning up, he (the resident) was very quiet, which is not like him. He is usually joking with us and talkative. I didn't see how she (staff member M) was wiping him, and I can't really see over him when we have him on his side. So, I didn't see anything if it happened.During an interview on 6/16/26 at 2:38 p.m., resident #1 stated, Nobody said anything when the incident happened, including the nurse when I reported it. I did not react when it happened because I was in shock that it even happened. She (staff member J) was in the room when it happened and didn't say anything either. I didn't know how to react; it was quite a surprise. I just want to put it in the back of my mind and forget about it. It was humiliating and made me feel really uncomfortable.During an interview on 6/16/26 at 3:27 p.m., staff member G stated, He (resident #1) has been more withdrawn lately and hasn't come out of his room as much after the incident happened.Review of resident #1's Quarterly MDS, dated [DATE], showed: Section B - Hearing, Speech, and Vision, B0600 - Speech Clarity, 0 - Clear speech - distinct intelligible words; B0700 - Makes Self Understood, 0 - Understood; B0800 - Ability To Understand Others, 0 - Understands - clear comprehension .Section C - Cognitive Patterns, C0500 - BIMS Summary Score, Add scores for questions C0200-C0400 and fill in the total score (00-15), 15.Section I - Active Diagnoses, I0020. Indicate the resident's primary medical condition category, 06. Progressive Neurological Conditions . I5300. Parkinson's Disease.Resident #1's Quarterly MDS showed he was able to understand, had clear speech, and had a BIMS of 15, showing he was able to speak his needs and concerns and was cognitively intact.Review of resident #1's clinical progress notes, dated 5/22/26, showed: UM was notified via floor RN that resident had had an issue with a CNA earlier today. UM went to visit with resident at 1615 (4:15 p.m.). Resident stated the 2 CNA's that were on his hall today by name and also stated he (resident #1) didn't like one of them and told the other (staff member J) that he didn't want her (staff member M) in his room. He doesn't think that was relayed as both CNA's attended to him at just before noon. Resident stated he had had a bowel movement and the CNA he didn't like stuck her finger in my butt about to the 2nd knuckle it felt like. When asked why he didn't say anything until now resident stated because it didn't bother me until I had thought about it and now it bothers me. Resident asked if he felt safe at this time and he stated that he does. ED notified and CNA has been pulled off the schedule until further notice. [sic]There were no other progress notes, assessments, or documentation about the incident in resident #1's chart. Review of a facility provided document titled Timeline, undated, showed: 5/22/26 - Staff member A spoke with the resident and removed the accused staff member from the schedule.5/23/26 - Abuse report filed. Staff member A spoke with staff member M and requested a written statement.5/25/26 - Staff discussion5/26/26 - Staff members A and B spoke with the witness, three other residents were interviewed, and staff member M was suspended.5/28/26 - Staff member A spoke with resident #1 about filing a police report, and a police report was filed.5/29/26 - Staff member A notified NF1 of the incident with resident #1. Findings submitted to the State Survey Agency showed the facility interviewed five other residents.Review of a facility document titled Abuse, Neglect and Exploitation with a review date of 1/9/26, showed: Policy: Each resident has the right to be free from abuse, including verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. This prohibition applies to everyone, including, but not limited to, facility staff (employees, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the facility), other resident staff of other agencies serving the residents, family members, legal guardians, friends, or other individuals.IV. Prevention of Abuse. The facility will utilize the following techniques for prevention of abuse. Recognizes signs of burnout, frustration, and stress in employees that may lead to abuse. Provide education on what constitutes abuse, neglect, exploitation of residents, and misappropriation of property. React to all allegations or questions from residents, family members, employees, or visitors.

Based on observation, interview, and record review, the facility failed to provide pain management which was acceptable to the resident's goals for 1 (#3) of 25 residents sampled. The deficient practice resulted in poor pain management and decreased quality of life for the resident who consistently reported having severe pain. Findings include:During an observation and interview on 1/14/26 at 3:45 p.m., resident #3 stated the pain in his back was horrific and rated it as 8/10. Resident #3 stated he pretty much always had back pain, and he did not feel the facility controlled it well. Resident #3 stated he would consider 5/10 to be an acceptable pain level. Resident #3 stated he had taken pain medication at noon and wanted something more for the pain. Resident #3 was observed lying in bed, grimacing, wincing, and frequently shifting his weight in the bed, during the interview.During an interview on 1/14/26 at 3:53 p.m., staff member M was notified of resident #3's pain and stated resident #3 had chronic pain issues. Staff member M stated nursing staff was responsible for notifying the resident's provider if pain was not well managed and did not know if the provider had considered any changes to resident #3's pain management to better assist with pain control. During an interview on 1/14/26 at 5:23 p.m., resident #3 reported he was still experiencing pain and rated it as 8/10. Resident #3 stated he had not received further pain medication since previous interview at 3:45 p.m., and the dose before this was given around noon that day per the resident. During an interview on 1/14/26 at 5:25 p.m., staff member N stated she attempted to contact the resident's provider, but the provider had not responded back. Staff member N stated she felt resident #3's pain control had been adequate. Staff member N stated it had not been well controlled that day (1/14/26), and resident #3 looked like he was hurting. Staff member N reported participation in therapy made resident #3's pain worse. Staff member N stated that nursing was not able to pre-medicate resident #3 for pain prior to therapy sessions because there was not set times for his therapy sessions. Staff member N stated she was unaware of the provider having been contacted about resident #3's pain management prior to 1/14/26.A review of resident #3's Care Plan showed,Goal: [Resident Name] will have pain managed AEB decreased non-verbal S/SX of pain and resident reporting acceptable level of pain in the next 90 days. [sic] The target date listed was 1/1/26.Interventions: . Notify MD of adverse effects or if pain medication ineffective PRN. Observe effectiveness of pain interventions and need for additional measures. Resident reports acceptable level of pain = 4. [sic]A review of resident #3's MAR for 1/14/26, showed:-acetaminophen 500 mg was administered at 6:00 a.m. and 2:00 p.m.-Lidocaine External patch 5% was applied at 8:00 a.m.-Gabapentin 300 mg was administered in the morning. -Hydrocodone/acetaminophen 7.5-325 mg was administered at 12:30 p.m. for a pain rating of 8/10. It was marked ineffective.-The MAR showed a pain rating of 7 to 10 was classified as severe.A review of resident #3's TAR for 1/14/26, showed:-pain monitoring on the 7:00 a.m. to 7:00 p.m. shift with pain rated as 8/10.-Interventions documented on the TAR included: 1. Repositioning, 2. Dim light/quiet environment, 5. Relaxation technique, and 6. Distraction. The entry was marked not effective.A review of resident #3's Pain Level Summary showed, between 1/6/26 and 1/14/26, resident #3's pain was documented at 7 or above (severe) 23 out of 49 times and occurred at a level of 7 or above (severe) daily.A review of a facility policy titled, Pain Management Program, last reviewed on 10/27/25, showed: Treatment:1. If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified. Monitoring:. 2. If re-assessment findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated. [sic]

Based on observations, interviews, and record reviews, the facility failed to date and monitor refrigerated foods, dry goods, and items brought in by families, to ensure items were used by the use-by date or discarded, and the facility failed to store food items off the floor. This deficient practice placed residents who received meals from the facility at risk of food-borne illness. Findings include:During an observation and interview on 1/12/26 at 10:10 a.m., the following items were found in the kitchen: - [NAME] sauce with no open or discard dates, brought in by family,- Goddess dressing with no open or discard date, brought in by family,- Soy Sauce with no open or discard date,- Dijon Mustard with no open or discard date, and a manufacturer's expiration of 4/5/25,- Raw honey with no open or discard date,- Vanilla flavoring with no open or discard date,- Olive Oil Mayonnaise with no open or discard date, - Teriyaki sauce with no open or discard date,- Enchilada sauce with no open or discard date,- Heavy-duty Mayonnaise with no open or discard date, and no manufacturer's expiration date on the bottle,- [NAME] dressing with no open or discard date,- Honey mustard with no open or discard date,- BBQ sauce with no open or discard date,- sliced cheese box with no open or discard date,- One half of a brick of cream cheese with no open or discard date,- Bucket of strawberries in juice with no open or discard date,- Frozen pancakes in a Ziplock bag, labeled with a resident's name, with no date, brought in by family,- Frozen waffles in two Ziplock bags, labeled with a resident's name, with no dates, brought in by family; and- Frozen donuts in two Ziplock bags, labeled with a resident's name, with no dates, brought in by family. During an interview on 1/12/26 at 10:12 a.m., staff member D stated all open food items were only good for seven days, and anything without an open date should be thrown out. During an interview on 1/12/26 at 10:14 a.m., staff member F stated, Good question, when asked how the kitchen would know when open items expired. Staff member F stated there was no list to follow that showed when to throw out food items in the kitchen. During an observation on 1/14/26 at 9:15 a.m., the following items were found in the kitchen: - Ground Ginger expired on 3/22/25,- Ground Coriander expired on 3/21/25,- Ground Allspice expired 7/22/23,- Fancy Pickling Spice expired 7/24/24,- Three open jars of Ground Marjoram expired 11/6/22,- Rubbed sage expired 10/26/23,- Ground Mustard expired 7/21/25,- Caraway seed expired 9/22/25, and - Pork Spice rub expired 7/10/25. During an observation on 1/15/25 at 9:04 a.m., the following items were found in the walk-in refrigerator stored on the floor: - Three milk carton cases- One five-gallon bucket of pickles Review of the facility's policy, Date Marking for Food Safety, dated 8/14/18, reflected: ' . 3. Condiments in their original containers can be used until manufacturer's use by date. 4. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. (use by date) 5. The individual (staff member) opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. Review of the facility's policy, Foods Brought in by Family Visitors, dated 11/27/17, reflected: . 2. All food items that are not in original containers brought in by the family or visitor must be labeled with use by date.b. Food not in its original container must be consumed by the resident within 4 days.

Based on observations, interviews, and record reviews, the facility failed to ensure food was served that was palatable, attractive, and at a safe and appetizing temperature for 7 (#s 40, 41, 49, 56, 66, 69, and 79) of 25 sampled residents. This deficient practice resulted in the residents' dissatisfaction with the food, and it potentially affected any resident who received food from the kitchen. Findings include: During an interview on 1/12/26 at 12:11 p.m., staff member R stated that when the food trays are delivered to the hall, the floor staff deliver them immediately. Staff member R stated that if the resident was not ready to eat, the tray was left on the bedside table in the room until the resident was ready to eat. Staff member R stated she did not check food temperatures before the residents started eating, and she did not reheat the food before the resident ate. Staff member R was not able to state what the temperatures the food should be served at, and she was unaware of anyone checking the temperatures of the meals/food once it was delivered to the halls to be passed out. During an interview on 1/12/26 at 1:40 p.m., resident #66 stated the food did not taste good. Resident #66 stated, The food has a funny taste, and stated, The soup we had a couple of days ago tasted rancid. Resident #66 stated he had been in the facility for a month, and the taste of the food had been an issue for the duration of his stay. During an interview on 1/12/26 at 2:03 p.m., resident #69 stated the meat was dry, hard to chew, and usually cold. Resident #69 stated she often could not eat the meat served. During an interview on 1/12/26 at 2:12 p.m., resident #41 stated the food was not good. Resident #41 stated she was tired of chicken being served over and over, and just adding sauce to the chicken did not make it better. Resident #41 stated the food was consistently cold and the meat was rubbery. Resident #41 stated she had complained several times, but staff member C did not listen to the resident concerns. During an interview on 1/12/26 at 2:17 p.m., resident #40 stated the facility served chicken and rice too often, and the food was cold. Resident #40 stated the chicken looked like chunks glued together with something, and it was like eating tasteless rubber. Resident #40 stated the food was so bad that she often depended on junk food to substitute her meals, or she would just go hungry. During an interview on 1/12/26 at 2:27 p.m., resident #56 stated the food was awful. Resident #56 stated the food was cold and agreed with the roommate that the chicken was like rubber chunks stuck together. During an interview on 1/12/26 at 3:48 p.m., resident #49 stated the food provided by the facility did not taste good and the flavor of the food needed improvement. Resident #49 stated he wanted more variety and selection, especially when the facility served items he did not like. Resident #49 stated the food arrived cold most days. During an observation and interview with staff member F, on 1/13/26 at 8:19 a.m., trays were sitting in the kitchen window. The food temperatures taken were as follows: - Biscuits and gravy: 100 degrees - Eggs: 110 degrees Staff member F stated the trays were for residents who had not arrived at the dining room. Staff member F stated that some residents came in late because they wanted to sleep in. Staff member F stated the temperature was not usually checked after the tray was made. Staff member F stated that the kitchen staff complete temperature checks on the tray line when serving the meals, but not after the tray was made. Staff member F stated she did not know when the two residents would arrive for breakfast so that they could receive the trays in the window. The kitchen was beginning to take down the service line in preparation for making lunch. During an observation on 1/13/26 at 8:25 a.m., temperatures were taken for the meal trays taken to the halls, which were to be delivered to residents in their rooms, and the five trays checked were as follows: - Biscuits and gravy: 107 degrees - Biscuits and gravy: 99 degrees - Ground meat: 100 degrees - Eggs:130 degrees During an interview on 1/13/26 at 11:05 a.m. resident #79 stated, It's not the best food in the world, and reported the food was bland and the eggs tasted funny. Resident #79 stated the food was edible, but not what she wanted to eat. Resident #79 stated she wanted more options for the meals. Review of a facility policy, Food Temperatures, dated 7/25/18, reflected: - . 1b. Hot food items may not fall below 135 degrees F (Fahrenheit) after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees F and reheated to at least 165 degrees F prior to serving. - 6. Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to the unit storage area to maintain temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods. Review of the facility policy, Food Preparation, dated 9/26/22, reflected: - . 3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature.

Based on interviews and record review, the facility failed to serve the substituted menu items to meet the nutritional needs of residents in accordance with established national guidelines and have the facility's dietitian review the changes for nutritional adequacy for 2 (#s 40 and 69) of 25 sampled residents. This deficient practice resulted in the residents becoming frustrated with menu selection and residents receiving food from the kitchen were not having nutritional needs met. Findings include: 1. During an interview on 1/13/26 at 4:11 p.m., resident #40 stated he wanted the chef salad alternate for lunch, but the kitchen sent everyone who ordered the chef salad chicken tenders instead. Resident #40 stated the kitchen often messed up the menus, and she was frustrated by the confusion. Resident #40 stated the CNAs .came around the night before and got your mouth watering for one thing, only to be disappointed the next day, when you did not get what you ordered. 2. During an interview on 1/13/26 at 4:20 p.m., resident #69 stated she would have preferred to receive the salad but had been served chicken tenders instead. During an interview on 1/13/26 at 12:40 p.m., staff member L stated that the night CNAs used the wrong menu day, and some residents were told they would receive chicken tenders. Staff member L stated that the kitchen decided to serve chicken tenders instead of the chef salad. Staff member L stated the plan was to serve chicken tenders for the dinner alternative as well. During an interview on 1/13/26 at 12:45 p.m., staff member D stated he did not get approval from the dietician to change the menu and stated he did not give authorization for the kitchen to change the menu. Review of the menu for week two, day 3, showed the alternate was the chopped chef salad for both lunch and dinner. During an interview on 1/13/26 at 1:20 p.m., staff member G stated she had not given approval for any menu changes and would want to verify that what was being served with the chicken tenders would still meet the nutritional requirements of the meal before approving the replacement. During an interview on 1/14/26 at 9:10 a.m., staff member D stated the CNAs used the incorrect menu list, again, last night (1/13/26), but the staff went around and asked the residents for menu selections again to correct the tickets. During an interview on 1/14/26 at 9:34 a.m., resident #40 stated she received the chef salad last night, but it did not have any meat on it. Resident #40 stated it was basically a side salad. During an interview on 1/14/26 at 9:40 a.m., resident #69 stated the chef salad did not have meat on it. During an interview on 1/14/26 at 4:41 p.m., staff member H stated the chef salad served for dinner on 1/13/26 did not have meat on it. During an interview on 1/14/26 at 4:47 p.m., staff member I stated the chef salad served on 1/13/26 for dinner did not have meat, and it was not served with any additional items. During an interview on 1/14/26 at 5:00 p.m., staff member D stated the chef salad should have been served with two ounces of turkey and two ounces of ham. During an interview on 1/15/26 at 11:33 a.m., staff member G stated that if the meat was not included on the chef salad, the chef salad would not meet the protein requirement for residents and the meal. Review of the facility's Dining Manager Chopped Chef's Salad, not dated, reflected that the chef salad recipe was a two-cup portion, which included 3/4 ounces of turkey and 3/4 ounces of ham. Review of the facility's policy, Food Preparation, dated 9/26/22, reflected: - . 1. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes.

Based on observations and interviews, the facility failed to maintain a comfortable environment for residents by maintaining a temperature range of 71 to 81 F in resident rooms for 1 (#64) of 25 sampled residents. This deficient practice resulted in resident #64 being cold. Findings include: During an observation and interview on 1/12/26 at 4:02 p.m., resident #64 was in her room with the door closed. Resident #64 was in bed covered with several blankets and stated she was cold. The thermostat was set to 75 degrees and the current temperature reading was 65 degrees.During an observation and interview on 1/12/26 at 4:10 p.m., staff member C used a temperature gun and tested the room temperatures at the request of the surveyor. The following temperatures were noted:- Room D102: 64 degrees- Room A112: 66 degrees- Room D104: 66.5 degrees- Room D108: 67 degrees- Room A101: 63 degrees- Room A103: 67 degreesStaff member C stated [Repair company name] had been in the building in the morning to drain a heat system line and had the heat turned off for those repairs. Staff member C stated the repairs only affected half of D hall. Staff member C stated he had not checked temperatures after the repairs were completed and was not notified by the floor staff of the cold temperatures on the unit. Staff member C stated he was calling the repair company back for an emergency repair.During an interview on 1/12/26 at 5:00 p.m., staff member A stated the facility offered residents extra blankets and room doors would remain open to allow heat in the hallway to warm the rooms. Staff member A stated the repair company was in route to the facility to determine what was wrong with the heat. Staff member A stated the floor staff should have notified the maintenance department and her of any temperature extremes immediately. Staff member A stated the facility would be offering hot drinks and soup to residents as well.During an interview on 1/12/26 at 7:41 p.m., staff member K stated his findings included bleeding the water lines for the heat, a computer component in the air handler was not working and found four thermostats in the rooms were not working. Staff member K stated each thermostat controlled two to three rooms. Staff member K stated he diverted the heat to ensure even heat for the night and would replace the thermostats in the morning, when parts were available.During an interview on 1/13/26 at 3:10 p.m., staff member C stated the heating repairs had been completed and room temperatures had risen to 71 degrees or higher. During an observation and interview on 1/13/26 at 4:15 p.m., staff member C used the thermostat gun to check the temperature in resident rooms. Findings included:- Room D102: 68 degrees- Room D104: 69 degreesThe thermostat on the wall showed 75 degrees and was set to 80 degrees. Staff member C stated he would be calling the repair company back for an emergency call. Resident #64 was in bed sleeping with several blankets layered on top of her.During an interview on 1/14/26 at 1:09 p.m., staff member C stated the thermostat in room D102, that controlled D102 and D104 was faulty and had been replaced in the morning. Staff member C stated the temperature was holding at 74 degrees and he would continue to check temperatures for all rooms twice daily over the next few weeks to ensure there were no further temperature issues.During an observation and interview on 1/14/26 at 1:20 p.m., resident #64 was in bed resting, with the blankets off. Resident #64 stated she was comfortable and no longer cold.

Based on observation, interview and record review, the facility failed to provide clean equipment for respiratory treatment for 1 (#69) of 5 residents sampled. This deficient practice placed the resident at risk for inhalation of foreign material and respiratory infections. Findings include:During an observation on 1/12/26 at 2:03 p.m., resident #69's nebulizer was observed to have a white crust and buildup on the mouthpiece and corrugated aerosol tubing that extended from the mouthpiece.During an interview on 1/14/26 at 12:16 p.m., staff member B stated that nursing staff were responsible for changing the nebulizer equipment and that this was done weekly. Staff member B stated that an order for changing nebulizer tubing was entered into the chart so it would alert the nursing staff to change the tubing each week.During an interview on 1/14/26 at 12:40 p.m., staff member P stated she did not know when resident #69's nebulizer tubing or mouthpiece had been changed. Staff member P stated the respiratory therapist was responsible for changing them weekly and was not sure why resident #69's nebulizer had not been changed.During an observation and interview on 1/14/26 at 2:00 p.m., resident #69's nebulizer was observed to still have a white crust and buildup on the mouthpiece and corrugated aerosol tubing that extended from the mouthpiece. There was no date on the nebulizer tubing or mouthpiece to show when it was last replaced. Resident #69 was unable to state when it had last been replaced. Resident #69 stated she had used her nebulizer since it was last replaced.A review of resident #69's physician Order Summary Report, dated 1/14/26, showed there was no physician order for changing the nebulizer tubing.Review of a facility policy titled, Nebulizer Treatments, last reviewed 10/27/25, showed: . Procedure:. 3. Nebulizer tubing to be changed weekly or according to facility protocol. [sic]

Based on interviews and record review, the facility failed to ensure a resident was free from misappropriation of resident funds by a staff member for 1 (#48) of 25 sampled residents. This deficient practice resulted in the loss of $500 plus travel expenses for resident #48. The facility identified the failure of a staff member accepting money from a resident and addressed and corrected the deficient practice before the survey, resulting in the findings of past non-compliance. Findings include:During an interview on 1/13/26 at 12:01 p.m., resident #48 stated he met staff member Q at the facility. Resident #48 stated he and staff member Q became friendly and at some point, in December of 2025, staff member Q offered to assist resident #48 with travel to [City] for medical appointments. Resident #48 stated that staff member Q agreed to be paid $1000 plus expenses. Resident #48 stated he purchased two first-class airline tickets and booked hotel rooms for the trip. Resident #48 stated he paid the staff member Q $500 up front and agreed to pay the remaining $500 after the trip. Resident #48 stated he paid staff member Q the $500 using his personal checking account, check #0101, and the check was cashed. Resident #48 stated, I thought he would just send me my money back. I had sucker written on my forehead. I want to get my money back; maybe it's time to get the sheriff back here. During an interview on 1/13/26 at 12:10 p.m., staff member A stated resident #48 declined to pursue charges against staff member Q during the initial police report, but she would immediately assist resident # 48 in calling the sheriff back to file charges against staff member Q and pursue reimbursement of all funds involved in travel plans previously made. Staff member A stated resident #48 had a BIMS of 15, cognitively intact, and was able to make his own decisions. Staff member A stated staff member Q was immediately removed from the schedule, and the police, spouse, his primary employer, Adult Protective Services, his physician, and the State Survey Agency were notified. Staff member A stated an investigation of possible misappropriation of funds from other residents found no other residents were affected. Staff member A stated the facility did re-education with all staff on 1/8/26, and a QAPI action plan was put into place. Review of text messages on resident #48's phone, dated 12/11/25 - 1/2/26, reflected staff member Q and resident #48 discussing payment for his services, the hotel, food, airline tickets, and a rental car. On 12/20/25, staff member Q requested payment for services in advance of the trip due to financial difficulties. On 12/21/25, resident #48 agreed to pay half of the $1000 for staff member Q's services, which was travel assistance to and from the travel destination. Review of a personal check written by resident #48, dated 12/23/25, reflected the check was addressed to staff member Q from resident #48 for $500, and the check was cashed on 12/21/25 at 5:12 p.m. Review of staff member Q's Relias Education, dated 1/6/26, reflected staff member Q had completed Professional Boundaries education on 12/7/25, and there was abuse, neglect, misappropriation of funds, and abuse reporting education provided on 10/13/24. Review of the Staff In-Service: Professional Boundaries, dated 1/5/26 - 1/8/26, reflected that staff education was completed on misappropriation of funds, accepting gifts, tips, and gratuities, and professional boundaries. Review of the QAPI agenda, no date, reflected the misappropriation of resident funds was to be addressed with an Action Plan at the upcoming QAPI meeting. The facility identified the concern related to misappropriation of resident funds and immediately protected the resident by suspending staff member Q and instructed him not to have contact with the residents. Notifications were made within the required 24-hour window to law enforcement, APS, and the State Survey Agency. The facility initiated an investigation of the incident and interviewed residents and staff in an effort to identify any other potential victims. No other victims were identified. The facility updated resident #48's care plan and implemented weekly monitoring to ensure sustained compliance. A psychiatric referral was made for resident #48. Education was provided to the facility staff regarding professional boundaries and not accepting money and/or gifts from residents. The incident was added to the facilities QAPI agenda for ongoing monitoring of compliance. Past noncompliance was identified due to the corrective actions taken by the facility.

Based on observation, interview, and record review, the facility failed to implement wound prevention measures for a resident with history of pressure wounds and elevated risk for the development of pressure ulcers; failed to implement pressure relieving measures after the development of a new Stage II sacral wound, and failed to accurately assess and monitor a new Stage II sacral wound for 1 (#7) of 11 residents sampled for wounds. The wound management failures placed the resident at risk for wound progression and infection. Findings include: During an observation and interview on 3/24/25 at 2:05 p.m., resident #7 was seated in a wheelchair in her room. There was no pressure relieving air mattress or overlay on resident #7's bed. Resident #7 stated she had a wound on her buttock and has had several wounds in the past related to paraplegia. Resident #7 stated, I heard through the grapevine that I would be getting an air mattress, but I haven't seen one yet. During an interview on 3/25/25 at 8:35 a.m., staff member B stated resident #7 had a pressure wound on her left buttock which was new as of the date of the interview and had notified the nurse on duty. During an interview on 3/25/25 at 8:44 a.m., staff member C stated she was not aware of a new pressure wound on resident #7. Staff member E stated, She (resident #7) has had some maceration and irritation on the left buttock and gluteal fold for a few weeks and we have been putting some barrier cream on it. During an interview on 3/25/25 at 9:45 a.m., staff member A stated the facility's process for addressing new wounds would be a secure message from the nurse to the DON, wound care nurse, and all licensed nursing staff. The wound care nurse came every Wednesday and would implement treatment. Interim treatment, if required, would be implemented by the DON. The DON would then add the secure message to the progress notes in the EHR. During the interview, staff member A stated she realized the facility had failed to follow up appropriately on resident #7's buttock wound, and stated she would have an air mattress placed on resident #7's bed today. Review of resident #7's nursing progress notes, dated 3/4/25, showed a secure message sent from staff member D to all licensed nursing staff, as well as the DON and wound care nurse as follows: Subject: New Wound . Resident has a 1.5 cm open area on her sacrum, site cleansed with NSS and covered with optifoam, and shearing noted to left buttock, resident also continues to have redness in groin with no improvement with ordered creams. Review of resident #7's nursing progress notes, dated 3/5/25 at 2:49 p.m., showed the wound care nurse replied to the secure message as follows: Resident with linear excoriation to upper sacral area, and bilateral gluteal creases. Recommend prevent barrier cream BID and PRN after incontinence episode. Would encourage air overlay or air mattress as well. Review of resident #7's nursing progress notes, dated 3/13/25 at 2:49 p.m., showed IDT met to discuss skin concerns. [Resident] has MASD on her buttocks. New 1.5 cm open area on her sacrum, site cleansed with NSS and covered with optifoam, and shearing noted to left buttock, resident also continues to have redness in groin with no improvement with ordered creams. Catheter in place. Applying barrier cream. Resident encouraged to get OOB and participate in activities. Air mattress will be placed to prevent further breakdown. IDT will continue to monitor. Review of resident #7's nursing progress notes, dated 3/19/25 at 1:01 a.m., showed, ALERT NOTE: New skin issue noted -please address. With current order for barrier cream to prevent further skin breakdown. Off loaded hip alternately with pillows. [sic] No additional wound or skin assessment documentation was located in the EHR for resident #7's wound for the period of 3/4/25 through 3/24/25. Review of facility policy, titled, Pressure Ulcer/Pressure Injury Prevention and Management, dated 10/14/24, showed: 1. Assessment of Pressure Ulcer/Pressure injury Risk . c. Conducted a full body skin assessment . after any newly identified pressure ulcer/pressure injury . e. Provide interventions based on specific factors identified in the risk assessment and skin assessment (e.g., moisture management, impaired mobility, nutritional deficit, etc . 2. Interventions for Prevention and to Promote Healing . - a. Implement interventions for prevention for all residents who are assessed at risk or who have a pressure ulcer/pressure injury present - b. Document interventions in the care plan - c. Document compliance with interventions in the weekly summary charting - d. Modify interventions as needed . Review of the facility policy titled, Documentation of Wound Treatments, dated 10/14/24, showed: Treatment Documentation Guidelines: . 1. Type of wound . 2. Ulcer stage/injury stage, if pressure ulcer (I, II, III, IV, unstageable, deep tissue injury)/pressure injury or wound depth, if non-pressure (partial or full thickness) . 3. Measurements done weekly and prn: height, width, depth, undermining, tunneling . 4. Description of wound characteristics . -a. Color of the wound bed -b. Type of tissue in the wound bed (i.e. granulation) -c. Temperature of the peri-wound (warm, inflamed, macerated) -d. Drainage/Exudate -e. Odor -f. Pain . 6. Weekly progress towards healing, effectiveness of current interventions .

Based on interview and record review, the facility failed to update a care plan to reflect a new pressure wound, for 1 (#7) of 11 residents sampled for wounds. The failure placed the resident at risk for improper wound care, wound progression, and infection. Findings include: During an interview on 3/24/25 at 2:05 p.m., resident #7 stated she has had wounds in the past and had a buttock wound currently related to paraplegia. During an interview on 3/25/25 at 9:45 a.m., staff member A stated the care plan should reflect all current care concerns for each resident. Staff member A stated the care plans are updated by the wound care nurse for any new wounds, including any new interventions or treatments. Review of resident #7's nursing progress notes showed a new pressure wound identified on 3/4/25, which remained unhealed as of the end of the survey period. Review of resident #7's care plan, initiated on 2/5/25 with revision on 2/17/25, failed to show the pressure wound identified on 3/4/25. The care plan noted an alteration in skin integrity from a sacral wound present on admission that was resolved. No updates were made to the care plan to reflect the resolution of the initial wound first noted on 2/5/25, and no updates were made to reflect the current management of the current pressure wound identified on 3/4/25.

Based on observations, interviews, and record review, the facility failed to ensure residents knew how to file a grievance and provide residents an option for reporting grievances anonymously, for 4 (#s 6, 14, 23 and 41) of 24 sampled residents. Findings include: During an interview on 11/5/24 at 9:27 a.m., resident #6 stated she had a complaint regarding an incident that occurred in early October. Resident #6 stated she did not know what a grievance was and was worried about retaliation, if the staff knew she had complained. During an interview on 11/5/24 at 10:31 a.m. resident #14 stated he had a grievance about staff showing no respect for his privacy and not being able to access his resident trust account on weekends. Resident #14 did not know how to file a grievance or how to submit one anonymously. During an interview on 11/5/24 at 10:34 a.m., resident #23 stated she could not access her resident trust account on weekends and would beg staff for change in order to use the vending machine. Resident #23 stated she was told residents had to wait until Monday to access their resident trust account funds from staff member M. Resident #23 stated she did not know how to file a grievance or how she could file one anonymously. During an interview on 11/5/24 at 11:01 a.m., staff member B stated the facility did not have a location in the facility where a resident could file an anonymous grievance. During an interview on 11/5/24 at 11:40 a.m., staff member N stated residents turn grievance forms into the Social Worker, Director of Nursing, or a staff member will turn in the form for the resident. Staff member N stated she was not aware of a way for residents to turn in a grievance anonymously. During an observation of the facility on 11/6/24 at 10:05 a.m., no grievance boxes were available for residents to place an anonymous grievance form. The only location found to obtain a grievance form was between the front office and the nursing station. No forms were available in other areas of the building. During an interview on 11/6/24 at 8:01 a.m., NF2 stated resident #41 had dentures when she was admitted to the facility. NF2 stated he asked several staff about where resident #41's dentures were, but staff stated they were not able to locate them. NF2 stated he went to the previous administrator about resident #41's missing dentures. NF2 stated he was not aware of a grievance process or how to file a grievance. NF2 stated he assumed the facility would address resident #41's missing dentures after he complained to the administrator. A review of the facility's Grievance Log, dated October 2023 to November 2024, reflected no grievances filed by residents #6, 14, 23, and 41 for their concerns mentioned above. Review of the facility's Grievance Policy, dated 4/22/24, did not reflect instructions on how to file a grievance anonymously.

Based on observations, interviews and record review, the facility failed to ensure a resident was referred for dental services after dentures were lost, while the resident was living at the facility for 1 (#41) of 24 sampled residents. This practice led to resident #41 being required to eat soft and pureed foods, and the facility had the opportunity to address the concerns over an extended period of time, and had multiple opportunities to correct the concerns, but did not. Findings include: During an observation and interview on 11/4/24 at 1:21 p.m., resident #41 did not have her dentures in her mouth. Resident #41 stated she did not have her dentures because somebody took them. Resident #41 stated she had to find soft foods to eat because she did not have her dentures. During an interview on 11/6/24 at 8:01 a.m., NF2 stated resident #41 had dentures when she was admitted to the facility. NF2 stated he asked several staff about the missing dentures, but the dentures were not found. NF2 stated he went to the previous administrator about the missing dentures and getting resident #41 new dentures, but the facility never scheduled resident #41 for a denture appointment. NF2 stated resident #41 would benefit from having her dentures, and he had shared his concerns with the management team during care conferences last year. NF2 stated resident #41 had plenty of money to cover new dentures if the facility would not take responsibility for the lost dentures. During an interview on 11/6/24 at 9:14 a.m., staff member C stated she reviewed the EHR and found the lower denture was lost on 10/26/21 but no record was found of when the upper denture went missing. Staff member C stated the facility would schedule a dental appointment for resident #41. Review of a facility policy, Dental Service, dated 4/22/24, reflected: - . 1. The facility will provide or obtain from an outside resource, routine and emergency dental services to meet the needs of each resident. - . 5. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location . Review of resident #41's dietary tickets from the facility kitchen, dated 11/6/24, reflected resident #41 received pureed meats and soft foods, including pudding, ice cream, and applesauce. Review of resident #41's Nursing Care Plan, with a last revision date of 9/9/24, reflected: - . {Resident #41} has upper and lower dentures. Assist her with oral/denture care twice daily and as needed. Date initiated: 2/25/21 .

Based on observations, interviews, and record review, the facility failed to ensure call lights were within reach for 3 (#s 5, 37, and 55) of 24 sampled residents, and the residents were not able to reach or use the call lights. Findings include: During an observation on 11/6/24 at 9:41 a.m., resident #5's call light was under her bed, with the bed against the wall. Resident #5 could not reach the call light. During an observation on 11/6/24 at 9:43 a.m., resident #37's call light was out of reach, on a nightstand on the right side, approximately two feet back from the bed. Resident #37 stated she did not know where her call light was located. During an observation on 11/6/24 at 9:44 a.m., resident #55's call light was on the nightstand, approximately one and a half feet away from the bed. Resident #55 stated she did not know where her call light was located. During an observation and interview on 11/6/24 at 9:46 a.m., NF1 stated he had just arrived and was not aware of the location of the call lights for residents #5, 37, and 55. NF1 stated the call lights for residents #5, 37, and 55 were not within reach, when observed with the surveyor. NF1 stated he would expect all call lights to always be within reach of the residents. During an interview on 11/6/24 at 11:01 a.m., staff member B stated the call lights should always be within reach of the residents. Staff member B then called out on the staff radio system for all call lights to be checked to ensure they were within reach of the residents. Review of a facility policy, Resident Rights, dated 1/11/24, reflected: - The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on interviews and record review, the facility failed to honor a resident's right to privacy by entering the residents' room without consent and going through residents' items for 2 (#s 6 and 14), and the practice upset the two residents involved; and the facility failed to ensure residents had the opportunity to engage in political voting for 2 [#s 5 and 19] of 24 sampled residents, and #5 and 19 wanted to vote if able. Findings include: RIGHT TO PRIVACY: During an interview on 11/5/24 at 9:27 a.m., resident #6 stated staff member K went through her drawers without permission, and she entered her room to find staff member K standing in her room with two knives in the air saying, Look what I found. Resident #6 stated, She was snooping in our drawers while we were out of the room. They were buried in a drawer. We used to cut fresh fruit like apples and such but haven't used the knives in a long time, so they have just stayed in the drawer. Resident #6 stated, A shouting match started, there's no respect, she (staff member K) said she was doing a deep clean. No one asked us or told us about a deep clean. During an interview on 11/5/24 at 10:31 a.m. resident #14 stated he had returned from lunch and found staff member K going through his dresser drawers. Resident #14 stated, They have no right to come in our room and go through our drawers without asking and without us present, and stuff always seems to happen when we go to appointments, out of the building, stuff just disappears. No respect. We have told them to stay out of our room when we are not here. During an interview on 11/5/24 at 12:32 p.m., staff member C stated she was not aware of a screaming match between resident #6 and staff member K. Staff member C stated she had heard resident #6 was refusing services from staff member K and staff member K was told to discuss the refusal with staff member I. During an interview on 11/5/24 at 4:01 p.m., staff member A stated she had interviewed resident #6, and resident #6 was now stating the screaming was on her part and staff member K did not scream back. Staff member A stated resident #6 and resident #14 agreed with a plan to allow all housekeeping staff to enter the room, if both residents were present. During an interview on 11/6/24 at 8:30 a.m., resident #6 stated she did not agree to allow staff member K into her room. Resident #6 stated, I do not want (staff member K) in our room at all, and no male housekeepers, as females are better cleaners. I did not agree to all housekeeping staff in here (her room). During an interview on 11/6/24 at 9:00 a.m., with staff members K and L, staff member L stated she had told residents #6 and #14 the week prior to the scheduled deep cleaning, but had no documentation of notifications or consents. Staff member L stated staff member K did enter the room on 10/10/24 to complete the deep cleaning as scheduled. A review of a facility-reported incident, dated 11/5/24 - 11/6/24 reflected: - Resident #6 stated she did not want staff member K in her room; - Resident #6 and resident #14 will be notified in advance of a deep cleaning schedule, so the residents could be present. A review of the facility's, Deep Clean Training Module, no date, reflected: 1. Always knock, wait and announce who you are, let them know your deep cleaning. . 9. With personal items, pick up, wipe, and put back in place. 10. We do not go through their [residents] stuff unless they are there going through it with you. RIGHT TO VOTE: a. During an interview on 11/4/24 at 1:08 p.m., resident #19 stated she had not received her ballot to vote. Resident #19 stated she told the activities staff she had not received her absentee ballot, but staff had not followed-up with her to assist her with voting. Staff member A was notified by the State Survey Agency surveyor that resident #19 was requesting to vote. b. During an interview on 11/5/24 at 8:20 a.m., staff member A reported staff member E would obtain an absentee ballot for resident #19 so she could vote. During an interview on 11/5/24 at 11:01 a.m., staff member B stated staff member E interviewed residents when they admitted to the facility, in order to determine the resident's interest in voting. Staff member E was to also determine if the resident voted absentee or at their voting location. Staff member B stated she was not aware of any follow-up completed to ensure those residents who reported a desire to use the absentee ballot received one. Staff member B stated an audit was currently in progress after resident #19's voting and ballot concern was brought to the facility's attention. 44770 c. During an interview on 11/5/24 at 10:20 a.m., resident #5 stated she did not get to vote but she wanted to. It was election day, and her roommate was able to vote by mail. Resident #5 said she did not get a ballot in the mail, but she would love to vote if it was still possible. Review of the facility's policy, Resident Rights, dated 1/11/24, reflected, . The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility .

Based on observation, interview, and record review, the facility failed to accommodate a resident's needs when he was sitting in his wheelchair, and complete an assessment for positioning aids, for 1 resident (#7) of 2 sampled residents with one sided weakness who require a wheelchair for mobility, but he was unable to hold up his torso/head, which would often lean forward. Findings include: During an observation on 11/4/24 at 4:11 p.m., resident #7 was sitting in his wheelchair in his room. His body was leaning far forward in the chair. Resident #7 appeared to be sleeping. During an observation on 11/6/24 at 8:23 a.m., resident #7 was in the dining room. He was sitting in his wheelchair, leaning forward with his face almost touching his food. Resident #7 was dozing off, but when his face would touch his plate, he would sit back up. During an interview on 11/6/24 at 9:41 a.m., staff member Q said resident #7 liked to stay in his wheelchair. She said he tipped (leans) forward frequently, and she would try to get him back to his room. She said sometimes he wouldn't want to go. She said she did not know if he required any kind of positioning pillow or equipment to help him be more comfortable in his wheelchair. During an observation on 10/6/24 at 3:14 p.m., resident #7 was leaning over in his chair in the dining room, and one foot was on the floor, the other was on the foot pedal. He was bent over so far, his head was almost touching his knees. During an observation on 10/7/24 at 8:12 a.m. resident #7 was sitting in the dining room, in his wheelchair, falling asleep. He was leaning forward in his wheelchair. The wheelchair did not have foot pedals. Resident #7's head was touching the edge of the table, and there was a CNA sitting behind him, assisting another resident. Staff member R asked resident #7 if he wanted to go back to his room. Resident #7 said, Sleep, sleep. Staff member R stated, This doesn't look very safe, referring to how the resident was sitting. Staff member S came over to the table and instructed staff to put the foot pedals on the resident's wheelchair to keep him from falling out. Staff member R stated, you were almost falling out of your chair. Resident #7 stated, Sleep, sleep, and at 8:35 a.m., staff member R repositioned resident #7 in the chair. During an observation on 10/7/24 at 9:14 a.m., resident #7 was observed in the dining area, with his head on a pillow, on the table. During an interview on 10/7/24 at 9:16 a.m., staff member T stated physical therapy and occupational therapy used a different system to document their assessments. She stated she had never assessed resident #7 for positioning in his wheelchair. She stated if there had been an assessment for positioning done, it would be updated in the resident's EMR. A request was made on 10/7/24 for physical therapy or occupational therapy notes for resident #7's positioning. A progress note from physical therapy was provided, which was dated after the surveyor made the request. No other physical therapy notes or occupational therapy notes were provided prior to the end of the survey. Review of resident #7's Focus area on the care plan showed, [Resident #7 name] has potential for falls related injury due to impaired mobility and balance from right sided hemiplegia, right wrist drop, generalized weakness and muscle atrophy, pain and use of narcotic medication, cognitive impairment, and incontinence. Under the Interventions section, there was one intervention related to resident #7's wheelchair, which showed, If [#7's name] is sleeping in his wheelchair, nursing staff will wake him and ask [#7's name] if he wants to rest in his bed. There were no interventions regarding the resident's positioning in the wheelchair on the care plan. Review of a nursing note dated 6/1/24 at 2:01 a.m., showed resident #7 was found on the floor on his right side next to his wheelchair. He complained of pain to his right shoulder.

Based on interviews and record review, the facility failed to ensure the accuracy of the Quarterly MDS assessment, for medications and hearing, for 2 (#s 11 and 23) of 24 sampled residents. Findings include: 1. During an observation and interview on 10/6/24, staff member P walked into resident #11's room. Resident #11 was having a hard time hearing the surveyor's questions. Staff member P stated, Let me get her hearing aid. Staff member P put one hearing aid in resident #11's ear. The hearing aid did not help resident #11's ability to hear. Review of resident #11's EMR, showed her Care Plan showed resident #11 used two hearing aids. A Significant Change MDS, on 9/16/24, showed resident #11 did not use hearing aids, but she had highly impaired hearing. A Quarterly MDS, dated [DATE], showed resident #11 did not use a hearing aid and had highly impaired hearing. A Quarterly MDS on 5/31/24 showed resident #11 did use hearing aids, and she had moderate hearing difficulty. During an interview on 10/7/24 at 11:17 a.m., staff member G stated, I don't even do those assessments. I can see that it did not get pulled in correctly. I have never really noticed that it had an error in there before. But this one is definitely inaccurate because according to the assessment she does have hearing aids. I will submit modifications for both of those (MDS assessments) right away. 48261 2. A review of resident #23's EHR MDS record, reflected an MDS, dated [DATE], which showed resident #23 was on an antibiotic for the last seven days. A review of resident #23's EHR, Physician Orders, dated 10/1/24 - 11/7/24, reflected no antibiotics were ordered or given to resident #23. During an interview on 11/4/24 at 1:44 p.m., resident #23 stated she was not on any antibiotics and did not know why antibiotics would be listed in her health records. During an interview on 11/5/24 at 4:11 p.m., staff member G stated he had reviewed the medications in October and November (2024) for resident #23 and was not able to find an antibiotic ordered. Staff member G stated he would be completing a correction for the MDS, dated [DATE].

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for a resident's foley catheter care within 48 hours of admission for 1 (#61) of 4 sub-sampled residents with a urinary catheter. Findings include: During an observation and interview on 11/6/24 at 3:09 p.m., resident #61 was observed sitting in a chair, in the activities room. Resident #61 stated he discharged from the hospital on 10/9/24. Resident #61 stated the foley catheter was placed in the hospital, and he was hoping it would be removed soon. During an interview on 11/7/24 at 10:46 a.m., staff member B stated resident #61 was admitted to the facility on [DATE]. Staff member B stated the nurses were responsible for developing baseline care plans for residents on admission. Staff member B stated the admission assessment would trigger care areas for the resident's baseline care plan. Staff member B stated she did not know why resident #61's baseline care plan did not address resident #61's foley catheter. Staff member B stated the nurse could have possibly missed checking the box on the assessment. A review of resident #61's baseline care plan, dated 10/9/24, showed resident #61 was admitted on [DATE]. The baseline care plan did not show any focus areas, goals, or interventions for resident #61's foley catheter.

Based on interview and record review, the facility failed to ensure licensed nursing staff on duty knew how to perform and complete a wound vacuum dressing change as ordered, for 1 (#7) of 1 sampled resident. This deficient practice had the potential to cause an infection and worsen the surgical wound being treated with the wound vacuum. Findings Include: Review of the facility's reported incident investigation showed: The facility administration had initially written a grievance for the delay in changing the wound vacuum dressing for resident #7 on 2/4/23, with a resolution on 2/7/23, of educating nurses on wound vacuum dressing changes. The facility received an APS notification on 2/9/23 of a complaint regarding the wound vacuum dressing not being changed timely for resident #7, reported it to the State Survey Agency, and started an investigation. A written statement by staff member B showed a drawing of resident #7's wound vacuum dressing with the left top corner open and staff member B did not complete the dressing change. Staff member B handed off the task to the oncoming shift. Staff member D, reported to staff member B during shift report she did not know how to change the dressing. Staff member B gave staff member D the directive to have the morning shift change the wound vacuum dressing. Staff member D did not realize the wound vacuum machine was off and open to air at that time. The other night nurse working on 2/3/23 did not know how to change a wound vacuum dressing either. Staff member D called the provider to get new physician orders when she saw the wound vacuum was turned off and open to air. The new orders were changed to a wet to dry dressing at approximately 11:00 p.m. on 2/3/23 until a morning shift nurse could replace the wound vacuum. During an interview on 7/6/23 at 8:29 a.m., staff member C stated, she knew how to do wound vacuum dressings from training at a prior job. Staff member C stated she had not been given any training by the facility on how to do a wound vacuum dressing change. Staff member C stated the facility has had several wound vacuums, but none currently. Staff member C stated there were a lot of times agency nurses did not know how to complete wound vacuum dressing changes. Staff member C stated they tried to find someone who could do the dressing when it came up. Staff member C stated, If the wound vac dressing change doctor's order was for your shift it should have been done on your shift. During an interview on 7/6/23 at 10:25 a.m., staff member B stated, he was covering the floor nurse due to an absence on 2/3/23. Staff member B stated he was unfamiliar with the halls he was covering and did not have the best time management. Staff member B stated he had started by turning off the wound vacuum for resident #7 to inject the lidocaine pain medication and give the resident a pain pill. Staff member B stated when he went to complete the dressing change, the resident still experienced pain when he pulled up a corner of the dressing, and he decided to wait a little longer. Staff member B stated he made other attempts to complete the dressing, but resident #7 was out and about and staff member B got busy doing other tasks. Staff member B stated at shift change report he passed on he did not get the wound vacuum dressing changed for resident #7, and the oncoming staff member told him she would try to get it done. Staff member B stated the wound vacuum was intact and working prior to his leaving at 6:00 p.m. on 2/3/23. Staff member B stated the nurse never called him after he left to say they could not complete the dressing, and he was available by phone. Staff member B stated agency nurses do not go through facility orientation or competencies. Staff member B stated the agency provides an online transcript of the nurses training including a competency list before they start working at the facility. During an interview on 7/6/23 at 10:30 a.m., staff member D stated, she came onto shift on 2/3/23, and staff member B shared in shift report he was unable to complete the wound vacuum dressing for resident #7 but had given the lidocaine injection and oral pain medication. Staff member D stated she told staff member B she had never done a wound vacuum dressing before, and staff member B gave the directive to have the next shift complete the wound vacuum dressing change. Staff member D was under the impression at the time of the report that the wound vacuum was on and functioning due to the directive to wait until the morning shift. Staff member D stated a CNA on shift reported to her resident #7 and his family were upset his wound vacuum dressing had not been changed yet. Staff member D stated she then went to the resident and saw the wound vacuum was off, and the dressing was open to air, which it should not have been. Staff member D stated due to this, she called the provider for new physician orders. The provider gave an order to take the wound vacuum off and place a wet to dry dressing on resident #7's surgical wound, and to replace the wound vacuum in the morning. Staff member D stated she had to keep apologizing to the resident and his family due to how upset they were. Review of resident #7's wound vacuum orders on the February 2023 TAR, showed the wound vacuum dressing was ordered to be changed every Monday, Wednesday, and Friday at noon, with a start date of 1/18/23, and discontinue date of 2/9/23. Review of nurse progress notes for resident #7 on 2/3/23 through 2/4/23 showed: - 2/3/2023 @ 1830 (6:30 p.m.)-During shift handover report, AM nurse reported that the wound vacuum dressing change was not done, though, the am nurse did inject the lidocaine already at around 1500 (3:00 p.m.). I explained to the am nurse that I am not comfortable of changing dressings of a wound vacuum as I have not done it before. AM nurse states to hand it over to the AM nurse the next morning. @1900 (7:00 p.m.), pt had requested to see the nurse. Pt states I have been lying in bed waiting for the other nurse to get my wound vac dressing to be changed. Pt and wife states that lidocaine was already administered and it has to be changed. The dressing was opened and wound vac was off. I apologized to pt and wife (who happened to be the pt's roommate). I explained to them that I am not comfortable with wound vac as I don't have any experience with it and that I also explained that to the am nurse during shift report. The RN on duty also is not comfortable with wound vac. Pt states he was hungry as he did not have his dinner yet waiting for his wound vac to be changed. Requested dinner for pt as soon as possible. Placed a call to on-call provider, and explained the situation. [On-call provider name] had to hang up the phone so she would find out what is the best thing to do and that she will research it out. [On-call provider name] called back and gave an order to take the dressings off and just apply wet to dry dressings. Explained it to pt and wife about the Dr's order. They verbalized their understanding. At 2230 (10:30 p.m.), wound vac discontinued and dressings off. Applied wet to dry dressings to the wound in the abdomen. Cleansed the wound with NS, pat to dry, wet to dry dressings applied with ABD pad over and tape to secure. [sic] -Staff member B never documented any issues with attempting to change resident #7's wound vacuum dressing. Review of the facility provided employee file for staff member B showed no trainings or competencies, including for wound vacuum dressing changes. Review of the staffing agency's training transcript and syllabus did not show wound vacuum or wound care education in the competency list for staff member D. Review of the facility's wound vacuum printed education, dated 2/8/23, showed staff member B's signature. Staff member D was not on the list. The education did not show if it was a competency-based education, who the educator was, or the educator's qualifications to provide the education. No other education was provided to the nursing staff for wound vacuum dressing changes.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided to prevent episodes of incontinence with feelings of anger, shame, anxiety, and guilt in 1 (#28); failed to provide assistance during meals for 1 (#33), which had the potential to result in reduced calorie intake and weight loss; failed to provide eating and bathing assistance for 1(#15); and for a lack of assistance with mobility for positioning, transfers, and toileting, which with feelings of shame and anger for 1 (#256) of 17 sampled residents. Findings include: 1. During an observation on 9/17/19 at 4:04 a.m., staff member F came out of resident #28's room with a soiled linen bag from an episode of incontinence. During an interview on 9/16/19 at 3:13 p.m., resident #28 stated she wakes at 4:00 a.m. daily and it takes staff an average of two hours to respond to her call light. Resident #28 stated, I'm perfectly continent, but if I have to wait for two hours, I'm gonna pee my pants. I can't toilet myself without help. The staff answer my call light, need assistance from another staff, turn off my call light, and leave. I turn the call light back on because they haven't done anything. I am a two person assist. If I need assistance, it's either I have to use the bathroom or I want my food tray removed, it's that simple. During an interview on 9/17/19 at 11:15 a.m., staff member G stated she did not feel they had enough staff to help provide care for the residents and not enough staff could affect the frequency of incontinence issues. Staff member G stated, There can always be more hands. During an interview on 9/17/19 at 11:25 a.m., resident #28 stated, I turned my call light on to use the toilet and it was responded to at 10:55 a.m. The staff turned off the call light and stated they would return with another staff to help. Resident #28 stated the two staff members returned 30 minutes later to assist with toileting. During an interview on 9/17/19 at 11:27 a.m., staff member F stated the average time to respond to resident #28's call light is 30 to 45 minutes, sometimes longer. During an interview on 9/17/19 at 11:48 a.m., resident #28 stated, When I am incontinent, I feel angry and shameful. I am an adult woman, who is continent, and I am ashamed when it happens. I feel anxious and am always wanting to know who is working and how many people are here. I feel guilt, like I let myself down. I have every bad feeling you can have. Resident #28 stated she is working hard to be a one person assist so it does not take as many staff to help her with toileting. Review of resident #28's Quarterly MDS Assessment, with an ARD of 4/30/19, showed transfers and toilet use required a two + persons physical assist. Review of resident #28's Quarterly MDS Assessment, with an ARD of 7/30/19, showed transfers and toilet use required a two + persons physical assist and a preventative toileting program had not been attempted. Review of resident #28's Care Plan Report, dated 9/17/19, showed the interventions for ADL assistance, related to incontinence: - uses a commode for toileting. - use pull-ups/briefs to manage incontinence. 2. During an observation on 9/17/19 at 8:34 a.m., resident #33 was self-feeding scrambled eggs and bacon. Staff member G was the only staff member available and did not provide any feeding assistance to resident #33. Resident #33 consumed 20% of her breakfast. During an interview on 9/17/19 at 8:43 a.m., staff member J stated resident #33 can self-feed finger foods, but we assist. Staff member J stated resident #33 has 1:1 assistance services with staff for every meal. Staff member J stated scrambled eggs do qualify as finger foods because staff cut the scrambled eggs into finger sized pieces. During an observation on 9/17/19 at 12:09 p.m., resident #33 was eating lunch in the facility's main dining room. Resident #33 was provided a scoop plate, which had a turkey and cheese sandwich on wheat bread, which was cut in half, and potato chips, on the plate. Throughout the meal, resident #33 struggled to move the sandwich to her mouth, and often would drop food onto her lap. There were also pieces of sandwich noted on the table next to resident #33's plate. Staff member G was the only staff member working in the dining room and staff member G did not offer assistance to resident #33 or anticipate her needs. Resident #33 did not vocalize a need for assistance. During an observation on 9/17/19 at 12:20 p.m., resident #33 held an eight-ounce cup in her left hand. The cup was covered with a plastic [MEDICATION NAME], and through the [MEDICATION NAME], emerged a straw, which had a paper cover over the top half (mouth end). Resident #33 inserted the paper end of the straw into her mouth. Upon putting the straw into her mouth, resident #33 asked for assistance. Staff member F removed the paper cover from the straw, then left the dining room. During an observation on 9/17/19 at 12:25 p.m., resident #33 had eaten 25% of her lunch. Resident #33 was observed positioned in her wheelchair, leaning to the right, with her right ear almost touching her right shoulder. Resident #33 had a [DIAGNOSES REDACTED]. During an interview on 9/17/19 at 12:31 p.m., staff member G stated resident #33 is okay with finger foods, and often does not require assistance. During an interview on 9/17/19 at 1:05 p.m., staff member [NAME] stated resident #33 has had an overall decline and on hospice. Staff member [NAME] confirmed resident #33 had a [DIAGNOSES REDACTED]. Staff member [NAME] stated even though resident #33 was able to self-feed, she had been on a 1:1 assistance during meals since suffering a clavicle fracture six months ago. Staff member [NAME] stated resident #33 will always try to eat with her fingers, even with the scoop plate, which was why the facility provided her with finger foods for all meals. Staff member [NAME] stated resident #33 had gained weight in the past four weeks, and in the past week, she had consumed about 50% of all meals. Staff member [NAME] stated there should be at least two staff in the dining room for meals so that someone could assist resident #33. If there were only one staff available, staff member [NAME] recommended the staff member should serve all other residents before serving resident #33 so they could provide 1:1 attention. During an observation on 9/18/19 at 8:16 a.m., resident #33 was self-feeding french toast and bacon. Staff member G was unable to sit with resident #33 throughout her meal as other residents required staff member G's attention. Half of a slice of bacon was noted on the table, next to the resident's scoop plate. Review of resident #33's care plan, with a goal date of 11/7/19, showed the resident requires assist with ADL's. Interventions included: providing guided maneuvering of extremities, verbal cueing, and sufficient time for resident #33 to perform and/or assist during dressing and other ADL's as needed. The care plan also showed resident #33 had difficulty moving her right arm and hand, and to allow extra time to compensate. Resident #33's [DIAGNOSES REDACTED]. 3. During an observation on 9/16/19 at 12:09 p.m., resident #15 was observed trying to use her silverware, unsucessfully. Resident #15 would move the fork across the plate, but was not able to pick up food. She would then move the empty fork to her mouth, as if the fork had food on it. She was unable to see the fork did not have food on it. During an observation on 9/17/19 on 8:22 a.m., at breakfast, resident #15 was not provided assistance with her meal and ate her food with her fingers. During an interview on 9/17/19 at 4:22 a.m., resident #15 stated she does not regularly get showers and does not get the assistance level needed during meals. Resident #15 stated she did not want to eat with her fingers during mealtimes. Meal Assistance: During an observation on 9/17/19 at 12:20 p.m., resident #15 was served an oriental chicken salad and watermelon, on a paper plate, with no assistive device around the plate. During an observation on 9/17/19 at 12:21 p.m., resident #15 was staring at her salad. Her fingers were resting on the side of the plate. No assistance was provided by staff for resident #15's meal. During an observation on 9/17/19 at 12:24 p.m., resident #15 had not taken a bite of food from her meal. Staff neither offered assistance, nor assisted her to eat any of her food. Resident #15 was leaning to the right with her arm over the wheelchair, head toward the edge of the table, and intermittently was bumping her head off the table. During an observation on 9/17/19 at 12:27 p.m., resident #15 had not consumed any of her salad. Staff member G was in the dining room serving the rest of the dining room and was not providing any assistance to the already served assisted dining table. During an observation on 9/17/19 at 12:30 p.m., resident #15 hit her head off the edge of the table. Staff member G, who was across the table, was assisting another resident. Resident #15 had not taken a bite of her salad. Staff member G said to resident #15 You keep bonking your head off the table and offered the resident an alternative sandwich. During an observation on 9/17/19 at 12:33 p.m., resident #15 was given a sandwich on a red plate. Resident #15 picked up the red plate, brought it to her mouth, licked the top of the sandwich, and set the plate back down on the table. Resident #15 struggled to pick the sandwich up off the plate. Resident #15 then lifted the plate back up, resting it on her chest with her left hand, and stated out loud, pick this up for me. No assistance was provided to the resident, and staff did not anticipate her needs. During an observation at 9/17/19 at 12:36 p.m., resident #15 started to wheel herself away from the table, and had neither consumed any food during lunch, nor received any assistance from staff. During an observation on 9/17/19 at 12:38 p.m., resident #15 stated to staff member G she was hungry. Staff member G then handed resident #15 her sandwich off the plate, which she was able to eat. No drink or fluid had been offered or given to resident #15 during the meal, until 1:03 p.m. During an observation on 9/18/19 at 7:53 a.m., resident #15 was sitting at the table for breakfast, with a spilled cup resting on her feet, and a brown pool of liquid to the left of her on the floor. During an observation on 9/18/19 at 8:12 a.m., resident #15 began eating with her fingers. She dropped food on herself, picked it up, ate it, and then asked for a food protector. The cup, which had spilled, still remained on her feet. During an interview on 9/18/19 at 8:16 a.m., staff member F stated she does not know when resident #15 spilled the fluid on her feet. Staff member F left the cup resting on resident 15's feet, and left the spilled matter on the floor. During an interview on 9/18/19 at 8:18 a.m., staff member G stated she did not know when the cup spilled, did not pick up the cup, or clean the spilled matter off the floor. During an observation and interview 9/18/19 at 8:21 a.m., staff member T stated he does not know when the cup spilled on resident #15. Staff T went over to the resident, picked up the cup, and started to clean up the spilled pool on the ground. During an interview on 9/18/19 at 8:23 a.m., staff member M stated a certified nursing assistant must be in the dining room to supervise and assist residents. Staff member M stated resident #15 needed supervision when eating because she was an aspiration risk. Staff member M stated resident #15 should be cued and assisted by the staff when needed. In the dining room, there should be two staff members, one to pass trays, and one to assist the assisted dining table. During an interview on 9/18/19 at 8:29 a.m., staff member C stated he ensured assistance in the dining room by listening to the radio and residents. Staff member C stated resident #15 had [MEDICATION NAME] degeneration and was looking for something that could make her spoon or fork line up with the food. Staff member C stated blind people were set up assist. Staff member C stated there was a finger food trial a while ago for resident #15 and salad would not be a finger food. Salad would require utensils. During an observation on 9/18/19 at 12:38 p.m., resident #15 was handed an ice cream cup with a spoon stuck in it. Resident #15 then put the end of the spoon to her mouth and tried to suck on the end of the spoon. No assistance was given to resident #15. During an interview on 9/19/19 at 8:05 a.m., staff member A stated when resident #15 was eating at the assisted dining table there should be a CNA present for supervision and assistance. Staff member B stated trained people would assist with feeding the residents if they could not feed themselves. During an interview on 9/19/19 at 1:56 p.m., staff member [NAME] stated resident #15, as it stands, was not designated for assistance or supervision. Staff member [NAME] stated resident #15 had trialed finger foods, but ultimately resident #15 wanted silverware, and to be on regular diet with intermittent assistance, as needed. Resident #15 would eat bent over at the waist and needed cuing. The process was that other residents would get their food, then those that needed assistance. Staff member [NAME] stated she had not assessed whether or not resident #15 could use silverware appropriately, and occupational therapy would have done the evaluation of that. Staff member [NAME] stated resident #15's weight had fluctuated, and her last weight was 210 lb on 9/16/19. Review of resident #15's weights showed on 6/8/19 that resident #15 weighed 218 lbs, and on 9/16/19 resident #15 weighed 210 lbs, which is a -3.67% loss in weight. Review of resident #15's Care Plan, dated 7/2/19, showed the following: - Assist with meals as need. (Resident #15) eats meals at the assisted dining table. She prefers a soup spoon with all meals. Provide a low vision plate and plate guard. The care plan does not address resident #15's [MEDICATION NAME] degeneration in relation to how it affects her ability to feed herself. Review of resident #15's nutritional intake record showed the following: -In (MONTH) 2019 resident #15's intake was 50% or lower for 28 meals. -In (MONTH) 2019 resident #15's intake was 50% or lower for 23 meals. -In (MONTH) 2019 resident #15's intake was 50% or lower for 26 meals. -From 9/1/19-9/10/19 resident #15's intake was at 50% or lower for 5 meals. Review of resident #15's clinical notes showed the following: -On 6/11/19, Notified by staff that resident has been observed attempting to feed herself with use of her hands instead of utensils. They question if finger foods would be appropriate. - On 6/20/19, Resident has been observed receiving feeding assistance at meals, as well as intermittently feeding herself with utensils during the finger food trial period. Will resume regular diet with level 4 textures, with staff continuing to provide assistance as indicated and as resident will allow. Bathing: Review of resident #15's Care plan, dated 7/2/19, showed the care plan did not include the level of bathing assistance the resident was to receive. Review of resident #15's bathing record showed: -No documented bathing assistance was provided for resident #15 for 17 days from 7/12/19 to 7/30/19. -No documented bathing assistance was provided for resident #15 for 19 days from 8/27/19 to 9/16/19. A request for an occupational therapy evaluation for resident #15 was requested on 9/19/19. No documentation was provided by the facility. 4. During an observation on 9/16/19 at 2:16 p.m., resident #256 turned on his call light. At 2:21 p.m. resident #256 got himself up from bed and walked to the bathroom. The call light was still on. Resident #256's front wheeled walker was on the other side of the room, by the doorway. During an observation on 9/17/19 at 4:14 a.m., resident #256 was in bed with his call light on. Resident #256's walker was on the other side of the room, by the doorway. Resident #256 walked to the bathroom, unassisted, at 4:19 a.m. During an observation and interview on 9/18/19 at 12:23 p.m., resident #256 said he feels pretty rough with constant shortness of breath and weakness, recovering from a respiratory infection. Resident #256 stated he was tired from walking to the bathroom unassisted, as his legs are weak and will give out, but the staff take too long to answer the call light. Resident #256 stated when he had to go to the bathroom, it was immediate. Resident #256 stated he tried to wait, but he has had accidents waiting for assistance and his call light was not always within reach. Resident #256 stated the incontinence accidents that have happened made him feel terrible about himself as he hung his head and rolled his shoulders forward in a protective manner. Resident #256 stated he felt he was on his own and had to fend for yourself around here (facility). Resident #256 voice lowered and was quiet as he spoke and took his left arm to gesture out the door and around the room. During an interview on 9/18/19 at 3:51 p.m., staff member O stated resident #256 is a fall risk and needs staff assistance for mobility. Staff member O stated resident #256 is still getting over a respiratory infection and should not be getting up on his own, or walking without assistance. A record review of resident #256's care plan, dated 9/13/19, showed a problem area for ADL assistance, with interventions as: - 1-2 person assist for transfers - weight bearing as tolerated - assist with ADL's such as positioning and mobility as needed - put the call light within easy reach and anticipate needs if unable to use the call light.

Based on observation, interview, and record review, the facility failed to protect 1 (#31) from abuse and neglect by not preventing a fall from a sit-to-stand lift, resulting in a head injury, which required eight stitches; the facility failed to protect 1 (#28) from neglect of care by not meeting the dependent resident's needs for toileting in a timely manner, and the neglect negatively affected the resident's psychosocial well-being causing ongoing feelings of anger, shame, anxiety, and guilt; and for a resident who feels there are ongoing abuse concerns and was upset, for 1 (#2) of 17 sampled residents. Findings include: [NAME] Record review of the facility's reported incident showed NF2 entered resident #31's room on 2/12/19 at 2:40 p.m. to find resident #31 on the bathroom floor, leaning against the toilet bowl, with a laceration on the resident's occiput, which measured 1.5 inches x 0.5 millimeters. NF2's note showed resident #31 was transferred to the emergency room around 3:05 p.m. The facility's incident report included a statement from NF1, who had witnessed resident #31's fall: At 2.35pm the resident requested the easy stand to toilet, not wanting to transfer from her wheelchair as she usually does. She stated that she had only 'tried' the stand once before. As I hook up the harness to her while she was sitting in her wheelchair, I straightened her as she complained of being crooked. I asked if she would let me attach the other straps and she said 'no more straps.' I lifted her only part way and attempted to move her to the bathroom. She asked the oxygen to be moved, as I was untangling the oxygen from her arms, she said 'I ' m not hanging on anymore' and she let go and slid out of the harness. (sic) Upon investigation, the facility concluded in their report, dated 2/15/19: .the previous neglect report submitted on 2/14/19 is substantiated. (NF1) did not follow facility protocol in regards to proper lift transfers which resulted in resident having a fall requiring stitches. Resident requested transfer to restroom and advised that she was too weak to stand. Resident requested (NF1) get assistance as she is too heavy for one person. (NF1) retrieved EZ Stand lift to transfer resident from wheel chair to bathroom. (NF1) admitted to not using the seat strap or leg straps during transfer but advised that resident asked not to use them and to hurry, hurry I have to go. Resident's statement advised this was an accident and that she told (NF1) that she was going to let go because she was too weak. (NF1) admitted that she has had training on proper use of lifts and that she attended the last lift training on 1/9/19. Facility audit of other floor staff showed that staff understand and follow proper lift transfer procedures. Staff receive annual lift training during facility sponsored skills fair. Next skills fair is 3/7/19 . (sic) The documentation showed the staff member is no longer working at the facility. During an interview with staff members B and C on 9/18/19 at 10:11 a.m., staff member B stated NF1 did not attach the EZ lift safety straps to resident #31 during the transfer. Staff member B stated she thought (the facility) had substantiated that neglect. Staff member C stated resident #31 was indeed capable of ambulating to the bathroom with her walker, and did not require an EZ lift. During an interview on 9/18/19 at 12:00 p.m., resident #31 stated upon recalling her fall in February, that she was told by staff she had hit her head on the door jam in the bathroom. Resident #31 had no complaints about staff and thought they were all very qualified. She called her fall an accident. During an interview on 9/18/19 at 3:37 p.m. with staff members A and B, staff member B stated resident #31 was a one-person assist, but at the time of the incident, resident #31 stated she was too weak to just use the assistance belt, which was why NF1 decided to use the EZ lift. Staff member A stated she suspended NF1 on 2/14/19 following the facility's investigation, and NF1 is no longer an employee. Staff member A stated there were no additional staff training's related to safe transfers in February. The facility did call the EZ lift company in (MONTH) to schedule a training, but the company could not offer the training until April. Staff member A stated, This incident just involved (NF1) and NF1 is no longer working at the facility, and the facility did not do any follow-up training's after the incident. Review of resident #31's (MONTH) 2019 care plan showed the resident was at risk for falls and required an extensive assist of one for transfers as needed. There was no mention of resident #31 requiring an EZ lift. Review of staff in-service training's showed NF1 had attended an EZ lift training on 1/9/19. Review of NF1's employee file showed a background check was completed upon hire, and NF1 had not been flagged for abuse or neglect. Review of NF1's nurse aide skill competency showed she had passed all demonstrations on 7/25/18, and had passed an abuse, mistreatment, and neglect training on 9/6/17. The facility did not provide documentation of a facility audit of transfer procedures as mentioned in the internal investigation report. B. During an observation on 9/16/19 at 11:30 a.m., four call lights were activated at the same time on one hallway. There was one CNA assigned to that hallway. During an interview on 9/16/19 at 3:13 p.m., resident #28 stated, I wake at 4:00 a.m. daily and it takes staff an average of two hours to respond to my call light. I'm perfectly continent, but if I have to wait for two hours, I'm gonna pee my pants. I can't toilet myself without help. I have had two UTI's this year, one in (MONTH) and one in July. The staff answer my call light, need assistance from another staff, turn off my call light, and leave. I turn the call light back on because they haven't done anything. I am a two person assist. If I need assistance, it's either I have to use the bathroom or I want my food tray removed, it's that simple. During an observation on 9/17/19 at 4:04 a.m., staff member F came out of resident #28's room with a soiled linen bag. During an interview on 9/17/19 at 11:15 a.m., staff member G stated she did not feel they had enough staff to help provide care for the residents, and not enough staff could affect the frequency of incontinence issues. Staff member G stated, There can always be more hands. Staff member G stated training on abuse and neglect is provided in the Health Care Academy system, through in-services, and pocket cards staff carry with them. During an interview on 9/17/19 at 11:25 a.m., resident #28 stated, I turned my call light on to use the toilet and it was responded to at 10:55 a.m. The staff turned off the call light and stated they would return with another staff to help. Two staff members returned at 11:25 a.m. so I could use the toilet. During an interview on 9/17/19 at 11:27 a.m., staff member F stated the average time to respond to resident #28's call light is 30 to 45 minutes, sometimes longer. During an interview on 9/17/19 at 11:37 a.m., staff member F stated, No, there aren't enough staff to provide care. Staff member F stated that not having enough staff probably affected the rates of incontinence. During an interview on 9/17/19 at 11:48 a.m., resident #28 stated it was her idea to have a blue, protective barrier pad under her while in the wheelchair. Resident #28 stated, Too many times my seat cushion, on my wheelchair, has been soiled and it takes a while to get it cleaned through laundry services. I have had to go on appointments without my seat cover on my cushion and that's an uncomfortable feeling. Resident #28 stated, When I am incontinent, I feel angry and shameful. I am an adult woman, who is continent, and I am ashamed when it happens. I feel anxious and am always wanting to know who is working and how many people are here. I feel guilt, like I let myself down. I have every bad feeling you can have. Resident #28 stated, I am working really hard to be a one person assist. During an interview on 9/19/19 at 1:25 p.m., staff member D stated regarding resident #28's incontinence, Timed voiding wasn't effective to prevent incontinence. She has a [MEDICAL CONDITION] bladder, and she feels sometimes when she has to go. It is all based on letting the staff know when she feels it. Review of resident #28's Quarterly MDS Assessment, with ARD of 7/30/19, showed: -transfers and toilet use requires two + persons physical assist -has a trial of a toileting program been attempted, box checked as No Review of resident #28's Care Plan Report, dated 9/17/19, showed resident uses a commode for toileting. Review of resident #28's provider's progress note, dated 2/4/19, showed the resident was seen by provider on 1/31/19 where UA was positive for urinary tract infection. Resident #28 was started on [MEDICATION NAME] 250 mg, one time daily, times five days. Review of resident #28's provider's progress note, dated 7/18/19, showed the resident had a UA performed on 7/17/19 and it was positive for UTI. Resident #28 was started on [MEDICATION NAME] 250 mg, at hour of sleep, for five days. C. During an interview on 9/16/19 at 2:18 p.m., resident #2 stated she still experiences troubles with abuse in the facility. Resident #2 stated she does not remember the specifics about the event on 3/7/19 but remembers being upset, and the staff member no longer works at the facility. During an interview on 9/19/19 at 8:05 a.m., staff member A stated, after notification of the abuse allegation from 3/7/19, she immediately went out on the floor to see if any other residents had concerns and suspended the employee, then did a thorough investigation. The employee is no longer working at the facility. Staff member A stated there was a training held a month later and no immediate education was given to the frontline staff on abuse or abuse reporting. Staff member A stated looking at the incident from an interdisciplinary perspective it was an isolated incident that had occurred and did not identify a trend of abuse throughout the facility. Review of the investigation findings, dated 3/11/19, showed the allegation of abuse was substantiated, and the Nurse admitted to stating, 'you did, you pulled it off to the resident', accusing the resident of removing the [MEDICAL CONDITION] bag. Nurse advised that she told the resident it was not her fault as the bag should have been changed by N[NAME] (night) shift staff. This caused the resident to be tearful and wish to move to another location. Witness interview of CNA present supported residents' claim tht nurse accused her of removing the colotomy bag.(sic) Review of all staff training for abuse showed it was held on 4/11/19 and 5/23/19.

Based on observation, interview, and record review, the facility failed to provide sufficient staffing to assist in resident care needs and services, to include: - dining room supervision and assistance for 1 (#15) resulting in weight loss, difficulty eating, and the feeling that staff were withholding food from resident #15; - dining room supervision and assistance for 1 (#33) which had the potential to result in malnutrition and weight loss for resident #33; - and, staff failed to answer call lights in a timely manner and assist the residents timely with ADL care needs, for 7 (#s 8, 18, 25, 28, 47, 50, 204) and for these residents the delays caused resident #18 to remain in bed due to the lack of staff availability to get the resident up; #25 was worried her room mate would not receive care; #28 was at increased risk of incontinence; and resident #204 to wait over an hour for pain medication, of 34 sampled and supplemental residents. Findings include: [NAME] During an observation on 9/17/19 at 12:20 p.m., resident #15 was served an oriental chicken salad and watermelon, on a paper plate, with no assistive device around the plate. During an observation on 9/17/19 at 12:21 p.m., resident #15 was staring at her salad, as her fingers were resting on the side of the plate. Staff did not provide the resident assistance with the meal or eating. During an observation on 9/17/19 at 12:24 p.m., resident #15 had not taken a bite of food and no staff have offered assistance or assisted her to eat any of her food. Resident #15 was leaning to the right with arm over the wheelchair, head toward edge of table and intermittently bumping head off table. During an observation on 9/17/19 at 12:27 p.m., resident #15 had not consumed any of her salad. Staff member G was in the dining room serving the rest of the dining room. Staff G was not providing any assistance to the assisted dining table, and the residents had been served. During an observation on 9/17/19 at 12:30 p.m., resident #15 hit her head off the edge of the table. Staff member G, who was across the table, was assisting another resident. Resident #15 had not taken a bite of her salad. Staff member G said to resident #15 You keep bonking your head off the table and offered the resident an alternative, which was a sandwich. During an observation on 9/17/19 at 12:33 p.m., resident #15 is given a sandwich on a red plate. Resident #15 then picks up the red plate brings it to her mouth and licks the top of the sandwich and sets the plate back down on the table. Resident #15 struggles to pick up the sandwich off the plate. Resident #5 then lifts the plate back up resting it on her chest with her left hand and stated out loud, pick this up for me. No assistance was provided to the resident. During an observation at 9/17/19 at 12:36 p.m., resident #15 started to wheel herself away from the table and had not consumed any food during lunch or received any assistance from staff. During an observation on 9/17/19 at 12:38 p.m., resident #15 stated to staff member G she was hungry. Staff member G then handed resident #15 her sandwich, which was on the plate, and she was able to eat. Staff did not offer any fluids to the resident for her to drink during the meal, until 1:03 p.m. During an interview on 9/18/19 at 8:23 a.m., staff member M stated a certified nursing assistant must be in the dining room to supervise and assist residents. Staff member M stated resident #15 needed supervision when eating because she was an aspiration risk. Staff member M stated resident #15 should be cued and assisted by the staff when needed. In the dining room, there should be two staff members, one to pass trays, and one to assist the assisted dining table. During an observation on 9/18/19 at 12:38 p.m., resident #15 was handed an ice cream cup with a spoon stuck in it. Resident #15 then put the end of the spoon to her mouth and tried to suck on the end of the spoon. Staff did not assist resident #15. During an interview on 9/17/19 at 4:15 a.m., resident #15 stated she felt the facility withholds her food. During an interview on 9/18/19 at 8:29 a.m., staff member C stated the facility is pulling from everywhere they can to address the lack of sufficient staffing. Staff member C stated he had covered five certified nursing shifts in the last ten days. Staff member C stated they are trying to get some agency staff to come work at the facility. Staff member C stated, to be fully staffed, there would need to be five certified nursing aides working on the floor for the day and evening shift, and three certified nursing assistants on for the night shift. Review of resident #15's nutritional intake records from 6/1/19 to 9/10/19, showed the resident's intake at meals was frequently less than 50% eaten. Refer to F677; ADL Care Provided to Dependent Residents, for more information for resident #15 related to intake of meals. Review of resident #15's weights showed from 6/8/19 to 9/16/19 resident #15 weight dropped from 218 lbs to 210 lbs. Review of the facility's employee call offs for (MONTH) and (MONTH) 2019 showed the following: -From 8/1/19 to 8/31/19 there were 17 call offs and 7 were covered. -From 9/1/19 to 9/18/19 there were 16 call offs and 6 were covered. Review of the staffing sheets, from 9/1/19 to 9/17/19, showed there were only a total of four shifts that had five certified nursing assistants working. B. During an observation on 9/17/19 at 8:34 a.m., resident #33 was self-feeding scrambled eggs and bacon. Staff did not provide any feeding assistance to resident #33 during breakfast. Resident #33 consumed about 20% of her meal. During an observation on 9/17/19 at 12:09 p.m., staff did not offer resident #33 assistance during the meal. Resident #33 consumed approximately 25% of her meal. During an observation on 9/17/19 at 12:25 p.m. of the dining room, during lunch time, staff member G was the only staff member present and responsible for serving and providing assistance for 22 residents. During an interview on 9/17/19 at 12:31 p.m., staff member G stated there were no residents that required 1:1 assistance, other than resident #33. Staff member G stated if there were another resident who required assistance during meals, an additional staff member would come and help. Staff member G stated she handled meal times as best she could. She said it would be helpful to have another staff member helping during meal times. During an interview on 9/17/19 at 1:05 p.m., staff member [NAME] stated there should be at least two staff in the dining room for meals so that someone can assist resident #33. If there were only one staff available, staff member [NAME] recommended a staff member should serve all other residents before serving resident #33 so they could provide 1:1 service to the resident. During an observation on 9/18/19 at 8:16 a.m., resident #33 was feeding herself french toast and bacon. Staff member G was unable to sit with resident #33 throughout the meal due to other residents requiring her attention, and other staff were not available. Review of resident #33's care plan, with a goal date of 11/7/19, showed the resident requires assist with ADL's. C. Call Lights During an observation on 9/16/19 at 11:30 a.m., four call lights were activated at the same time on one hallway. There was one CNA assigned to that hallway. During an interview on 9/16/19 at 11:44 a.m., resident #23 stated, Last night was really bad for staffing, they only had one CNA in the building. Resident #23 stated staff took a long time to answer call lights. During an interview on 9/16/19 at 2:11 p.m., resident #47 stated, It's hard to take care of me, they don't have enough staff. They should have at least one staff member on each hall. Sometimes they only have two staff in the building and only one at night. During an interview on 9/16/19 at 2:25 p.m., resident #204 stated, They are very short handed here, especially on night shift. Call light response time is three to four hours, and weekends are worse. I asked for pain medication at 1:00 p.m. and just got it at 2:10 p.m. During an interview on 9/16/19 at 3:13 p.m., resident #28 stated,I wake at 4:00 a.m. daily and it takes staff an average of two hours to respond to my call light. I'm perfectly continent, but if I have to wait for two hours, I'm gonna pee my pants. I can't toilet myself without help. The staff answer my call light, need assistance from another staff, turn off my call light, and leave. I turn the call light back on because they haven't done anything. I am a two person assist. If I need assistance, it's either I have to use the bathroom or I want my food tray removed, it's that simple. During an interview on 9/17/19 at 7:41 a.m., resident #25 stated she was worried about her roommate's well-being in getting the help she needed to transfer and use the bathroom. Resident #25 stated, The staff care, there just isn't enough of them. During an interview on 9/17/19 at 11:15 a.m., staff member G stated she did not feel they had enough staff to help provide care for the residents and not enough staff could affect the frequency of incontinence issues. Staff member G stated, There can always be more hands. During an interview on 9/17/19 at 11:25 a.m., resident #28 stated, I turned my call light on to use the toilet and it was responded to at 10:55 a.m. The staff turned off the call light and stated they would return with another staff to help. Resident #28 stated the two staff members returned 30 minutes later to assist with toileting. During an interview on 9/17/19 at 11:27 a.m., staff member F stated the average time to respond to resident #28's call light is 30 to 45 minutes, sometimes longer. During an interview on 9/17/19 at 11:37 a.m., staff member F stated, No, there aren't enough staff to provide care. Staff member F stated that not having enough staff probably affected the rates of incontinence. During an interview on 9/17/19 at 1:42 p.m., staff member F stated new employees will often quit a few weeks after they have been hired. Staff member F stated, It would be nice to have another person to help with transfers. Staff member F stated staff have not been able to answer call lights as quickly and residents have not been getting as many showers because of high staff turnover rates. During an interview on 9/18/19 at 3:30 p.m., resident #8 stated there are less staff to help and it takes more time to get help. Resident #8 stated, I wait til they (staff) are available, I wait because there isn't enough people to help me. It takes me a lot longer to get into my clothes because I wait for help and I rely on those people because I can't do it myself. During an interview on 9/18/19 at 4:05 p.m., resident #50 stated there are never enough people to help with transfers and mobility issues. Resident #50 stated, When I turn on my call light it takes anywhere from 10-45 minutes for a response. I have reported this at the monthly resident meetings, to the CNA, and to the nurse. During an interview on 9/19/19 at 12:57 p.m., resident #18 stated she had a difficult time getting staff to come help her. Resident #18 stated, The problem here is not (my ability) to use the (call light). I can use it, but no one will come for hours. She continued to explain that she required the Hoyer lift, and that is a huge process. Resident #18 stated she would like to get up out of bed today, 9/19/19, but I will stay in bed because it would take too much effort for me and for the people who work here. A request was made on 9/16/19 for a call light response time log. Staff member A stated they have no way of tracking call lights. No documentation was received.

Based on interview and record review, the facility failed to thoroughly assess, identify, evaluate, monitor effectively, and provide interventions for a resident who had a decline in status since her admission, to ensure the resident's needs were met for hydration, constipation, emesis, and a weight loss; and the resident set restrictions on her own food and drink preferences. The resident continued the decline and passed away, for 1 (#312) of 24 sampled residents. Findings include: Review of resident #312's MDS showed she was admitted to the facility on [DATE], and passed away at the facility on [DATE]. Review of resident #312's SBAR, dated [DATE], showed the resident had a history of [REDACTED]. The SBAR showed Caregiver notes an increase in lethargy compared to baseline, and a dry mouth. Would you suggest giving IVF? The physician ordered lab work, and stated the resident was Better today/continue to observe. Review of resident #312's Nutrition Note, dated [DATE], showed the resident preferred two peanut butter and jelly sandwiches with Dr. Pepper, for all three meals, each day. Her potential for dehydration was not identified or addressed further. Review of resident #312's Progress notes, dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], showed the resident experienced episodes of emesis. Review of resident #312's Physician Visit Note, dated [DATE], showed Nursing reported that the resident had complained of dizziness and had emesis this morning, which has been a chronic problem. Last documented bowel movement was 12 days ago, though there is a verbal report of possible she had one last week. The plan and assessment included acute on chronic constipation, obstipation. Refusing clear lax, will DC. Verbal report that she had a bowel movement last week. The last documented BM was on ,[DATE] (8 days prior). No vomiting or signs of obstruction. [MEDICATION NAME] 30 cc every 4 hours until adequate bowel movement then start senna 2 by mouth at bedtime. Resident #312's hydration status was not addressed. Review of resident #312's bowel monitoring record showed no bowel movements for [DATE] to [DATE]. A suppository was given on [DATE], per physician's orders [REDACTED]. Review of the facility bowel protocol showed, For constipation, may give MOM on 3rd day no BM; Suppository 1 per rectum of 4th day no BM; Fleets enema 1 per rectum on 5th day no BM. The bowel protocol was not followed for the resident. Review of resident #312's TAR for (MONTH) (YEAR) showed one suppository was given, after a physician order. The resident should have received several suppositories and an enema, per the facility policy and protocols for bowel management. Review of resident #312's SBAR, dated [DATE], showed a significant weight loss. The SBAR showed, RD to observe resident during meals. Spoke with kitchen staff to ensure PB and J sandwiches are made to resident's preference. During an interview on [DATE] at 1:20 p.m., staff member R stated she was aware of resident #312's weight loss and preference for the PB and J sandwiches and Dr. Pepper. She stated, I was working with her on the right ratio of peanut butter to jelly. I had thought IV fluids was the next step, and thought nursing had initiated this (hydration). Review of resident #312's SBAR, undated, and signed by the physician, on [DATE], showed Vomits even without doing anything. The MD responded with No N/V per nursing, no abdominal pain. Will evaluate further next week. Although the SBAR and the physician response did not show similar information relating to the nausea and vomiting, further f/u was not completed by the facility at the time. Review of resident #312's SBAR, undated, showed Care taker suspects that the resident's episodes of daily vomiting is connected to dehydration. Consider IV fluids per caretaker's request. The SBAR did not show a physician response or a stamp to show it was faxed or acknowledged by the physician. No follow up was completed by the facility on the facsimile. Review of resident #312's SBAR, dated [DATE], showed Resident has not been taking adequate liquids or food. Too sleepy and dry lips. Please evaluate for dehydration. The physician replied with Noted. No further action was taken by the facility to identify what the Noted meant for the request for the evaluation for hydration. During an interview on [DATE] at 1:55 p.m., staff member I stated the facility made almost daily requests regarding resident #312's declining status. I feel awful about it. She should have received at least two suppositories for her constipation. It was the only thing that worked. During an interview on [DATE] at 10:26 a.m., staff member T stated We tried to get her hydration (by notifying and working with physician to obtain an order for [REDACTED]. She died suddenly. Review of resident #312's Physician Visit note, dated [DATE], showed By mouth intake has been dismal. Pt with frequent emesis. Per previous care manager, this is related to dehydration. Unable to draw labs yesterday. Last bowel movement was on [DATE]. Reported one brief change yesterday, usually change is ,[DATE] times per day. Hematoma noted to right eye secondary to fall on [DATE]. The resident was diagnosed with [REDACTED]. No interventions were implemented regarding her emesis or hydration status. During an interview on [DATE] at 9:00 a.m., staff member S stated resident #312 had the dwindles (diminish gradually) but she was surprised she had passed away. Staff S stated, It wasn't a good situation. Staff member S said she did not think IV fluids were necessary (due to the resident being on comfort measures) at the time. She stated she was aware of the resident's constipation. Review of an email from resident #312's Case Manager, sent to the QIC, dated [DATE], showed I again stressed the importance of (resident) receiving hydration via IV when she is having issues with drinking. When I visited her on Sunday, she had not been drinking and her lips were very dry and sticking together. Review of resident #312's Physician Visit note, dated [DATE], showed (Resident) is declining, she may be actively dying. She appears dehydrated and uncomfortable. Will attempt to give fluids for comfort. This was almost one month after the nursing staff first began to address hydration with the physician. During an interview on [DATE] at 11:22 a.m., NF1 stated he received the call that (resident) had passed away. I was able to talk to a few nurses, who were very upset, stating that (resident) was in fact, significantly dehydrated, and that shortly before her death, when she was in distress, they had tried to get an IV in her, but could not find a vein due to the dehydration.

Based on interviews and record reviews the facility failed to identify neglect for a resident left on a bed pan for 5.5 hours, and failed to thoroughly investigate the incident; and failed to report the neglect to the State Agency for 1 (#16) of 24 sampled and supplemental residents. Findings include: IMMEDIATE JEOPARDY During a recertification survey, an Immediate Jeopardy situation was announced by the surveyors at 3:35 p.m. on 9/15/16, at Riverside Health Care Center. The administrator and director of nursing were notified that an Immediate Jeopardy situation existed in the areas of Resident Behaviors and Facility Practices, and Sufficient Staffing. PLAN TO RESOLVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to remove the immediacy on 9/16/16 at 10:00 a.m. A summary of the plan included: - Neglect would be reported to the SA for the resident (#16), identified in the sample. - The facility would complete a thorough investigation of the allegation of neglect for resident #16, to include obtaining statements from staff. - All staff would be inserviced regarding the abuse and neglect policy, to include reporting the events. This would also include each person's responsibility in identifying, and timely reporting of possible abuse and neglect, and reporting unusual circumstances. -All nursing staff would receive an in-service regarding the proper use of bed pans, including the risks involved in extended periods of use and contact with skin. - The Licensed Nurses and CNA schedules would be reviewed each month by the Administrator and DON to determine if adequate staffing levels were in place to meet resident care needs, and to develop a plan for action to be taken of staffing concerns occurred. - Staffing levels, hiring statistics, and retention rates would be reviewed each month by the Facility Quality Council - The investigation process for abuse and neglect was reviewed and changes made to ensure documentation of the investigation was adequate to show a thorough investigation occurred. - All incidents investigated for possible abuse or neglect would be reviewed at the Interdisciplinary Managers Meeting each day. - A summary of all incidents investigated each month would be reviewed by the Facility Quality Council and assessed for trends and patterns. - The facility would continue to utilize the active program for retention and recruitment of staff, and staffing levels, hiring statistics, and retention rates would be reviewed each month by Facility Quality Council. Findings include: During an interview on 9/13/16 at 4:30 p.m., staff member C stated resident #16 had been neglected on the early morning of 8/13/16. She stated the resident had been left on a bedpan for greater than five hours. She stated that it was not intentional in nature. She was told that the night CNA had checked on the resident several times, and that the resident did not want to get off the bedpan. She also stated that the CNA was busy with other residents, and failed to return to check on the resident. The CNA then went home without getting the resident off the bed pan. She stated that an alternate CNA removed resident #16 from the bedpan at approximately 6:45 a.m. A change of shift had occurred from when the resident was left on the bedpan, to when she was removed from the bedpan. She knew that the prior CNA had placed the resident on the bed pan before 1:30 a.m. Staff member C stated she was bothered that when she mentioned the concern about the event to management staff they had not reported it to State or followed up with training of some kind. She and approximately 15 other staff had seen pictures of the resident's buttocks after she had been on the bedpan, which was from the local hospital medical record system. She stated there was an obvious ring of black skin with visible blisters on the resident's buttocks. Review of the resident's Skin Risk Braden form (skin assessment), completed on 8/2/16, showed the resident had decreased range of motion. Her bed mobility indicated on the form that she needed extensive assistance. The resident was also identified as being at moderate risk for skin break down due to friction and shearing. Review of the residents Clinical Notes for 8/4/16 showed resident #16 required two person extensive assist for bed mobility, toileting by bedpan, and for dressing. Review of a nursing communication report, dated 8/10/16, showed the resident had red moist areas of excoriation on her peri area and buttocks. A barrier cream was to be applied to the resident's perineal area BID and PRN. Review of a physician's visit on 8/10/16, under review of systems, reflected that the resident had ongoing back pain, generalized weakness, and loose stools which were sometimes quite watery in nature. A [MEDICAL CONDITION] Toxin test was pending. Review of the laboratory follow-up on 8/15/16 showed that the [MEDICAL CONDITION] Toxin, PCR, test result was negative. Review of a Nursing Home to Hospital Transfer Form, dated 8/14/16, showed (under reason for transfer) that the resident was identified to have a fever, dehydration, low blood pressure, and [MEDICAL CONDITION] prior to being transferred to the hospital. The transfer record lacked evidence for information relating to the condition of the resident's buttocks. Review of pictures taken by a local hospital which were taken on 8/14/16, showed a dark black ring circling the resident's buttocks where skin was discolored from the bedpan use. Staff member S, who had provided care for the resident, and was the CNA who was assisting the resident on the night of the bedpan event, no longer worked at the facility, and could not be reached by telephone. Upon notification of the Immediate Jeopardy, facility management staff conducted interviews with staff on 9/14/16 at 9:00 p.m The statements showed: - A written statement was received from staff member A at 3:30 p.m. on 9/15/16, which showed staff member A had spoke with staff members J and U. The conversation was about resident #16 being left on the bed pan on 8/13/16. The statement showed that staff member V came to the CNAs at approximately 6:30 to 7:00 a.m. on 8/13/16, to inform them that resident #16 needed to be attended to. The statement showed that staff members J and U found a bed pan beneath the resident, and she had diarrhea. They stated there was a dark ring and blisters on the resident's buttocks. Staff members J and U notified the nurse (staff member N), who came in and attended to the resident. Staff members J and U had not been told in report from the night shift CNA that resident #16 was still on the bedpan. - An interview with staff member S, the night CNA who was working the floor on 8/12/16, showed she thought she put resident #16 on the bed pan around 1:30 a.m. on 8/13/16. She stated she went back to check on the resident several times but the resident did not want to get off the bed pan. The resident said that she would call when she was done. - On 9/14/16 at around 9:00 p.m., staff member F was unaware of the bedpan incident on the morning of 8/13/16, but had found out the next day when on shift. She stated that staff member S had talked to her about the incident and felt really bad. Staff member F stated that it was typical for resident #16 to use a bed pan and typical to want to stay on the bed pan. She also remembered staff member S going into resident #16's room [ROOM NUMBER]-4 times. During an interview 9/14/16 at 4:30 p.m., staff member C stated she had been upset when she had been shown pictures of a resident who had been left on a bed pan for as long as 5 hours. The pictures were so upsetting to her, she spoke with her supervisor about the incident. Staff member C was told by her supervisor an in-service on the use of a bedpans would be forth coming. Staff member C stated she did not speak with the administrator about the incident as her supervisor stated the administrator was aware of the incident. Staff member C was upset by what she felt was a lack of response to the incident by the facility. Staff member C hoped action would be taken after she spoke with her supervisor. The staff member worried she could be fired for pushing the issue further, and she did not know how to proceed further with her reporting. The staff member also stated, she had spoken with the resident's physician regarding the incident, after she had seen the pictures. During an interview on 9/14/16 at 8:00 p.m., staff member N stated resident #16, was not in good shape when she was removed from the bed pan shortly after 6:30 a.m. on 8/13/16. The resident had a red mark around her buttocks from being on the bed pan for so long. After about an hour the mark turned to a violet color. Staff member N stated that staff member O stood with her as she documented a clinical note on the incident. Staff member N was told by staff member O not to mention that the resident had been left on the bed pan by the night shift. Staff member N was told to write only her observations. Staff member N was confused, and wondered why she was directed to leave information out of her notes. Staff member N stated the incident was clearly negligence, but that it was not really the CNA's fault, because there was not enough staff on shift. During an interview on 9/14/16 at 8:05 p.m., staff member F stated she had seen the buttocks of resident #16 after she was removed from the bedpan. The resident had a circle around her buttocks with a thin line of purple bruising. The resident was in a lot of pain. Staff member F stated considered the incident to be neglect, and she felt really bad. Staff member F stated it was hard to describe how bad the staff felt, and wished they could have turned back the clock. Staff member F stated she was confident the incident had been reported. She felt comfortable reporting through the chain of command. During an interview on 9/14/16 at 8:40 p.m., staff member O stated that when the facility was fully staffed they had 6 or 7 CNAs working on the floor. Staff member O stated that If we only had two CNA's working, that would be neglect. Staff member O stated she had never worked a shift in the facility when there was not enough staff. Staff member O stated, I've never experienced a shortage of staff (in this facility). Staff member O stated she could not recall a time a resident had been neglected due to a lack of staff, that nothing had been mentioned regarding staffing issues in report or at the team meetings. Staff member O was asked if she had ever advised a staff member not to include certain information in the clinical notes. Staff member O stated she had never advised anyone to exclude information from documentation. During an interview on 9/15/16 at 10:40 a.m., Professional Person BB stated while viewing the pictures taken on admission of the buttocks of resident #16, Everyone can see (the resident) was left on the bed pan way too long. During an interview on 9/15/16 at 12:45 p.m., Professional Person AA stated she was told about the incident with the bed pan by a nurse working at the hospital, after resident #16 was transferred from the facility to the hospital. She stated she had assumed the incident with resident #16, which was for being left on the bedpan, had been reported to the State Agency. She did not know how long the resident had been left on the bedpan. She also stated the incident should have been investigated and reported so a plan could be made to avoid occurrences like that in the future.

Based on record reviews and interviews, the facility failed to ensure 1 (#16) resident was free from mistreatment and neglect. Specifically, the resident was left on a bedpan for 5.5 hours, which resulted in the development of a stage II pressure ulcer to the residents buttocks, out of 24 sampled and supplemental residents. Findings included: Review of the residents Skin Risk Assessment/Braden form, which was completed by nursing staff after the resident's admission on 8/2/16, showed that the resident had decreased range of motion, and her bed mobility was described as she needed extensive assistance from staff. She was also identified as being at moderate risk for skin break down due to friction and shearing. Review of the resident's Clinical Notes for 8/4/16 showed resident #16 required two person extensive assist for bed mobility, toileting by bedpan and for dressing. Resident #16 had refused her leg wraps, stating they are making the swelling worse. The nurses' note went on to show that the resident wanted this staff to throw her on the floor so she could return to the hospital. She stated, Why did they kick me out of the hospital. Review of a Nurse's Communication Report, dated 8/10/16, showed that resident #16 had red moist areas of excoriation on her peri area and buttocks. A barrier cream was to be applied to the resident's peri area BID and PRN. Review of a physician's visit, dated 8/10/16, under review of systems: showed that the resident had ongoing back pain, generalized weakness, and loose stools which were quite watery in nature. A [MEDICAL CONDITION] Toxin test was pending. Review of a laboratory follow up on 8/15/16 showed that the [MEDICAL CONDITION] Toxin, PCR, was negative at the time of the test. Review of a Nurse's Communication Report, dated 8/13/16 at 3:31 p.m., showed, Resident on bed, she pooped and soiled all over her bed. Changed bedding, rashes on her buttocks noted. [MEDICATION NAME] cream applied on red area. Bottom has bruises and marks left from her bedpan. Left buttock has open wound, cleansed and covered with foam dressing. Right buttock has raw and open spots due to shearing, cleansed and covered with foam dressing. Temperature was 101.6 at 6:00 a.m., rechecked at 10:00 a.m., temperature was 101. Stated that her temperature rise (sic) because she was covered with 3 blankets and complains of cold. She refused to get her blood culture test. Doctor on call was notified about her temperature and her rashes on her buttocks. Advised to give Tylenol. Passed stool 3 times, soft in consistency. Refused to eat breakfast and lunch, she only wanted to sleep. Review of a Nursing Home to Hospital Transfer Form, dated 8/14/16, showed (under reason for transfer) that the resident had a fever, dehydration, low blood pressure, and [MEDICAL CONDITION] when she was transferred to the hospital. The form did not show any concerns relating to the resident's breakdown on her buttocks. During an interview on 9/13/16 at 4:30 p.m., staff member C stated that resident #16 had been neglected on the early morning of 8/13/16, and was left on a bedpan for greater than five hours. She stated it was not intentional in nature, but had been told that the night shift CNA had checked on the resident several times, and the resident did not want to get off the bed pan. She also stated that the CNA got busy with other residents, and failed to return to check on the resident. The CNA had gone home prior to taking the resident off the bedpan. She stated that a CNA on the following day shift had removed resident #16 from the bedpan at approximately 6:45 a.m. She knew that the prior CNA had placed the resident on the bed pan before 1:30 a.m. Staff member C was bothered that when she mentioned it to management staff they had not reported the event to the State or followed up with training of some kind. Staff member C, and approximately 15 other staff, had seen pictures of the resident's buttocks after being on the bedpan by way of the local hospital medical record system. She stated that in the photos the residents buttocks had a ring of black skin and obvious blisters around the buttocks. A written statement was received from staff member B on 9/15/16. The statement showed she had spoken to staff member S about leaving resident #16 on the bedpan, which had occurred on 8/13/16. Staff member S stated that she put the resident on the bedpan between 5 to 5:30 a.m. She went back to get the resident off the bedpan about 10 minutes later, and the resident wanted to stay on the bedpan. She stated she went back again another time, and the resident told her that she would call her when she wanted to get off the bed pan. The resident never called before the end of the CNAs shift. At approximately 6:30 a.m., the medication technician went to give resident #16 her medications and noticed an odor. She told the day shift CNA's who then went into the resident's room and found that she was on the bedpan. The CNAs notified the nurse on duty (staff member N), who assessed the resident's buttocks. The assessment showed bruising and wounds which had developed. She addressed the wounds, and notified the physician. Staff member B educated staff member S on the importance of taking residents off the bedpan in a timely manner. Staff member S stated she understood. A review of statements received and obtained by management staff on 9/14/16 were provided to the survey team on 9/15/16. The statements contained information from follow-up interviews regarding the bedpan concern, and showed: - Staff member S worked the floor the night shift of 8/12/16, and thought she put resident #16 on the bedpan on 8/13/16 around 1:30 a.m. She could not really remember exact details of the event. Staff member S stated she had gone back to the resident's room to check on the resident a couple of times but the resident didn't want to get off the bedpan, and said she would call when she was done. - Interviews from staff J and U showed they stated that staff member V came to them on 8/13/16 at approximately 6:30 to 6:45 a.m. to let them know that resident #16 needed attention. They said they found a bedpan beneath the resident, and she had diarrhea. They had observed a dark ring and blisters on the residents buttocks. They notified staff member N, who then came in and attended to the resident. They had not been told in report from the night shift that resident #16 had been left on the bedpan. Review of the facility's Abuse, Neglect and Exploitation Plan, created and approved on 9/1/16, page 1, #2 (definition of abuse means) The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also included the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Page 2, #7 (definition of neglect was) The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Page 4, item IV, Identification of abuse, neglect and exploitation showed: The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: - resident, staff or family abuse - physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body - physical injury of a resident, of unknown source - resident reports of theft of property, or missing property - verbal abuse of a resident overheard - physical abuse of a resident observed - psychological abuse of a resident observed - failure to provide care needs such as feeding, bathing, dressing, turning & positioning - notice of photographs, videos or other recordings of a resident posted on any social media network or forum Page 4, item V, investigation of alleged abuse, neglect and exploitation showed: When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: - interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses - interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. - obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement - document the entire investigation chronologically Page 5, item VII, response and reporting of abuse, neglect and exploitation, showed: Anyone with knowledge or concerns about the care of a resident in the facility can report suspected abuse to the abuse agency hotline or file a complaint with the State Survey agency. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: - respond to the needs of the resident and protect them from further incidents - notify the director of nursing and administrator - initiate an investigation immediately - notify the attending physician, resident's family/legal representative and medical director - obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately - contact the State Agency and the local Ombudsman office to report the alleged abuse/neglect - monitor and document the resident's condition, including the response to medical treatment or nursing interventions - document actions taken in steps above in the medical record The policy directed staff to document their actions taken. During an interview on 9/14/16 at 3:50 p.m., staff member B stated, A CNA placed resident #16 on a bed pan. When the CNA went back to take her off the bed pan the resident did not want to get off. Staff member B stated she did not know how long the resident had been left on the bed pan. Staff member B stated she had investigated the incident. The staff member said the incident occurred in the morning, and the resident had a red ring around her buttocks. When asked if this would be a reportable incident, staff member B stated, I don't know. Staff member B stated, It was not neglect, the resident wanted to stay on the bed pan. During an interview on 9/14/16 at 4:30 p.m., staff member C stated an investigation of the bed pan incident had been completed by staff member G. The investigation was requested from the facility, but was not provided prior to the completion of the survey. During an interview on 9/14/16 at 5:30 p.m. with staff members A and B, staff member B stated she had seen the photographs taken of the residents' buttocks upon her admission to the hospital on [DATE]. Staff member A stated he had not seen any photographs of the residents' buttocks. During an interview 9/15/16 at 1:30 p.m., staff member A stated the incident with resident #16, being left on the bed pan for 5 hours, was not reported as neglect because Neglect would be not providing a service. The staff member did check on the resident, but the resident did not want to get off the bed pan. The staff did clean her up when she was removed from the bed pan. When asked about an investigation into the incident, staff member A stated, I and (staff member B) talked about the incident. We brought the CNA in, and were told by the CNA that the resident had been checked on. I (staff member A) did not consider it neglect. A review of the Clinical Notes Report, dated 8/14/16, showed, (Resident #16) requested to be sent to the ER due to fever that has been occurring over the last few days. (Resident #16) wanted to take all of her belongings because she said she was not coming back to this facility however, her things were left at our facility. A review of the documentation from the emergency department at the local hospital showed on 8/14/16, PT (patient) also with bruising/marks from bedpan that was used at Riverside. PT states that she was left on bedpan for hours at a time while at Riverside. The documentation also showed, Additionally, she has a skin wound presumably from the commode that is circumferential of her bilateral buttocks area. A review of the Assessment and Plan area of the documentation showed, Stage II decubitus ulcers: These are the buttocks area. Wound care will be consulted. A review of the Physical Examination section showed, There are pressure ulcers in the gluteal folds, and a circumferential ulceration over her entire buttocks. A review of the Progress Notes from the local hospital, dated 8/15/16, showed, Doesn't want to go back to the SNF; hopes to remain in the hospital until she is ready to go home.

During an interview on 9/14/16 at 8:00 p.m., staff member N stated some shifts were very difficult due to a shortage of staff. Staff member N stated on 8/13/16 she came to work at 6:00 a.m. Staff member N was called into resident #16's room. She then witnessed the resident on the bed pan, and reported the incident as being scary. Staff member N stated the resident was not in very good shape, she had a fever, and had been refusing her medications. Staff member N stated she had worked a number of shifts at the facility as a CNA, but had found it too difficult to keep up with the work load even if two CNA's were scheduled. She stated two CNA's was not enough staff. During an interview on 9/14/16 at 8:08 p.m., staff member F stated the facility staff were trying so hard to manage being short staffed. She stated the staff were overwhelmed. Staff member F stated there had been an incident with a resident who had been left on a bed pan, and all the staff felt very bad about the occurrence. Staff member F stated on that night there were a couple of hours when only one CNA was working. Staff member F stated the staff member who had placed the resident on the bedpan went back to check on the resident a couple of times, and then got busy running all over the facility meeting the needs of other residents, and forget about the resident on the bedpan. Staff member F stated the CNA was very upset, she really felt bad. During an interview on 9/14/16 at 4:30 p.m., staff member C stated she had been concerned about the staffing at the facility. Staff member C stated there were often times when only one nurse and one CNA were scheduled for a night shift. Staff member C had recently been concerned when she was told by another staff member that a resident had been left on a bed pan for about 5 hours. During an interview 9/14/16 at 8:05 p.m., staff member F stated that usually two CNA's were scheduled for night shift but sometimes one will call off. The two CNAs who were scheduled make a plan, and the nurses on shift agree to help where they can. The plan included resident checks, changes, and charting. This worked until the CNAs would get burned out, and then they would quit. Staff member F stated the staff had been very frustrated for at least the last six months. During an observation on 9/14/16 at 8:30 p.m., six CNAs, one RN, one LPN, and six members of management were busy working the floor. They were answering call lights, and readying the residents for the night. During an interview 9/14/16 at 10:40 a.m., resident #10 stated, The staff here are great, they just need a lot more staff. They are helpful, but sometimes it takes 30 to 45 minutes for them to come when I put on my call light. During an interview on 9/12/16 at 1:50 p.m., resident #22 stated she was only receiving a shower once a week, and she would like to shower more often. During an interview 9/13/16 at 3:30 p.m., resident #23 stated she liked the staff in the facility, but there was a definite problem with not having enough staff. During an interview on 9/14/16 at 8:10 p.m., resident #23 stated she was waiting to go to bed as usual. She stated that last winter the facility had one CNA for all the halls, as two didn't call or show up. Most of the winter, and then again during the summer, the concern with staffing went on. Resident #23 stated, We have been short of staff, it has been terrible here lately. They get their training here and then leave. Based on observations, interviews and record reviews, the facility failed to provide sufficient qualified nursing staff for needed resident care to enable residents to attain their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility was staffed with only one LPN and one CNA for a period of one hour and 48 minutes from 2:07 a.m. to 3:55 a.m. on 8/13/16. During this time resident #16 was left on a bedpan for an extended period of time. This failure also affected 4 residents (#'s 10, 16, 22, and 23) of 24 sampled and supplemental residents. The findings include: 1. A review of the resident's medical record showed she was alert and oriented, and able to make her own decisions. A review of a document, written by staff member B on 8/15/16, showed staff member B spoke with staff member S on 8/13/16. The topic of the conversation was an event that occurred on 8/13/16, where resident #16 was placed on the bedpan early in the morning on 8/13/16. The report showed staff member S stated that she put resident #16 on the bedpan between 5:00 a.m. and 5:30 a.m. A review of a record, written by staff member B on 9/14/16, showed that staff member B had re-interviewed staff member S on 9/14/16. The report showed that staff member S thought she had placed resident #16 on the bedpan around 1:30 a.m. but that she really could not remember. A review of a record, written by staff member B on 9/14/16, showed that staff member F was interviewed by staff member B, on 9/14/16. The report showed that staff member F was unaware that a resident had been left on a bedpan for an extended period of time, and she did not hear of the incident until the next day when she came back on shift. A review of a record, written by staff member B on 9/14/16, showed that staff member Y was interviewed by staff member B on 9/14/16. The report showed that staff member Y arrived to work about 4:00 a.m. on 8/13/16, and was unaware that a resident had been left on a bedpan for an extended period of time. A review of a statement written by staff member A on 9/15/16 at 3:30 p.m., reflected that member A had spoken with staff members J and V regarding resident #16 having been left on the bed pan for an extended period of time on 8/13/16. They stated that staff member V came to them at approximately 6:30-7:00 a.m. on 8/13/16, to let them know that resident #16 needed attention. Both staff member J and staff member U said they found a bedpan beneath the resident, and she had diarrhea. The statement showed there was a dark ring and blisters on the residents buttocks. 2. A review of the facility's employee time records for the actual hours worked on 8/12/16 and 8/13/16 showed: - On 8/13/16 the facility was staffed with only one LPN (staff member F), and one CNA (staff member S), for a period of one hour and 48 minutes. This was from 2:07 a.m. to 3:55 a.m. - At 2:00 a.m., a total of one LPN and three CNAs were working. One CNA left at 2:05 a.m., and one at 3:07 a.m. This left one LPN with one CNA (staff member S), to care for all the residents in the facility. A CNA then arrived at 3:55 a.m. If, as is shown above, staff member F was unaware of the bedpan incident on the early morning when it occurred, only one staff person remaining in the facility, (staff member S), would have been aware that resident #16 remained on the bedpan during the hours between 2:07 a.m. and 3:55 a.m. By 6:00 a.m. on 8/13/16, the facility had one LPN and nine CNAs working in the facility.

Based on record reviews and interviews, facility administration failed to identify, thoroughly investigate, and report an allegation of neglect, and failed to utilize the facility policy and procedure to ensure future care for the resident was addressed to prevent the deficient practice of neglect from occurring in the future for 1 (#16) of 24 sampled and supplemental residents. The findings include: Review of the staffing schedules for the night shift of 8/12/16 showed: - Staff member F started at 5:59 p.m. on 8/12/16, and was off work at 6:49 p.m., on 8/13/16. - Staff member S started at 6:08 p.m. on 8/12/16, and worked until 6:19 a.m. on 8/13/16. - Staff member T started work at 2:00 p.m. on 8/12/16, and was off work at 2:15 a.m. on 8/13/16. - Staff member J started work at 6:08 a.m. on 8/13/16. - Staff member U started work at 6:05 a.m. on 8/13/16. - Staff member N started work at 5:41 a.m. on 8/13/16. In the early morning hours from 2:07 a.m. until 3:55 a.m. (a period of 1 hour and 48 minutes) on 8/13/16, there was only one CNA and one nurse working on four separate wings in the facility. Refer to F353 Sufficient Staffing. During follow-up interviews conducted by management staff on 9/14/16, two separate CNA's who worked the day shift on 8/13/16 showed there was no communication at shift exchange, and they were not aware that resident #16 was left on a bedpan when the prior CNA had left the facility. A review of the Incident Log for the month of August 2016, failed to show the incident of neglect (refer to F224) had been recorded on the log. This failure would have prevented those reviewing the log in the future from using the information regarding facility statistics, or addressing concerns for needed action. During an interview on 9/14/16 at 3:15 p.m., staff member B said, We didn't consider the incident on the bedpan as neglect, that's why we didn't report it. (Staff member B) said the incident had not been reported to the State. Review of the Abuse, Neglect and Exploitation Policy showed all allegations of neglect should be identified, investigated and reported, and that training should follow when warranted. The facility failed to perform all these for this particular event. The abuse policy also showed: - Section V, investigation of alleged abuse, neglect and exploitation showed that when the suspicion of abuse, neglect, exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. - Section VII, response and reporting of abuse, neglect and exploitation showed anyone with knowledge or concerns about the care of a resident in the facility can report suspected abuse to the abuse agency hotline or file a complaint with the State Survey agency. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: - respond to the needs of the resident and protect them from further incidents - notify the director of nursing and administrator - initiate an investigation immediately - notify the attending physician, resident's family/legal representative and medical director - obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately - Contact the State Agency and the local Ombudsman office to report the alleged abuse/neglect - Monitor and document the resident's condition, including the response to medical treatment or nursing interventions - Document actions taken in steps above in the medical record - Section IV, for the identification of abuse, neglect and exploitation the policy showed the facility would consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators (not all inclusive): - physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body - physical injury of a resident, of unknown source - psychological abuse of a resident observed - failure to provide care needs such as feeding, bathing, dressing, turning & positioning - notice of photographs, videos or other recordings of a resident posted on any social media network or forum