Every finding on record at Shady Lawn Health and Rehabilitation

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a Foley (indwelling catheter) securement device was in place to prevent tension and pulling on the catheter for one (1) of two (2) residents reviewed for bowel and bladder/catheters. (Resident #53). Findings include:A review of the facility's policy Incontinence Management, revised 01/2020, revealed, . Management of an Indwelling Catheter in the Long-Term Care Setting . Secure catheters to the upper thigh or lower abdomen to avoid bladder and urethral trauma .A record review of the admission Record revealed the facility admitted Resident #53 initially on 1/27/26 and readmitted on [DATE] with diagnoses including Bladder-Neck Obstruction.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/02/26 revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident's cognition was severely impaired. A review of Section H revealed the resident had an indwelling catheter.A record review of the Order Recap Report revealed Resident #53 had a Physician's Order, dated 3/17/26, for . Foley Cath 20 Fr (French) 10 cubic centimeter (cc) bulb DX (diagnosis): obstructive urinary retention . Foley Cath Care with soap and water every shift and as needed .On 3/24/26 at 4:34 PM, during an observation of catheter care completed by Certified Nurse Aide (CNA) #1 with assistance from CNA #2 for Resident #53, residue was observed on the resident's left inner thigh. CNA #1 reported the residue appeared to be from a catheter securement device that had come off. During the same interview, CNA #1 reported residents with catheters are to have a securement device in place to prevent pulling and stated she would notify the nurse to apply a new device.On 3/25/26 at 12:56 PM, during an interview with Registered Nurse (RN) #1, she reported residents with indwelling catheters are required to have a securement device in place at all times to prevent tension, pulling, and complications.On 3/25/26 at 1:34 PM, during an observation and interview with RN #2 for Resident #53, the resident was observed lying in bed with pants on, with catheter tubing extending through the right pant leg to a drainage bag, and no catheter securement device was in place. RN #2 reported residents with catheters are to have a securement device in place and confirmed the device is used to prevent pulling and complications. She stated CNAs are expected to notify the nurse if the device is not in place so a new device can be applied. RN #2 confirmed no staff had reported the absence of a securement device for Resident #53.On 3/25/26 at 1:45 PM, during an interview with CNA #3, she reported she provided care to Resident #53 on 3/24/25 and 3/25/26 and did not recall seeing a catheter securement device in place on either day. She confirmed she had not reported the absence of the device to the nurse and stated it is the CNA's responsibility to notify the nurse if the device is not in place.On 3/25/26 at 4:05 PM, during an interview with the Director of Nursing (DON), she reported all residents with indwelling catheters are required to have a securement device in place to prevent pulling and tension. She confirmed she expects CNAs to notify nursing staff immediately when a device is not in place so it can be reapplied, unless the resident refuses and the refusal is care planned.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure daily nurse staffing information was posted in a manner that was readily accessible and readable to residents, staff, and visitors for three (3) of four (4) survey days, with the potential to affect all eighty-three (83) residents in the facility. Findings include:A review of the facility's policy Facility Staff Posting Information, revised 09/2023 revealed, . It is the standard of this facility to have sufficient qualified staff available to provide nursing and related services.Standard Explanation and Compliance Guidelines . 4. The information posted will be clear, readable and in a readily accessible area to residents and visitors.On 3/23/26 at 12:00 PM, during an observation of Station 1 nurse's station, a document titled Daily Staffing Posting without Units and with Staffing Ratios was observed posted behind the nurse's station in a plastic cover. The document was displayed vertically while printed in landscape format, making the information difficult to read. The posting included the date, facility name, census, staffing by shift, staff categories, staff-to-resident ratios, hours, and number of staff scheduled. The print was small and not readable from outside the nurse's station and was not visible to individuals in a wheelchair.On 3/24/26 at 2:14 PM, during an observation of Station 1 nurse's station, the daily staffing posting remained in the same location and format and was not readable from outside the nurse's station.On 3/25/26 at 4:15 PM, during an observation and interview with the Director of Nursing (DON) at Station 1 nurse's station, she confirmed the daily staffing information is posted behind the nurse's station and the day shift charge nurse is responsible for posting it prior to the start of the shift. During the observation, the DON confirmed she could not read the staffing information from outside the nurse's station or from the entrance of the station. She reported only staff are permitted behind the nurse's station. She confirmed the document was displayed vertically despite being printed in landscape format and could only be read if removed from the plastic cover.On 3/25/26 at 4:59 PM, during an interview with the Administrator, he reported he was not aware the daily staffing posting was not readily accessible or readable to residents, staff, and visitors. He confirmed the current display method made the information difficult to read and stated he expects staffing information to be posted in accordance with regulations and readily accessible to all residents, staff, and visitors.

Based on observations, resident and staff interview, record review, and facility policy review the facility failed to develop a smoking care plan for Resident #36 and failed to develop a care plan for nail care for Resident #63 for two (2) of 19 care plans reviewed. Resident #36 and Resident #63. Findings include. A review of the facility policy with a revision date of 03/2019, titled Comprehensive Care Plan, revealed: Standard: It is the policy of this facility to develop and implement a comprehensive person - centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Resident #36 Record review of Resident #36's care plan with a date initiated:5/4/22 and a resolved date: 9/29/22 revealed Focus RESOLVED: The resident is at risk for injury r/t (related to) smoking Cigarettes and keeps a Cigar in his mouth . The desired outcome and all interventions were marked RESOLVED. Record review of Resident #36's .Smoking and Safety evaluation dated 3/20/24 revealed .2. Which of the following products does the Resident use? The response was checked 1. Tobacco An interview on 05/01/24 at 3:50 PM, with the Minimum Data Set (MDS) Nurse confirmed that Resident #36 does smoke tobacco occasionally and that he does not have a current care plan for smoking but that he should. The MDS nurse confirmed that the resident had a care plan for smoking that was resolved 9/29/22. The MDS nurse revealed that the purpose of having a care plan is to guide the residents care safely and that without a care plan a resident can receive care the wrong way. An observation and interview, on 05/01/24 at 4:00 PM with Licensed Practical Nurse (LPN) #1 confirmed Resident #36 does smoke tobacco occasionally, but not every day. LPN #1 stated We offer him to go for each smoke break, sometimes he does and sometimes he doesn't go. LPN #1 revealed that the resident has one full unopened pack of cigarettes and one pack of cigarettes that is open and has cigarettes missing from the pack. Both packs of cigarettes had the residents name written on them and they were located inside of the facility smoke box. An interview, on 05/01/24 at 4:05 PM with Resident #36 confirmed that he does smoke tobacco occasionally. An interview on 05/02/24 at 8:00 AM, with the Administrator confirmed that the purpose of the care plan is to guide the residents care safely and without the care plan the resident can receive the wrong care. Resident #63 Record review of the care plans revealed (Proper name of Resident #63) has an ADL (Activities of Daily Living) deficit .Desired Outcome .The resident will maintain or improve current ability in .Personal Hygiene . There were no interventions/task developed for nail care for Resident #63 included in the care plan. During an observation on 4/30/2024 at 2:42 PM, Resident #63 was sitting in a wheelchair in the activity room. Excessively long, thick, discolored fingernails observed on both hands measuring approximately one-half (1/2) inch in length. An observation and interview on 5/1/2024 at 10:35 AM, with Licensed Practical Nurse (LPN) #2, confirmed Resident #63 had long nails that needed to be cut. An interview with the Minimum Data Set Nurse (MDS) on 5/2/2024 at 10:01 AM, confirmed the resident did not have a care plan developed for nail care. She revealed they did not have the nail care task developed for Resident #63; therefore, a care plan had not been developed. She explained the purpose of the care plan was to guide the staff with the resident care to be given. 47874

Based on observation, resident and staff interviews, record review, and facility policy review the facility failed to transmit accurate assessments for two (2) of 2 residents reviewed for Minimum Data Set (MDS) assessments. Resident #5 and Resident #10. Findings include: Review of the facility policy titled, Medicare Management with a revision date of 10-2023 revealed, .b .Coding of Assessment: i. All disciplines shall follow the guidelines in Chapter 3 of the current Resident Assessment Instrument (RAI) Manual for coding each assessment. Review of the facility policy titled, Chapter 3: Overview to the item-by-item guide to the MDS 3.0 dated October 2023 revealed, This chapter provides item-by-item coding instructions for all required sections and items in the MDS Version 3.0 item sets. The goal of this chapter is to facilitate the accurate coding of the MDS resident assessment and to provide assessors with the rationale and resources to optimize resident care and outcomes . Resident #5 A record review of Admission 5-day MDS with an Assessment Reference Date (ARD) of 4/3/2024 revealed, Section H-Bladder and Bowel that Resident #5 was coded under Urinary and Bowel Continence as always incontinent. A record review of the Documentation Survey Report dated March 2024 and April 2024 for the seven (7)-day look back period of March 27-April 2 for Resident #5 revealed the resident had 13 bladder incontinent episodes, nine (9) continent bladder episodes and had 10 bowel incontinent episodes and eight (8) continent bowel episodes. During an interview on 5/01/24 at 11:40 AM, Resident #5 revealed I usually use my bedside commode or ask for a bedpan. Still, I occasionally have an accident which is why I wear briefs. During an interview and record review on 5/01/24 at 2:40 PM, the MDS Nurse confirmed during the seven-day look-back period documentation from March 27 through April 2, Resident #5 was continent of the bladder 9 times and incontinent 13 times. She confirmed the resident was incontinent of bowel 10 times and had 8 continent bowel episodes. She confirmed Resident #5 should have been coded as frequently incontinent of bowel and bladder instead of coded as always incontinent. An interview on 5/01/24 at 3:05 PM, the Director of Nurses (DON) confirmed Resident #5's Bowel and Bladder (Section H) MDS assessment was coded inaccurately and failed to represent an accurate assessment of the resident. A record review of Resident #5's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Fracture of the right Patella, End Stage Renal Disease, and Diastolic (Congestive) Heart Failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/3/24 revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident is cognitively intact. Resident #10 Record review of the Order Summary Report with active orders as of 4/17/24 for Resident #10 revealed orders dated 11/21/2023, Wanderguard: Check placement and function every shift and Wanderguard: Monitor residents whereabouts q (every) 2 (two) hrs (hours). An observation on 4/30/2024 at 10:40 AM, revealed Resident #10 sitting in a chair in the activity room. A wander alert bracelet was observed on his right arm. Record review of Resident #10's Quarterly MDS with an ARD of 4/17/2024 revealed under section P, wander/elopement alarm was indicated not used during the assessment look back period. An interview with the MDS Nurse on 5/1/2024 at 12:00 PM, confirmed an error was made on Resident #10's Quarterly MDS. She revealed that the wanderguard should have been marked as used daily. She revealed the purpose of the MDS was to paint a complete picture of the resident. An interview with the Director of Nursing (DON) on 5/1/2024 at 3:12 PM, confirmed an error was made on Resident #10's MDS and the wanderguard was not captured. She revealed the MDS did not represent an accurate assessment of the resident. Record review of the Admission Record revealed the facility admitted Resident #10 on 8/21/2023 with medical diagnoses that included Schizophrenia and Mild intellectual disabilities. 47874

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide the necessary nail care for a resident as evidenced by long, thick fingernails for one (1) of 17 sampled residents. Resident #63 Findings Include: Review of the facility policy titled Resident Hygiene with a revision date of 06/2022 revealed Purpose: The purpose of this procedure is to clean the nail bed to keep nails trimmed and to prevent infections. Nail care includes cleaning and trimming as needed. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin . An observation on 4/30/2024 at 2:42 PM, revealed Resident #63 sitting in a wheelchair in the activity room. He had excessively long, thick, discolored fingernails observed on both hands measuring approximately one-half (1/2) inch in length. During an observation and interview with Licensed Practical Nurse (LPN) #2 on 5/1/2024, at 10:35 AM, confirmed Resident #62 had long nails that needed to be cut. She revealed that the nails could cause skin injury. She explained that the resident was a diabetic and a Registered Nurse (RN) must cut his nails. An interview with the Director of Nursing (DON) on 5/1/2024 at 10:51 AM, revealed the Wound Care Nurse was responsible for cutting the diabetic nails and confirmed the facility did not have a nail care task implemented for Resident #63. She revealed that long nails could cause skin injuries. Record review of the Admission Record the facility admitted Resident #63 on 3/25/2023 with medical diagnoses that included Type 2 diabetes mellitus.

Based on record review, staff interview and facility policy review, the facility failed to accurately complete the Minimum Data Set (MDS) for the correct discharge, and the administration of antipsychotic medications for two (2) of 21 resident Minimum Data Sets reviewed, Residents #79 and #49. Findings include: Review of the facility's policy revealed that the facility follows the Centers for Medicare Services Resident Assessment Instrument (RAI) Version 3.0 Manual, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. Resident #79 Record review of a physician's orders [REDACTED].#79 was discharged home with (Name of Home Health) on 08/09/19. Record review of the Social Worker Discharge to Home-Durable Medical Equipment (DME)-Follow up Appointment Instructions, dated 08/09/19, revealed Resident #28 was discharged home with home health. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/19, revealed the Discharge Status in Section A, Item A2100, was coded as discharged to an acute hospital. Record review of the Discharge Summary, dated 08/12/19, revealed the resident was discharged , on 08/09/19, home with family. The reason for discharge was Condition Improved. On 09/11/19, at 2:32 PM, an interview with the Assistant Director of Nursing (ADON), revealed the MDS was coded wrong, that Resident #79 went home. On 09/11/19 2:35 PM, an interview with MDS Coordinator, revealed the Discharge MDS, with an ARD of 08/09/19, was coded wrong. She stated she checked the wrong box and it should have been coded discharge to home. The MDS Coordinator stated, We are supposed to check to be sure of the accuracy before we close it and that the facility follows the Resident Assessment Instrument (RAI) manual policy. She stated she would do a correction for that assessment. Review of the Face Sheet for Resident #79 revealed the resident was admitted by the facility, on 5/29/19, with a primary [DIAGNOSES REDACTED]. Resident #49 Review of the Quarterly MDS, with an ARD of 8/9/2019, revealed the MDS was coded that the resident received seven (7) days of an antipsychotic medication during the seven day look back period. Review of the Medication Administration Record [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Care Plan revealed no antipsychotic medications were identified as a concern/problem/need. An interview with Registered Nurse (RN) #1, on 09/11/2019 at 4:30 PM, revealed the information for how many days a resident receives a medication is taken from the Medication Administration Record [REDACTED]. RN #1 stated that it was an error in coding. RN #1 stated, it's very important that they are coded correctly, due to that drives the Care Area Assessments (CAAs), care plans, and how we take care of the residents.

Based on observation, staff interview and facility policy review, the facility failed to store perishable foods in a manner to prevent possible foodborne illness for two (2) of two (2) kitchen tours; the facility failed to maintain the ice maker in a clean and sanitary manner for one (1) of two (2) kitchen tours; the facility failed to ensure the refrigerator was in proper working order for one (1) of two (2) kitchen tours; and the facility failed to store the flour and cornmeal scoops in a sanitary manner for one (1) of two (2) kitchen tours. Findings include: Review of the facility's policy, Policy: Storage and Using Leftover Meats and Vegetables (undated), revealed: 1. Leftovers must be dated, labeled, cooled and stored (within 1/2 hour) not at room temperature. 2. If not used within 48 hours, item must be disposed of. During the initial tour of the kitchen with the Dietary Manager (DM), on 08/06/18 at 10:45 AM, an observation of the refrigerator labeled C3, revealed a gallon size zip top bag of approximately five (5) slices of deli type meat. The bag was not labeled with a date. Also observed, was one (1) white plastic nine (9) by 13 by four (4) inch pan of sliced tomatoes, covered with clear plastic wrap, dated 07/25/18. The DM confirmed these observations. An observation of the refrigerator labeled C3, with the DM on 08/07/18 at 3:45 PM, revealed, three (3) individual 4 ounce bowls of green lettuce with shredded carrots, covered with clear plastic wrap, in the refrigerator. The bowls were not labeled or dated. The DM confirmed the bowls were unlabeled. In an interview, with the DM on 08/08/18 at 02:46 PM, regarding the purpose of labeling and dating perishable foods, she stated, To prevent contamination from spreading. Once you store something and use it, you have to go on and get rid of it due to contamination. It's important when you have foods like that, you want to make sure you have a time frame to limit contamination of the product and infection control. Review of the facility's policy, Cleaning and Sanitizing Equipment (undated), revealed, Standard: All equipment is kept clean and food contact surfaces are cleaned and sanitized. Review of the facility's policy, Cleaning Schedule (undated), revealed Standard: The Dietary Manager shall establish a cleaning schedule for the dining service department to ensure that food is stored and prepared under sanitary conditions. Procedure: 1. All equipment and work areas are cleaned after each use, or, on a routine basis. 2. Equipment and work areas are sanitized with a sanitizing solution after cleaning. During the inital tour of the kitchen, with the DM on 08/06/18 at 10:45 AM, an observation of the ice maker in the kitchen revealed a pink substance on the white, plastic guard that ran across the inside of the ice maker. The DM confirmed there was pink substance on the inside of the ice maker. In an interview with the DM, on 08/06/18 at 10:50 AM, regarding the kitchen's ice maker, the DM stated, I believe that is a form of algae. You want to keep that clean and sanitized. We empty the whole ice maker every six (6) months and we clean it daily around the lids and sides. A review of the Sample Monthly Cleaning Schedule Form, for the month of July, revealed that the ice machine was not listed as one of the dietary equipment cleaned. Review of the New Cleaning Schedule, for the week of 07/02/18 and 07/09/18, revealed the ice machine was not listed as one of the dietary equipment cleaned. During the initial tour with the DM on 08/06/18 at 10:45 AM, six (6) gallon size zip top bags filled with sliced deli meat, shredded cheese, sliced jalapenos, sliced white onions, white whipped topping, and vanilla pie filling, were observed on the second shelf from the top of refrigerator C3 in a large tray filled with water. Water was observed dripping from a metal tube in the top of the refrigerator into this tray. The DM confirmed this observation. In an interview with the DM on 08/08/18 at 2:46 PM, regarding the water leak inside the refrigerator labeled C3, she stated, You could have caused wide spread contamination if that water would have got in there and got on some of the products. It could have caused serious harm. In an interview on 08/08/18 at 8:57 AM, the Administrator confirmed the water leak in the drain pipe in the top of the C3 refrigerator. The Administrator revealed he had no knowledge of this prior to this time. Review of the facility's policy, Storage of Canned and Dry Food (undated), revealed, Standard: The facility ensures the quality and safety of canned and dry food through accepted storage practices. Procedure: 10. Scoops are stored in covered containers and not in the storage bin. During the initial tour on 08/06/18, at 10:45 AM, with the DM, an observation of white, plastic bins labeled Flour and Corn Meal revealed a scoop inside the flour and corn meal bins, with only the handles visible. The DM confirmed this observation. In an interview with the DM on 08/06/18 at 10:50 AM, regarding the scoops inside the bins, the DM stated, Infection control is the reason for scoops not being in the product, contamination and infection.

Based on observation, staff interview, provider pharmacist interview, record review and facility policy review, the facility failed to ensure the label on a medication card was accurate for one (1) of five (5) residents observed during medication pass; Resident #72. Findings Include: A review of the facility's policy, Medication Labels, undated, revealed: medications are labeled in accordance with facility requirements and state and federal laws. Improper or inaccurately labeled medications are rejected and returned to the dispensing pharmacy. A review of the facility's policy, Medication Administration-General Guidelines, undated, revealed: medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Observation on 08/07/18 at 9:30 AM, revealed Licensed Practical Nurse (LPN) #1 performed a medication administration pass on Resident #72, who had a Percutaneous Endoscopic Gastrostomy (PEG) tube. An observation of Resident #72's medication label for Potassium Chloride Extended Release revealed, give one (1) tablet by mouth one time a day and label for [MEDICATION NAME] HCL Tablet 25 milligrams (mg) revealed to give one (1) tablet by mouth three (3) times a day. A review of the Medication Administration Record [REDACTED]. On 08/08/18 at 03:21 PM, an interview with the Assistant Director of Nurses (ADON) revealed, the inaccurate medication label would pose a problem, because all patients here that are PEG tube feedings have orders that are nothing by mouth and that would put them at risk for aspiration. On 08/08/18 at 3:25 PM, an interview with Registered Nurse (RN) #1, revealed, the medication label should have been labeled to give per peg tube, because it violates the five (5) rights. RN #1 stated the medication may have accidentally be given by mouth and the resident could choke. On 08/08/18 at 3:38 PM, an interview with RN #2, revealed, Resident #72's medication order did not match the route. RN #2 stated, the staff needed to get an order clarification, because if someone gave the medication by mouth, it could cause injury to the resident such as aspiration or choking. On 08/08/18 at 3:55 PM, an interview with the Consultant Pharmacist, revealed, the pharmacy doesn't always control the label that is put on the medication card. The Consultant Pharmacist revealed, he always tell the nurses to follow the MAR. The Consultant Pharmacist stated, We want to try to get the label to match what the order says. The Consultant Pharmacist revealed, if you get a nurse that is not paying attention to what the MAR indicated [REDACTED]. On 08/08/18 at 9:18 AM, an interview with Licensed Practical Nurse (LPN) #1, revealed, the medication card for Potassium Chloride and [MEDICATION NAME] Acid (HCL) should have been labeled per PEG tube instead of by mouth because absorption could be a problem and with the resident being NPO (nothing by mouth), he could choke. A review of the facility's Face Sheet revealed, the facility admitted Resident #72 on 12/06/17, with [DIAGNOSES REDACTED].

Based on observations, staff interview, record review, and the facility policy review, the facility failed to clean shelves and repair cracked, chipped floor paint in the food storage area for three (3) of three (3) kitchen observations. Findings include: Review of the facility's Sanitation and Infection Control Cleaning Schedule policy, not dated, revealed the dietary manage shall establish a cleaning schedule for the dining service department to ensure that food was stored and prepared under sanitary conditions. All equipment and work areas are to be cleaned after each use or on a routine basis. The facility letterhead statement revealed a work schedule for Dietary was originated from staff through the computerized system and all work orders were put in from staff to include the dietary aides. Observation on 4/13/2017 at 4:35 PM in the dry storage area, revealed wooden shelves which contained large aluminum pots approximately 20 quart size that were turned upside down on the bottom shelf. Dirt, dust, and black oily type residue was on the shelves. The floors were concrete type material and painted industrial gray. The floor paint was chipped and allowed the concrete to show through. There was also a sticky residue on the floor. In an interview on 4/13/2017 at 4:35 PM, the Dietary Manager (DM) stated the shelves needed cleaning and she would get it done today. She further stated she had been short of help. Observation, on 4/14/2017 at 8:00 AM, in the dry storage area revealed the dust, dirt, and black substance remained on the shelves. There was lemonade and cooking oil in gallon jugs on the bottom of another shelf. The aluminum pots and the gallon jugs of oil and lemonade were stored on the bottom shelf approximately four (4) inches from the floor. Interview on 4/14/2017 at 10:50 AM with the facility Administrator revealed that he was not aware of the condition of the floors in the dry storage area. Record review of the weekly cleaning schedule revealed the storeroom was to be cleaned on Wednesdays by the morning aide. An in-service that was given on 2/20/2017 included a handout on dry storage was to be at least six (6) inches off the floor.

Based on observation, staff interview, and record review, the facility failed to ensure resident care plans were implemented related to catheter care for two (2) of three (3) care plans reviewed for Resident #9 related to catheter care and for Resident #4 related to personal hygiene and grooming. Findings include: Resident #9 A review of Resident #9's Comprehensive Care Plan, dated 4/5/2017, revealed a care plan that read Resident #9 was at risk for Urinary Infection because of the indwelling catheter. During incontinent care, on 4/12/2017 at 2:45 PM, observation revealed when Certified Nursing Assistant (CNA) #1 pulled back the comforter on Resident #9's bed, the resident's catheter bag was lying in the bed beside her instead of hanging below the level of the bladder. After providing incontinent care, CNA #2 hung the catheter bag on the top of the left bedrail above the level of the bladder and left the room. During an interview, on 4/12/2017 at 3:45 PM, Registered Nurse (RN) #2 stated the policy of the facility was to hang the catheter below the bladder at all times. RN #2 said the CNA's should have hung the bag in the catheter cover on the bed frame below the level of the bladder. During an interview on 4/13/2017 at 5:15 PM, RN #1 confirmed the facility failed to follow the care plan by placing the catheter bag in the resident's bed and by hanging it on the top of the bedrail instead of the bed frame below the bladder. Review of the Face Sheet revealed the facility admitted Resident #9 on 08/31/2010, with [DIAGNOSES REDACTED]. A review of the current quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/08/2017 revealed Resident #9 scored eight (8) on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. Resident #4 Review of Resident #4's Comprehensive Care Plan revealed interventions to provide adequate lighting, will encourage resident to wear glasses when needed, assist to dining for meals, involve in daily activities to help with excess energy, provide resident with watching TV/movies, assist with dressing and grooming. On 4/11/14 at 3:30 PM, observation revealed Resident #4 lying supine in bed with eyes closed with no glasses. The resident's room had no lights on and the window blinds were closed. There was no staff present. The resident's television was off. Resident #4 was not dressed and facial hair was present on the resident's chin. On 4/11/17 at 4:50 PM, observation revealed Certified Nurse Assistant (CNA) #5 seated at the resident's bedside feeding Resident #4. The window blinds were closed and the lights were off. Resident #4 was not wearing her glasses and continued to have long facial hair on chin. On 4/12/17 at 3:50 PM, observation revealed Resident #4 wearing a hospital gown lying supine in bed in her room with blinds closed and no room lights or television on. No staff member was present in the resident's room. Resident #4 was not wearing her glasses. Observation revealed, on 4/12/17 at 5:15 PM, Resident #4 seated in a wheelchair in dining room with no glasses, smiling, and responding with long hairs on chin. On 4/12/17 at 6:30 PM observation revealed Resident #4 without glasses and facial hairs on chin seated in wheelchair in dayroom/atrium area. On 4/13/17 at 11:37 AM, observation revealed Resident #4 lying in bed with no lights and blinds closed. There was no television playing. The resident was wearing a hospital gown and had yellowish secretions in eyes and long hairs on chin. Interview on 4/13/17 at 11:40 AM with CNA #4 revealed facility staff have not been getting Resident #4 out of bed because she is weak. CNA #4 stated that Resident #4 used to get up but because she leans forward in a wheelchair, staff does not get her up. Review of the activity log revealed for the month of April 2017, the facility provided Resident #4 activities four (4) times from 4/1/17 through 4/13/17 (13 days). Review revealed for March 2017, the facility provided Resident #4 activities for 15 of the 30 days, and for the month of February 2017, the facility provided Resident #4 with activities for 12 of the 28 days. The Activities Director confirmed the accuracy of the log. Interview and observation on 4/13/17 at 12:08 PM revealed CNA #3 was feeding Resident #4 in her room with the lights off and the blinds closed. Resident #4 was not wearing her glasses. CNA #3 confirmed Resident #4 had clothes and glasses, but stated she only puts the clothes and glasses on the resident if she gets the resident out of bed. CNA #3 stated Resident #4 is not able to get out of bed because she cannot sit in a wheelchair. Interview with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) on 4/13/17 at 12:20 PM revealed the ADON confirmed the resident was able to sit up the previous evening for the meal, but Resident #4 was not wearing her glasses while in the dayroom. The DON stated she was unable to explain why the resident was still in her gown at noon and without her glasses. The DON confirmed the resident's care plan was not followed. Review of the Face Sheet revealed the facility admitted Resident #4 on 11/02/15, with [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/6/17 revealed a Brief Interview for Mental Status (BIMS) score of three (3) indicating severe cognitive impairment with extensive assistance with transfers, eating, hygiene, and did not ambulate.

Based on observation, staff interview, family interview, record review, and facility policy review, the facility failed to ensure residents with dementia received individualized person centered care and services to ensure psychosocial needs were met for two (2) of nine (9) residents reviewed with dementia diagnoses, Residents #4 and #16. Findings include: Review of the facility's Dementia Management in Long Term Care policy, not dated, revealed the facility Standard read, to provide a systematic approach to recognition, assessment, treatment and monitoring of residents with dementia, including impaired cognition and problematic behavior. The policy read that expected outcome from the standard was to respond appropriately to changing needs of a resident with dementia. Resident #4 Observation on 4/11/17 at 11:20 AM revealed Resident #4 lying supine in bed with her daughter at bedside. Record review revealed according to the Significant Change Minimum Data Set (MDS), dated [DATE], the resident had a Brief Interview for Mental Status (BIMS) score of three (3) indicating the resident had severe cognitive impairment and required extensive two person physical assistance with transfers, hygiene, eating, and did not ambulate. Interview on 4/11/17 at 11:20 AM with Resident #4's daughter revealed the resident has been declining over the past few months. She stated the resident had a fall in January which caused her to not get out of bed much since the fall. On 4/11/14 at 3:30 PM, observation revealed Resident #4 lying supine in bed with eyes closed without her glasses. The resident had long facial hairs on her chin and yellow secretions in her eyes. The resident's room had no lights on and the window blinds were closed. There was no staff or family present. The resident's television was off. Observation on 4/11/17 at 4:50 PM revealed Certified Nurse Assistant (CNA) #5 seated at the resident's bedside feeding Resident #4. The window blinds were closed and the lights were off. Resident #4 was not wearing her glasses. On 4/12/17 at 3:50 PM, observation revealed Resident #4 wearing a hospital gown in bed in her room with blinds closed and no room lights or television on. The facility had the resident's privacy curtain pulled and resident positioned facing the curtain. There was no staff member present in the resident's room. The resident continued to have long facial hairs on her chin. Observation revealed, on 4/12/17 at 5:15 PM, Resident #4 seated in a wheelchair in dining room not wearing her glasses, smiling, responding to the surveyor appropriately. Resident #4 was sitting upright in the wheelchair with an ischial drop down positioning cushion without leaning and with no restraint. On 4/12/17 at 6:30 PM, observation revealed Resident #4 without her glasses seated in wheelchair with an ischial drop down positioning cushion in dayroom/atrium area without leaning or restraint. On 4/13/17 at 11:37 AM, observation revealed Resident #4 lying in bed with no lights and blinds closed. There was no television playing. The resident was wearing a hospital gown and had yellowish secretions in eyes. Interview on 4/13/17 at 11:40 AM with CNA #4 revealed facility staff have not been getting Resident #4 out of bed because she is weak. CNA #4 stated that Resident #4 used to get up but because she leans forward in a wheelchair, staff does not get her up. When asked about activities or social interaction, CNA #4 stated the Activities Director goes in the resident's room sometimes. When told the resident was up in the dining room the previous evening, the CNA stated, oh. Interview on 4/13/17 at 11:52 AM with the Activities Director (AD) revealed she provides in room activities for Resident #4 because she has not been coming out of her room lately. The AD stated all activities are documented on the activity log and she does not write a report in the residents' records. Review of the activity log revealed for the month of April 2017, the facility provided Resident #4 activities four (4) times from 4/1/17 through 4/13/17 (13 days). Review revealed for March 2017, the facility provided Resident #4 activities for 15 of the 30 days, and for the month of February 2017, the facility provided Resident #4 with activities for 12 of the 28 days. Interview and observation on 4/13/17 at 12:08 PM revealed CNA #3 was feeding Resident #4 in her room with the lights off and the blinds closed. Resident #4 was not wearing her glasses. Interview with CNA #3 revealed she felt like the resident did not like the blinds open. After stating this, she turned on the over bed light. CNA #3 confirmed Resident #4 had clothes and glasses, but stated she only puts the clothes and glasses on the resident if she gets the resident out of bed. CNA #3 stated Resident #4 is not able to get out of bed because she cannot sit in a wheelchair. When informed that Resident #4 was out of bed in a wheelchair the previous evening, CNA #3 did not respond. Interview with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) on 4/13/17 at 12:20 PM revealed Resident #4's family expressed concern with getting her up out of bed for long periods of time and only wanted their mother up for short periods. The ADON acknowledged that the resident was able to sit up the previous evening for the meal. The ADON also acknowledged that Resident #4 was not wearing her glasses while seated in the dayroom. The ADON stated she felt like staff members were cradling the resident because of her recent decline and believed the staff needed training on stimulating the resident's emotional and social needs, not just physical needs. The ADON stated staff feel like they are protecting her by not getting her up in a chair. The DON stated the facility has one or two Geri-chairs but thought they were a restraint and therefore, were not using them. The DON stated she was unable to explain why the resident was still in her gown at noon and without her glasses. Interview by phone with Resident #4's son on 4/13/17 at 4:50 PM revealed his mother enjoyed watching television throughout her life. And was ambulatory until the end of last year when she began to decline. Resident #4's son confirmed after coming to the facility and discovering his mother had been seated in a wheelchair slumped over in the activity room for hours, he asked that the staff not keep her sitting in the wheelchair for extended amounts of time. Resident #4's son stated that since his mother's fall, he feels like the facility has not been meeting her needs as well. Observation on 4/13/17 at 5:30 PM revealed the DON feeding Resident #4 with the window blinds open and sun shining in the room. Resident is wearing her glasses, is more alert than previous observations, and is eating well. Long hairs remain on resident's chin. Review of the resident's comprehensive care plan revealed the care plan had not been updated or individualized for the recent decline related to dementia or her assessed preferences. Review of the Face Sheet revealed the facility admitted Resident #4 on 11/02/15 with [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/18/16 revealed a Brief Interview of Mental Status (BIMS) Score of 12 and that Resident #4 was independent with transfers, ambulation, limited assistance with dressing, eating, and hygiene. Comparison to Resident #4's Significant Change MDS with an ARD of 12/30/17 revealed a BIMS score of three (3) and revealed the resident required extensive two person physical assistance with transfers, hygiene, eating, and did not ambulate. Review of the MDS dated [DATE] also revealed a BIMS score of 3 (severely impaired cognition) with extensive assistance with transfers, eating, hygiene, and did not ambulate. Resident #16 Observation revealed Resident #16 wandering into other resident's rooms on 04/12/2017 at 10:48 AM. Observation on 04/13/2017 at 5:30 PM revealed Resident #16 in his room after the meal fidgeting and cleaning his empty food tray items and moving tray table around. There was no television, activity items, or other individualized personal interest items in Resident's room. Review of the face sheet revealed the facility admitted Resident #16 eight (8) months ago, and the facility identified Resident #16 had a history of [REDACTED]. During an interview on 04/14/2017 at 9:10 AM with Certified Nursing Assistant (CNA) #7, she stated she assists Resident #16 with setting up meal trays, bathing, and getting to the dining room. CNA #7 stated that Resident #16 likes to takes apart his bed linens and give to the CNA staff. She revealed Resident #16 does not like to attend structured activities in the Activities Room and usually wanders back to his room. An interview on 04/14/2017 at 11:47 AM with the Social Worker (SW) revealed that Resident #16 does not interact much, and she was not sure about his previous history and life experience. The SW stated she tried to get the resident's family to bring more items for this room and she should encourage them to bring items from home for him interact with while in his room. During an interview on 04/14/2017 at 11:56 AM with the Activities Director (AD), the AD revealed she had gotten a tool set for the residents and Resident #16 liked it but it did not keep his interest long. The AD stated he will not stay in the Activities Room where the tool kit is kept. The AD stated Resident #16 looks for keys and often goes into other residents' rooms in search of keys. The AD stated staff call her to assist him to the Activities Room, but Resident #16 does not stay in structured activities. AD confirmed the facility had not provided him activities to do in his room and had not considered providing anything for him to do in his room. AD stated she was not exactly sure of his previous history and life experience but stated she thought he liked cars. A review of the Face Sheet revealed that the facility admitted Resident #16 on 08/24/2016 with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/14/2017 revealed that the Resident's Brief Interview for Mental Status (BIMS) score was a three (3), indicating severe cognitive impairment.

Based on observation, staff interview, family interview, record review, and facility policy review, the facility failed to revise the comprehensive care plan for a resident with a significant decline in physical and mental status for one (1) of nine (9) residents reviewed with Dementia, Resident #4. Findings include: Review of the facility's RAI/Care Planning Management policy, revised August 2015, revealed under Process for Completing the MDS, CAAs and Care Plan objective, was 3. To assure that all residents are reviewed and reassessed based on their individual needs and OBRA guidelines. and, If modifications, deletions, additions are necessary, changes should be made at the time of occurrence. Review of Resident #4's Comprehensive Care Plan revealed under the falls care plan, the intervention listed keep walker in reach and ensure resident has on nonskid shoes/socks. Review of the activities care plan revealed offer resident materials/supplies for independent use. Review of Resident #4's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/6/17, revealed a Brief Interview of Mental Status (BIMS) score of three (3), indicating severe cognitive impairment and extensive assistance with transfers, eating, hygiene, and did not ambulate. Review of Resident #4's Significant Change MDS with an ARD of 12/30/17 revealed a BIMS score of three (3) and revealed the resident required extensive two person physical assistance with transfers, hygiene, eating, and did not ambulate. Review of the resident's MDS ARD of 7/18/16 revealed a (BIMS) Score of 12 and that Resident #4 was independent with transfers, ambulation, and limited assistance with dressing, eating, and hygiene. On 4/13/17 at 11:40 AM, an interview with Certified Nurse Assistant (CNA) #4 revealed the facility staff did not get Resident #4 out of bed because of weakness. CNA #4 stated that staff used to get Resident #4 up but because she leans forward in a wheelchair, staff does not get her up any longer. CNA #4 stated the Activities Director goes in the resident's room sometimes for activities or social interaction. Interview and observation on 4/13/17 at 12:08 PM revealed CNA #3 stated Resident #4 is not able to get out of bed because she cannot sit in a wheelchair. Interview on 4/13/17 at 6:05 PM with the Minimum Data Set (MDS) Nurse revealed care plans are updated by her after CNAs report changes in a resident's status. She reported the CNAs should have reported the changes in Resident #4 but did not tell her the resident was not able to walk on the walker at all anymore. She also stated at staff nurses could update the care plan if needed. Review of the Face Sheet revealed the facility admitted Resident #4 on 11/02/15 with [DIAGNOSES REDACTED].

Based on observation, record review, facility policy review, and staff interview, the facility failed to develop an individualized care plan for activities based on previous history and life experience for a resident with Dementia for one (1) out of nine (9) residents reviewed (Resident #16). Findings include: Review of the facility's RAI/Care Planning Management policy, revised August 2015, revealed on page three (3) of eight (8) under Process for Completing the MDS, CAAs and Care Plan, revealed the care plan objective was 2. To assure that an interdisciplinary team assesses the emotional, psychosocial, mental, and physical needs of each resident. 3. To assure that all residents are reviewed and reassessed based on their individual needs and OBRA guidelines. A review of the facility's Plan of Care, dated 11/23/2016, revealed the facility failed to develop an individualized care plan related to Resident #16's past life experiences and attention span. The facility developed a generic care plan related to attending activities. Observation on 04/12/2017 at 10:48 AM revealed Resident #16 roaming into other residents' rooms. An observation on 04/13/2017 at 5:30 PM revealed Resident #16 fidgeting and cleaning empty food tray items and moving tray table around. During the observation, there was no activity board or other individualized items present in the resident's room. On 4/13/17 and 4/14/17, the surveyor requested a copy of Resident #16's Activity Logs. The facility failed to provide these for Resident #16. During an interview on 04/14/2017 at 9:10 AM, Certified Nursing Assistant (CNA) #7 revealed that Resident #16 does not like to stay in the Activities Room and walks back to his room. She stated she only assists Resident #16 with setting up meal trays, bathing and getting to the dining room. CNA #7 also stated that Resident #16 takes apart his bed linens and gives to the CNA staff. During an interview on 04/14/2017 at 11:31 AM, Registered Nurse (RN) #1 stated development of person-centered activities on the care plan was the responsibility of Social Services. RN #1 stated that she only does the nursing part of the care plans. In an interview on 04/14/2017 at 11:47 AM with Social Worker (SW), the SW confirmed that it was a shared duty for Social Services and Activities to create and implement person-centered individualized care plans for each Resident. The SW stated that Resident #16 does not interact much and was not sure about his previous history and life experience. The SW stated she tried to get family to bring more items for this room and she should encourage them to bring items from home for him to fidget with in his room. During an interview on 04/14/2017 at 11:56 AM with Activities Director (AD), the Activities Director confirmed that there was not an individualized care plan for Resident #16. The Activities Director stated she documents but is not sure why the care plan does not appear individualized. The Activities Director stated she had gotten a tool set for the residents to use in the Activity Room, and Resident #16 liked it but it did not keep his interest long. The Activities Director stated he will not stay in the Activities Room where the tool kit is kept. The Activities Director stated Resident #16 looks for keys and often goes into other residents' rooms and staff calls her to assist him to the Activities Room, but Resident #16 does not stay. The Activities Director stated there is nothing provided for him activity related to do in his room and had not considered providing anything for his room. The Activities Director was not exactly sure of his previous history and life experience but stated she thought he liked cars. A review of the Face Sheet revealed that the facility admitted Resident #16 on 08/24/2016 with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/14/2017 revealed that the Resident's Brief Interview for Mental Status (BIMS) score is a three (3), indicating severe cognitive impairment.

Based on observation, record review, and staff interview, the facility failed to provide activities of interest related to a resident with Dementia's past history for one (1) of 13 sampled residents (Resident #16). Findings include: Observation on 04/12/2017 at 10:48 AM revealed Resident #16 wandering into other resident's rooms. Observation on 04/13/2017 at 5:30 PM revealed Resident #16 in his room after the meal fidgeting and cleaning his empty food tray items and moving tray table around. There was no television, activity items, or other individualized personal interest items in Resident's room. Review of the face sheet revealed the facility admitted Resident #16 eight (8) months ago. During an interview on 04/14/2017 at 9:10 AM with Certified Nursing Assistant (CNA) #7, she stated she assists Resident #16 with setting up meal trays, bathing, and getting to the dining room. CNA #7 stated that Resident #16 likes to takes apart his bed linens and give to the CNA staff. She revealed Resident #16 does not like to attend structured activities in the Activities Room and usually wanders back to his room. Review of the facility's Face Sheet revealed the facility identified Resident #16 was employed as a station attendant for an oil company before admission to the facility. An interview on 04/14/2017 at 11:47 AM with the Social Worker (SW) revealed that Resident #16 does not interact much, and she was not sure about his previous history and life experience. The SW stated she tried to get the resident's family to bring more items for this room and she should encourage them to bring items from home for him interact with while in his room. During an interview on 04/14/2017 at 11:56 AM, the Activities Director revealed she had gotten a tool set for the residents and Resident #16 liked it but it did not keep his interest long. The Activities Director stated he will not stay in the Activities Room where the tool kit is kept. The Activities Director stated Resident #16 looks for keys and often goes into other residents' rooms in search of keys. The Activities Director stated staff call her to assist him to the Activities Room, but Resident #16 does not stay in structured activities. The Activities Director confirmed the facility had not provided him activities to do in his room and had not considered providing anything for him to do in his room. The Activities Director stated she was not exactly sure of his previous history and life experience but stated she thought he liked cars. A review of the Face Sheet also revealed the facility admitted Resident #16 on 08/24/2016 with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/14/2017 revealed that the Resident's Brief Interview for Mental Status (BIMS) score was a three (3), indicating severe cognitive impairment.

Based on observation, staff interview, family interview, and facility policy review, the facility failed to ensure a resident was groomed according to the care plan and resident preference for one (1) of 13 residents reviewed for grooming, Resident #4. Findings include: Review of the facility's Resident Hygiene policy, revised November 2014, revealed bath and shower standard to Bathe each resident daily, to include a sponge and/or bed bath five times weekly(or more often, if needed) including a tub bath, whirlpool bath or shower at least thrice weekly. The policy read that bathing includes shaving facial hair. Under oral care, the policy read the standard of the facility was that every resident will receive oral care at least twice daily, and as needed. On 4/11/14 at 3:30 PM, observation revealed Resident #4 lying supine in bed with long facial hairs on her chin and the resident's mouth had a thick film on teeth and lips. On 4/12/17 at 3:50 PM, observation revealed Resident #4 wearing a hospital gown lying supine in bed in her room with long facial hairs on her chin and mouth dry with thick film covering teeth. No staff member was present in the resident's room. On 4/13/17 at 11:37 AM, observation revealed Resident #4 lying in bed wearing a hospital gown and had yellowish secretions in eyes. Interview on 4/13/17 at 4:50 PM by phone with Resident #4's son revealed that since his mother has declined in her health it seems as though the facility has not been caring for her as well. He stated he had noticed that his mother's teeth were not being brushed. Interview and observation on 4/13/17 at 12:08 PM revealed Resident #4 was not wearing her glasses and had on a hospital gown. Interview with CNA #3 confirmed Resident #4 had clothes and glasses, but stated she only puts the clothes and glasses on the resident if she gets the resident out of bed. Interview with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) on 4/13/17 at 12:20 PM revealed the ADON stated she felt like staff were cradling or protecting the resident because of her recent decline. The DON stated she was unable to explain why the resident was still in her gown at noon and without her glasses. Observation on 4/13/17 at 5:30 PM revealed long hairs remain on Resident #4's chin. Review of the Face Sheet revealed the facility admitted Resident #4 on 11/02/15 with [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/6/17 revealed a Brief Interview for Mental Status (BIMS) score of three (3) indicating severe cognitive impairment with extensive assistance with transfers, eating, hygiene, and did not ambulate.

Based on observation, staff interview, record review, facility in-service review, the facility failed to ensure the indwelling Foley catheter bag was kept below the bladder to decrease the potential of Urinary Tract Infection [MEDICAL CONDITION] for one (1) of three (3) residents reviewed with indwelling catheters; Resident #9. Findings include: During observation of incontinent care on 4/12/2017 at 2:45 PM, CNA #1 pulled the comforter back to provide incontinent/catheter care for Resident #9 revealed a Foley catheter bag with urine lying in the bed. After providing incontinent/catheter care on 4/12/2017 at 3:30 PM, CNA #2 hung the Foley catheter bag with urine on the top of the bed rail. During an interview with Registered Nurse (RN) #2, on 4/12/2017 at 3:35 PM, confirmed that the facility failed to hang the Foley catheter below the waist to prevent possible urinary tract infections. During an interview, on 4/13/2016 at 4:40 PM, CNA#1 confirmed the facility failed to hang the Foley catheter below the waist. CNA #1 said she thought it was okay to put the catheter in bed if a towel was place under it to prevent infection control. CNA #1 also said that she should have put the catheter back on the bed frame below the waist. During an interview with RN #3 on 4/13/2017 at 5:05 PM, RN #3 confirmed the facility failed to prevent possible urinary tract infection by not keeping the catheter bag below the waist. RN#3 said the staff was trained to never place the catheter above the waist. A review of the facility's training in-service titled Additional Pointers of incontinence Care revealed Certified Nursing Assistant (CNA)#1 and CNA #2 failed to follow the facility policy by placing the catheter bag in the bed with resident #9 and hanging the bag on the top of the bedrail. A review of the Face Sheet revealed the facility admitted Resident #9 on 8/31/2010 with [DIAGNOSES REDACTED]. A review of Resident #9's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/8/2017 revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated moderate cognitive impairment.

Based on observation, family interview, staff interview, record review, and facility policy review, the facility failed to ensure staff served food at a palatable temperature for one (1) of 10 residents reviewed for meal service, Resident #4. Findings include: Review of the facility's Meal Services Resident Tray Service and Delivery policy, not dated, revealed, Hot foods are held at or above 135°F (135 degrees Fahrenheit). A dining service employee tastes all food items, including modified foods, to confirm acceptable quality. The nursing staff is responsible for taking the meal trays into the resident's room. Interview on 4/11/17 at 11:20 AM with Resident #4's daughter revealed she was concerned because when she visits, her mother's meals are cold. Observation on 4/12/17 at 8:10 AM revealed Resident #4's tray delivered to hall. The tray remained on the open cart for approximately 20 minutes. At 8:32 AM, Certified Nurse Assistant (CNA) #6 took Resident #4's tray off the open tray cart and into Resident #4's room where she began preparing the tray to serve the resident. Upon request by the surveyor, the Dietary Manager (DM) can to the resident's room and obtained temperatures of the food on the resident's tray. Observation, on 4/12/17 at 8:35 AM, revealed the following temperatures obtained by the DM: Oatmeal- 92 degrees, Eggs- 80 degrees, Meat-70 degrees, Waffles- 68 degrees. The DM then tasted the eggs and stated, The eggs are cold. The DM went to the dietary department and got the resident some fresh hot eggs. Interview on 4/12/17 at 8:40 AM with the DM revealed when she questioned her dietary staff about the cold tray, her staff stated the tray was sent to the resident's room then returned by the nursing staff untouched to the dietary department. She stated the tray was then sent again down the hall to the resident's room. The DM stated Resident #4 used to eat in the dining room until she started declining a few months ago. Review of the Face Sheet revealed the facility admitted Resident #4 on 11/02/15 with [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/6/17 revealed a Brief Interview for Mental Status (BIMS) score of three (3) indicating severe cognitive impairment with extensive assistance with transfers, eating, hygiene, and did not ambulate.

Based on observations, staff interviews, and the facility statement, the facility failed to maintain an oven door in good repair for one (1) of eight (8) essential equipment appliances in the kitchen. Findings include: Review of the facility's statement revealed the work schedule was originated by staff through the computer system. All work orders were put in from staff to include the dietary aides. The work orders were to be followed up by the Plant Manager and completed by the Administrator and the corporate team to make sure the work was done. Observation in the kitchen on 4/13/2017 at 4:10 PM revealed the oven door on the left side would not close. The Dietary Manager (DM) stooped down and reached under the oven and pulled out a round metal object which she then placed on the oven door to hold the oven door shut. The DM stated, It's a magnet. That's what the administrator gave me to use. The magnet was approximately seven centimeters wide and approximately one-half inch thick. Interview on 4/14/2017 at 8:00 AM with the Maintenance Supervisor revealed he was unaware of the magnet being used to keep the oven door closed. He stated he had no report of it. Interview on 4/14/2017 at 10:50 AM with the Administrator revealed the stove was old and couldn't get the part for the door anymore. He further stated he would get a quote on a new stove.

Based on observation and staff interview, the facility failed to ensure a safe environment as evidenced by a medication cabinet unlocked at the nurses' station #2, for one (1) of four (4) medication storage units, Station #2. Findings include: The facility did not have a policy to address concerns of locked medication cabinets. On 02/04/16 at 4:30 PM, an observation with Registered Nurse (RN) #1 revealed the medication storage cabinet for station #2 was unlocked. The cabinet contained Pulmocare Gastrostomy feeding, Docusate Sodium 100 mg, two (2) bottles of Multi-vitamin with Iron, Magnesium Oxide 500 mg and Acidophilus. On 02/04/16 at 4:30 PM, an interview with RN #1 concerning the unlocked medication room, It should stay locked. The med cart nurse has the keys. I do not know why it's unlocked. On 02/04/16 at 4:30 PM, an interview with RN #3 about the unlocked medication room, revealed, The lock is unsteady. It had too much slack. We will take the medication out of the cabinet for tonight and have maintenance look at it in the morning.

Based on record review, facility policy review and staff interview, the facility failed to follow comprehensive care plans for nutrition related to meal set up for one (1) of nine (9) residents observed for meals, Resident #5. Findings include: A review of the facility's policy, titled Care Plan revised 2015, revealed, The care plan is the foundation that provides direction to the interdisciplinary team and staff on providing care and treatment to the resident. The care plan must describe the services that are to be provided to attain or maintain the resident's highest practicable physical mental and psychosocial well being. A review of Resident #5's care plan, dated 6/30/15, revealed a potential for alteration in nutrition and hydration and listed an intervention to set up foods as needed. A review of Resident #5's Kardex, dated 12/10/15, listed Activities of Daily Living (ADL), revealed that resident requires supervision and one (1) person physical assist with bed mobility and setup help for eating. During an observation on 2/4/16 at 8:20 AM, Certified Nursing Assistant (CNA) #5 entered Resident #5's room and placed the tray on the over bed table at the foot of the bed and left the room. Resident #5 was observed attempting to pull the table with the food tray closer, would attempt, lay down, attempt, lay down, four (4) times before getting the table to the center of the bed. Resident #5 began to set up the tray by removing covers, preparing coffee and food, and lying back on pillows at times during the process. During an observation on 2/4/16 at 8:35 AM, the Physical Therapist entered Resident #5's room and raised the head of the bed. This enabled the resident to sit up with back support. Resident #5 completed set up of tray and began to eat at 8:45 AM. Interview with CNA #5 on 2/4/16 at 12:15 PM revealed that she normally raised the head of the bed and sets up the food tray, but did not this morning. CNA #5 stated, she does review the Kardex to determine the amount of assistance the resident needs. CNA #5 stated, if the residents are in the bed they do need assistance with tray set up. Interview with the Director of Nursing (DON) on 2/4/16 at 2:50 PM revealed that the CNA should have raised Resident #5's head of the bed and set up her tray. The DON stated, the CNA should look at the Kardex every day at the beginning of their shift to see if any changes with their residents have developed. The DON stated, the CNA failed to follow the care plan as it was developed for Resident #5. Record Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/15, revealed that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Review of the facility's face sheet revealed, the facility admitted Resident #5 on 11/15/07 with [DIAGNOSES REDACTED].