Every finding on record at Cadia Rehabilitation Capitol

Based on interview and record review, it was determined that for one (R5) out of nine residents reviewed for medication administration, the facility failed to ensure that R5 received the correct dose of morphine sulfate for pain when R5 erroneously received 15 mL (milliliter) of the concentrated morphine sulfate oral solution instead of the physician prescribed dose of 0.25 mL on 12/7/25 at 10:58 AM. With this significant medication error, R5 was at risk of a severe, life-threatening respiratory depression or death. R5 was administered Naloxone 0.4 mg/mL intramuscularly two times to reverse R5's overdosage on 12/7/25 at 4:13 PM and 8:02 PM. An immediate Jeopardy (IJ) was identified starting 12/7/25. Due to the facility's corrective measures following the last incident, this is being cited as immediate jeopardy, past non - compliance with an abatement date of 12/11/25. Findings include: A facility policy titled Medication Administration, dated 1/13/26, documented, It is the policy of this facility to ensure that all medications are administered safely, accurately, timely, and in accordance with physician's orders, federal and state regulations . Medication administration shall comply with the Rights of Medication Administration . Definitions . Medication Administration Rights: Right resident, right medication, right dose, right route, right time, right documentation, right reason, right response. Review of R5's clinical record revealed:8/16/19 - R5 was admitted to the facility with diagnoses including but not limited to dementia.9/25/25 - R5's quarterly MDS (Minimum Data Set) assessment revealed that R5's cognition was moderately impaired with a BIMS score of 10 and was receiving opioids (a class of drugs used primarily to treat moderate - to - severe pain).11/21/25 - R5 had a physician's order for 0.25 mL = 5 mg (milligram) morphine sulfate (an opioid concentrate) oral solution every three hours as needed for pain.12/7/25 7:04 AM - R5 had a new physician's order for MS Contin (morphine sulfate) oral tablet extended release 15 mg by mouth two times a day for pain. 12/7/25 4:43 PM - A nurse progress note documented, At about 1530 (3:30 PM) during rounds on (unit), the outgoing nurse called me because 300 mg morphine sol (sic) was given to [R5]. [P1] (facility Medical Director) was called, family was made aware and Hospice was too (sic). [R5] monitor for any changes.12/7/25 7:11 PM - A nurse progress note documented, Late entry at 1520 (3:20 PM) order from [P1] for naloxone (medication used to reverse or reduce the effects of opioids). Naloxone was given at 1613 (4:13 PM). 12/7/25 7:44 PM - A nurse progress note documented, Naloxone HCL (hydrochloride) Injection Solution 0.4 MG/ML Inject 0.4 mg/ml intramuscularly STAT (at once/immediately) for overdose.12/7/25 8:02 PM - A nurse progress noted documented, gave 2nd dose of Naloxone 0.4 mg/ml per [P1].12/7/25 - A written statement by E30 (LPN) documented, On December 7, 2025 at about 0900 am (sic), I made a medication error during my morning medication pass. I administered 15 mL of morphine to a patient [R5] instead of the intended dose of 0.25 mL. The system displayed the ordered dose of morphine 15 mg, while the patient's bottle label stated 0.25 mL. I sought clarification from my supervisor, who confirmed that I should follow the dose listed in the patient's MAR (Medication Administration Record) in the system. Unfortunately, I incorrectly interpreted 15 mg as 15 mL. 12/7/25 - A written statement by E19 (3-11 shift RN Supervisor) documented, During my rounds on (unit) the off going (sic) nurse [E30] called me and she said 'I made a medication error on the narcotic' . I called [P1] and notified her of the error . 12/8/25 9:12 AM - A physician note by P1 documented, I was notified yesterday, 12/7/25 at 3:30 PM by nursing staff that pt (patient) was given 15 ml of liquid morphine by floor nurse at 930 AM 12/7/25. Liquid morphine has concentration of 20 mg/ml so pt was given 300 mg of morphine instead of 5 mg. I was told that the nurse made a mistake. I was told that pt's sleepy but vitals are stable. I requested 0.4 mg Narcan to be administered. I called back at 5 PM and was told that pt's heart rate is dropping, so I ordered another dose of Narcan 0.4 mg. I also advised staff to hold all PO meds until further orders. I called back at 9 PM, and I was told that pt is stable and is resting. I have emailed DON and Administrator today to set up a call to investigate this grave med error and so that we can do a root cause analysis.12/10/25 - A facility follow up report documented that approximately 9:00 AM E30 administered 15 mL of morphine sulfate concentrate to R5 after reading morphine 15 mg 1 tablet on the MAR. During the shift exchange (between 7-3 and 3-11) E30 recognized the error in administration of mL versus mg. The follow up report further documented, [R5] had order for Morphine Sulfate Solution 100 mg/5mL give 0.25 mL every 3 hours as needed. On 12/7 [R5] had new order for MS Contin oral tablet give 15 mg two times a day for pain which was pending delivery from the pharmacy . Upon identification of medication error, [R5] was assessed and monitored. [P1] was notified and order was given for Narcan (Naloxone), which was administered twice. [R5] was placed on alert charting and vital signs, respiratory status and mentation monitored. [P1] gave order to hold medications . 1/22/26 2:20 PM - In an interview, E12 (RN) stated that she was the supervisor on 12/7/25 during the 7-3 shift. E12 stated that on that morning she was doing her rounds and was walking to E30's unit on her way to see another resident. E12 stated she saw E30 who was passing meds. E30 stopped her to ask what to do when a resident's narcotic medication ran low, and whether to administer the last dose of the medication or to hold it. E12 stated that she told E30 to administer the medication as ordered by the physician and to call the doctor and pharmacy for refill. E12 further stated, I did not know what specific narcotic medication she was talking about. I thought it was just a general procedure question that she asked me as I walked past her on my way to another resident's room. At the end of our day shift, I was notified by the incoming nurse that [E30] gave the wrong dose of medication to [R5]. 1/22/26 3:34 PM - During an interview, E16 (LPN) stated that she worked on 12/7/25 and was the incoming and reliving nurse on the 3 - 11 shift. E16 stated that she saw E30 looking at the narcotic book and told her that R5 ran out of the concentrated morphine sulfate. E16 stated that she worked a double shift (7-3 and 3-11) the day before on the same unit with R5 on her assignment and was familiar with R5's morphine sulfate dosage order. E12 further stated, I know [R5] gets 0.25 mL morphine sulfate every three hours when needed for pain. I left my shift at 11:00 PM on 12/6/25, with [R5's] 17.25 mL remaining morphine sulfate concentrate in the bottle. [E30] informed me that she gave 15 mL morphine sulfate concentrate to [R5]. The facility failed to ensure that R5 was free from significant medication administration error when R5 received 15 ml of the concentrated morphine sulfate oral solution instead of the ordered dose of 0.25 ml on 12/7/25 at 10:58 AM. This resulted in a significant medication error for R5 who received 59 more doses of the morphine sulfate solution than the prescribed physician order.1/27/26 10:45 AM - An Immediate Jeopardy (IJ) was called and reviewed with the facility leadership including E1 (NHA). During this conference, E1 confirmed that there had been no other incidents of significant medication error after the 12/7/25 incident. 1/22/26 - E1 (NHA) presented to surveyor an acceptable documentation of corrective action plan that was fully abated on 12/11/25. The facility's corrective actions at the time of the incident included:1. Upon discovery of the medication error, R5 was immediately assessed, and physician was notified. New order for Narcan (Naloxone) obtained and administered out of an abundance of caution. R5's responsible party and Hospice were also notified. R5 was placed on alert charting to monitor vital signs and respiratory status. R5 remains in the facility and had no adverse outcomes related to the medication error.2. All residents with orders for liquid morphine have the potential to be affected by this deficient practice. An audit was completed on like residents receiving morphine and no other errors were identified. An audit of like residents receiving controlled substances was completed to determine if any other residents had orders for the same medication in two different forms and no other residents were identified. 3. The facility conducted a root cause analysis, and it was determined that the assigned nurse failed to perform the five rights of medication administration when the nurse misinterpreted 15 mg as 15 ml. Education with licensed nurses was completed on five rights of medication administration. Education was completed on 12/11/25. Medication error was reviewed with medical director at an ad hoc QAPI meeting on 12/10/25. The facility was back in substantial compliance on 12/11/25.4. Director of Nursing will conduct audits of liquid morphine medication administration. The audits will be performed weekly or until 100% compliance is achieved for 3 consecutive weeks. Audits will continue monthly until 100% compliance is achieved for 3 consecutive months. Once 100% compliance is met, the deficient practice will be considered resolved. All audits will be reviewed by the Quality Assurance Performance Improvement Committee.No immediate action required related to past non-compliance. This was verified by review of facility documents and interview with facility staff and residents.1/27/25 5:45 PM - Findings were reviewed at the exit conference with E1 (NHA) and E2 (DON).

Based on interview and record review, it was determined that for two (R30 and R108) out of nine residents sampled for abuse, the facility failed to report an allegation of abuse to the state agency within two hours. Findings include:2. Review of R108's clinical record revealed: 10/26/25 - E7 (CNA) documented in a written statement, On October 25, 2025 .around 11:15 PM I went to check on all my patients. When I got to [R108] she stated that 'the CNA that had her torn her clothes and was rough with her . 10/26/25 11:08 AM - The facility submitted an allegation of staff to resident abuse incident involving R108 to the state agency, greater than two hours after R108's initial report to the facility. 1/23/26 10:19 AM - During an interview E7 (CNA) confirmed the aforementioned written statement and that R108's allegation of abuse was reported to a nurse on 10/25/25. 1/23/26 1:57 PM - During an interview E3 (ADON) confirmed the finding. E3 stated, I found out through reading notes and things that it happened on the 25th but no one made leadership aware. 1/27/26 5:45 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON). The facility policy on abuse last updated 1/9/26 indicated, Allegations of abuse shall be reported to the appropriate state regulatory authority within two hours. 1. A review of R30's clinical record revealed: 1/6/19 – R30 was admitted to the facility. 10/25/25 7:15 PM – R30 reported E4 (CNA) was rough with care. 10/27/25 11:09 AM – The facility reported an allegation of abuse to the State agency. 1/22/25 11:07 AM – During an interview with E3 (DON), it was confirmed that the allegations of abuse must be reported within two hours. 1/22/25 12:00 PM – During an interview with E1 (NHA), it was confirmed that the alleged abuse was not reported within two hours. The facility failed to report the allegation of abuse to the State Agency within the designated timeframe of two hours. 1/27/26 5:45 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview it was determined that the facility failed to maintain accurate and complete records for one (R119) out of three residents reviewed for beneficiary notification. Findings include:Review of R119's medical record revealed:7/25/25 - The facility provided a Notice of Medicare Non-Coverage (NOMNC) to R119 to relay that services would end on that date.1/23/26 - During the beneficiary notification review, a review of R119's worksheet and relevant documents lacked evidence of the second page, the signature page to validate the resident or their responsible party received and understood the notice.1/23/26 1:15 PM - During an interview, E6 (SW) confirmed the finding and relayed that the facility was unable to locate R119's signature page to their NOMNC.1/27/26 5:45 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview it was determined that for one (R81) out of five residents reviewed for unnecessary medication review the facility failed to implement the MRR policies when recommendations made by the pharmacist and agreed by the provider were not completed by the facility. Findings include: The facilities Pharmacist monthly drug review policy last updated 1/23/26 indicated, Facility will encourage physician/prescriber or other responsible parties and the DON to act upon the recommendations contained in the monthly drug review.Review of R81's clinical record revealed:5/15/25 - R81 was admitted to the facility with multiple diagnoses including dementia with behavioral disturbance, anxiety, depression and an allergy to bee venom. 5/30/25 - An MRR recommended an EpiPen be considered related to R81's bee venom allergy, and that R81's Risperdal prescribed for major depressive disorder was an inappropriate use for an antipsychotic. The recommendations were marked as agreed by R81's physician. 6/29/25 - An MRR recommended an EpiPen be considered related to R81's bee venom allergy. The recommendation was marked as agreed by R81's physician.7/27/25 - An MRR recommended an EpiPen be considered related to R81's bee venom allergy, and that R81's Risperdal prescribed for mood was an inappropriate use for an antipsychotic. The recommendations were marked as agreed by R81's physician. 1/22/26 10:00 AM - Review of R81's physicians orders revealed the order for Risperdal continued as indicated for 'mood'. There was no order written for an EpiPen, 1/22/26 10:38 AM - During an interview E9 (LPN) unlocked and opened the medication cart where R81's medications were stored and confirmed that there was no EpiPen prescribed to R81 in the medication cart. 1/22/26 10:40 AM - During an interview E8 (LPN, UM) confirmed that the correct diagnosis for R81's order for Risperdal not listed and that there was no epi-pen ordered for the resident. 1/27/26 5:45 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on observation, interview and record review it was determined for one (R6) out three residents sampled for respiratory care the facility failed to provide professional standards of practice by ensuring R6's BiPap equipment was stored in a protective plastic bag when not in use. Findings include:A review of R6's clinical record revealed:1/10/24 - R6 was admitted to the facility with diagnoses of acute respiratory failure and interstitial pulmonary disease.12/28/25 - A quarterly MDS documented that R6 was cognitively intact.1/20/26 - A physician's order documented BIPAP application at bedtime (HS) and PRN. The order specified: BIPAP setting: 10 cm H O with O bleed-in at 2 liters.1/26/26 - A review of the treatment administration record lacked evidence of an order directing that the BIPAP mask and tubing be stored in a protective plastic bag when not in use.1/20/26 at 10:11 AM - R6's BIPAP mask was observed lying on the bedside table, with the tubing on the floor.1/21/26 at 8:40 AM - R6's BIPAP mask was again observed lying on the bedside table, with the tubing on the floor.1/21/26 at 8:50 AM - During an interview, E5 (LPN) stated that BIPAP masks and tubing are required to be stored in a protective plastic bag when not in use. Following the interview, E5 entered R6's room and confirmed that the BIPAP mask and tubing were not stored in a protective plastic bag. E5 immediately placed the BIPAP mask and tubing into a protective plastic bag.1/21/26 8:50 AM - During an interview, E5 (LPN) stated that BIPAP masks and tubing are required to be stored in a protective plastic bag when not in use. Following the interview, E5 entered R6's room and confirmed that the BIPAP mask and tubing were not stored in a plastic bag. E5 immediately placed the BIPAP mask and tubing in a protective plastic bag.1/27/2026 5:45 PM - Findings were reviewed at the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R5) out of three residents reviewed for PASRR (Preadmission Screening and Resident Review), the facility failed to refer R5 for a PASRR evaluation as required when a resident experiences a significant change in mental health status. Findings include: Review of R5's clinical record revealed:2/6/23 - R5 was re-admitted to the facility. 11/13/23 - R5's Notice of PASRR Level II Outcome indicated that R5 had the following mental health diagnoses: -Adjustment Disorder with depressed mood-Delusional Disorder-Dementia-Mood Disorder NOS (not otherwise specified) -Anxiety Disorder NOS-Psychotic Disorder NOS-Insomnia-Major Depressive Disorder, recurrent, severe, with psychotic symptoms2/14/25 - R5's quarterly MDS (Minimum Data Set) assessment revealed R5's new psychiatric/mood disorder diagnoses including bipolar disorder, adjustment disorder with mixed anxiety and depressed mood and unspecified mood affective disorder. 3/25/25 - R5's significant change MDS assessment revealed R5's psychiatric/mood disorder diagnoses including but not limited to: bipolar disorder, restlessness and agitation, unspecified mood affective disorder and adjustment disorder with mixed anxiety and depressed mood. 6/25/25 - R5's quarterly MDS (Minimum Data Set) assessment revealed R5's new psychiatric/mood disorder diagnoses including but not limited to: bipolar disorder, adjustment disorder with mixed anxiety and depressed mood and unspecified mood affective disorder. 9/25/25 - R5's quarterly MDS (Minimum Data Set) assessment revealed R5's new psychiatric/mood disorder diagnoses including but not limited to: bipolar disorder, adjustment disorder with mixed anxiety and depressed mood and unspecified mood affective disorder. 12/26/25 - R5's quarterly MDS (Minimum Data Set) assessment revealed R5's new psychiatric/mood disorder diagnoses including but not limited to: bipolar disorder, adjustment disorder with mixed anxiety and depressed mood and unspecified mood affective disorder. 1/22/26 2:00 PM - A review of R5's mental health diagnoses report revealed that R5's new diagnoses with onset dates included:-Adjustment Disorder with mixed anxiety and depressed mood (7/24/24)-Bipolar Disorder, unspecified (1/17/24)-Unspecified Dementia, unspecified severity with other behavioral disturbance (1/17/24) 1/22/26 4:00 PM - During an interview, E1 (NHA) confirmed that R5's PASRR evaluation was not updated and submitted to the PASRR state authority when R5 was diagnosed with Adjustment Disorder with mixed anxiety and depressed mood, Bipolar Disorder and Unspecified Dementia unspecified severity with other behavioral disturbance in 2024.1/27/26 5:45 PM - Findings were reviewed at the exit conference with E1 (NHA) and E2 (DON).

Based on observation, interview, and facility policy review, the facility failed to ensure that beard guards were worn during food production in accordance with professional standards for food service safety and failed to store food in accordance with professional standards for service safety with the potential to affect 109 of 109 residents who consumed food from the kitchen. This failure had the potential for physical contamination of the food in the facility. Findings include: 1. Review of the facility's policy titled, Dress Code dated [DATE], revealed sanitary food preparation staff must wear: hair net or a disposable hat while on duty. Any employee with facial hair must wear a beard guard. During observation of the lunch meal preparation on [DATE] at 11:45 AM, two male Dietary Aide (DA)2 and DA 3 with beards did not have beard nets covering their beard at the food preparation station. During observation of the dinner meal preparation on [DATE] at 4:45 PM, DA2 and DA3,with beards did not have beard nets covering their beard at the food preparation station. During observation of the breakfast meal preparation on [DATE] at 8:10 AM, DA2 and DA3 with beards did not have beard nets covering their beard at the food preparation station. During observation of the noon meal preparation on [DATE] at 11:30 AM, while accompanied by the Dietary Manager (DM), DA2 and DA3 with beards did not have beard nets covering their beard at the food preparation station. During an interview on [DATE] at 11:40 AM, the Food Service Director (FSD) stated that staff with beards must wear a beard net to cover their beard. I did not observe the two male kitchen staff members not wearing beard nets until I observed them today. During an interview on [DATE] at 1:25 PM, the Dietary Aide (DA) 2 stated, Yes, I know that I must wear a beard guard when I'm in the kitchen. I just forgot. During an interview on [DATE] at 1:30 PM, the Dietary Aide (DA) 3 stated, Yes, I know that I must wear a beard guard when I'm in the kitchen. I just forgot. 2. During the observation of the main refrigerator on [DATE] at 09:30 AM, while accompanied by the FSD the following food items were expired or had no current dates after being used: Cardboard box with black substance on the right side of the outside of the cardboard box. Inside the cardboard were two 64 oz containers of potato salad that were split open. Outside the cardboard box was a dated [DATE]. One gallon size plastic container of Thousand Island salad dressing was dated [DATE]. Twenty peeled, hard-boiled eggs were wrapped individually in plastic wrap without a date. One 64-ounce grape jelly glass jar with half a jar remaining contained no date. Chicken salad in a 64-ounce metal container was half full and undated. 3. During the observation of the main freezer on [DATE] at 10:30 AM, while accompanied by the FSD the following food items that were expired or had no current dates after being used: An open cardboard box revealed an open plastic bag of 32 frozen chicken cutlets with no date. Open cardboard box revealed an open plastic bag of 40 frozen hamburger patties with no date. During an interview on [DATE] at 10:55 AM, the FSD stated that the weekend kitchen staff are supposed to check and throw out food items that are out of date.

Based on record review, interview and policy review, the facility failed to complete a through investigation of an allegation of abuse for one of six residents (Resident (R) 11) reviewed for abuse and neglect out of a total sample of 29. This failed practice had the potential to affect resident safety at the facility. Findings include: Review of R11's electronic medical records (EMR) revealed the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/24 found under the MDS with an admitted [DATE] and a Brief Interview for Mental Status (BIMS) score of 15 out 15 which indicated R11 was cognitively intact. Interview on 12/10/24 at 8:43AM, R11 stated that he has never had any problems with staff at the facility. R11 also stated that no one has ever been rough with him during care, and no one has ever pulled on his testicles. During an interview on 12/12/24 at 9:30AM, the Director of Nurses (DON) stated that R11 reported on 01/11/24 that while receiving care on 12/25/24, Certified Nurse Aide (CNA)9 was rough with him during care; forcefully pulling on his genitals. The DON stated that CNA9 was suspended pending an investigation. The DON stated that the investigation revealed that the facility could not substantiate R11's allegation due to lack of evidence. The DON stated that the facility interviewed a female resident and no other residents, whether there were any issues with CNA9 being rough during care. The DON was asked if the facility should have interviewed other male residents that CNA9 had provided care to on 12/25/24. The DON stated that other male residents should have been interviewed. Review of the facility's investigative document revealed that the facility had only interviewed one female resident about how CNA9 had provided care. There was no documentation of interview with other residents especially male residents regarding the care CNA9 provided. Review of the facility's policy titled Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime dated 01/03/24 indicated, .all alleged incidents involving abuse . shall be reported to the NHA [Nursing Home Administrator] or designee immediately. The NHA or designee shall investigate allegations . All persons identified as involved in or with knowledge of the occurrence will be interviewed.

Based on observation, interviews, and record review, the facility failed to ensure one of 29 residents (Resident (R) 29 reviewed had a mattress that fit the bed frame. The failure created the potential for an injury if R29 's feet became tangled in the gap between the mattress and the footboard of the bed. Findings include: Review of the Admission Record located under the Profile tab in the electronic medical record revealed R29 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction, and disorders of bone density and structure. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R29 was cognitively intact. On 12/10/24 at 11:56 AM, R29 was observed in bed with the head of the bed in an upright position. A large gap, which measured 11 inches from the mattress to the footboard was observed. The footboard was noted to be angled away from the mattress. R29 was asked if she ever slides down, toward the footboard, when in bed and stated, Yes, I have many times when I am put in the bed. When asked if her feet had ever become entangled in the gap, R29 said, Yes. On 12/11/24 at 10:37 AM, R29 was observed in bed with the head of the bed in an upright position and a six inch gap was noted between the mattress and the footboard. On 12/11/24 at 11:02 AM, the Administrator, Director of Nurses (DON), and Nurse Consultants (NC1 and NC2) observed the gap between the mattress and the footboard of R29's bed. The DON was asked to measure the gap which was noted to be six inches. R29 stated, My feet have gotten down in the hole before, when I move the bed up. The DON stated, Yes, six inches. We need a bolster. The Administrator and DON were asked to provide a policy on ensuring resident's mattress fits bed frames. No policy was provided as of the exit, on 12/12/24 at 5:45 PM.

Based on interview, record review, and policy review, the facility failed to ensure two (Residents (R) R71 and R37 ) of six residents reviewed for abuse, were free from resident-to resident abuse for two separate incidents. This had the potential to affect resident safety at the facility. Findings include: Review of the facility's abuse policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, . It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse . 1. Review of R52's electronic medical record (EMR) revealed a Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnosis of depression, dementia, anxiety disorder and Alzheimer's. Review of the quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 11/09/24 indicated a Brief Interview for Mental Status (BIMS) score of 0 out of 15 indicating the resident was severely cognitively impaired. The assessment indicated the resident exhibits physical and verbal behavior toward others. Review of the Care plan located in the EMR under the Care Plan tab indicated R52 had a tendency to be verbally and physically aggressive to others. Review of the Progress Note located in the EMR under the Progress Note tab revealed that on 11/25/23, R71 was ambulating in the hallway and began urinating in the floor. R52 walked up to R71 and struck him in the back. The residents were immediately separated. Review of R71's Face Sheet located in the EMR under the Profile tab in the EMR indicated the resident was admitted to the facility on [DATE] with diagnosis of alcohol abuse, schizophrenia, anxiety, and depression. Review of the quarterly MDS located in the EMR under the MDS tab with an ARD of 09/05/24, indicated the resident had a BIMS score of four out of 15 indicating the resident was severely cognitively impaired. Review of R71 Care Plan located in the EMR under the Care Plan tab indicated the resident with a behavior of being verbally aggressive. Review of a facility incident reported 11/25/23 revealed R71 was ambulating in the hall outside of his room and started to urinate on the floor. The nurse attempted to redirect the resident to his room without success. R52 was ambulating in the hall and yelled at R71. R52 walked up to R 71 striking him in the back. During an interview on 12/12/24 at 10:01 AM, Registered Nurse 2 (RN) stated that both residents can get agitated, but both can be redirected easily. Interview on 12/12/24 at 12:59 PM, the Director of Nursing (DON) stated the incident was resident to resident abuse. 2. R63 was admitted to the facility on [DATE] with diagnosis of toxic encephalopathy, alcohol abuse, anxiety disorder, depression, and dementia. Review of the quarterly MDS located under the MDS tab with an ARD of 10/25/24 indicated a BIMS score of nine out of 15 indicating the resident was moderately cognitively impaired. The assessment indicated the resident exhibits verbal behaviors directed at others. Review of the resident's care plan located under Care Plan tab in the EMR revealed R63 was identified with behaviors of resisting care with use of his walker and wheelchair. R37 was admitted to the facility on [DATE] with diagnosis of subarachnoid hemorrhage, dementia, depression, and traumatic brain injury. Review of R37's Annual MDS located under the MDS tab in the EMR indicated a BIMS of four out of 15 indicating the resident was severely cognitively impaired. Review of the resident's Care Plan located in the EMR under the Care Plan tab indicated the resident exhibited verbal behavior toward others. Review of the facility's investigation of the incident revealed that on 05/07/24 at 17:00, R63 and R37 were reported to have gone for the same chair at dinner. R63 stated that R37 got smart with him, and he smacked her on the left side of the face. No redness, swelling or any other injury noted. R37 denied having said or done anything to R63. During an interview on 12/12/24 at 08:59 AM, the DON stated that the incident with R63 slapping R37 was resident to resident abuse.

Based on observations, interview, and record review, the facility failed to ensure one of 29 residents (Resident (R) 39 reviewed had their call light accessible for use creating the potential for needs not to be met. Findings include: Review of the Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R39 was initially admitted on [DATE] with diagnoses that included adjustment disorder with depressed mood, congestive heart disease, chronic kidney disease stage three, and gout. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/29/24 revealed R39 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R39 was moderately cognitively impaired. On 12/09/24 at 12:44 PM, R39 was in bed and the call light was underneath his bed. On 12/09/24 at 1:09 PM, R39 was observed in bed and the call light was underneath the bed. During an interview at the time of the observation. R39 said he did not know where the call light was. During an observation on 12/11/24 at 8:35 AM, R39 was in bed and the call light was underneath his bed. During an interview on 12/11/24 at 9:41 AM, Licensed Practical Nurse (LPN1) was asked was R39's call light. LPN1 located the call light under the bed and confirmed that R39 was able to use the call light if it was in reach of his right hand. LPN1 stated, He can't use his call light if it's under the bed, the staff know better than this. During an interview on 12/11/24 at 10:39 AM, Certified Nurse Aide (CNA3) stated, Yes, I took care of [R39] this morning. I didn't realize the call light was under the bed. Interview on 12/11/24 at 4:30 PM, R39 demonstrated how he was able to push the call bell with his right hand and stated, I can push it, just my left hand doesn't work. Interview on 12/12/24 at 9:16 AM, the Director of Nurses (DON) confirmed that the CNAs were to ensure that each resident had their call light accessible to them during and after cares. Interview on 12/12/24 at 4:00 PM, the Nurse Consultant (NC2) stated, We don't have a policy on call lights.

Based on observation, interview, and record review, the facility failed to ensure one of 29 sample residents (Resident (R) 50 had an alternative call light device available when the call light system malfunctioned. The failure created the potential for the resident's care needs to be unmet. Findings include: Review of the Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R50 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure with hypoxia, and interstitial pulmonary disease. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/03/24 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated R50 was severely cognitively impaired. Observation on 12/11/24 at 10:46 AM, R50 had no call light plugged into the wall unit, or a substitute call device available. R50 stated, I haven't had one, the other one broke. When asked how she would call staff for assistance, R50 stated, I don't have anything, just my voice. During an interview on 12/11/24 at 11:10 AM, the Administrator, Director of Nurses (DON), and nurse consultants (NC1 and NC2) were notified of R50 not having a call bell device. R50 stated to the administrative staff, I guess I could try to yell. The DON looked for the doorbell device in the resident's room, however none was located. During an interview on 12/11/24 at 11:59 AM, the Administrator identified that the call light system had failed in May 2024. All but two rooms returned to normal functioning. R50 resided in one of the two rooms that did not have a functioning call light system. The Administrator stated, Due to the wiring. [R50's] room could not be fixed. The DON stated, we gave them all a doorbell. Observation of the two rooms identified not having a functioning electronic call light system, on 12/11/24 at 12:13 PM, revealed three of the four residents (R4, R12, and R14) had doorbell like devices which rang into the hall. R50 had no such device. On 12/11/24 at 4:30 PM, the Administrator stated, The Certified Nurse Aides (CNAs) know to check on the residents. We will make sure they check for the bell too. Interview on 12/12/24 at 8:47 AM, CNA3 stated, Yes, we check for the bell. I don't know what happened to it.

Based on record review, interview and policy review, the facility failed to ensure an incident of resident-to-resident abuse was reported to the State Agency (SA) within two hours of the incident as required for one residents (R)71) from six residents reviewed for abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, . It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse .Guidelines .Reporting and Response .Allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours . 1 Review of R52's electronic medical record (EMR) revealed a Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnosis of depression, dementia, anxiety disorder and Alzheimer's. Review of the quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 11/09/24 indicated a Brief Interview for Mental Status (BIMS) of 0 out of 15 indicating the resident was severely cognitively impaired. Review of R71's EMR revealed a Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnosis of alcohol abuse, schizophrenia, anxiety, and depression. Review of the quarterly MDS located under the MDS tab with an ARD of 09/05/24 indicated a BIMS score of four out of 15 indicating the resident was severely cognitively impaired. Review of the facility incident report dated 11/25/23 revealed R71 was ambulating in the hallway outside of his room and started to urinate on the floor. R52 yelled at R71 then walked up to him, striking him in the back. During an interview on 12/12/24 at 12:59 PM, the Director of Nursing (DON) stated she became aware of the incident when she was reading notes from her home and called to find out what happened. The nurse that was on duty when the incident occurred failed to follow the reporting requirement to notify her of the incident. She stated that she reported the incident to the SA as soon as she was aware, but it should have been reported within two hours of the incident.

Based on interview, record review and review of other facility documentation it was determined that for one (R1) out of three residents reviewed for accidents the facility failed to provide adequate supervision to prevent an accident. R1, a totally dependent resident was rolled out of bed when a staff person lost grip on R1 during care. R1 rolled from the bed and fell three (3) feet to the floor sustaining a laceration to the head and was emergently transported to the hospital, this resulted in harm to R1. 6/6/17 - R1 was admitted to the facility with diagnoses of but not limited to unspecified dementia (a brain disorder with memory loss), sarcoidosis (an inflammatory disease) and aphasia (neurological condition affecting language). 5/20/24 - An annual MDS documented R1 as totally dependent for self-care, bed mobility and was severely impaired cognition. 6/3/24 - R1's care plan included that the resident was at risk of falls and interventions included: anticipate and meet the resident's needs. 6/1/24 - 6/12/24 - A review of CNA documentation revealed R1 was totally dependent on staff for self-care and mobility. 6/12/24 10:23 PM - A progress note documented, R1 was emergently transferred to the hospital and admitted to Neuro ICU with hourly neuro checks from an acute subdural hemorrhage. 6/13/24 at 1:21 AM - A progress note by E5 (LPN) documented, 6/12/24 9:20 PM This nurse was notified by CNA that resident fell out of bed while giving her a bed bath. Noticed resident lying supine on the floor with blood smeared on the roommate's bed frame and the floor under the bed. Resident noted with moderate amount of blood at the back of head on the floor. Unable to move or assessed where laceration is located at the back of her head, due to the possibility of neck or head injury. Resident is fully conscious, vital signs and neuro check within normal level. No rotation or shortening noted. Skin remains intact. T97.9 P75 R20 B/P 134/52. 7/12/24 11:36 AM - During an interview with the E6 (CNA) it was revealed that R1 was totally dependent for care and that personal care hygiene (bath) was being provided to R1 when the accident occurred. E6 stated that E6 was cleaning R1 with right hand and holding R1 with left hand, when rolling R1 away from her, E6 lost grip on R1 and R1 rolled off the bed and onto the floor. E6 stated that it was an accident, R1 was responding, R1's eyes were open and E6 asked R1 if she was okay R1 responded yes, E6 went to get the nurse and returned to R1. E6 further revealed that R1 was bleeding when E6 returned to the room. E6 stayed with R1 and talked with R1 until the ambulance arrived. R1 remained conscious while at the facility. 7/12/24 approximately 2:30 PM - In an interview with E2 (DON) and E3 (CNO) it was revealed that the facility recognized the seriousness of the 6/12/24 accident. The state agency was provided with the facility investigation, root cause analysis, a facility wide sweep to identify other residents that might be affected by the deficient practice, education, who completed the education, a plan to address staff who were PRN or on leave and audits that were in place for monitoring. After reviewing documents, completing staff interviews and current observations, it was determined that the facility regained compliance on 6/14/24 and past non-compliance was recommended by the state agency. 7/16/24 3:00 PM - Findings were reviewed with E1, E2, E3 (CNO), E10 (COO), E11 (Corporate Nurse) and E12 (Corporate Nurse). 7/17/24 4:30 PM - An observation and visit with R1 revealed that she had returned to baseline and continues to be totally dependent.

Based on record review and interview, it was determined that for two (R98 and R417) out of twenty-nine residents reviewed for resident assessment, the facility failed to accurately complete MDS assessments to reflect resident status. Findings include: 1. Review of R98's clinical record revealed: 5/9/23 - R98 was readmitted to the facility with dementia. 5/10/23 1:00 AM - A provider progress note documented that R98 was, referred from home to Cadia for LTC (long term care) due to progressive dementia. 5/11/23 - R98's care plan included that R98 had impaired cognitive function or impaired thought process related to dementia. 5/17/23 - R98's admission MDS assessment did not include R98's diagnosis of dementia. 5/31/23 12:42 PM - A psychiatric progress note documented that R98 had a diagnosis of dementia with behavioral disturbances. 8/15/23 1:00 AM - A provider progress note documented a history of dementia. 8/17/23 - R98's quarterly MDS assessment did not include R98's diagnosis of dementia. 11/7/23 10:44 AM - During an interview, E26 (RNAC) confirmed that R98's admission and quarterly MDS assessments failed to include R98's MDS diagnosis of dementia. 2. Review of R417's clinical record revealed: 7/30/22 - R417 was admitted to the facility after a stroke affecting his left side. 8/5/22 - R417's MDS assessment documented that R417 did not have any pressure ulcers. 8/12/22 12:17 PM - A nursing progress note documented that R417 had 2 new open areas to his buttocks. 8/13/22 3:11 PM - A nursing progress note documented that R417 has a open stage 2 wound on outer left ankle. 8/17/22 - R417's discharge MDS assessment documented that R417 had one stage 2 pressure ulcer that was present on admission and one unstageable pressure ulcer present on admission. R417 did not have any pressure ulcers on admission. Review of R417's clinical record was not consistent with the MDS data. 11/7/23 1:30 PM - During an interview, E3 (CNO) confirmed the R417's 8/17/22 MDS assessment was inaccurate based on the the initial 8/5/22 admission assessment. 11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on interview and record review, it was determined that for four (R30, R38, R40 and R74) out of five residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR screening was completed following a new diagnosis of psychotic disorder which was not listed on the previous PASARR. Findings include: 1. Review of R30's clinical record revealed: 3/7/18 - R30 was admitted to the facility. 3/6/18 - A review of R30's medical record revealed that R30 had a PASARR level I that indicated R30 had a documented serious mental illness (mood disorder with depressive features) and demonstrated a full level II was not indicated at that time. 9/17/18 - A review of R30's medical record revealed that R30 had a PASARR level I.5 that indicated R30 had a documented serious mental illness (mood disorder with depressive features) and demonstrated a full level II was not indicated at that time. 9/7/22 - A review of R30's medical record revealed that R30 has the following new diagnoses: major depressive disorder, delusional disorder, hallucinations, and adjustment disorder with depressed mood. 11/1/23 1:58 PM - An interview with E7 (social worker) confirmed that a PASARR level II was never requested for R30. 11/7/23 8:40 AM - An email correspondence with, S3 (PASARR State Authority) revealed that, .The facility should have submitted a status change or another resident review PASARR at that time of or timely discovery that the Level 1.5 (Notice Date 9/7/18) was not an accurate reflection of (R30) mental health status and new diagnoses. 2. Review of R40's clinical record revealed: 2/7/17 - R40 was admitted to the facility. 5/19/17 - A review of R40's medical record revealed that R40 had a PASARR level I that indicated R40 had a documented serious mental illness (bipolar, major depressive disorder, and anxiety) and demonstrated a full level II was not indicated at that time. 10/1/22 - A review of R40's medical record revealed that R40 had the following new diagnoses: adjustment disorder with depressed mood, dementia with agitation, delerium, and delusional disorder. 5/14/23 - A review of R40's MDS revealed anxiety, bipolar, depression, psychotic disorder, and non-alzheimer's dementia were documented. 11/1/23 1:58 PM - An interview with E7 (social worker) confirmed that a PASARR level II was never requested for R40 when new diagnoses were identified. 11/7/23 8:40 AM - An email correspondence with, S3 (PASARR State Authority) revealed that, .The facility should have submitted a status change or another resident review PASARR at that time of or timely discovery that the Level 1 (Notice Date 5/19/17) was not an accurate reflection of (R40) mental health status and new diagnoses. 40260 3. Review of R38's clinical record revealed the following: 2/3/16 - R38 was admitted to the facility. 9/26/17 - A PASARR Level I Screen was completed, which stated, Individual does not require additional evaluation due to the following determination and needs can be met at a NF (nursing facility): The individual does have a documented serious mental illness . and the individual needs can be met in a NF without further evaluation . 10/30/23 2:20 PM - A review of R38's diagnoses in his clinical record revealed the following diagnoses were added on 12/1/22: adjustment disorder with depressed mood; major depressive disorder, recurrent, severe with psychotic symptoms; anxiety disorder, unspecified; delusional disorders; suicidal ideations; persistent mood (affective) disorder, unspecified. 11/1/23 1:58 PM - During an interview, E7 (SW) stated the State PASARR contractor will tell the facility that an updated PASARR Level II was not needed, but she would check. She provided a list of residents currently being considered for a PASARR Level II and R38's name was not included. 11/3/23 approximately 1:50 PM - E3 (CNO) provided a report dated 11/3/23 from the State PASARR contractor confirming that a PASARR Level II was needed for R38. 11/8/23 9:00 AM - During an interview, E3 and E2 (DON) confirmed additional mental health diagnoses had been added to R38's diagnoses, but no PASARR Level II was completed. They confirmed that E7 will coordinate the PASARR Level II evaluation for a representative to meet with R38 to conduct a face-to-face PASARR Level II evaluation. 11/8/23 2:42 PM - E3 advised the survey team that the PASARR team coming on 11/9/23 to evaluate the four residents who need a level II PASARR. 40163 4. Review of R74's clinical record revealed: 10/15/20 - R74's preadmission PASARR documented that R74 was exempt for a level II PASARR. 1/15/21 - R74 was admitted to the facility including, but not limited to a diagnosis of dementia. 8/21/22 - R74 had a new diagnosis of persistent mood (affective) disorder. 8/23/22 - R74 had a new diagnosis of post-traumatic stress disorder. 11/2/23 9:53 AM - During an interview, E7 (SW) confirmed that R74 only had one PASARR completed three months prior to his 1/15/21 admission, and had not been referred to [State PASARR contractor] for any further review with his new diagnoses. E7 stated that she would submit another level 1 PASARR to [State PASARR contractor] for further review with his new diagnoses. 11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on interview and record review, it was determined that for three (3) (R40, R89, and R514) out of twenty nine residents reviewed for care plans, the facility failed to develop and implement a comprehensive person-centered care plan for an identified need. Findings include: 1. Review of R40's clinical record revealed: 2/7/17 - R40 was admitted to the facility. 2/26/21 - A comprehensive care plan was initiated for R40's verbally aggressive behavior with the following interventions: allow 10-15 minutes to calm down then reapproach; explain all procedures; and identify triggers that cause outbursts. 10/1/22 - A review of R40's medical diagnoses revealed a diagnosis of dementia unspecified severity with agitation. 5/14/23 - A review of R40's MDS revealed that R40 had a diagnosis of non-alzheimers dementia. 11/1/23 10:25 AM - A review of R40's progress notes revealed R40 was receiving services from psychology related to dementia and bipolar disorder. 11/3/23 2:03 PM - An interview with E21(LPN) revealed that care and interventions are based on a care plan and if a resident does not have one to notify the unit manager to update. 11/3/23 2:12 PM - An interview with E13 (LPN UM) confirmed that R40 did not have a comprehensive person centered care plan related to dementia. 44706 2. Review of R514's clinical record revealed: 7/6/23 - R514 was admitted to the facility with a diagnosis of COPD. Review of R514's physician orders revealed: Respiratory inhaler for COPD. 11/1/23 10:52 AM - An interview with R514 confirmed the use of a respiratory inhaler. 11/1/23 11:11 AM - During an interview, E10 (LPN) confirmed that R514 was administered his respiratory inhaler every morning. 11/1/23 11:14 AM - During an interview, E11 (RN,UM) confirmed that R514 had a diagnosis of COPD and physician orders for respiratory interventions. A record review lacked evidence of a person-centered care plan for R514's respiratory status that included interventions for COPD. 40163 3. Review of R89's clinical record revealed: 4/13/22 - R89 was admitted to the facility. 4/11/23 1:32 PM - R89's weight was documented as 172.8 pounds. 8/24/23 - R89's significant change MDS assessment documented a significant weight loss of 5% in one month or 10% loss in six months, and was not on MD (doctor) prescribed weight loss program. 10/12/23 11:56 AM - A quarterly nutrition assessment documented, Decline in overall meal intakes and unplanned weight loss noted this review period. 10/23/23 11:18 AM - R89's weight was documented as 158.2 pounds (an 8.45 % weight loss since 4/11/23). 11/02/23 2:18 PM - During an interview, E22 (RD) confirmed that although R89 had a significant weight loss, R89's nutrition care plan was not initiated until 10/30/23. E22 stated that it fell through the cracks. 11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference

Based on interview and record review, it was determined that for four (R7, R20, R56, and R87) out of twenty-nine residents reviewed for care plans, the facility failed to ensure the care plan was revised to reflect current care needs. For R7 and R20, the facility failed to have the required members present for the IDT (interdisciplinary team) meeting. Findings include: 1. Review of R56's clinical record revealed the following: 11/22/21 - R56 was admitted to the facility. A care plan for R56 was documented for having a potential/actual impairment impaired mobility with a goal of [R56] will have no complications r/t (related to) DTI (deep tissue injury of the second tow through the review date was initiated on 9/29/22 and revised on 10/21/22. 6/12/23 at 2:52 PM - A nurse's note revealed the following: Resident was noted to have an open area on left foot second toe. Measurement 1.50cm X 0.6cm. Area was measured, dressed and NP and unit manager was informed. 7/24/23 - Bilateral arterial duplex scans completed and revealed no doppler flow detected in left posterior tibialis artery and right dorsalis pedis artery. 8/1/23 - E17 (NP) note for wound assessment documented a wound to the right second toe on the right leg. 10/30/23 9:59 AM - During an interview, R56 stated he has a wound on my toe and it has to be amputated. 11/7/23 12:18 PM - Interview with E3 (CNO) at which time the care plan was reviewed with him. Although the care plan problem was revised on 10/13/23, it refers to a DTI (deep tissue injury) and not an arterial wound. It also did not address R56's current situation. E3 stated he will ensure that the care plan is updated. 46988 2. Review of R87's clinical record revealed: 3/7/22 - R87 was admitted to the facility. 3/14/22 - A careplan for R87 was initiated for ADL self care performance deficit related to limited mobility. 12/8/22 - A physicians order was written for R87 to get out of bed for lunch daily. 11/2/23 9:17 AM - A review of R87's care plan revealed that current interventions did not include R87 to get out of bed for lunch daily. 11/7/23 10:42 AM - An interview with E15 (CNA) confirmed that the CNA task sheet and care plan did not include R87's intervention of getting out of bed daily for lunch. The facility failed to update R87's careplan to reflect the current needs of R87. 44706 The facility's policy on Care Planning revision date 1/12/2023 documented,A comprehensive care plan must be prepared by an interdisciplinary team, that includes . - The attending physician; - A nurse with responsibility for the resident; - A nurse aide with responsibility for the resident; - A member f the food and nutrition services staff; - To the extent practicable, the participation of the resident and the resident's representative; - Other appropriate staff as determined by the resident's needs or as requested by the resident. 3. Review of R7's clinical record revealed: 7/6/23 - R7 was admitted to the facility. 7/22/23 3:27 PM - A review of R7's comprehensive person-centered care plan conference notes revealed the physician and CNA were not present. 11/2/23 2:08 PM - A review of R7's comprehensive person-centered care plan conference notes revealed the physician and CNA were not present. 4. Review of R20's clinical record revealed: 6/12/23 - R20 was admitted to the facility. 6/22/23 10:53 AM - A review of R20's comprehensive person-centered care plan conference notes revealed the physician and CNA were not present. 9/19/23 1:46 PM - A review of R20's comprehensive person-centered care plan conference notes revealed the physician and CNA were not present. 11/7/23 11:18 AM - During an interview, E7 (SW) confirmed there was no physician or their designee in attendance at the meetings. E7 stated they never attend the meetings, I didn't think they had to. E7 also confirmed there wasn't a CNA in attendance at any of the meetings. 11/7/23 12:33 PM - During an interview, E3 (CNO) confirmed that neither the physician, designee or CNA attended or provided input at the meetings. The facility lacked evidence that the post-admission care plan conference meetings included Physician input and CNA input with responsibility for the resident. 11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 and E4 (COO) during the exit conference.

Based on observation, interview and record review, it was determined that for one, (R7), out of three residents reviewed for (ADLs) for activities of daily living, the facility failed to ensure that residents who are unable to carry out ADLs received the necessary services to maintain good grooming. Findings include: 1. 4/3/23 - R7 was admitted to the facility following a stroke. 4/8/23 - An admission MDS documented R7 as needing one person extensive assistance with grooming. 10/30/23 approximately 10:00 AM - During an observation and subsequent interview, R7's fingernails were long and he was unshaven. R7 stated that he would like to have his finger nails trimmed and to be shaved. 11/2/23 1:06 PM - During an interview, at R7's bedside E12 (CNA) confirmed that finger nails on both hands were long and R7 would like them trimmed. E12 stated, I'll trim them, and I'll shave him. E12 also confirmed that grooming was part of providing care. 11/2/23 through 11/6/23 - Multiple observations of R7 revealed that his finger nails had not been trimmed and he was unshaven. 11/6/23 1:15 PM - During an observation R7's finger nails were not trimmed and he was still unshaven, a follow up interview R7 revealed he still wanted to have his finger nails trimmed and to be shaved. 11/6/23 1:23 PM - During an interview, E11 (RN, UM) confirmed that R7's nails had not been trimmed and still remained unshaven. E11 stated that he would, take care of it. 11/7/23 2:55 PM - Observation of R7 revealed his finger nails were trimmed but was still unshaven. Despite shaving being a part of providing grooming to a resident, R7 was not shaved. 11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on observation, interview and record review, it was determined that for two (R58 and R87) out of twenty-nine (29) residents reviewed for quality of care, the facility failed to follow physician orders. Findings include: 1. Review of R58's clinical record revealed: 8/8/22 - R58 was admitted to the facility with dementia. 9/15/23 12:29 AM - A nursing progress note documented, Resident [R58] in roommate's bed hitting him, trying to make him get out of his bed. Staff attempted to redirect resident to his bed, however, resident punched and kicked staff. 9/15/23 11:24 AM - A Physician order included: Resident (R58) placed on 1:1 (one to one) supervision. 11/1/23 3:35 PM - During an interview E3 (CNO) confirmed the facility lacked evidence of one-to-one supervision implemented following a resident-to-resident altercation. 46988 2. Review of R87's clinical record revealed: 3/7/22 - R87 was admitted to the facility. 12/8/22 - A physician's order was written for R87 to get out of bed daily at lunch time. 5/31/23 - A quarterly MDS revealed that R87 is totally dependent for transfer with hoyer lift. 11/01/23 12:38 PM - An observation of R87 in bed during lunch. 11/02/23 12:22 PM - An observation of R87 in bed during lunch. 11/07/23 10:42 AM - An interview with E15 (CNA) revealed that the CNA flow sheet did not reflect the physician's order to get R87 out of bed for lunch daily and confirmed that the CNA's were not aware of this order. 11/07/23 10:52 AM - An interview with E16 (UM) confirmed that nurses will transcribe orders into the electronic records and update the CNA flow sheets to reflect new orders. The facility lacked evidence of following a physician's order for R87 to get out of bed daily for lunch. 11/8/23 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (CNO) and E4 (COO) during the exit conference.

Based on observation, interview, record review and review of the CDC's (Centers for Disease Control) guidance, it was determined that the facility failed to follow the CDC's recommendations during a COVID-19 facility outbreak for one ( R1) out of five sampled, COVID-19 positive residents. The facility failed to ensure adherence to isolation precautions after R1, a COVID-19 positive resident, was observed in the hallway of the non-designated COVID-19 unit without a mask. Residents and employee's were potentially exposed to COVID-19 which could result in the likelihood of a serious outcome if COVID-19 was transmitted from this failure to isolate a COVID-19 positive resident with a history of dementia and wandering into other resident rooms. An immediate jeopardy was called on 11/13/2020 at 4:00 PM and was abated on 11/16/2020 at 1:00 PM. Additionally, the facility failed to send employees home after screening questions yielded responses consistent with signs and symptoms of COVID-19. Lastly, the facility failed to ensure signs related to COVID-19 precautions were placed outside of the door for one (R4) out of five sampled COVID-19 positive residents. Findings include: 1. Review of the CDC's webpage entitled Preparing for COVID-19 in Nursing Homes, last updated 11/20/2020, indicated the following: Implement Source Control Measures. -Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. -If a resident requires a higher level of care or the facility cannot fully implement all recommended infection control precautions, the resident should be transferred to another facility that is capable of implementation. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. Review of the CDC's web page entitled Responding to COVID-19 Considerations for the Public Health Response to COVID-19 in Nursing Homes, last updated 4/30/2020, indicated the following: Response to Newly Identified [DIAGNOSES REDACTED]-CoV-2-infected HCP or Residents Resident with new-onset suspected or confirmed COVID-19 -Ensure the resident is isolated . -If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html. Review of the facility policy for COVID-19, last updated 11/10/2020, indicated the following: Person Under Investigation/COVID-19 confirmed: -The resident will be immediately placed in isolation with contact/droplet precautions . -The resident should wear a facemask to contain secretions, if tolerated. Outbreak management: The facility will establish a separate COVID unit with a separate entrance and exit and dedicated staff where possible. If a sister facility has an established COVID unit, COVID positive residents in previously naive (no suspected or COVID 19 positive residents) facility may be transferred to the organizations designated COVID unit. Review of the facility policy on recommendations for Terminal COVID-19 Isolation Room/Unit Cleaning, last updated 5/20/2020, indicated to wait 24 hours before cleaning or disinfecting, if 24 hours was not feasible wait as long as possible. Review of R1's clinical record revealed: 10/7/2020 - A care plan for socially inappropriate behaviors as evidenced by wandering in and out of others rooms was initiated with a goal that R1 will have less than 3 incidents of wandering in and out of other residents rooms for 90 days. Interventions included to calmly redirect resident out of other's rooms, and re-direct and discourage behavior when noted. 11/2/2020 - A quarterly MDS assessment documented R1 was severely cognitively impaired with a BIMS score of 4 and a [DIAGNOSES REDACTED]. 11/12/2020 1:49 PM - A nurses note documented, spoke with resident's son and informed them that R1 has tested positive for COVID 19 . 11/12/2020 - An order was written for contact isolation secondary to COVID 19 for 14 days. 11/12/2020 -A care plan for R1 testing positive for COVID-19 was initiated and updated 11/13/2020 with a goal of recovering from the illness in 30 days. Interventions for this care plan included: maintain droplet precautions, monitor food/fluid intake, refer to dietary as needed, monitor vital signs and for signs and symptoms related to COVID-19. Notify MD/NP for any changes. 11/12/2020- An additional COVID-19 care plan was initiated with the goal that R1 would not have any complications by the review date and included interventions such as to elevate the head of the bed for comfort and lung expansion, give medications as ordered, monitor for side effects and effectiveness, maintain precautions, isolation - Contact and Droplet, monitor vital signs and any s/sx related to COVID-19 (i.e. fever, sob, cough), notify MD/NP for any changes, and perform hand hygiene before and after resident care. There was no evidence that R1's care plan for wandering was updated to reflect his/her isolation status. 11/12/2020 3:03 PM - A progress note documented, R1 evaluated via telehealth video, assisted by facility NP, roommate tested positive for COVID. R1 was noted with temperature of 99.4 (slightly elevated/low grade temperature) early this morning. +COVID on rapid testing today. Temperature down to 97.8 after Tylenol . Resident is currently otherwise asymptomatic. 11/13/2020 12:22 AM - A nurses note documented resident is on droplet/isolation precautions due to + COVID testing. R1 complied with staying in his/her room this shift, was observed standing at the door and was able to be redirected back to his/her side of the room. 11/13/2020 7:00 AM - During the entrance conference with E5 (DON), it was reported that the facility had a designated 30 bed COVID-19 unit and that some of our COVID positive residents and PUI's are on the non-designated COVID-19 unit as well because of overflow, we ran out of room. 11/13/2020 at 9:20 - 9:23 AM - R1 was observed leaving his room without a mask, then walking toward the beginning of the hall, in the direction of the nurses station. R1 stood for several minutes, then returned to his room without any staff intervention. E15 (CNA) was at the nurses station and stated, R1's COVID -19 positive, but they can't make (R1) stay in their room. 11/13/2020 9:34 AM - A nurses note documented, attempted to encourage R1 to stay in room and wear mask due to COVID Positive, R1 continues to walk in hallway with no mask, and becomes agitated when asked to wear mask or to return to room. 11/13/2020 9:35 AM - R1 was again observed leaving his room without a facemask. R1 walked toward the beginning of the hall and stood for several minutes. E15 (CNA) walked toward R1 and ushered R1 back into his room. 11/13/2020 11:45 AM - E8 (LPN) reported that R1 was transported to the facility's designated COVID-19 unit. During an interview on 11/13/2020 at 11:10 AM with E14 (LPN), when asked if E14 observed R1 going into other residents rooms, E14 stated, we usually catch R1 before that happens. 11/13/2020 2:55 PM - A progress note for R1 documented, yesterday (temperature) at 99.4°F, afebrile (no elevated temperature) since, with stable sats (oxygen levels) in the mid 90's on room air and unchanged activity tolerance. Severe cognitive deficit, has left isolation unit on multiple occasions, wander guard (bracelet worn by residents that are at risk for wandering ; alerts staff with audible alarm when resident is near an alarmed door) in place .resident educated and placed in isolation with droplet precautions for a minimum of 14 days .High risk for elopement - close monitoring advised. There was no evidence of additional monitoring. 11/13/2020 3:20 PM - A nurse's note documented this nurse arrived to the unit this morning and noted resident to be out in the hallway. Staff reports he is COVID positive and they redirect R1 as needed. I went to the resident and was able to get R1 back in his room without difficulty. Later in the morning I noted R1 was in the hallway again while I was helping on the unit. I asked R1 to come back into his room and R1 yelled he was fine where he was. I told R1 there was something on TV to watch and R1 did go into the room and sit down. I finished the task at hand and left the unit. When I returned early afternoon I noted that R1 was no longer on the unit. E8 (LPN) confirmed to the surveyor that R1 was transported to the COVID unit at 11:45 AM. 11/13/2020 at 4:00 PM - An immediate jeopardy (IJ) was called. E1(NHA) began drafting an abatement plan that included education of staff, immediately after notification of the IJ. 11/1/2020- 11/15/2020 - Review of R1's behavior monitoring flowsheet for socially inappropriate behavior evidenced by wandering in and out of residents rooms revealed absence of documentation of monitoring from the overnight shift on 11/11 through the day and evening shift on 11/12 and three episodes of wandering during the day shift on 11/13. During an interview on 11/16/2020 at 8:10 AM, E5 (DON) reported that R1 was not moved to the designated COVID -19 unit upon positive [DIAGNOSES REDACTED]. 11/16/2020 - Review of the census list for the facility's designated COVID-19 unit for 11/12/2020 revealed resident rooms [ROOM NUMBERS] were empty and rooms with COVID positive residents were available for cohorting. During an interview on 11/16/2020 at 11:15 AM, E8 (LPN), E20 (LPN) and E16 (CNA) confirmed receiving education in accordance to the abatement plan upon arrival for their shift. During an interview on 11/16/2020 at 11:30 AM, E4 (former NHA) reported 32/90 nursing employees had received the education indicated in the abatement plan. E4 stated, we are working on something for those who are out of work and off, that accounts for our numbers, either telephone (education) or virtual. 11/16/2020 - The IJ was abated at 1:00 PM. During an interview on 11/17/2020 at 7:50 AM, E19 (LPN) confirmed receiving education related to the abatement was completed upon entry to work. 2. Review of the CDC's webpage entitled Preparing for COVID-19 in Nursing Homes, last updated 11/20/2020 in the Core practices section indicated the following: Evaluate and Manage Healthcare Personnel. - Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that support HCP to stay home when ill. - Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. -Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. Symptoms of Coronavirus, last updated 5/13/2020: People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: -Fever or chills -Cough -Shortness of breath or difficulty breathing -Fatigue -Muscle or body aches -Headache -New loss of taste or smell -Sore throat -Congestion or runny nose -Nausea or vomiting -Diarrhea This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Review of the CDC's webpage entitled Considerations for Use of [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME] Testing in Nursing Homes, last updated 10/23/2020 indicated: Considerations for interpreting [MEDICATION NAME] test results in nursing homes: Testing of symptomatic residents or HCP If an [MEDICATION NAME] test (POC) is presumptive negative, perform RT-PCR immediately (e.g., within 48 hours). -Symptomatic residents and HCP should be kept in transmission-based precautions or excluded from work until RT-PCR results return. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. Review of the facility policy for COVID-19, last updated 11/10/2020, indicated in the Preventative Measures section to perform active screening of health care professionals for signs and symptoms of COVID-19. 11/13/2020 6:45 AM - During an observation of facility screening practices for employee entry, E10 (supply clerk) entered the facility and was screened by E11 (LPN) who obtained E10's temperature and then proceeded to ask E10 screening questions related to symptoms of COVID-19. E10 answered yes to the following signs/symptoms of COVID-19 fatigue, muscle aches, headaches, and GI symptoms nausea, vomiting, diarrhea. E10 then stated, I feel like sh*t, to E11, who directed E10 to go see the nursing supervisor. During an interview on 11/13/2020 at 9:35 AM, E10 (supply clerk) confirmed that he/she was still having symptoms. E10 stated, I waited in my office, they tested me (for COVID-19) and I was negative so now I'm out delivering supplies. E10 was observed on the Scott unit refilling PPE in carts. Immediately following the surveyor interview, E3 (RNC) was observed directing E10 to go home. Review of the 11/13/2020 day shift screening logs revealed that R6 (RN) answered yes to the following signs and symptoms of COVID-19 asked on the screening log sore throat, fatigue, muscle aches, head ache, and GI symptoms nausea, vomiting, diarrhea. During an interview on 11/13/2020 at 3:04 PM, E6 (RN) confirmed the symptoms documented on the screening form and reported that prior to arriving at the facility for work, E6 spoke on the phone with both E5 (DON) and E4 (former NHA), relayed symptoms and was not told to stay home. During an interview on 11/13/2020 at 4:05 PM with E5 (DON) and E4 (former NHA), both confirmed that E6 (RN) reported symptoms prior to arriving to work. E5 stated, I would have sent E10 (supply clerk) home if I had found out sooner, with E6 (RN), I thought it was only a headache. During an interview on 11/13/2020 at 4:09 PM with E2 (RDO), it was reported that since both E5 (RN) and E10 (supply clerk) tested negative for COVID-19 on their (POC) test that day, it was sufficient for them to continue working. E2 stated, they were tested and that is sufficient, otherwise we would be sending everyone home, they could be sick from anything, people have other illnesses. 3. Review of the CDC's webpage entitled Responding to Coronavirus (COVID-19) in Nursing Homes Considerations for the Public Health Response to COVID-19 in Nursing Homes, last updated 4/30/2020, indicated the following: Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html. Review of R4's clinical record revealed the following; 11/12/2020 - An order was written for R4 to be on isolation precautions Contact/Droplet secondary to Covid-19 for 14 days. 11/13/2020 2:00 AM - A progress note documented, late entry for 11/12/2020 at 2200 (10:00 PM). Resident who tested positive with the [MEDICAL CONDITION] . 11/13/2020 - Review of the list of residents with confirmed or suspected cases of COVID-19 provided by the facility at the entrance conference indicated R4 was COVID-19 positive. 11/13/2020 8:45 AM - During observation and a tour of the non-designated COVID-19 unit, which housed COVID-19 positive, COVID-19 naive and PUI residents, R4's room did not have signs instructing HCP of required PPE for entering R4's room. R4 was a COVID-19 positive resident. During an interview on 11/13/2020 at 8:49 AM, E7 (RN) confirmed that R4 was a COVID-19 positive resident and that there was no signage indicating the needed appropriate PPE outside of R4's room. E7 stated, that's R12's (RN-ICP) responsibility. 11/13/2020 8:56 AM - E17 (CNA) was observed leaving R4's room and confirmed knowing that R4 was COVID-19 positive. When asked how E17 was made aware of which residents were COVID-19 positive due to no sign outside of R4's door, E17 stated, I ask when I come on the hall because they change rooms and residents and I want to be sure. During an interview on 11/19/2020 at 12:02 PM, E12 (RN-ICP) confirmed responsibility for placing signs outside of COVID-19 positive residents rooms. E12 then stated, I usually do it, but anyone can do it, the signs are in the isolation carts on the unit. I was off, so the nurse should have placed it. These findings were reviewed with E1 (NHA) and E5 (DON) during the exit conference on 11/20/2020 at 10:00 AM.

Based on record review, observation, and interviews it was determined that for two (R19 and R28) out of 37 sampled residents the facility failed to provide care and treatment to prevent the development of pressure ulcers (PU) and promote the healing of existing pressure ulcers. For R19 the facility failed to ensure consistent offloading of the bilateral heels and R19 developed avoidable bilateral heel PUs. This resulted in harm when an unstageable PU was identified on R19's left heel. Additionally R19 developed a gluteal pressure ulcer; missed 3 days of treatments when orders expired; and, was observed to be sitting in a wheelchair for approximately 4 hours without repositioning, despite an order to remain in bed except for meals. R28, who had a PU and a history of healed PU, was observed without turning and repositioning every two hours. Findings include: 1. The following was reviewed in R19's clinical record: [DATE] (revised [DATE]) - Care plan for PU - Actual Pressure Ulcer: stage 3 ulcer of right gluteus. (R19) to be out of bed for meals only at this time. [DATE] Right heel stage 2; left heel unable to stage. Approaches included: -Braden risk assessment on admission, quarterly, and PRN -off load heels -measure weekly -pressure relieving device to bed/chair; air mattress to bed -skin check every 2 hours -treatment as ordered -weekly skin check on shower days -turn and reposition every two hours and PRN MDS -Significant change dated [DATE] : -Bed mobility-extensive assist of two -Transfer-extensive assist of two -Toileting-extensive assist of one -Always incontinent of bowel and bladder Braden Scale: [DATE] - 13 moderate risk for PU. [DATE] - 12 high risk for PU. Weekly Skin Checks: [DATE] -no issues identified. [DATE] -open area to left (actually right) buttocks. [DATE] - no skin check documented. [DATE] - treatment in progress to right buttocks, new area to bilateral heels, wound care evaluated today. a. [DATE] OT note - Patient seen at bedside for bed positioning due to active buttocks (sic). Patient was properly positioned in bed in side lying (sic) to alleviate pressure. Staff was educated on proper positioning in bed and a new wheelchair gel cushion warranted in order to decrease risk of skin breakdown. [DATE] 8:23 AM - In bed on back head of bed up 45 degrees pillow under knees and heels against bed not offloaded. [DATE] 10:03 AM- R19 in bed on back. Pillow beneath knees and heels against the mattress. Pillow to right side of R19 and not offloading gluteal pressure ulcer. [DATE] 11:33 AM - R19 in bed and on back with head of bed at 45 degrees. Pillow under legs and heels against mattress. [DATE] 9:32 AM - R19 on back and head of bed at 45 degrees. Pillow under knees and heels against bed. [DATE] - Consultant wound nurse documented: -Full-thickness wound of the left heel 2.0 x 3.2 cm. Wound base is 50% reabsorbing blood blister, 50% granular . -Partial thickness wound of the right heel 1.2 x 1.2 cm. Wound base is a serous blister . [DATE] 3:41 PM - Progress note documented wound care to the left heel DTI (deep tissue injury) as cleanse with normal saline solution and apply [MEDICATION NAME] and clean dry dressing daily. [DATE] 2:23 PM - R19 observed in bed on right side pillow under calves and feet/heels against mattress. [DATE] 3:38 PM - Observation of left heel elevated on pillow with offloading but right heel resting on bed with pillow under calf. [DATE] 8:01 AM - Observation in bed on right side with both feet on bed. Although there are pillows under legs, there is no offloading of heels. [DATE] 9:25 AM - Observation in bed on back with both heels on bed. [DATE] 9:21 AM - Interview with E7 (RN/UM) revealed that prior to the heel wound developing skin prep was being used on R19's heels. It was confirmed that there was no weekly skin assessment documented between ,[DATE] and [DATE] when the heel pressure ulcers were found. E7 stated that after developing a pressure sore on her right buttock, R19 was put on bedrest except for meals. E7 stated that she thought that lying down so much may have contributed to the heels breaking down. Observations of lack of heel offloading was reviewed with E7. [DATE] 10:50 AM - Interview with E20 (OT) and E19 (Rehab Director) revealed that E20 was seeing R19 for feeding issues and was asked to assess her positioning and wheelchair cushion. Although R19 had a cushion in her wheelchair it was not a good one for her and a gel cushion was recommended. She stated that the last time she checked the gel cushion had not been put in place and stated that nursing obtains and places the seat cushions. E19 and E20 then went to R19's room with the surveyor to check the wheelchair and the resident's positioning. The gel cushion was in the wheelchair. R19 was in bed with both heels resting on the mattress with no offloading. It was noted that the resident has fixed contractures to the lower extremities with legs crossed and was unable to move or reposition her own legs. E19 did however state that the resident has some trunk movement and could move her upper body from side towards back when positioned on side. Additional pillows were obtained and R19 was repositioned with heels offloaded. E6 (RN) entered room during repositioning and assisted. E20 stated that she has reviewed proper positioning with the aide during her visits with the resident but confirmed positioning information was not included in the care instruction sheets located in the resident's closet. [DATE] 11:50 AM - Interview with E2 (DON), E3 (ADON) and E4 (CRN) about proper positioning, revealed that inservice with staff is done if needed and communication can be put in the point of care in the EMR (no positioning instructions found in point of care). It was added that if therapy found a good way to position a resident a picture could be put in the closet. The facility failed to ensure consistent offloading of R19's heels resulting in the development of two avoidable PU. R19 was harmed by the development of an avoidable unstageable pressure ulcer to the left heel. b. [DATE] - Progress note documented the identification of a new stage 3 gluteal pressure ulcer. [DATE]- Evaluation by facility contracted Wound Care Consultant confirmed pressure ulcer of the right gluteal area of new onset and ordered a Santyl (wound [MEDICATION NAME]) treatment daily and as needed. ,[DATE] - [DATE] - physician's orders [REDACTED]. [DATE]-[DATE] -No treatment order noted or documentation on treatment record for the right gluteal pressure ulcer. [DATE] - physician's orders [REDACTED]. [DATE] 1:58 PM - Interview with E7 (RN/UM) and E16 (RN) revealed that R19 had a sacral wound and a wound between overlapping toes on left foot. Last dressing done to gluteal pressure ulcer was [DATE]. Reported Santyl dressings in facility are only done for 7 days then require re-evaluation and new orders. The re-evaluation was not done until [DATE]. [DATE] 12:06 PM- Interview with E7 who reported that gluteal wound onset was [DATE]. First evaluated by wound care nurse practitioner on [DATE]. Per E7 the staff was just doing a dressing from ,[DATE]-[DATE]. She confirmed that Santyl dressings are only done for 7 days in the facility and then re-evaluated. New orders must be obtained for new treatment or to continue the same treatment. There was no evidence that staff obtained a treatment order for ,[DATE] - [DATE] when the initial order had expired. [DATE] 10:45 AM - Interview with E17 (RN) confirmed that there was no new order for a treatment of [REDACTED]. New order not written until [DATE]. [DATE] 10:58 AM - Interview with E3 (ADON) who also confirmed that the treatment record reflected missing documentation for treatment of [REDACTED]. The facility failed to: promote wound healing; re-evaluate the wound; and, obtain a physician's treatment order for 3 days. c. [DATE]- Revised care plan for actual pressure ulcer stage 3 of right gluteus included: R19 to be out of bed for meals only. [DATE] - Surveyor observation revealed the following: - 8:53 AM, R19 up in wheelchair in activity room for breakfast. - 9:07 AM, R19 in wheelchair parked across from the nurses station. - 9:44 AM, R19 remains in wheelchair in front of nurses station. - 10:07 AM, R19 remains in wheelchair in activities room. - 11:06 AM, R19 remains in activities up in wheelchair. - 12:23 PM, R19 remains out of bed in wheelchair in activities and at table for lunch. - 12:54 PM - R19 remains up in wheelchair across form nurses station. - 8:53 AM - 12:54 PM, no noted repositioning while in wheelchair despite a documented approach to turn and reposition R19 every 2 hours and PRN. - 8:53 AM - 12:54 PM, R19 was out of bed and in a wheelchair for approximately 4 hours despite a documented approach that R19 was to be out of bed in a wheelchair only for meals. [DATE] 11:50 AM - Interview with E2 (DON), E3 (ADON) and E4 (CRN) revealed that gel cushions are kept in E3's office and when initiated there should be a note in the record (no note found). The gel cushion was currently in place. The facility failed to: promote healing; reposition every two hours; and, ensure R19 was only out of bed for meals. 2. The following was reviewed in R28's clinical record: [DATE] (revised [DATE]) PU care plan for potential for PU related to decreased functional ability with approaches that included: -Braden risk as ordered -cushion to wheelchair as ordered -encourage turn and reposition every 2 hours and as needed -ensure measures are taken to prevent/reduce potential shearing or friction during transfers. -neuropedic bed provided -preventative skin measures as ordered -weekly skin assessment [DATE] - physician's orders [REDACTED]. [DATE] - significant change MDS documented severe cognitive impairment, extensive assistance with two person physical assist with bed mobility, dependent on staff for eating and hygiene, at risk for PU, unhealed PU that was unstageable. [DATE] - Care plan for actual PU - Unstageable to left gluteus with approaches that included: -measure weekly -pressure relieving device to bed/chair -skin check every 2 hours -treatment as ordered -weekly skin check on shower days [DATE] - physician's orders [REDACTED]. [DATE] - physician's orders [REDACTED]. [DATE] - Braden scale 11 high risk [DATE] - Care plan for PU - Actual PU left ear -measure weekly -pressure relieving device to be on the oxygen tube -treatment as ordered July (YEAR) - CNA data lists turn and reposition every 2 hours does not mention side to side turning. Observations during the survey revealed: [DATE] 3:21 PM - in bed on back. [DATE] 8:32 AM; 9:34 AM; 10:37 AM; 12:43 PM; 2:21 PM - in bed on back. [DATE] 8:03 AM and 9:31 AM in bed on back. [DATE] 12:18 PM - Interview with E6 (RN) revealed that the PU to the left gluteus had healed. [DATE] 12:11 PM - Interview with E6 revealed that the order for side to side turning should have been discontinued when the PU resolved and the resident should be turned side, back, side. The CNA data only indicated turn and reposition every two hours and did not mention side to side turning. [DATE] 12:08 PM - Interview with E2 (DON), E3 (ADON), and E4 (CRN) lack of turning and repositioning was reviewed. These findings were reviewed on [DATE], at approximately 4:30 PM with E1 (NHA), E2, E3 and E4 during the exit conference.

Based on review of the clinical records and interviews it was determined that the facility failed to identify the significance of the ear drainage and failed to notify the MD and the supervisor of that significant change in status at the onset for one (R1) out of 5 sampled residents. R1 was admitted to the facility on [DATE] with history of a recent fall that occurred on 4/15/18, and which resulted in a subarachnoid hemorrhage and a subdural hemorrhage of the brain. R1 sustained harm when the onset of the ear drainage documented on 4/27/18 at 10:30 PM failed to be identified as a significant change. This failure resulted in R1 not being assessed for approximately 10 hours, at which time R1 exhibited additional symptoms of headache and weakness. These failures resulted in a delay in treatment and a delay in transportation to a higher level of care. Findings include: Cross refer F689 and F 678 Review of R1's hospital record and clinical record revealed the following; R1 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. R1 was discharged from the hospital to the facility on [DATE]. The interagency transfer form, a form that described R1's status and care from the hospital provided to the facility, documented R1 as confused, oriented to person, cooperative, able to communicate and understand using speech, a fall risk with a history of falls, requiring partial assistance to transfer and ambulate. Discharge instructions provided advised to get help right away if experiencing: Sudden weakness in face, arm, leg. Trouble talking or understanding. Trouble walking. Loss of balance or movement clumsy and uncoordinated. Suddenly have a very bad headache. R1 was admitted to the facility on Friday, 4/27/18 at 7:18 PM. 4/27/18 at 9:59 PM - a progress note written by E11 (LPN) documented R1 arrived to the facility at 7:18 PM alert with confusion, no signs or symptoms of respiratory distress and multiple [DIAGNOSES REDACTED]. 4/27/18 at 10:30 PM (Approximately 3 hours after admission) A progress note written by E11 (LPN) documented, upon assessment R1 noted to have fluid draining from his left ear. There is no evidence that a physician or supervisor was notified of this change. 4/28/18 at 8:37 AM - A progress note written by E4 (RN) documented received report from 11-7 nurse (E10 (LPN)) that resident had drainage leaking from left ear. E4 (approximately 10 hours after the above documented ear drainage) immediately went to assess R1. E8 (CNA) reported that she had cleaned yellow brownish drainage from resident's ear during ADL's. Vital signs and neurological checks were performed and hand grasps were weak. R1 reported he had a headache and felt weak. E4 documented she told R1 he would get something for his headache, notified the supervisor (at the nurses station) and E10 of the assessment and to call a doctor to make them aware of the concerns. There was no documentation in R1's record of physician notification. Review of R1's clinical record did not reveal documentation of any additional assessments or monitoring after the initial set of vital signs and neurological checks performed by E4 (RN). 4/28/18 - An untimed physical therapy note written by E7 (PT) documented When entering R1's room, patient presented with signs of distress and legs dangling out of bed. R1 was unable to speak clearly and complaining about a headache. All extremities were flaccid, patient needed assistance of two staff for sitting at the edge of the bed. Communicated with nurse (E4 (RN)) about concerns and her opinion about sending R1 out. R1 fell from the bed unattended and was found unresponsive. On an additional written statement documented on 5/10/18 E7 estimated her arrival to R1's room on 4/28/18 to be around 7:00 AM. During an interview on 5/10/18 at 10:42 AM with E7 (PT) it was confirmed that upon E7's entry into the room for an initial physical therapy assessment R1 was in distress, head back, tried to talk he would say a few words, I asked if he had a headache and he said yes. E7 reports she then notified R1's nurse (E4 (RN)). During an interview on 5/10/18 at 11:15 AM E8 (CNA) confirmed that R1 had a change in status between ADL care and the physical therapy assessment, stating earlier during ADL care, R1was talking and stated he wasn't in pain. During an interview on 5/11/18 at 9:08 AM with E4 (RN) it was reported that E4 entered R1's room at the beginning of the shift and R1 complained of a headache and E8 (CNA) confirmed drainage from his ear. E4 then told the supervisor that she was concerned about R1 due to his recent medical history and was instructed to perform neurological checks and then notify the doctor. E4 stated she went back to read through R1's chart and hospital records then returned to R1's room to perform the neurological checks. When E4 assessed R1 she stated he was alert, but not talking to me, but he had talked to aide previously during his bath, he had some overall all weakness, and hand grasp weakness on the right side. E4 reported that she was told by E7 (PT) that the description of the resident on the hospital discharge record was different from her assessment and that R1 according to the prior record could walk, but E7 (PT) assessed a lot of weakness. E4 reports she finished report to relieve E10 (LPN), who was the assigned nurse prior shift, received keys to her cart and then E9 (CNA) told her that R1 was on the floor. E4 estimated having left R1 alone after the neurological assessment about 15 minutes. The surveyor asked if R1 should have been monitored and supervised while having a change in status as evidenced by a new onset of complaint of headache, decreased verbal response and weakness. E4 indicated that the resident should have been monitored but stated no, but I had to call the doctor. E4 explained she did not delegate to E8 to stay with R1 because he was in bed and the breakfast trays were on the unit to be handed out to residents. During an interview on 5/11/18 at 3:06 PM with E10 (LPN) it was reported that, on 4/28/18, R1 had drainage from his ear, and was alert throughout the night. E10 explained that in the morning when giving report to E4, we went to see him and E8 (CNA) said he was complaining of a head ache and E10 stated she left about 7:45 AM. Following a documented change of status as evidenced by a new onset of ear drainage, followed later by a new onset of head ache, documented weakness during neurological checks and decreased verbal response, R1 on the morning of 4/28/18 developed signs and symptoms of respiratory distress and the need for emergent care and was transported to the hospital. These findings were reviewed with E1 (NHA) and E2 (DON) on 5/11/18 at 3:00 PM.

Cross refer to F 684 and F 678 Based on review of clinical records and interviews it was determined that the facility failed to provide adequate supervision resulting in an unsupervised fall, immediately followed by non-responsiveness which resulted in the need for CPR, emergent care and hospital transport for one (R1) out of 5 sampled residents. R1 sustained harm when he was left alone unsupervised and fell during a period of change in status that was later followed by non-responsiveness. This failure by the facility culminated in transport of R1 to the emergency room . Findings include: Review of R1's clinical record and hospital record revealed the following; R1 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. R1 was discharged from the hospital to the facility on [DATE]. The interagency transfer form, a form that described R1's status and care from the hospital provided to the facility, documented R1 as confused, oriented to person, cooperative, able to communicate and understand using speech, a fall risk with a history of falls, requiring partial assistance to transfer and ambulate. Discharge instructions provided advised to get help right away if experiencing: Sudden weakness in face, arm, leg. Trouble talking or understanding. Trouble walking. Loss of balance or movement clumsy and uncoordinated. Suddenly have a very bad headache. R1 was admitted to the facility on Friday, [DATE] at 7:18 PM. [DATE] at 9:59 PM - a progress note written by E11 (LPN) documented R1 arrived to the facility at 7:18 PM alert with confusion, no signs or symptoms of respiratory distress and multiple [DIAGNOSES REDACTED]. [DATE] at 10:30 PM (Approximately 3 hours after admission) A progress note written by E11 documented upon assessment R1 noted to have fluid draining from his left ear. There is no evidence that a physician or supervisor was notified of this change. [DATE] - An initial fall risk assessment scored R1 as an 18 and moderately at risk for falls. [DATE] at 8:37 AM - A progress note written by E4 (RN) documented received report from ,[DATE] nurse (E10 (LPN)) that resident had drainage leaking from left ear. E4 (approximately 10 hours after the above documented ear drainage) immediately went to assess R1. E8 (CNA) reported that she had cleaned yellow brownish drainage from resident's ear during ADL's. Vital signs and neurological checks were performed and hand grasps were weak. R1 reported he had a headache and felt weak. E4 documented she told R1 he would get something for his headache, notified the supervisor (at the nurses station) and E10 of the assessment and to call a doctor to make them aware of the concerns. The next moment I was informed (by E9 (CNA)) the resident had fallen on the floor. Upon re-entering the room, R1 was laying on his back. R1's roommate reported that the resident hit his head on the oxygen machine when he fell . [DATE] - E8 (CNA) documented in a written statement that R1 was on the floor when I went in, he was not responsive, we did a sternal rub and he came to .within seconds he became unresponsive again and we did the sternal rub again, no response then he started turning blue, I called for a crash cart because we had a pulse for a couple of minutes. E8 documented this occurred at an estimated time of 7:40 AM. [DATE] - An un-timed written statement by E9 (CNA) documented this morning around 8:00 AM I walked down the hallway with the food cart to pass breakfast trays I turned to go into a resident room and saw R1 on the floor. [DATE] - An untimed physical therapy note written by E7 (PT) documented When entering R1's room, patient presented with signs of distress and legs dangling out of bed. R1 was unable to speak clearly and complaining about a headache. All extremities were flaccid, patient needed assistance of two staff for sitting at the edge of the bed. Communicated with nurse (E4 RN) about concerns and her opinion about sending R1 out. R1 fell from the bed unattended and was found unresponsive. On an additional written statement documented on [DATE] E7 estimated her arrival to R1's room on [DATE] to be around 7:00 AM. During an interview on [DATE] at 11:15 AM with E8 (CNA) it was reported that after assisting E7 (PT) in positioning R1 in bed, E8 left R1 in the room for about 15 minutes then, E9 (CNA) said he was on the floor. E8 confirmed that R1 had a change in status between ADL care and the physical therapy assessment, stating earlier during ADL care, R1was talking and stated he wasn't in pain. During an interview on [DATE] at 9:08 AM with E4 (RN) it was reported that E4 entered R1's room at the beginning of the shift and R1 complained of a headache and E8 (CNA) confirmed drainage from his ear. E4 then told the supervisor that she was concerned about R1 due to his recent medical history and was instructed to perform neurological checks and then notify the doctor. E4 stated she went back to read through R1's chart and hospital records then returned to R1's room to perform the neurological checks. When E4 assessed R1 she stated he was alert, but not talking to me, but he had talked to aide previously during his bath, he had some overall all weakness, and hand grasp weakness on the right side. E4 reported that she was told by E7 (PT) that the description of the resident on the hospital discharge record was different from her assessment; and E7 stated that R1, according to the prior record could walk, but E7 assessed a lot of weakness. E4 reports she finished report to relieve E10 (LPN) who was the assigned nurse prior shift, received keys to her cart then E9 (CNA) told her that R1 was on the floor. E4 estimated having left R1 alone after the neurological assessment about 15 minutes. The surveyor asked if R1 should have been monitored and supervised while having a change in status as evidenced by a new onset complaint of headache, decreased verbal response and weakness, E4 indicated that the resident should have been monitored but stated no, but I had to call the doctor. E4 explained she did not delegate to E8 to stay with R1 because he was in bed and the breakfast trays were on the unit to be handed out to residents. During the same interview on [DATE] at 9:08 AM with E4 (RN) it was reported that on [DATE] I went in the room and R1 was on the floor .and he wasn't looking good and I guess when he fell , his nasal (nose) cannula (tube to deliver oxygen) had fell out, his oxygen level was reading 76 and I titrated and it wasn't going up so I told the aide I was gonna (sic) go get a non-rebreather mask. Following a documented change of status as evidenced by a new onset of ear drainage, new onset of a head ache, documented weakness during neurological checks and decreased verbal response, R1 was left unsupervised and experienced an unwitnessed fall on the morning of [DATE]. R1 developed signs and symptoms of respiratory distress and the need for emergent care following this unwitnessed fall. R1 had been left unsupervised for an estimated 15 minutes during which R1 experienced a fall and hit his head on the oxygen machine. R1 experienced an avoidable accident related to the absence of supervision and monitoring during a change in status. These findings were reviewed with E1 (NHA) and E2 (DON) on [DATE] at 3:00 PM.

Based on record review, staff interviews, and review of other documentation as indicated it was determined that the facility failed to ensure that one (1) of four (4) residents reviewed (R1) was free of significant medication errors. R1 received six (6) doses of [MEDICATION NAME], a blood-thinning medication, after this medication should have been discontinued according to physician orders. Subsequent to the six erroneously administered doses, R1 experienced extensive superficial bruising of the abdomen, right side, and right leg after she (R1) was found lying across her roommate's legs on her (R1's) abdominal area and right side. Findings include: R1 was admitted to the facility on [DATE] with a physician's orders [REDACTED]. (a blood test which measures the time it takes for a person's blood to clot) was greater than 2 (seconds). The hospital discharge instructions called for staff to "continue ([MEDICATION NAME]) until INR greater than 2 (seconds)". This hospital discharge instruction was correctly copied onto the Medication Administration Record (MAR) in the area where the nurses were to sign off administration of this medication. In addition to [MEDICATION NAME], R1's admission orders [REDACTED]. A laboratory report dated 3/26/14 indicated that R1's INR was 2.59 seconds which meant that the [MEDICATION NAME] should have been discontinued since R1's INR was "greater than 2 (seconds)". The facility nurses, however, failed to discontinue the medication and administered [MEDICATION NAME] 60 mg subcutaneously to R1 on the following dates / times documented on the MAR: -3/26/14 8 PM -3/27/14 8 AM -3/27/14 8 PM -3/28/14 8 AM -3/28/14 8 PM -3/29/14 8 AM On 3/28/14, a laboratory report indicated that R1's INR had increased to 3.39 seconds. When notified of this result, R1's physician (E3) ordered R1's [MEDICATION NAME] (a different blood thinning medication taken in pill form) to be held for the next 4 days. According to an incident report, dated 3/29/14 timed 6:30 PM, R1 was observed to have bruising of the abdomen and right side and was sent to the hospital for evaluation. R1's INR was tested on that date in the hospital and revealed a result of 2.41 seconds (within the therapeutic range of 2 - 3 seconds printed on the laboratory report). E8 (hospital physician) examined R1 upon admission to the hospital and documented that her abdomen was soft and non-tender with extensive bruising towards the right side of R1's abdomen and flank. The discharge summary for this hospitalization following diagnostic tests and evaluation dated 4/5/14 indicated that R1 had "abdominal bruising secondary to [MEDICATION NAME] injection" which was much improved. The facility reported the six (6) medication errors involving [MEDICATION NAME] erroneously administered to R1 to the State survey agency and conducted an internal investigation. After obtaining written statements and interviewing the nurses involved, E2 (Director of Nursing) stated to the surveyor on 4/2/14 at approximately 1:50 PM that the five (5) nurses involved had acknowledged that the instruction to discontinue the [MEDICATION NAME] when R1's INR was greater than 2 seconds was written on the MAR, however, they (nurses) failed to read it. During their investigation of the medication error, the facility identified that on the morning of 3/29/14, R1 had been found lying on the legs of her roommate (R4) while R4 was in her own bed. The surveyor interviewed R4 on 4/7/14 at 6 PM and R4 confirmed that she had awakened that morning (on 3/29/14) and was alarmed because she (R4) could not move her legs. R4 stated that she then opened her eyes and saw R1 lying on top of her (R4's) legs. R4 stated that she was unsure how long R1 had been there". R4 confirmed that R1's right side and abdominal area were leaning against R4's legs. Findings were confirmed with E1 (Administrator) and E2 on 4/10/14 at 2 PM.

Based on record review and staff interviews, it was determined that the facility failed to ensure that one (R234) out of 43 sampled residents was provided with sufficient fluid intake to maintain proper hydration and health. The facility failed to properly assess and identify the increased risk of dehydration for R234 when the resident experienced diarrhea, had changes in mental status, lost approximately 12 pounds (#) in one week and an additional seven pounds the following week while continuing to receive [MEDICATION NAME] (diuretic) 80 mg. (milligrams) on a daily basis. The facility failed to respond in a timely manner to address the above risk factors and failed to closely monitor R234 which resulted in abnormal laboratory values indicating dehydration and requiring intravenous (IV) fluids through the veins. In addition, when the facility identified the presence of the dehydration, the facility failed to ensure aggressive oral hydration of an additional 120 cc (cubic centimeter) of fluids with each medication pass (five times per day) was carried out consistently. Findings include: R234 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] documented that R234 was independent with daily decision making, was moderately impaired for vision, had partial loss of one side (left) of the body of arm and leg, required extensive assistance of one staff for eating, and was frequently incontinent of bowel and bladder. In addition, R234's height and weight was 64 inches and 225 pounds (#) respectively. Subsequent MDS assessments dated 1/16/09 and 2/2/09 noted R234 was independent with eating and required set-up only and that her weight was 230# and 211# respectively (noted resident triggered for 5% or more wt loss within last 30 days). The admission blood work at the facility dated 1/6/09 indicated that the resident's blood urea nitrogen (BUN) level was elevated at 31 (normal range 10-26 mg /dl) and that the creatinine (creat.) level was elevated at 1.7 (normal range 0.5-1.5 mg/dl). In addition, the sodium level was within normal at 139 (normal range 135-145 mmol/L). BUN, creatinine, and sodium levels are indicators of fluid imbalance and renal function. Initial registered dietician (RD) assessment dated [DATE] documented R234's estimated fluid requirement of 1,989 cc per day and that the resident was at "no to low risk" for hydration issues. RD progress note dated 1/12/09 documented average meal intake of 95 % with 1,066 cc fluids from meals. In addition, weight was stable between 225# (1/6/09) and 229.8# (1/10/09). The care plan for potential for alteration in nutrition implemented on 1/8/09 included the following approaches: - encourage oral fluids. - monitor oral intake, labs, weights, skin, medications, and hydration. The goals included adequate hydration. There was no update on this care plan. The resident's care plan for potential for dehydration implemented on 1/9/09 included the following approaches: - encourage fluid consumption and to monitor adequate intake. - monitor labs as available. - monitor level of consciousness changes. The goal included that R234 will have no signs or symptoms of dehydration. Although the resident was noted to have increasing BUN and [MEDICATION NAME] along with weight loss, the only revision in the care plan was noted on 2/3/09. The 2/3/09 revision noted that on 1/30/09, the physician was notified of BUN 90 (incorrect information since BUN was 97); creat. 2.4 and that IV fluids were initiated. Lab result on 2/2/09 was BUN 80; creat. 2.0. Will continue to observe/monitor. Fluids have been encouraged and given to R234 frequently secondary to impaired vision, also noted with some occasional confusion recently. Attending physician (E22) progress note dated 1/21/09 noted R234 complaints of frequent loose stool and an order to test the stool for [MEDICAL CONDITION] was ordered (1/26/09 negative result obtained). Although this note documented complaints of frequent loose stool, review of the nurses notes from admission 1/6/09 through 1/31/09 failed to document any loose stool. Review of weekly weights noted the following: 1/17/09 230.1# 1/24/09 218.0# (approximately 12# loss) Review of facility's policy titled "Weights-Taking and Recording Monthly and Weekly" noted re-weights will be done on any resident who experienced a 10 # weight fluctuation and is >or = to 200# and that re-weight will be done within 24 hours with the presence of a nurse and once the fluctuation has been confirmed, the Dietician/designee will be notified and that the resident will be reported at the next weekly High Risk Committee by the RD/or designee and the Unit Manager/Designee will notify the resident's physician and family member. Record review lacked evidence of a re-weight, a referral to the RD, the High Risk Committee, notification of the attending physician, or a family notification. Above findings were reviewed with the administrator (E1) and Director of Nursing (E2) on 12/2/09 at approximately 1:45 PM. In addition, interview with the attending physician (E22) on 12/2/09 at approximately 2:30 PM revealed that he does not recall whether he was notified of the approximate 12 # weight loss, however, as the facility's medical director, with this weight loss, the expectation was that the physician be notified as well as the family and the resident's condition be discussed in the High Risk Committee. Subsequent review of laboratory results dated [DATE] indicated both BUN and creat. were abnormal at 65 and 2.0 respectively. A handwritten initial by the attending physician (E22) was noted on the document and with a date of "2/11/09." An interview with E22 on 12/2/09 at approximately 2:30 PM revealed that he does not recall whether he was notified of the results on 1/24/09 and that the initial and date reflected the date when he physically saw the report in the facility. Review of the "24 hours report" for 1/24/09 with the DON (E2) on 12/1/09 at approximately 11 AM confirmed that there was no communication of the abnormal laboratory result for R234 in the 24 hour report or in the nurse's notes. Review of nurse's note dated 1/25/09 timed 7 AM-7 PM noted changes in mental status with resident being confused and disoriented. The attending physician was notified and an order was received for urine culture and sensitivity (results negative on 1/30/09 for infection). Although R234's fluid consumption was documented on the CNA Food Intake from 1/24/09 through 1/29/09 it was noted that R234's fluid intake was less than half of her estimated need, there was no nursing or dietician response. Review of 1/30/09 BUN and creat. noted increased results at 97 and 2.4 respectively. E22 was contacted and the following physician order [REDACTED]. - to give 120 cc of extra fluids per medication pass (five med pass scheduled per day) - decrease [MEDICATION NAME] to 40 mg. daily - one liter of normal saline at 125 cc per hour IV Nurse's note dated 2/1/09 timed 7 AM - 7 PM noted "chronic diarrhea" and medicated with [MEDICATION NAME]. Also, that the episodes of diarrhea were not as frequent but needs to be monitored for future episodes. Even though this note indicated chronic diarrhea, review of the January Medication Administration Record (MAR) lacked any evidence of that the [MEDICATION NAME] was administered. Interview with the DON and Unit Manager on 2/8/09 at approximately 9:30 AM confirmed the lack of documentation. Subsequent to the above complaint of diarrhea, on 2/3/09, the resident was ordered [MEDICATION NAME] 2 mg. capsule every four hours as needed which R234 received three doses each day on 2/4/09 and 2/5/09. Review of the January 2009 MAR revealed that R234 was provided the additional 120 cc of extra fluids per med pass (five med pass per day). Next weekly weight on 1/31/09 was 211.4#, approximately seven (7) additional pound loss in one week. Despite an order for [REDACTED]. The MAR revealed a hand-written intervention of "120 cc extra fluids per med pass, however, there was no signature by the staff nurses which indicated that these additional fluids were given to R234. Review of R234's fluid consumption, as documented on the CNA Food Intake document from 2/1/09 through 2/5/09 noted R234's fluid intake to be only 540cc, 720cc, 420cc, 480cc, and 720cc. An interview with the DON (E2) and the Unit Manager (E6) on 12/2/09 at approximately 10 AM revealed that the extra fluids would have been documented on the MAR and in addition, E2 and E6 confirmed that no tracking of total fluids on a daily basis was being completed for R234. Thus, the facility failed to have a system to monitor R234's fluid consumption. On 2/2/09, BUN was 80 and creat. 2.0 and nurse's note dated 2/2/09 timed 2:30 PM documented results faxed to attending physician's office per on call physician's request. On 2/3/09, order received from E22 for an additional one liter of normal saline via IV which was administered on 2/3/09. physician progress notes [REDACTED]. Under assessment "(A)/plan (P): Azotemia (the accumulation of abnormally large amounts of nitrogen containing compounds such as urea, [MEDICATION NAME], various body waste compounds in the blood)/CKD recheck labs today, continue aggressive p.o. (oral) hydration." Review of 2/5/09 laboratory result noted BUN and creat. of 89 and 2.2 respectively and E22 was contacted. Order received for one additional liter of normal saline at 125 cc per hour. Nurse's note dated 2/5/09 and timed 4PM noted unable to start IV at the facility and that E22 was notified. An order was received to send R234 to the hospital for insertion of a IV line in which R234 received one additional liter of normal saline fluid. Review of nurse's note dated 2/5/09 timed 3PM-11 PM shift noted resident returned from the emergency room and was noted to have dry mucous membranes during the nursing assessment. The facility failed to have a system in place to monitor R234's fluids which resulted in the resident requiring the administration of IV fluids.