Every finding on record at Cadia Rehabilitation Pike Creek

Based on observation, interview, and record review, it was determined that for two (R1and R2) out of three residents reviewed for accident hazards and falls, the facility failed to ensure that R1 and R2 received adequate assistance and supervision to prevent falls to the extent possible. R1, a cognitively impaired and completely dependent resident, sustained a fall on 6/9/26 at 4:15 PM when a staff member used an incorrect mechanical lift and sling to perform a transfer from the wheelchair to the bed. This fall caused R1 to suffer a hematoma to the front of her head, and she was sent emergently to the hospital. R1 was diagnosed with multiple brain bleeds and skull fractures. Due to this failure, an Immediate Jeopardy (IJ) was called at 9: 00 AM on 6/16/26. For R2, a resident who required two staff members' assistance with bed mobility, was repositioned in the bed with one person's assistance. R2 fell from the bed to the floor and was sent emergently to the hospital. Based on review of the facility's evidence to correct the deficient practice and substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 6/12/26. Findings include:A facility document entitled Fall Assessment, Prevention and Management, dated 6/2006 and revised 1/20/23 and 1/13/26, included, It is the policy of (name of facility) to assess for fall risks and implement measures to prevent and manage the identified risks. 1. R1's clinical records revealed: 12/19/23 – R1 was admitted to the facility with diagnoses including but not limited to dementia, stroke, and end-stage kidney disease. 4/28/26 – R1' s transfer care plan included, Resident [R1] requires Hoyer lift for transfers (Assist of 2). 5/28/26 – R1's annual MDS assessment documented a BIMS score of 00, indicating a severely impaired cognitive status. R1 was completely dependent on staff for all transfers between surfaces. 6/9/26 4:20 PM – R1's clinical documentation included, .Called to the resident's room and saw the resident lying on the floor. The resident slipped out of the Hoyer lift during transfer. The resident was assessed by the NP, and a bump on the back of her head was noted. Husband present and asked for her to be assessed at the ER [emergency room]. 911 was called. 6/9/26 5:26 PM – A facility reported incident submitted to the Division documented, Resident transferred to the ED [emergency department] s/p [status post] related to contusion to posterior head. 6/15/26 1:20 PM – During an interview, E4 (CNA) stated, I answered the call bell and saw the resident sitting in the wheelchair in her room. Her husband [F1] asked me to put her to bed. I got the Hoyer lift and the sling. I placed the sling under the resident and hooked it up to the lift. I started to raise the lift, and the resident fell to the floor. I went and got the nurse. The Surveyor asked E4 how long he had been a CNA and if he had worked with R1 prior to the fall. E4 stated, I have been a CNA for three months, and this is my first job. This was the first time I was working with this resident. The Surveyor then asked E4 how he knew what R1's transfer was and what equipment was needed for the transfer. E4 stated, I checked her transfer status in the closet and saw that she needed a Hoyer lift. I went out to the hallway and saw the lift, but there was no sling attached to it. I got a sling from the storage room. I didn't know that sling was not the correct one for that lift. E4 used a Hoyer lift and a sling to demonstrate how he attached the sling to the lift. The Surveyor then asked E4 whether he knew that two staff members were needed for a Hoyer lift for transfers. E2 stated, Yes. 6/15/26 2:15 PM – During a telephone interview, F1 stated, We had just returned from an appointment, and my wife wanted to go to bed because she was tired. I rang the call, and the aide came into the room. He put the sling under her and hooked it up to the lift. He began to raise the lift, and she fell to the floor. She fell and cracked her head. She is in the hospital with multiple brain bleeds and skull fractures. She is not a candidate for surgery and is not expected to recover. We are planning to meet with the hospice to discuss end-of-life care. 6/16/26 10:00 AM – During an interview, E2 (DON) stated, The facility has two types of Hoyer lifts, and they use two different types of slings. One of the slings snaps into place, and the other one hooks into place on the lifts. Our investigation revealed that [name of CNA] did not use the correct sling for the lift that he used to transfer the resident. He used the one that hooks on the lift rather than the one that snaps into place. I was in the facility when the resident fell, and I went to the unit to assess her. I saw that she was lying on the floor with the sling under her body. The investigation also revealed that a second staff member was not present during the transfer. I immediately provided education to him about having two staff members for Hoyer lift transfers and using the correct slings and lifts. I put pictures of the slings and other information on the lifts to show what types of slings should be used on the specific lifts. I began education for all other staff as well. The Surveyor observed the lifts with pictures of slings on them. The facility failed to use the appropriate sling for the Hoyer lift and to have the required two staff members for R1 during the transfer from the wheelchair to bed. R1 sustained a traumatic fall which resulted in multiple brain bleeds and skull fractures. The facility's action plan included: Like residents who require a mechanical lift for transfers were identified to ensure the transfer status order is in place. DON completed a random audit of residents on 6/9/26 with no further deficient practice identified. A review of risk management for 90 days was completed to validate that no additional fall incidents related to mechanical lift transfers occurred, with no additional incidents identified. A full review of all residents' care plans requiring two-person assistance for transfers. The CNA involved was immediately removed from the floor and in-serviced by the rehabilitation director. The facility immediately initiated education with certified nursing assistants on 6/9/26. Facility attached laminated photos to each mechanical lift to show the correct type of sling based on the lift in use. The facility began audits of mechanical lift transfers to validate the proper level of staff assistance and ensure that the correct sling is utilized for the lifts. The facility is conducting ongoing audits to monitor compliance. The facility will continue audits 3 times a week for one week or until 100% compliance is reached, then weekly for 3 weeks until 100% compliance is reached, and then monthly for 1 month until 100% compliance is reached. The facility QAPI committee will review the results of the observations made by the DON/designee to identify any trends/conduct root cause analysis, and develop a plan of action for follow-up and resolution if necessary. 6/17/25 1:00 PM – Based on the Surveyor's review of the facility's investigation, documented response, completion of audits from 6/9/26 to 6/12/26, staff interviews, and no further falls or injuries from the mechanical lift, the IJ was considered past non-compliance with a compliance date of 6/12/26 at 5:30 PM. 2. R2's clinical record revealed: 8/25/23- Resident (R[2]) admitted to the facility with diagnoses including, but not limited to, hemiplegia (paralysis of one side of the body) & hemiparesis (weakness on one side of the body) following unspecified cerebrovascular disease (a problem with the blood vessels in the brain) affecting the left side of the body. 4/6/26- R2 had an order stating Transfer: Hoyer lift (assist of 2); Bed Mobility (side to side): Assist of 2; left bed enabler to assist with bed mobility; Ambulation: N/A. 5/27/26- The most recent quarterly MDS documents R2's BIMS score as 14, indicating she is cognitively intact. The MDS also documented that R2 is dependent on staff for hygiene, bathing, toileting, and activities. 5/31/26 5:15 AM- A facility incident report submitted to the Division stated Resident with witnessed fall from bed while receiving ADL care .Transferred to ED for clinical follow-up. 6/16/26 11:30 AM- During an interview, E5 (CNA) stated, I was performing toileting and bowel clean up on R2. I knew she was a 2-person assist, but I was the only CNA on the unit during this shift. I have worked with R2 before, and I am usually able to handle her on my own. While I was tolieting R2, she rolled away from me on the bed. I was unable to catch her, and she fell to the floor. E5 confirmed that she was the only facility staff member present during this encounter. 6/16/26 12:00 PM- A review of the facility's investigative document revealed that E5 performed toileting care on R2 without the assistance of another staff member present. The facility failed to ensure that R2 was free from accidents when she fell from her bed while receiving care. 6/17/25 1:00 PM – Based on the Surveyor's review of the facility's investigation, documented response, completion of audits, staff interviews, and no further falls or injuries, the second example was considered past non-compliance with a compliance date of 6/12/26 at 5:30 PM. The IJ was abated on 6/16/25 at 1:00 PM. 6/16/26 1:30 PM – Findings were reviewed at the exit conference with E1 (NHA), E2 (DON), and E3 (COO).

Based on record review and interview, it was determined that for one (R1) out of three residents reviewed for reporting of alleged violations, the facility failed to identify and report an allegation of neglect. The facility submitted a State reportable incident for a fall with injury and failed to acknowledge the actual allegation of neglect when a staff person transferred a resident incorrectly, resulting in a fall with significant injury. Finding include:R1's clinical records revealed: 12/19/23 - R1 was admitted to the facility with diagnoses including but not limited to dementia, stroke, and end-stage kidney disease. 4/28/26 - R1' s care plan included, Resident [R1] requires Hoyer lift for transfers (Assist of 2). 5/28/26 - R1's annual MDS assessment documented a BIMS score of 00, indicating R1 is unable to complete the cognitive assessment. R1 was completely dependent on staff for all transfers between surfaces. 6/9/26 4:15 PM- Per facility investigation, E2 observed R1 lying on the floor with the sling underneath her; CNA reported the resident and sling fell from the Hoyer lift during transfer. RN/NP assessed the resident, noted a bump to the posterior head, and the resident's husband requested transfer to the ED; 911/ED transfer initiated. 6/9/26 4:20 PM - R1's clinical documentation included, .Called to the resident's room and saw the resident lying on the floor. The resident slipped out of the Hoyer lift during transfer. The resident was assessed by the NP, who noted a bump on the back of her head. Husband present and asked for her to be assessed at the ER [emergency room]. 911 was called. 6/9/26 5:26 PM - A facility reported incident submitted, via the State reporting system, to the Division documented, Fall with Injury, Resident transferred to the ED [emergency department] s/p [status post] related to contusion to posterior head. 6/16/26 10:25 AM - During an interview, E2 (DON) stated, I was in the resident's (R1) room immediately after the incident occurred. I knew that the CNA used the wrong sling for the wrong Hoyer lift and that he did not have a second staff member present during the transfer. Although E1 (NHA) and E2 were aware of the actual circumstances of the fall immediately after the incident, the incident report remained vague and did not disclose the known transfer error, lack of required two-person assist, or the unsafe staff action contributing to the event that should have been identified as an allegation of neglect.

Based on observation, interview, and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans prior to storage. In addition, the facility failed to ensure staff with facial hair wore a beard guard for facial hair. These failures increased the risk of foodborne illness by allowing wet pots and pans to be stored before fully drying and by failing to cover facial hair. This had the potential to affect 103 of the 152 residents receiving dietary services. Findings include:During an observation and interview on 05/11/26 at 9:30 AM, [NAME] (C) 1 was observed prepping food for lunch. C1 was observed to have a goatee that was approximately 0.25 – 0.50 inches in length and was not wearing a beard guard. C1 stated, I didn't think it was long enough to need to be covered. The Regional Food Service Director (RFSD) was present at the time and confirmed C1 was not wearing a beard guard and provided him with one. During an observation and interview on 05/11/26 at 9:35 AM, the Food Service Director (FSD) confirmed two pans, 6 inches by 12 inches by 4 inches; seven pans, 6 inches by 6 inches by 6 inches; five pans, 12 inches by 18 inches by 3 inches cleaned and stacked for use, were still wet. The pans had been stacked while still wet and were not given adequate time to air-dry before stacking. The FSD stated, They [pans] should be dry before they are stacked for use. Being wet increases the risk of contamination. Review of the facility's policy titled, Personnel Adherence to Sanitary Procedures, dated 01/07/26, revealed, Policy: . food services and dietary personnel will be required to adhere to the following sanitary standards. a. Hair nets, caps, beard nets, approved hats, or other effective hair restraints which cover all of the hair, must be worn at all times while on duty in order to keep hair from contacting food and food contact surfaces . Review of the facility's policy titled, Washing Pots and Pans, dated 01/07/26, revealed, . Remove pots and pans from sanitizer and place on drying rack in dish room to air dry. Remove pots and pans in dish room after they dry and move to pan rack in kitchen .

Based on interview, record review, and facility policy review, the facility failed to ensure residents either had an advanced directive in place or failed to provide the residents and/or their resident representatives (RR) written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for four of 13 residents (Resident (R) 9, R77, R6, and R161) reviewed for advanced directives out of a total sample of 55 residents. This failure created the potential the residents' wishes would not be followed if the residents were unable to speak for themselves. Findings include:1. Review of R9's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R9 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R9's EMR revealed no documentation that R9 had an advance directive or that the facility provided written information to the resident, or the resident representative (RR) concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Review of R77's admission Record, located under the Profile tab of the EMR, revealed R77 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R77's EMR revealed no documentation that R77 had an advance directive or that the facility provided written information to the resident, or the RR concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 05/14/26 at 8:40 AM, the Administrator stated, I don't have any record of them being given information about advance directives, only that it was discussed. 3. Review of R6's admission Record, located under the Profile tab of the EMR, revealed R6 was admitted to the facility on [DATE]. Review of the Social Services Assessment, dated 03/31/26, provided by the Administrator, revealed the section titled Advance Directives was incomplete and did not indicate whether the family was offered or desired assistance formulating an advance directive. During an interview on 05/14/26 at 8:40 AM, the Administrator stated that the Social Service Assessment did not indicate whether the resident had an advance directive or whether the family would like assistance to formulate one. The Administrator indicated that she spoke with the Social Worker (SW) who stated that he spoke to the resident's family member regarding advance directives, and that the family was unsure if the resident had one and would look into it, and that he planned to follow up with the family during the next care conference. The Administrator indicated that they needed to improve their process to obtain advance directives and help formulate one when they did not have one. During an interview on 05/14/26 at 1:30 PM, the Social Worker (SW) stated that R6 was non-verbal and that on 03/31/26, while completing the Social Services Assessment, he asked the family whether R6 had an advance directive, power of attorney, or living will. The family said they were unsure. The SW further stated that he asked whether they wanted information on how to establish one, but they stated that they were unsure. The SW acknowledged that he did not provide the family with information on how to create an advance directive or document the conversation because he became sidetracked when the family expressed greater concern about getting the resident back home. The SW also stated that R6 was in a vegetative state and was unlikely to be discharged home due to the level of care required. 4. Review of Resident 161's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, Multiple Sclerosis, acute and chronic respiratory failure, paraplegia, and a need for assistance with personal care. The EMR further indicated the resident's code status as Full Code. Review of the admission Documentation, located under the Profile Summary tab in the EMR confirmed the resident's code status was documented as Full Code, and the Advanced Directive section was marked as completed. However, the facility was unable to provide supporting documentation demonstrating that the resident was informed of advanced directives or provided education regarding advanced directive rights at the time of admission or thereafter. During an interview on 05/12/26 at 2:24 PM, the Administrator indicated that advance directive information was typically provided during the admission process; however, staff were unable to produce documentation or provide specific confirmation that R161 or the resident representative were educated on advance directives or offered the opportunity to complete or review such documentation. Review of the facility's policy titled, Advance Directives, dated 01/07/26, revealed, . Policy: It is the policy of Cadia Healthcare to offer residents assistance with creating or modifying Advance Directives. Purpose: To establish a process for education and informing residents of their right to create, modify, or revoke an Advance Directive. Procedure: Prior to or upon admission, the facility will identify if the resident has or wishes to create an advance directive. A resident has the option to execute an advance directive if he/she does not have one but will not be required to do so. Further review of the policy revealed the policy failed to document the facility providing written information to the residents, or the resident representative concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure ordered pressure ulcer treatments were completed and/or newly identified skin changes were reported for three of five sampled residents (Resident (R) 182, R37, and R20) reviewed for pressure ulcers out of a total sample of 55. Failure to complete wound treatments as ordered and report changes in skin integrity placed the residents at increased risk of infection and wound deterioration. Findings include:Findings include: 1. Review of R182's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R182 was admitted to the facility on [DATE]. R182's pertinent diagnoses included spinal muscular atrophy, pneumonia, acute and chronic respiratory failure with hypoxia, severe sepsis with septic shock, severe protein-calorie malnutrition, hypotension, polyneuropathy, and generalized muscle weakness. Review of R182's 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/26/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. The resident did not exhibit behaviors or rejection of care during the review period. R182 required total dependence on staff for bed mobility, transfers, bathing, toileting, and toileting hygiene, and required substantial to maximum assistance with eating and oral hygiene. R182 was always incontinent with bowel and bladder. R182 was at risk for pressure ulcer development and had three unstageable pressure ulcers present on admission. R182 utilized pressure-reducing devices for both the bed and wheelchair and received pressure ulcer/injury care during the review period. Review of R182's Care Plan, dated 10/31/25 and located under the Care Plan tab of the EMR, revealed R182 had unstageable pressure ulcers to his left buttock, right buttock, and right great toe that were present upon admission and a reddened area to the sacrum. The pertinent interventions directed staff to administer treatments as ordered and monitor for effectiveness. Review of R182's Physician Orders, dated 10/2025 through 11/2025, located under the Orders tab of the EMR, revealed the following pertinent orders: -10/21/25: Santyl External Ointment 250 Unit/ gram (GM) (collagenase). Apply to bilateral buttocks topical one time a day for wound maintenance. Discontinued 11/12/25. -10/22/25: Cleanse left buttock with normal saline, pat dry, apply Santyl, cover with calcium alginate, and dry dressing one time day for wound maintenance. Discontinued 11/12/25. -10/22/25: Cleanse right buttock with normal saline, pat dry, apply Santyl and cover with calcium alginate and cover with a dry dressing one time day for wound maintenance. Discontinued 11/12/25. -11/03/25: Cleans sacrum with normal saline, pat dry, apply Santyl, cover with calcium alginate, and a dry dressing one time a day for skin integrity. Discontinued 11/12/25 -11/12/25: Cleanse left buttock with normal saline, pat dry, apply Silvadene, calcium alginate and cover with a dry dressing one time day for wound maintenance. -11/12/25: Cleanse right buttock with normal saline, pat dry, apply Silvadene, calcium alginate, and cover with a dry dressing one time a day for wound maintenance. -11/12/25: Cleanse sacrum with normal saline, pat dry, apply Silvadene, cover with calcium alginate, and a dry dressing one time day for skin integrity. Review of the Wound Treatment Administration Record (WTAR), dated 11/2025, located under the Orders tab of the EMR, revealed staff failed to document completion of wound treatments to R182's right and left buttock on 11/02/25 and 11/15/25, and to the sacrum on 11/15/25, as ordered. Review of R182's Progress Notes, dated 11/02/25 through 11/15/25 and located under the Progress Notes tab of the EMR, revealed no documentation indicating the ordered wound treatments to R182's right and left buttock and sacrum were completed on 11/02/25 and 11/15/25, nor was there documentation providing a clinical rational for the missed treatments. During an interview on 05/15/26 at 12:30 PM, Assistant Director of Nursing (ADON) 2 stated that R182 was admitted to the facility with multiple wounds, including the sacral wound (redness) and bilateral buttocks. ADON2 reviewed the 11/2025 WTAR and acknowledged that the wound treatments to R182's right and left buttock and sacrum were not signed off as completed on 11/02 and 11/15/25. ADON2 stated that the Unit Managers were responsible for monitoring the treatment records to ensure they were completed. ADON2 stated that if the wound treatments were not documented, then they were not done. During an interview on 05/15/26 at 12:59 PM, Unit Manager (UM) 3 stated nursing staff and leadership were responsible for monitoring the treatment records to ensure they were completed. UM3 reviewed the 11/2025 WTAR and acknowledged that the wound treatments for R182 were not signed off as completed on 11/02 and 11/15/25. UM3 stated that if the treatments were not signed off as completed, then they were not done. UM3 could not recall if the treatments for R182 were reviewed or if they identified any issues with them not being completed. 2. Review of R37's admission Record, located under the Profile tab of the EMR, revealed R37 was admitted to the facility on [DATE] and readmitted on [DATE]. R37's pertinent diagnoses included chronic respiratory failure with hypoxia, persistent vegetative state, ventilator dependent, cognitive communication deficit, non-traumatic subarachnoid hemorrhage, peripheral vascular disease, anemia, moderate protein-calorie malnutrition, hypotension, neuropathy, and generalized muscle weakness. Review of R37's quarterly MDS, with ARD of 03/11/26 and located under the MDS tab of the EMR, revealed R37 was in a vegetative state due to anoxic brain injury and was ventilator dependent. R37 was dependent on staff for assistance with all activities of daily living. R37 was always incontinent with bowel and bladder. R37 was at risk for developing pressure ulcers, had one unhealed stage 4 pressure ulcer that was present upon admission, and received pressure ulcer/injury care during the review period. Review of R37's Care Plan, last revised on 03/23/26 and located under the Care Plan tab of the EMR, revealed R37 had a stage 4 sacral pressure ulcer. The pertinent interventions directed staff to administer treatment as ordered and monitor for effectiveness. Review of the Order Summary Report, dated 02/01/26 through 05/15/26 revealed the following pertinent orders: -02/06/26: Cleanse sacral wound with Vashe (wound solution), lightly pack with Vashe soaked gauze, cover with ABD [Abdominal pad] and secure with tape. Discontinued 02/09/26 -02/09/26: Cleanse sacral wound with normal saline, pat dry, apply hydrofera blue and cover with dry dressing one time a day every Monday, Wednesday, and Friday for wound management. Discontinued 03/30/26 -03/23/26: Cleanse sacrum with normal saline and apply alginate and dry dressing (dd) one time a day every Monday, Wednesday, and Friday for wound care. Discontinued 03/25/26 -03/25/26: Cleanse sacrum with normal saline and apply alginate and dd one time a day every Monday, Wednesday, and Friday for wound care. Discontinued 03/30/26 -03/31/26: Cleanse sacral wound with normal saline, pat dry, apply hydrofera blue and cover with dry dressing one time a day every Monday, Wednesday, and Friday for wound management. Review of the WTARs, dated 02/2026 through 05/2026 and located under the Orders tab of the EMR, revealed staff failed to document completion of ordered wound treatments to R37's sacral pressure ulcer on 02/08/26, 03/24/26, 04/08/26, and 04/17/26. Review of R37's Progress Notes, dated 02/01/26 through 05/15/26 and located under the Progress Notes tab of the EMR, revealed no documentation indicating the ordered wound treatments to R37's sacral pressure ulcer was completed on 02/0826, 03/24/26, 04/08/26, and 04/17/26, nor was there documentation providing a clinical rationale for the missed treatments. During an interview on 05/15/26 at 12:30 PM, ADON2 stated that R37 had a pressure ulcer on her sacrum and one on her left heel. ADON2 reviewed the 02/2026 through 05/2026 WTARs and acknowledged that the wound treatments to R37's sacral pressure ulcer were not signed off as completed on 02/08/26, 03/24/26, 04/08/26, and 04/17/26. ADON2 stated that if the wound treatments were not documented, then they were not done. During an interview on 05/15/26 at 6:00 PM, the Director of Nursing (DON) stated that staff are expected to document on the WTARs when they complete wound treatments. The DON stated that she was unsure if the wound nurse was off on those days or if the lack of documentation was an oversight. The DON stated that if the wound treatments were not signed off as completed, then it was not done. 3. Review of R20's Face Sheet, located under the Profile tab in the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, acute chronic respiratory failure, and heart failure. Review of R20's quarterly MDS, with an ARD of 05/01/26, and located in Internet Quality Improvement and Evaluation System (IQIES), revealed R20 had a BIMS score of 00 out of 15, which indicated the resident was severely cognitively impaired. It was recorded R20 was at high risk for the development of pressure ulcers and had no current skin concerns. It was recorded R20 was dependent on staff for all activities of daily living (ADLs) and required a two-person assist with a Hoyer lift for transfers. Review of the R20's Care Plan, revised on 01/28/26, and located under the Care Plan tab in the EMR, revealed interventions to prevent skin breakdown and promote skin integrity. Interventions included completion of Braden risk assessments, a wheelchair cushion, pressure redistribution mattress, offloading heels while in bed, and skin checks every two hours and as needed. During an interview on 05/14/26 at 1:35 PM, R20's family member (F) 1 stated after assisting with incontinence care earlier in the day (on 05/14/26), she observed a discoloration of the skin on R20's right upper buttocks. During an interview on 05/14/26 at 1:57 PM, Certified Nursing Assistant (CNA) 13 stated he was assigned to R20 and provided incontinence care at approximately 8:30 AM and again at 1:02 PM. CNA13 revealed he observed a red area on the resident's right buttock at 8:30 AM. CNA13 stated that the area appeared unchanged in size and condition during the subsequent care provided at 1:02 PM. CNA13 stated he did not report the identified new red area on the R20's right buttock to his charge nurse, as directed by facility protocol. During an interview on 05/14/26 at 4:24 PM, Unit Manager (UM) 4 confirmed CNAs were expected to report any observed skin changes. UM4 stated R20's newly identified skin change was identified at approximately 9:00 AM on 05/14/26. UM4 reviewed R20's Kardex and stated the documentation indicated no skin concerns were observed or noted. Review of a Progress Note, dated 05/15/26 at 11:57 AM and located under the Progress Notes tab in the EMR, revealed R20 was noted to have an open area to the upper right buttock measuring approximately 0.5 centimeters (cm). During an interview on 05/15/26 at 5:45 PM, the Administrator confirmed staff should adhere to ordered care interventions to ensure early identification of changes in a resident's condition. Review of the facility's policy titled, Pressure Ulcer Prevention and Management, last revised 01/17/23, revealed, It is the policy of Cadia Healthcare to promote skin integrity in residents through the recognition, treatment and prevention of pressure ulcers . Residents will have a plan of care developed and updated as needed. Interventions implemented are added to the resident's plan of care .

Based on interview, record review, and facility policy review, the facility failed to safeguard controlled medications used in facility stock and failed to safeguard controlled medications and/or ensure the availability of physician ordered medications for two of 55 sampled residents (Resident (R)178 and R5). These failed practices placed residents at risk for medication diversion, unmanaged symptoms, and failure to receive medications as prescribed. Findings include:1. Review of a Pharmacy Delivery Manifest, dated 09/10/25, provided by the Director of Nursing (DON), revealed one pill of Oxycodone IR (an immediate release narcotic pain medication) 5 milligrams (mg) was delivered to the facility for a stock replacement order in the Omnicell (a secured automated medication dispensing cabinet). The Pharmacy Delivery Manifest for 09/10/25 had a delivery time of 7:28 AM and was signed by Licensed Practical Nurse (LPN)10. During an interview on 05/13/26 at 10:00 AM, the DON stated she received an email from the pharmacy on 09/15/25 informing the facility the Oxycodone IR 5 mg replacement pill for the Omnicell, delivered on 09/10/25, was never placed into the Omnicell. The DON stated she then checked the Omnicell, and the Oxycodone IR 5 mg pill was not in the Omnicell. The DON stated she then interviewed LPN10, who signed for the Oxycodone delivery on 9/10/25. The DON stated LPN10 verified she did accept and sign for the Oxycodone IR 5 mg pill from the pharmacy on 09/10/25. The DON stated she was told LPN10 and LPN3 attempted to put the pill into the Omnicell upon receipt, but the Omnicell was not working at the time. Both LPN10 and LPN3 contacted their Registered Nurse Unit Manager (RN-UM)1 and gave the Oxycodone IR 5 mg pill to RN-UM1 until the Omnicell was working. The DON stated RN-UM1 was interviewed on 09/15/25 and could not locate the Oxycodone IR 5 mg pill. The DON stated RN-UM1 verified she never placed the pill into the Omnicell. The DON stated all medication rooms and carts in the facility were searched without success in locating the pill. The DON stated the police were called, and a report was filed, and RN-UM1 was terminated on 09/15/25. The DON stated the Oxycodone IR 5 mg pill should have been double locked in the medication storage cart until the Omnicell was working. During an interview on 05/15/26 at 9:30 AM, LPN10 revealed one Oxycodone IR 5 mg pill was delivered to the facility on [DATE]. LPN10 stated she signed for the medication and took LPN3 to the medication room for a witness to insert the pill into the Omnicell. LPN10 stated the Omnicell was not working at the time. LPN10 stated she and LPN3 then informed RN-UM1 about the pill being delivered and the Omnicell not working. LPN10 stated RN-UM1 then took the Oxycodone IR 5 mg pill and RN-NM1 stated she would put it into the Omnicell once it was working. LPN10 stated she never heard anything else about the Oxycodone until 09/15/25 when the DON informed her the pill was missing. During an interview on 05/15/26 at 9:45 AM, LPN3 revealed she was with LPN10 on 09/10/25 when they attempted to place the Oxycodone IR 5mg pill into the Omnicell. LPN3 verified the Omnicell was not working, and the pill was immediately given to RN-UM1 who stated she would take possession of the pill until the Omnicell was working. Review of the facility policy titled, Controlled Medication Storage and Disposal, with a revision date of 01/09/2026, revealed Schedule II-V medications (Oxycodone IR is a Schedule II drug with a high potential for abuse with use potentially leading to severe psychological or physical dependence) were to be stored in a double-locked, permanently affixed compartment separate from all other non-narcotic medications. The nurse on duty maintained possession of the key to the controlled medication storage area. 2. Review of R178's admission Record, and located under the Profile tab in the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or near total loss of voluntary movement (paralysis) on one side of the body) and hemiparesis (partial weakness or loss of strength on one side of the body) following cerebral infarction (occurs when a blood vessel in the brain is blocked or restricted), aphasia (language disorder caused by damage to the brain's language center), and seizures (a sudden, uncontrolled burst of abnormal electrical activity in the brain). Review of R178's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/08/25, and located under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive impairment. Review of R178's Physician Orders, and located under the Orders tab in the EMR, revealed an order, dated 08/02/25, for Lorazepam (an antianxiety medication) 0.5 mg to be given every eight hours for anxiety as needed. Review of R178's Controlled Drug Administration Record, and located under the Misc tab in the EMR, revealed on 09/19/25 at 7:00 AM the shift change count for Lorazepam 0.5 mg was nine tablets. This 7:00 AM count occurred with on-coming LPN10 and off-going LPN9. On 09/19/25 at 3:00 PM, the shift change count for Lorazepam 0.5 mg was eight tablets. This 3:00 PM count occurred between off-going LPN10 and on-coming LPN6. During an interview on 05/15/26 at 9:30 AM, LPN10 revealed she was the nurse who cared for R178 from 7:00 AM to 3:00 PM on 09/19/25 and conducted the count for Lorazepam 0.5 mg at 7:00 AM with an off-going nurse and at 3:00 -PAM with an on-coming nurse. LPN10 stated on 09/19/25 at 7:00 AM there were nine Lorazepam 0.5 mg tablets and at 3:00 PM there were eight. LPN10 stated she did not give R178 any Lorazepam during her shift. LPN10 stated she had no idea what happened to the pill, but it may have possibly fallen out of the pill pack when she was cleaning the medication cart. LPN10 stated she immediately reported the missing pill to the DON. LPN10 stated she, along with the DON and Assistant Director of Nursing (ADON), looked in the cart, medication room, and on the unit for the missing pill but were unable to locate it. Review of the 09/19/25 Medication Administration Record (MAR), and located under the Orders tab in the EMR, revealed R178 was not administered Lorazepam 0.5 mg on 09/19/25. During an interview on 05/13/26 at 10:20 AM, the DON revealed there was a missing Lorazepam 0.5 mg pill reported to her and the ADON by LPN10 on 09/19/25 at 3:00 PM. The DON stated on 09/19/25 there were nine pills at 7:00 AM during shift change narcotic count and on 09/19/25 at 3:00 PM there were eight pills of Lorazepam 0.5 mg for R178. The DON stated that she and the ADON searched the medication cart, medication room, and the unit where R178 was located, and the pill was not located. The DON stated the police were called, and a report was filed, and LPN10 was terminated. 3. Review of R5's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R5 was admitted to the facility on [DATE]. R5's pertinent diagnoses included constipation, irritable bowel syndrome (IBS), and a history of fecal impaction. Review of R5's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/26 and located under the MDS tab of the EMR, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. It was recorded R5 was frequently incontinent of their bowels and did not have constipation during the review period. Review of R5's Care Plan, dated 04/05/26 and located under the Care Plan tab of the EMR, revealed the resident had constipation, IBS, a history of fecal impaction, and was non-compliant with bowel protocol. The care plan directed staff to follow facility bowel protocol for bowel management, monitor/report as needed signs and symptoms of complications related to constipation, and to record bowel movement patterns each day. Review of R5's Physician Order, dated 04/05/26 and located under the Orders tab of the EMR, revealed an order for naloxegol oxalate (medication used to treat opioid-induced constipation) 25 milligram (mg), give one tablet orally each morning for constipation. Review of R5's Medication Administration Record (MAR), dated 05/2026 and located under the Orders tab of the EMR, revealed staff documented a 9 indicating the medication was not administered on 05/09/26, 05/10/26, 05/11/26, 05/12/26 and 05/13/26. Review of R5's Progress Notes, dated 05/09/26 through 05/13/26 and located under the Progress Notes tab of the EMR, revealed that on 05/09/26, staff did not administer naloxegol oxalate to the resident because it was pending delivery from the pharmacy and that the Nurse Practitioner (NP) was aware. On 05/10/26, 05/11/26, 05/12/26, and 05/13/26, staff noted that the medication was still on order. Further review revealed no documented evidence staff contacted the provider to notify them that the medication was still unavailable. During an interview on 05/12/26 at 9:56 AM, R5 stated that he did not receive his naloxegol oxalate for the last four days and did not know why, but any constipation at this time. During a combined observation and interview on 05/14/26 at 8:55 AM, Registered Nurse (RN) 2 verified that the pharmacy had not delivered R5's naloxegol oxalate. RN2 then called the pharmacy to inquire about the medication and was told that the medication would be delivered that evening. RN2 stated the nurses were responsible for ordering medications when supplies run low, and that if a medication was not available, they were to contact the pharmacy and physician and obtain an order to hold the medication or replace it with one that is available. RN2 stated that she did notify the NP and noted that she was aware the medication was not available but did not obtain an order to hold the medication until it was available. During a telephone interview on 05/14/26 at 10:45 AM, the Quality Assurance Pharmacist stated that on 04/22/26 at 9:26 AM, the pharmacy delivered a 14-day supply of naloxegol oxalate to the facility, and that the pharmacy did not receive the next refill request from the facility until 05/14/26 at 9:00 AM, and it was scheduled for delivery that evening. An attempt to interview the NP on 05/14/26 at 2:47 PM was unsuccessful. A message was left for the NP to return the call; however, the NP did not return the call prior to the survey exit. During an interview on 05/15/26 at 6:41 PM, the Director of Nursing stated that if a medication was unavailable, staff were to notify the pharmacy and notify the provider to see if they wanted to substitute the medication with another available medication or obtain an order to place the medication on hold until it was available. The DON stated that all nurses were responsible for ordering medications and this was missed. Review of the facility policy titled, Medication Unavailable, last revised on 01/12/23, indicated, . When a medication is unavailable through the pharmacy, nursing may check the backup supply for the medication. If the medication is not available from the backup supply, notify the physician for additional or alternative orders. If the provider is not available, contact the Medical Director for directions and or orders. Document provider or Medical Director notification and orders in the resident's medical record .

Based on observation, interview, record review, and policy review, the facility failed to ensure residents who experienced a change in condition received timely treatment for one of four sampled residents reviewed for a change in condition (Resident (R)162). R162's had a fall at home prior to admission and sustained a subdural hematoma requiring a craniotomy (a surgical procedure where a neurosurgeon makes an opening in the skull to access and remove a blood clot (hematoma) that has formed to relieve pressure on the brain). R162 experienced changes in his condition after a fall he sustained on 10/10/24. On 10/14/24 R162 was emergently transferred to the hospital and was diagnosed with an acute subdural hematoma with a left to right shift requiring a craniotomy and intubation while in the hospital resulting in a delay of care. The Administrator and Director of Nursing (DON) were notified on 04/17/25 at 6:28 PM that Immediate Jeopardy existed. The failure to identify R162 exhibited symptoms of a potential head injury and failure to send R162 to the hospital timely created an immediate jeopardy situation resulting in a delay in treatment. Once hospitalized on [DATE], R162 had craniotomy surgery due to an acute re-injured subdural hematoma with left to right shift of his brain. The facility's failure to identify R162 was exhibiting signs and symptoms of a head injury and send him to the hospital timely put him at risk for significant injury and potentially death. The facility did not identify any failures from this incident and no corrective measures were implemented to ensure future residents with changes in condition would receive timely treatment. An acceptable Immediate Jeopardy Plan of Removal was provided on 04/17/25 at 8:00 PM and was validated on 04/18/25 at 1:16 PM. The Administrator was notified on 04/18/25 at 1:16 PM that the Immediate Jeopardy was removed. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of a D Findings include: Review of the facility's policy titled, Alert Charting dated 01/03/25 revealed It is the policy of [Name of Facility] to utilize alert charting for residents experiencing changes in condition that warrant heightened observation as determined through nursing judgment .Residents placed on alert charting are assess by the nurse each shift and assessment data entered into nursing notes .Document objective data related to the resident's condition i.e. vital signs .level of consciousness; .and response or lack of response to treatment .Report change in resident condition to the physician and the responsible party . Review of the facility's policy titled, Neurological Checks dated 01/03/25 revealed Neurological checks are initiated for residents experiencing a fall (change in plane) with a suspected head injury and/or a change from the resident's neurological baseline . Review of R162's undated admission Record in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of traumatic subdural hemorrhage. Review of R162's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/29/24 in the EMR under the MDS tab revealed R162 was admitted to the facility on [DATE] and had a goal of discharging to the community. According to the MDS the facility assessed R162 to have a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated the resident was severely cognitively impaired. R162 had clear speech, was usually understood by others, and sometimes understood others. R162 exhibited no mood or behavioral concerns. Review of R162's Care Plan dated 09/25/24 in the EMR under the Care Plan tab revealed, [R162] wishes to be discharged to home/another facility. Interventions in pertinent part were, Make arrangements with required community resources to support independence post-discharge . During an interview on 04/15/25 at 1:37 PM, Family Member (F) 5 stated R162 had been living at home with family when he experienced a fall getting into her car which resulted in the initial subdural hematoma and craniotomy in September 2024. F5 stated when R162 was admitted to the facility from the hospital, he needed assistance with walking and the goal was for him to get stronger and return home. F5 stated R162 rarely slept while at the facility and was always up, active, and often at the nursing station even at night. F5 stated when she came in to visit R162 on the morning of 10/14/24, he was not responsive at all, and she knew something was seriously wrong. F5 stated she insisted that Nurse Practitioner (NP) 1 send R162 to the hospital. The facility's Administrator was notified on 04/17/25 at 6:28 PM that Immediate Jeopardy existed related to the failure to identify and respond timely to a change in condition on 10/12/24 after Resident (R) 162 fell and hit his head on 10/10/24. The Immediate Jeopardy began on 10/11/24 when R162 experienced a change in condition. During an interview on 04/16/25 at 2:44 PM, R162's Personal Care Physician (PCP) 1 stated R162 was able to communicate his needs upon admission but was impaired in cognition. Review of R162's Nurse's Note dated 10/10/24 and located in the resident's EMR under the Progress Notes tab revealed R162 was found on the floor of his room after the staff heard a loud thud. The note read, Pt [Patient] found on floor holding the right side of his face. Pt says he did hit his head. Pt was assessed and able to move all extremities. Pt was assessed by supervisor and then helped off the floor. Pt has a superficial laceration on right side of face near right eye. Pt also sustained a skin tear on his lower left arm. The area was cleaned, and a dry dressing was applied. Pt was given an ice pack for facial laceration. NP [Nurse Practitioner (NP)1] made aware of fall and skin injuries .Pt unable to remember how he fell and what caused his fall . Wheelchair was in room near where pt was on the floor. Review of R162's Nurse's Note dated 10/10/24 at 5:00 PM and located in the resident's EMR under the Progress Notes tab revealed Resident was found on the floor in front of his bed. Resident was trying to get into bed unassisted and fell .On call notified and new orders for a CBC [complete blood count], BMP [basic metabolic panel], chest x-ray, and UA [urinalysis] C&S [culture and sensitivity]. Neuro checks initiated . Review of R162's Physical Therapy Summary of Skill Notes showed a decline between 10/09/24 and 10/11/24 as follows: - Review of a PT Summary of Skill note dated 10/09/24 provided by the facility revealed R162 walked 118 feet on this date, completed four minutes of standing with support, and performed marching for improved balance. -Review of a Physical Therapy (PT) Summary of Skill note dated 10/10/24 and provided by the facility and signed at 4:57 PM, revealed R162 ambulated ten feet with a rolling walker. In addition, R162 completed 15 minutes on the omni cycle. It was unknown whether therapy occurred before or after R162's fall on this date. -Review of a PT Summary of Skill note dated 10/11/24 at 5:31 PM revealed R162's condition had changed from 10/10/24 as follows, Pt [Patient] sitting in WC [wheelchair] very drowsy with limited eye opening .increase confusion .Pt complete x3 STS [sit to stand] and present with difficulty completing task of pivoting. SPT [stand pivot transfer] WC [wheelchair] to recliner with Mod [moderate] of 2 person assist for proper positioning . Per the Summary of Skill R162 did not walk on this date. The PT who wrote the Summary of Skill notes no longer worked at the facility and was unavailable for interview. -Review of the next and last PT Summary of Skill note dated 10/14/24 revealed, Pt encountered in recliner very drowsy with limited eye opening. Pt [unable to] complete transfer to WC on multiple attempts due to increase resistance . Review of R162's Nurse's Note dated 10/12/24 at 11:38 AM and located in the resident's EMR under the Progress Notes tab revealed R162 was experiencing a change in his mental status as follows, Resident is not able to wake up for medication tried waking him to transfer him to bed but not waking up resident is snoring breathing but will not open eyes not safe to give medication resident vital signs were taken but unable to get temp [temperature] due to him sleeping and not waking up to close his mouth while sleeping tried to take [sic] wake up several times will continue to monitor was not able to eat breakfast will try lunch. Review of R162's Nurse's Note dated 10/12/24 at 2:22 PM and located in the resident's EMR under the Progress Notes tab revealed, Resident continue to sleep resident did not eat lunch was able to only take small bite of cheesecake but coughed and then offered ginger ale and water . could not drink eyes are closed was telling resident to open eyes resident would mumble but not verbalize using words resident son was here and notified him of the situation that he did not eat breakfast or lunch and was not able to get medications this shift on the on call NP [Nurse Practitioner] was notified and he said can hold medication for 24 hr [hours]. Review of R162's Nurse's Note dated 10/12/24 at 9:10 PM and located in the resident's EMR under the Progress Notes tab revealed, Patient slept most of the shift. Alert. Not oriented. Open eyes to voice. Vitals wnl [within normal limit]. Med [medications] melatonin/buspirone on hold. Review of R162's Nurse's Note dated10/13/24 at 3:07 PM and located in the resident's EMR under the Progress Notes tab revealed Resident post fall resident was on nuero [sic] checks resident was more awake and alert this shift ate about 50-75% breakfast did not eat lunch son was here and offered but refused this morning when he was done eating breakfast I tried taking vital signs and giving medication but resident was pushing me away and saying no resident speech was not clear was not able to communicate clear this shift .resident was also very weak and unable to do two person assist to take to the bathroom had to use the sit and stand lift to use the bathroom . Review of R162's Nurse's Note dated 10/14/24 at 12:21 PM and located in the Progress Notes tab revealed, Patient is noted with increased lethargy this shift. NP evaluated; patient's daughter was at bedside. Daughter wishes for patient to be sent to ER [emergency room] for eval. 911 was called, NP called report to ER. 911 arrived to facility at 1221, was transported to ER with all appropriate paperwork. Review of R162's NP's Encounter note dated 10/14/24 and located in the resident's EMR under the Progress Notes tab revealed, Nursing reporting that patient has increased lethargy and generalized confusion. Patient is currently out of bed to the chair and awakens to verbal commands, but does not communicate needs and has increased confusion. Patient's daughter is at the side of the chair and requesting patient to be sent to the hospital for acute change of mental status. Patient awakens eyes to verbal commands and unable to follow simple commands, even with redirection. Nursing reports acute change in mental status overnight . 1. Acute delirium: Pt with acute onset of change in overall mentation. Pt is not currently at baseline, and workup is still pending including urinalysis. Family at the bedside and requesting patient to be sent to the hospital for further evaluation. Discussed with nursing staff and orders given to send the patient to the ED. Review of R162's Neurological Flow Sheet provided by the facility and initiated on 10/10/24 at 4:30 PM and completed on 10/13/24 on the 7:00 AM - 3:00 PM shift, revealed a change in R162's level of consciousness that started on the 7:00 AM - 3:00 PM shift on 10/12/24 with a change from fully conscious - awake, aware and oriented to lethargic - responds slowly to verbal stimuli that persisted through 10/13/24, the end of the monitoring period. In addition, the Neurological Flow Sheet revealed a change in R162's speech from clear to slurred that started on 10/12/24 on the 7:00 AM - 3:00 PM shift and persisted through 10/13/24, the end of the monitoring period. Review of 162's hospital ED [Emergency Department] Physician Record dated 10/14/24 and provided by the facility revealed, I reviewed the patient's CT head once it was available in the [name] system and on my interpretation, I am concerned for a large left sided subdural hematoma with midline shift. I immediately active a trauma alert given the patient's age, intracranial hemorrhage, and altered mentation . Review of R162's hospital CT [computed tomography] Head Scan dated 10/14/24 and provided by the facility revealed, Impression: Left cerebral convexity and left parafalcine subdural hematoma measuring up to 15 mm in thickness resulting in 7 mm left to right midline shift. During an interview on 04/15/25 at 5:59 PM, Registered Nurse (RN) 2 stated LPN12 should have contacted the Unit Manager regarding the change in condition (change in level of consciousness) observed on 10/12/24 (Saturday). RN2 stated there was no NP in the facility on the weekends at the time of the change in R162's mental status occurred. RN2 stated, considering R162's history of a subdural hematoma and change in level of consciousness, she would have had R162 sent to the hospital on [DATE]. During an interview on 04/16/25 at 11:15 AM, LPN12 stated on 10/12/24, she could not wake R162 up for breakfast and he did not eat lunch or dinner either. In addition, he refused to take his pills. LPN12 stated she was concerned R162 was experiencing a change in condition and was aware the change in cognition could be a trigger for a head injury from the fall on 10/10/24. LPN12 stated she conveyed all information to the weekend on call NP on 10/12/24 who instructed her to hold medications for 24 hours and monitor him. LPN12 stated the NP did not instruct her to send R162 to the hospital. LPN12 stated R162 was a little better on 10/13/24 as he was able to eat breakfast and was more alert. During an interview on 04/16/25 at 1:14 PM, NP1 stated she assessed R162 on 10/10/24 after his fall and on 10/14/24 when notified he experienced a change in condition. NP1 stated when she evaluated R162 on 10/14/24, he was different from his baseline and had experienced an acute change in cognition. NP1 stated R162 was not usually sleepy and had previously been more alert and able to communicate his needs. She stated on 10/14/24 R162 was not making sense. When reviewing the description of R162 documentation by LPN12 on 10/12/24, NP1 stated LPN12's documentation of symptoms was similar to the acute change in mental status that she witnessed on 10/14/24 when she sent the resident out to the emergency room. During an interview on 04/15/25 at 10:22 AM, Forensic Nurse (nurses who conduct comprehensive medical examinations to assess injuries, document findings, and determine the need for medical intervention) (FN) 3 from the hospital stated R162 was admitted to the hospital on [DATE] with subdural hematoma. A craniotomy was performed and R162 had to be intubated (tube inserted inside the windpipe through the mouth or nose). FN3 stated the hospital staff was concerned regarding the delay in sending R162 to the hospital after he started exhibiting signs and symptoms of a change in condition on 10/12/24. FN3 stated when R162 arrived at the hospital, he had obvious signs of injury to his forehead and staff were unable to wake him for more than a few seconds. R162 was unable to communicate verbally and was groaning and coughing when he arrived. FN3 stated R162 was placed onto hospice services while in the hospital. During an interview on 04/17/25 at 1:20 PM, FN4 stated there were three CT scans taken for R162 following his initial fall in 09/10/24. FN4 stated the first CT scan on 09/10/24 showed the hematoma measured 25 mm thickness; the 09/17/24 CT scan was not measured but showed marked improvement; the 10/14/24 CT scan showed a 15 mm thickness with a seven mm shift. FN4 stated the shift was due to the bleeding pushing the left side of the brain to the right-side accounting for the shift from left to right. FN4 stated R162 had a re-injury of the subdural hematoma, based on the CT scan dated 10/14/24 with a craniotomy recommended and performed to relieve the pressure. FN4 stated, due to the previous subdural hematoma in September 2024, R162 was at increased risk and should have been sent to the hospital right away on 10/14/24 after hitting his head when he fell on this date. During an interview on 04/17/25 at 2:38 PM, NP1 reviewed the Emergency department report and the CT scan for R162 both dated 10/14/24. NP1 stated the documentation revealed an intracranial bleed and that an intervention was needed to alleviate the pressure. She stated the midline shift was the concern and indicated that something acute had occurred. NP1 reviewed the Therapy Note dated 10/11/24 showing a decline in R162's cognition the day after the fall and stated if she had known about that, she would have had R162 sent to the hospital at that time. During an interview on 04/15/25 at 1:37 PM, Family Member (F) 5 stated R162 went onto hospice while in the hospital due to his deteriorated condition and was discharged from the hospital to a different nursing facility where he passed away a few months later. Review of the facility's Immediate Jeopardy Removal Plan dated 04/17/25 revealed the facility took the following actions: -Rl62 no longer resides in the facility. No immediate actions can be taken for this resident. -The facility Medical Director was made aware of the immediate jeopardy citation on April 17, 2025. -All residents who have fallen within the last 72 hours were assessed by a medical provider for changes in condition on April 17, 2025. -All current residents who have fallen within the last 30 days were reviewed to validate that they did not experience an unidentified change in condition on April 17, 2025. -Immediate education of all licensed nurses other than those on leave on identifying and notifying providers of changes in condition after a fall was initiated and completed by the DON/ designee on April 18, 2025. Any staff on leave will be educated prior to their next scheduled shift. -Audits will be conducted by the DON [Director of Nursing]/ designee on residents who sustain a fall to validate that residents are monitored for changes in condition, that changes in condition are identified timely, and the medical provider is notified. The facility QAPI committee through ad hoc will monitor weekly for four weeks to review any trends, findings, issues, or concerns and develop plan of action for follow up or resolution. During an interview on 04/17/25 at 8:16 PM, DON1 stated the training consisted of educating nurses on clinical evaluations, subjective versus objective data, level of consciousness, and provider notification of changes in condition. DON1 stated if the nurses did not agree with the provider, such as whether to send a resident to the hospital, they were to notify the DON, and the DON would notify the Medical Director. The Medical Director will make the final decision for the resident. During an interview on 04/17/25 at 8:19 PM, LPN14 verified she had been trained by DON1 and verbalized understanding of the training when asked specific questions. During an interview on 04/17/25 at 8:21 PM, LPN7 verified she had been trained by the DON and verbalized understanding of the training when asked specific questions. During an interview on 04/17/25 at 8:24 PM, RN7 verified she had been trained by the DON and verbalized understanding of the training when asked specific questions. During an interview on 04/18/25 at 9:11 AM, the Director of Rehabilitation (DOR) and Interim DOR stated they started educating therapy staff last night about change of condition, and how therapy staff should communicate this information to nursing. Therapy was to notify and inform nursing and bring the information to department heads in the morning meetings.

Based on observation, interview, and record review the facility failed to ensure that two of 10 residents reviewed for accidents (Resident (R) 114 and R90) were provided supervision to prevent accidents. Both residents were planned for two staff for bed mobility and transfer but only one staff provided care. R114 was harmed when injuries from the all required emergecy room treatment with stitches to a laceration to the skull. R90 sustained minimal injuries. Verification of training and binder review confirmed the incident with R114 was corrected 12/3/24 and determined to be past-non compliance. The citation for R90 was a D level finding was verified as corrected on 3/21/24. Findings include: 1. Review of the facility's policy titled, Care Planning revised on 01/12/23 revealed that The services provided or arranged by the facility, as outlined by the comprehensive care plan, must: Be provided by qualified persons in accordance with each resident's written plan of care. Review of R114's admission Record located in the Profile tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage and persistent vegetative state. Review of R114's Care Plan located in the resident's EMR under the Care Plan tab revealed an intervention dated 10/13/23 to: Assist with transfers and repositioning in bed as ordered. Review of R114's Order Summary Report located in the resident's EMR under the Orders tab revealed an order dated 04/05/24 for Bed Mobility [side to side]: assist of two. Review of R114's Transfer Status Sheet dated 04/05/24 and located in the Misc tab of the EMR revealed R114 required assist of two with rolling side to side. Review of R114's Fall Risk Evaluation, dated 10/14/24 and located in the Evaluations tab of the EMR revealed R114 was not at risk of falling. Review of R114's annual MDS assessment with an ARD (assessment reference date) of 10/16/24 and located in the MDS tab of the EMR revealed R114 was in a persistent vegetative state with no discernible consciousness. R114 had functional limitation in range of motion to both upper and lower extremities and was dependent on staff for rolling side to side. Review of a facility provided Incident Report, dated 11/28/24 and completed by LPN11 revealed CNA14 reported R114 fell out of bed during care. R114 was observed lying on the floor next to the bed, bleeding from the left side of his head. R114 went out to the emergency room for evaluation. Review of R114's Progress Notes, located in the Progress Notes, tab of the EMR revealed: A Nurses Note dated 11/28/24 at 2:42 PM which documented R114 fell onto the floor during care around 12:55 PM. R114 was assessed and an injury to the left side of his head was cleaned and a pressure dressing placed. 911 was called, and R114 left for the hospital at 1:27 PM. An Orders - General Note from eRecord dated 11/29/24 at 12:04 PM which documented R114 returned to the facility at 8:55 AM. R114 had a laceration with stitches on the back left side of his head from the 11/28/24 fall. During an interview on 04/15/25 at 11:53 AM, CNA14 reported she had rolled R114 by herself on 11/28/24 when providing incontinence care. CNA14 had raised the bed to working height, rolled R114 away from her, and reached to grab wipes and a clean brief when R114 slowly fell out of bed. CNA14 reported R114 was supposed to be assisted by two staff to roll but that when she was unable to find someone to assist, she had provided care alone. During a concurrent observation and interview on 04/15/25 at 3:26 PM, CNA13 and CNA19 repositioned R114 in bed. R114 was observed to be totally dependent on staff for mobility with no discernible response to verbalizations. CNA13 reported R114 had little movement, but residents in his state coughed or spasmed at times with rolling, which could cause them to move. When asked how staff knew how to transfer or position residents, CNA13 opened R114's closet door to reveal his Transfer Status Sheet which showed R114 required two staff for rolling side to side. During an interview on 04/16/25 at 12:14 PM, LPN11 stated she was notified by a CNA on 11/28/24 that R114 had fallen from the bed. When LPN11 lifted R114's head, she felt blood on her glove and got another nurse to further assist with assessing. CNA14 reported to LPN11 that when R114 was rolled on his side for incontinence care, he jerked and fell off the bed. He likely coughed or something. CNA14 was the only staff in the room providing care when R114 fell. R114 was supposed to have two staff when rolling. During an interview on 04/16/25 at 6:00 PM, DON1 stated she expected staff to follow the plan of care for rolling, transferring, and ambulation. Nursing staff were educated to look for the plan of care inside the resident's closet doors. If the plan of care stated to roll with the assist of two staff, she expected two staff to be utilized. Review of a facility provided binder revealed the facility started a Quality Assurance and Performance Improvement (QAPI) plan following the 11/28/24 fall. An Action Plan titled Resident Staff Assisted Bed Mobility was initiated on 11/29/24. Certified staff received re-education on utilizing the ordered amount of staff assistance with bed mobility from 11/29/24 to 12/03/24. Audits were completed on utilizing the required staff assistance with bed mobility three times weekly until compliance was consistent at 100% for three consecutive audits. Following this, audits were completed weekly until consistent compliance was achieved over three consecutive weeks. Finally, monthly audits were performed, which began in January 2025. The last audit form in the binder was dated 01/10/25. 2. Review of R90's undated admission Record located in the EMR under the Profile tab revealed he was admitted on [DATE] with multiple diagnoses which included vegetative state, acute respiratory failure, tracheostomy, contractures, gastrotomy, and nontraumatic intracerebral hemorrhage. Review of R90's annual MDS assessment with an ARD of 10/18/24, located in the EMR under the MDS tab revealed R90 was not interviewable and could not be assessed for mental status. The MDS indicated that R90 was dependent on staff for eating, oral hygiene, toileting, shower, upper and lower body dressing, personal hygiene, rolling, and transfers. Review of R90's Care Plan, dated 02/24/23, located in the EMR under the Care Plan tab revealed a focus of ADL self-care performance deficit r/t [related to] vegetative state with interventions of Picture in closet for positioning dated 01/18/24, and Transfer: The resident requires Mechanical Lift (Hoyer) with 2 staff assistance for transfers (dated 02/24/23). Review of R90's Nurses Note, dated 02/22/25, located in the EMR under the Prog Note tab revealed Charge nurse came in to the Unit and reported to the nursing supervisor that resident has a fall during provision of care. Nursing supervisor ran to resident's room. Resident has contractures of the upper limbs and very limited movement in lower extremities. No evidence of bones fracture. Resident presented: excoriations of the right side of forehead, small hematoma/elevation of the middle of the forehead, scant amount of dry blood on the inferior lip, small skin tear on right shoulder. Resident was resistant to mouth evaluation. Review of R90's Nurses Note, dated 02/22/25, located in the EMR under the Prog Note tab revealed . Resident was assessed by NPs [nurse practitioners] and new order received to send resident to the Hospital for evaluation and treatment . Review of R90's Nurses Note, dated 02/22/25, located in the EMR under the Prog Note tab revealed pt [patient] returned from hospital s/p [status post] fall. no new orders received. pt vitals are stable. no signs of distress noted. no signs of pain or discomfort. call bell within reach . Review of R90's Facility Reported Incident (FRI), dated 02/22/25, provided by the facility revealed the five-day report was sent to the State Survey Agency (SSA) on 02/28/25 which documented CNA10 stated she was cleaning the resident and went to turn him, and he rolled off the bed. During an interview on 04/14/25 at 8:50 PM, Family Member (F) 9 stated there was an incident on 02/22/25 when two staff were not present when turning R90 in bed during care. F9 also stated the CNA told him that she was giving a bath to R90, then she turned him away from her and he fell off the bed onto the floor. F9 stated the CNA stated R90 had a few scraps on him but no injuries. During an interview on 04/17/25 at 3:33 PM, DON1 confirmed she completed R90's fall investigation and concluded CNA10 did not wait for another nursing assistant to assist her in providing care to the resident on 02/22/25, which was the required level of assistance per the care plan. DON1 also stated the care plan was posted in each resident's armoire. DON1 indicated R90 returned from the hospital with no injuries. DON1 also indicated CNA10 was suspended during the investigation and terminated after the investigation was concluded. DON1 stated training was provided to all staff on 02/24/25 then auditing was conducted which included observations of the nursing assistants providing care to the residents. Training was provided to all nursing staff on 02/24/25 on patient transfer status and bed mobility by the DON. Audits were conducted three times weekly by the Staffing Coordinator from 02/24/25 to 03/21/25 through observations on each floor of assistance required with bed mobility per the QAPI Plan.

Based on observation, interview, review of the pest control contract, pest control service records, and work orders, the facility failed to ensure the kitchen and adjacent cart storage area were free from pests including fruit flies and ants. The facility failed to keep the kitchen clean and to make needed repairs to deter pests as recommended by their pest control provider. This created the potential for the harborage of insects and vermin. Findings include: 1. During the initial kitchen observation on 04/14/25 from 9:34 AM to 10:22 AM, the following observations were made with the Dietary Manager (DM): a. The dish washing room was observed with deteriorating tile where the tile back splash met the tile floor. This extended the length of the wall beneath where the dish machine and counters were located. Several of the tiles were broken or partially affixed to the wall. There was an area several feet in length and approximately a foot wide where a covering was taped over a hole in the wall/tile. The tape was peeling off; the area was not sealed. There was a significant amount of food scraps/food particles on the floor in this area, which was located below the dirty side of the counter and dishwasher. There were approximately 15 small black flying insects flying around the dish machine. The DM observed and identified the insects as fruit flies. There were a couple of ants crawling on the floor in the same area. The DM confirmed these observations. b. There were approximately ten fruit flies observed flying around in the janitor closet and surrounding area confirmed by the DM. c. There were a few fruit flies observed flying around in the cook's preparation area confirmed by the DM. d. The flooring surrounding a floor drain and the floor drain, behind the fryer, ovens, and steamer, was covered with a thick congealed layer of grease and numerous food particles/spills, and there was a black substance extending about a foot in each direction from the floor drains. The DM verified the floor was dirty and needed to be cleaned. There were several fruit flies flying around in this area. e. In the food cart storage area adjacent to the kitchen, there was a large hole in the sheet rock, approximately three feet by four inches above the tile trim. The DM stated the facility planned to repair all the areas identified on the inspection. 2. Review of the Pest Management Maintenance Agreement dated 12/16/24 and provided by the facility, revealed that food residue on and under the kitchen equipment should be cleaned on a more consistent basis. The Pest Management Maintenance Agreement read, Small fly and large fly issues primarily in the kitchen area .Fly control programs are greatly enhanced when proper cleaning is performed frequently and consistently. 3. Review of the pest control Summary of Service records provided by the facility revealed: a. The Summary of Service dated 01/21/25 revealed, Kitchen - Cracks or damage to floor allowing pest access. Please repair to prevent pest entry . Treated the kitchen for flies . b. The Summary of Service dated 02/11/25 revealed, Kitchen - Grease build-up noted in drain. Please clean drain to prevent unsanitary conditions and attraction by pests .Kitchen - Cracks or damage to floor allowing pest access. Please repair to prevent pest entry .I found one drain with heavy food debris on it and around it . c. The Summary of Service dated 02/25/25 revealed, Kitchen - Employee sanitation practices need improvement . Kitchen - Grease build-up noted in drain. Please clean drain to prevent unsanitary conditions and attraction by pests .Cracks or damage to floor allowing pest access. Please repair to prevent pest entry. d. The Summary of Service dated 03/11/25 revealed, Kitchen - Employee sanitation practices need improvement .Grease build up noted in drain. Please clean drain to prevent unsanitary conditions and attraction by pests .Cracks or damage to floor allowing pest access. Please repair to prevent pest entry .The table that stores the onions and potatoes has quite a lot of activity. I highly recommend storing onions and potatoes in clear plastic containers with closed lids. Fruit flies can transmit bacteria such as E coli, salmonella, and listeria. Fruit flies transmit such diseases thru [sic] coming in contact with food or clean surfaces. Fruit flies tend to lay eggs on food. e. The Summary of Service dated 03/25/25 revealed, Kitchen - Employee sanitation practices need improvement .There is still drain fly activity. I found some food debris left in the sinks in the dishwasher room .Food debris on the floor under kitchen equipment .containing onions and potatoes in bins with lids as the drain flies are drawn to them. The kitchen dustpans are in need of a good scrubbing . Accumulation of food product from damaged goods noted .Employee sanitation practices need improvement .Grease build up noted in drain .Cracks or damage to floor that allows pest access . f. The Summary of Service dated 04/08/25 revealed, Kitchen - Employee sanitation practices need improvement .An accumulation of food product from damaged good noted .Cracks or damage to floor allowing pest access .Sanitation continues to be an issue. Potatoes and onions are still in containers without lids. They really need to have lids. The kitchen had food all over the floor. The drains need to be cleaned more often . 4. Review of a Work Order created by the DM on 03/19/25 and provided by the facility revealed a request for repair of a large hole in back hallway by door across from cook's entrance where wall and flooring meet. The Work Order was coded as being in progress. It had not been completed. Review of a Work Order created by the DM on 03/19/25 and provided by the facility revealed, loose tiles along wall and under dish machine, walls are not sturdy and have openings where the wall and flooring meet. The Work Order was documented as being in progress. It had not been completed. 5. During an interview on 04/15/25 at 10:43 AM, the Maintenance Director (MD) stated he had been in his position since mid-December. He stated he was not sure how long the dish room and adjacent areas had been in disrepair. The MD stated the covering taped on the wall under the dish machine was there to cover holes in the wall. The MD stated he was waiting for a second estimate for the repairs and had one bid so far, but it did not cover everything. The MD stated he was waiting for an additional bid before a decision was made regarding the repairs. The DM stated there were a lot of fruit flies in the kitchen on 04/14/25 and it needed better cleaning. During an interview on 04/17/25 at 5:22 PM, the MD stated he was aware of the pest control provider's recommendations for the kitchen to be repaired and cleaned more thoroughly. The DM stated the ants, and the fruit flies were a result of the kitchen not being clean. During an interview on 04/18/25 at 9:53 AM, the DM stated none of the pest control service provider's recommendations regarding improving cleanliness in the kitchen had been shared with her by the pest control provider or by maintenance staff. The DM stated she was not aware of ongoing kitchen recommendations made by the pest control provider. During an interview on 04/18/25 at 11:52 AM, the District Manager of Housekeeping stated food was an attraction for ants and it was important to keep the entrance and areas clean. During an interview on 04/18/25 at 12:47 PM, the Administrator stated they had a quote for the kitchen repairs; however, she was not sure what the current status of getting the repairs was.

Based on observation, interview, and record review, the facility failed to ensure there was not more than a 14-hour gap between the evening meal (dinner) and breakfast the following day for 118 out of 158 residents (40 residents received nutrition via tube feedings). The planned meal gap between dinner and breakfast the following day was 15 hours. The resident group had not approved the 15-hour gap between dinner and breakfast. This created the potential for residents to experience hunger while waiting for breakfast. Findings include: Review of the undated Mealtimes document provided by the facility revealed breakfast was scheduled to be served at 8:00 AM to Limestone, 8:10 AM to Millcreek Low, 8:20 AM to Millcreek High, 8:30 AM to Delcastle Low, 8:40 AM to Delcastle High, 8:50 AM to [NAME] Clay High, and 9:00 AM to [NAME] Clay Low. Dinner was scheduled to be served at 5:00 PM in Limestone, 5:10 PM in Millcreek Low, 5:20 PM in Millcreek High, 5:30 PM in Delcastle Low, 5:40 PM in Delcastle High, 5:50 PM in [NAME] Clay High, and 6:00 PM in [NAME] Clay Low. There was a 15-hour span for each location from dinner until breakfast the following day. Meal observations revealed breakfast was served late on 04/18/25 with the breakfast meal cart being served to residents in rooms Delcastle High at 09:18 AM. Staff were serving breakfast trays to residents with 12 trays remaining on the cart at this time. According to the scheduled mealtimes, Delcastle High meals were to be served at 8:40 AM. During an interview with the Resident Group on 04/16/25 at 2:00 PM with six residents (R38, R58, R34, R143, R19, and R36). The group stated the 15-hour gap between dinner and breakfast the next day was too long. All six residents confirmed the 15-hour gap between dinner and breakfast had not been approved by resident council. 1. Review of R38's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/29/25 and located in the electronic medical record (EMR) under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. 2. Review of R58's quarterly MDS with an ARD of 01/09/25 and located in the EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. 3. Review of R34's quarterly MDS with an ARD of 01/09/25 and located in the EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. 4. Review of R143's admission MDS with an ARD of 02/03/25 and located in the EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. 5. Review of R19's quarterly MDS with an ARD of 01/30/25 and located in the EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 11 out of 15 which indicated the resident was moderately cognitively impaired. 6. Review of R36's quarterly MDS with an ARD of 02/12/25 and located in the EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. During an interview on 04/14/25 at 9:34 AM, the Dietary Manager (DM) stated mealtimes were 8:00 AM for breakfast, 12:00 PM for lunch, and 5:00 PM for dinner. During an interview on 04/15/25 at 8:26 AM, the DM stated she was invited to and attended resident council meetings, adding she had been employed for approximately five months in her position as DM. The DM stated she was not aware of the 15-hour gap, and it had not been brought up in resident council when she had attended. During an interview on 04/17/25 at 4:57 PM, Registered Dietician (RD) 2 stated the time span between dinner and breakfast the next day should be 14 hours or less, unless the resident council approved of a longer period. During an interview on 04/18/25 at 9:46 AM, Activity Aide (AA) 1 stated she had been employed about a year and a half and attended the resident council meetings. She stated she did not remember any conversation about a gap of more than 14 hours between dinner and breakfast or the gap being discussed and/or approved of by the resident council. AA1 stated there were complaints about the consistency of mealtimes; however, the AA did not indicate if she acted on these complaints. During an interview on 04/18/25 at 9:53 AM, the DM stated she had not calculated the gap between dinner and breakfast, but confirmed it was 15 hours. She stated she was aware of the requirement for no more than 14 hours between dinner and breakfast. The DM stated the current mealtimes had been in place when she started in her position. The DM confirmed that a discussion with the resident council to approve the 15-hour gap had not occurred since she had been in her position. During an interview on 04/18/25 at 12:47 PM, the Administrator stated she was not aware the facility's planned mealtimes exceeded the 14-hour requirement from dinner to breakfast the next day. The Administrator stated she was not aware of the requirement that a time span of over 14 hours from dinner to breakfast required both an approval from the resident council and a substantial evening snack be provided.

Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner. Specifically, the dish room was in a state of disrepair, the floors lacked regular cleaning, dishware was not clean, there was no garbage can in the handwashing sink area that prevented contamination of one's hands, wiping rag sanitizer solutions were not at the proper concentration, and food was not properly labeled. These failures placed 118 out of 158 residents (40 residents received nutrition via tube feedings) at risk for foodborne illness. Findings include: Review of the facility's policy titled, Storage of Food and Supply, dated 01/03/25 revealed, Food storage areas shall be maintained in a clean, safe, and sanitary manner .Prepared foods with potentially hazardous ingredients must be labeled with a 'use-by date' not to exceed (3) days if held below 41 degrees F [Fahrenheit] .This standard also applies to containers of commercially processed foods once opened. Such food will be tightly sealed with plastic wrap, foil or a lid and labeled . Review of the facility's policy titled, Handwashing Hygiene for Food Handlers dated 01/03/25 revealed, Food service personnel shall wash hands: .As often as required to remove soil and contamination; After working with unclean equipment, work surfaces, clothing, wash cloths, etc . 1. During the initial kitchen observation on 04/14/25 from 9:34 AM to 10:22 AM, the following observations were made with the Dietary Manager (DM): a. Observation at the handwashing sink revealed there was no garbage can in the area in which paper towels from handwashing could be disposed of without contaminating one's hands by removing the soiled garbage can lid of a 55-gallon garbage can. b. The dish washing room was observed with deteriorating tile where the tile back splash met the tile floor. This extended the length of the wall beneath where the dish machine and counters were located. Several of the tiles were broken or partially affixed to the wall. There was an area several feet in length and approximately a foot wide where a covering was taped over a hole in the wall/tile. The tape was peeling off and the area was not sealed. There was a significant amount of food scraps/particles on the floor in this area, which was located below the dirty side of the counter and dishwasher. The DM confirmed these observations. c. The flooring surrounding a floor drain behind the fryer, ovens, and steamer was covered with a thick congealed layer of grease and numerous food particles/spills, and there was a black substance extending about a foot in each direction from the floor drains. There was also a large pool of congealed grease on the floor located below the grill. The DM verified the floor was dirty and needed to be cleaned. She stated the dietary staff power washed the floor on a weekly basis. d. On the wall beneath the handwashing sink, the back splash was coming away from the wall. e. In the food cart storage area adjacent to the kitchen, there was a large hole in the sheet rock, approximately three feet by four inches above the tile trim. d. Two buckets of wiping rag sanitizer solution, which were set up and in use, were tested by the DM for concentration of sanitizer. Both buckets read zero parts per million (PPM) of lactic acid concentration. The DM stated the product was called Sink and Surface Cleaner and review of the label for the test strips and confirmation by the DM revealed the concentration should be between 272 - 700 PPM. The DM disposed of the buckets with the solutions stating the buckets did not have any sanitizer. The DM verified the solutions were used to wipe up spills and to clean kitchen surfaces. e. There were two steamtable pans with leftovers in the walk-in refrigerator. The first pan was labeled Potato with Friday documented. The second pan was labeled Chili with Wednesday documented. It was unclear which Friday and Wednesday applied and the DM stated it had been more than three days for the pan of chili with Wednesday so it should be discarded. f. There were three plastic cereal/soup bowls stored on a tray as clean that were soiled with food residue/particles adhered to the inside surface of the bowls. The DM verified the bowls were not clean and she removed them, placing them on the dirty side of the dish counter to be washed. g. There were two pans of sliced meat, one ham and one chicken, in the cook's reach in refrigerator. Neither had a label with the name of the food or date. The DM stated they should be labeled. 2. A follow-up observation was made on 04/15/25 at 10:43 AM. The following concerns were noted: a. Observation at the handwashing sink revealed there was no garbage can in the area in which used paper towels from handwashing could be disposed of without soiling one's hands by removing the soiled garbage can lid of a 55-gallon garbage can. The DM stated they used to have a garbage can located by the handwashing sink that was foot operated and could be operated without soiling one's hands, but she did not know where it was. The DM verified one's hands were potentially contaminated by removing the garbage can lid with clean hands. The garbage cans lid was visibly soiled with food residue. b. There was a plastic cereal/soup bowl stored as clean that had large food pieces adhered to the inside surface. The DM verified it was not clean and removed it. c. The areas noted on 04/14/25 in need of repair (floor, tiles, walls) remained in the same condition as noted during the initial inspection. 3. During an interview on 04/15/25 08:26 AM the DM stated she had been in her position for about five months. She stated she had been focusing on decluttering and cleaning and getting work orders for repairs. The DM indicated the dish room had been in disrepair for a while. During an interview on 04/17/25 at 5:22 PM, the Maintenance Director (MD) verified the kitchen was not kept clean enough. The MD stated he had been in his position about five months and was not sure how long the kitchen dish room had needed repair of the tile, flooring, and walls. He stated they were waiting for an additional estimate for repair. During an interview on 04/18/25 at 9:53 AM, the DM stated there were cleaning assignments for staff; however, there were no sign off sheets to show the work was completed. She stated the assignments were built into the position assignments. The DM stated the kitchen did not have a power washer for the floors and staff had to borrow one from maintenance. During an interview on 04/18/25 at 4:45 PM, the MD stated he observed the floor in the kitchen on 04/14/25 was soiled with built up food.

Based on observation, interview, and record review, the facility failed to allow family visitation for one out of 49 sampled residents (Resident (R)10). The facility restricted visitation of R10's family member (Family Member (F) 4). This failure violated R10's right as a resident of the facility. Findings include: During an interview on 04/18/25 at 12:33 PM, the Administrator stated the facility did not have a visitation policy. Observation on 04/18/24 at 8:30 PM revealed a sign was posted at the facility entrance that read, Recommended visiting hours 10:00 AM - 7:00 PM. Review of R10's undated admission Record, in the electronic medical record (EMR) under the Profile tab revealed R10 was admitted to the facility on [DATE]. Review of R10 admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/25, located in the EMR under the MDS tab revealed the facility assessed R10 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During an interview on 04/14/25 at 2:25 PM, F4 stated R10 had almost fallen out of bed twice at night and he had caught her. F4 stated he visited R10 in the evening and at night to make sure R10 was safe, and to make sure her needs were met such as making sure R10 got her pain medications, assistance she needed in the evening/at night, and to follow up on everything. F4 stated he did not sleep while in R4's room and the curtain was pulled between R10 and her roommate. F4 stated he was quiet and did not disturb R10's roommate. F4 stated one of the reasons they chose the facility was because it allowed 24-hour visitation. F4 stated he was told about a week ago that he could no longer visit at night due to R10 having a roommate. F4 stated R10 wanted him there in the evenings/nights. F4 stated there was an incident about a week ago when Registered Nurse (RN) 2 was working at night and told him he could not visit R10, and if he did not leave, she was going to call the police. F4 stated he was denied visitation and left the building without visiting R10. F4 stated the facility recently posted recommended visiting hours by the entry door into the facility. During an interview on 04/15/25 at 11:02 AM, R10 stated when she was admitted to the facility, she was very weak. R10 stated the mattress was much narrower than what she was used to at home, and she almost fell out of bed twice, but F4 had caught her. R10 stated she felt safer when F4 was there at night. R10 stated the facility advertised they were open 24 hours, and she thought visitation was allowed. R10 stated the staff recently told her F4 could come after 9:00 AM but could not stay past 8:00 PM. R10 stated one-night last week F4 came to visit her, and they would not let him visit and if he did not leave, told him they would call the police. R10 stated this was upsetting to her. Review of R10's Progress Notes including Nursing, Physician, Social Services, etc. from admission through 04/18/25, located in the resident's EMR under the Progress Notes, tab revealed no documentation about F4's visitation, about him being disruptive or causing any concern. There was no mention at all of F4 in the Progress Notes. During an interview on 04/15/25 at 6:30 PM, RN2 stated F4 had a history of coming in at 9:00 PM and leaving at 11:00 PM or visiting during the night. RN2 stated F4 recently came in at 10:00 PM, and she told him that R10 had a roommate, and he needed to respect her sleep. RN2 stated she told F4 he could not visit and that she would call the police if he did not leave. RN2 stated F4 looked homeless and scary, he wore black clothing, a mask, sunglasses, and pushed a cart. RN2 stated the staff recently put the sign up for recommended visiting hours due to F4's visits. RN2 stated she was only aware of one other family that visited at night. During an interview on 04/16/25 at 9:27 AM, Licensed Practical Nurse (LPN) 14, the Unit Manager for DelCastle stated she had been notified by nursing staff that F4 was staying at the facility at night. LPN14 stated the administrative team discussed it and agreed it was not appropriate for F4 to be visiting at night. LPN14 verified R10's roommate had not complained about F4's visits. LPN14 stated F4 could visit at night if R10 wanted to come out to the dining room common area. During an interview on 04/17/25 at 11:36 AM, Certified Nursing Assistant (CNA) 16 stated R10's roommate had not complained about F4 being in the room; however, CNA16 stated the room was small and F4 was sometimes in the way. CNA16 stated there were some families on Limestone unit that spent the night, but those were private rooms. During an interview on 04/18/25 at 9:33 AM, Social Services (SS) stated she had been recently hired. She stated she was not aware that F4 was not allowed to visit at night. SS stated the visitation hours posted were recommended hours. SS stated families should not be told they could not come in. SS stated F4 visited at night and brought stuff with him; she denied he caused problems. SS stated she had not heard of any concerns from R10's roommate about F4's visits. During an interview on 04/18/25 at 10:51 AM, Director of Nursing (DON) 1 stated the facility had 24-hour visitation and recommended visiting hours. The DON stated the staff spoke with F4 about the recommended visiting hours. She stated the facility had lounge areas and F4 could visit after hours in the lounge with R10. During an interview visit on 04/18/25 at 12:33 PM, Administrator1 stated the posted hours were recommended visiting hours. Administrator1 stated it was not appropriate for F4 to visit at night in R10's room considering R10 had a roommate, and this violated the roommate's rights. Administrator1 verified R10's roommate had not alleged a concern about F4's visits.

Based on observation, interview, and record review, the facility failed to ensure a homelike environment was maintained for one resident (Resident (R) 90) out of 49 sampled residents. Facility nursing staff disposed of a soiled brief in R90's trash can which caused urine odor in the resident's room. This had the potential to create odors throughout the facility. Findings include: Review of R90's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with multiple diagnoses that included vegetative state, acute respiratory failure, and nontraumatic intracerebral hemorrhage. Review of R90's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/18/24, located in the EMR under the MDS tab, revealed R90 was always incontinent of bowel and bladder. Observation on 04/17/25 at 5:45 PM with Licensed Practical Nurse (LPN) 6 revealed a soiled brief in R90's trash can in his room. During an interview at this time, LPN6 confirmed the soiled brief in the trash can was saturated with urine. LPN6 stated she was not aware of nursing assistants disposing of briefs in the trash can until now. During an interview on 04/17/25 at 6:23 PM, Certified Nursing Assistant (CNA) 13 confirmed he was assigned to R90 and had changed his brief earlier. CNA13 stated he disposed of soiled brief in R90's trash can in his room. CNA13 also stated he should have placed the brief in the plastic trash bag and then taken it to the soiled utility room, but he was asked to assist another nursing assistant and so he had not gone back to his room to remove it yet. CNA13 indicated this practice caused R90's room to smell like urine. Observation on 04/18/25 at 9:50 AM with the Assistant Director of Nursing (ADON) and LPN21 revealed a urine-soaked brief was in R90's trash can in his room. During an interview at this time LPN21 confirmed the brief was in the trash can, but she did not know what the nursing assistants were trained to do after removing briefs from residents. During an interview on 04/18/25 at 9:45 AM, LPN6 stated she trained the nursing assistants on removing briefs and taking them to the soiled utility room for disposal. LPN6 also stated CNA20 had already changed several residents and had disposed of their briefs in the trash can prior to the training. During an interview on 04/18/25 at 10:20 AM, CNA20 stated she changed R90's brief at 8:00 AM, disposed of it in the trash can, but had not taken the trash bag to the soiled utility room yet. CNA20 also stated she had not been trained to take urine-soaked briefs out of the room during orientation at the facility. During an interview on 04/14/25 at 8:50 PM, Family Member (F) 9 stated the CNAs were disposing of R90's briefs in the trash can and he could smell feces and urine when he visited several times a week. During an interview on 04/18/25 at 10:13 AM, the Staffing Coordinator stated incontinence care was discussed, and competencies were provided; however, the competency and discussion did not include disposal of briefs. The Staffing Coordinator also stated disposing of soiled briefs in the soiled utility room was a standard of practice that all nursing assistants should have learned in their CNA courses. During an interview on 04/18/25 at 10:15 AM, Housekeeper (HK) 1 stated she had observed briefs disposed of in residents' trash cans on the unit while she was cleaning their rooms. During an interview on 04/18/25 at 10:34 AM, Director of Nursing (DON) 1 stated she did not know what the standard was when CNA20 was hired, but soiled briefs and wipes should be placed in the clear trash bag and then disposed of in the soiled utility room. During an interview on 04/18/25 at 2:21 PM, the Administrator stated she expected staff to dispose of the briefs in the dirty utility room on the units to decrease smells to create a homelike environment. The Administrator also stated she did not have a homelike environment policy.

Based on interview, record review, and review of facility policy, the facility failed to thoroughly investigate an allegation of an injury of unknown origin for one resident (Resident (R) 101) of 17 residents reviewed for abuse. Findings include: Review of a facility policy titled Abuse, Neglect, Mistreatment, Exploitation, and Reasonable Suspicions of Crime, dated 01/03/25 indicated .The NHA [Nursing Home Administrator] or designee shall investigate allegations and report to appropriate regulatory agencies and/or law enforcement.All persons identified as involved in or with knowledge of the occurrence will be interviewed. Review of R101's admission Record located in the resident's electronic medical record (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R101's Care Plan located in the resident's EMR under the Care Plan tab dated 01/17/24 indicated the staff were to assist the resident with repositioning in bed as ordered. Review of R101's Physician Orders located in the resident's EMR under the Prog Note tab dated 02/20/25 indicated the resident was ordered to have two staff members to assist with bed mobility (side to side). Review of R101's quarterly Minimum Data Set (MDS), and located in the resident's EMR under the MDS tab with an assessment reference date (ARD) of 04/02/25 indicated the staff could not determine the resident's BIMS score. The resident was totally dependent on all activities of daily living by staff. Review of R101's hospital records, dated 05/08/24, indicated the resident had a history of chronic left shoulder dislocation. The hospital records revealed the resident had a CT scan, of the resident's right shoulder, which revealed the resident had a fractured humerus or scapula. The scan stated that the resident had osseous (bone) structures were mildly demineralized diffusely. There was evidence of an anterior-inferior dislocation of the humeral head in relation to the glenoid (the shallow socket of the shoulder). The remainder of the visualized osseous structures appear intact without evidence of other acute osseous abnormality or suspicious osseous lesion. Mild osteoarthrosis was demonstrated. The resident was not a candidate for surgery. Review of a document provided by the facility titled Facility Incident Investigations dated 05/14/24 indicated that the facility reported the injury of unknown origin for R101 to the State Survey Agency (SSA) timely and a follow-up five-day summary. There was no evidence that the facility interviewed potential witnesses (staff) as part of their internal investigation. This investigation was completed by the former Director of Nursing (DON) 2. During an interview on 04/17/25 at 3:24 PM, DON2 remembered R101's injury of unknown origin and stated that he typically did collect witness statements and would go back at least 48 hours to gather statements from the staff who worked with the resident. During an interview on 04/17/25 4:23 PM, the Clinical Consultant and the current Administrator stated they could not locate any staff interviews for the injury of unknown origin which involved R101. During an interview on 04/18/25 at 10:25 AM, the current DON1 confirmed she was the facility's abuse coordinator. DON1 stated she would gather witness statements, interview the suspect, if there was and decide what happened.

Based on observation, interview, record review, and facility policy review, the facility failed to revise a person-centered care plan related to falls for one resident (Resident (R) 141) out of nine residents reviewed for accident. This had the potential for the residents to have injuries related to falls due to care needs not being identified. Findings include: Review of R114's admission Record located in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage and persistent vegetative state. Review of R114's Care Plan located in the resident's EMR under the Care Plan tab revealed a problem area, Actual Fall, initiated on 12/27/24 with interventions, dated 12/02/24, for perimeter mattress and bilateral fall mats to reduce the likelihood of any fall-related injury. Another problem area, The resident is at risk for falls, initiated on 10/13/23 had interventions which included, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed and Keep pathway to the bathroom clear and clutter free both initiated 10/13/23. Review of R114's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/25 and located in the MDS tab of the EMR revealed R114 was in a persistent vegetative state with no discernible consciousness. R114 had functional limitation in range of motion to both upper and lower extremities and was dependent on staff for rolling side to side. R114 had a fall with injury since the last assessment. During an observation on 04/14/25 at 11:42 AM, R114 was observed in bed on an air mattress, not a perimeter mattress, and without fall mats in place. During a concurrent observation and interview on 04/15/25 at 3:26 PM, Certified Nursing Assistant (CNA) 13 and CNA19 repositioned R114 in bed. R114 was observed to be totally dependent on staff for mobility with no discernible response to verbalizations. R114 wore splints due to contractures of both hands. CNA13 reported that R114 had no fall mats or perimeter mattress since he really had no movement. During an interview on 04/17/25 at 2:00 PM, Licensed Practical Nurse (LPN) 6 who was the Unit Manager for R114's unit stated the Assistant Director of Nursing (ADON) reviewed falls for care planning interventions, and the MDS Coordinator completed general care planning. During an interview on 04/18/25 at 10:46 AM, MDS Coordinator (MDSC) 1 stated falls were discussed daily in the morning meeting and nursing, usually the ADON, updated the Care Plan interventions. For day-to-day changes in fall interventions, the unit managers updated the Care Plans. The MDSCs reviewed and revised the care plans with each quarterly, annual, or significant change MDS assessment. If a resident had a fall intervention which was not being used, the unit managers or ADON reviewed this since they were more directly involved in care. Care plans were expected to be person-centered. During an interview on 04/18/25 at 11:27 AM, the ADON stated she had been in and out of the ADON role. She usually spearheaded the fall interventions. Falls were discussed in the morning meeting and a root cause analysis was determined. Current fall interventions were reviewed, and if not relevant, they were resolved. The ADON reviewed R114's fall interventions and stated encouraging call light use and keeping pathways clear were prepopulated interventions and could probably be removed. R114 had moved rooms multiple times, so the mattress and fall mats may not have moved with him. If the perimeter mattress and fall mats were not used, the care plan should reflect that and the resident's status. During an interview on 04/18/25 at 1:10 PM,Director of Nursing (DON) 1 stated she expected care plans to be resident-centered and to reflect a resident's current status. If an intervention was no longer in use, it should be resolved. Review of the facility's policy titled, Care Planning revised 01/12/23 revealed, The comprehensive care plans should be reviewed and revised by the interdisciplinary team after each assessment. Review of the facility's Fall Assessment, Prevention, and Management policy revised 01/20/23 revealed, Nursing will complete a post fall clinical evaluation and treatment as necessary, obtain orders and implement resident-centered care plans and interventions .The plan of care and interventions are reviewed and modified when necessary.

Based on interview, record review, and facility policy review, the facility failed to obtain wound treatment orders and provide wound care upon admission to the facility for one of eight residents reviewed for pressure ulcers (Resident (R) 170). Findings include: Review of the facility's policy titled Pressure Ulcer Prevention and Management, revised 01/17/23, provided by the facility revealed Policy: It is the policy of the facility to promote skin integrity through the recognition, treatment and prevention of pressure ulcers. Purpose: To identify residents at risk for skin breakdown and develop an individualized plan of care for prevention, recognition, and treatment of pressure ulcers . Review of R170's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with multiple diagnoses which included displaced comminuted fracture of shaft of the left femur, encounter for other orthopedic aftercare, and history of falling. Review of R170's admission Assessment, dated 03/05/25, located in the EMR under the Evaluations tab revealed she was admitted with a stage 2 pressure ulcer on the sacrum and a new dressing was applied. Review of R170's Weekly Skin Check, dated 03/06/25, located in the EMR under the Evaluations tab revealed an existing skin issue on the sacrum. Review of R170's Weekly Skin Check, dated 03/10/25, located in the EMR under the Evaluations tab revealed an existing skin issue wound on sacrum. Review of R170's Encounter Note, dated 03/08/25, located in the EMR under the Prog Notes tab revealed Chief complaint/Nature of presenting problem: pain, wound sacrum History of Present Illness: .Patient was also assessed due to wound to sacrum area that was bleeding and nursing instructed to cleanse and apply dressing. Surrounding areas to wound deep red and nursing instructed to return patient to prevent further breakdown .Sacral Wound start and continue with daily dressing to wound consult wound team per facility schedule continue with q [every] turns . Review of R170's Physician's Orders, dated 03/11/25, located in the EMR under the Orders tab revealed an order to cleanse sacrum with normal saline, apply collagen and cover with a dry dressing one time a day every Monday, Wednesday, and Friday and notify the provider for signs/symptoms of infection and complications. Review of R170's Medication Administration Record (MAR), dated March 2025, located in the EMR under the Orders tab revealed there was no documented treatment provided to the sacral wound until 03/12/25. Review of R170's Wound Consult, dated 03/12/25, located in the EMR under the Misc tab revealed an unstageable pressure wound on the sacrum measuring 6 centimeters (cm) length x 8 cm width x undetermined cm depth (48 square cm) and was debrided. Review of R170's Wound Consult, dated 03/19/25, located in the EMR under the Misc tab, revealed an unstageable sacral wound measuring 7 cm length x 9.5 cm width x undetermined cm depth (66.5 square cm) and was debrided. During an interview on 04/16/25 at 2:19 PM, the Assistant Director of Nursing (ADON) confirmed R170 had a sacral wound upon admission and there was no alert charting completed on the wound, or a treatment order obtained for the wound until 03/11/25. The ADON stated the former wound nurse saw R170 when she was admitted to the facility and documented the wound on her sacrum. The ADON also stated she should have seen R170 on 03/06/25 and 03/07/25 but she resigned from the position without obtaining a treatment order. The ADON stated Licensed Practical Nurse (LPN) 12 notified her of the sacral wound without a treatment order on 03/10/25 after she completed R170's skin check. The ADON indicated she interviewed the nurses that were assigned to R170 over the weekend (03/08/25 and 03/09/25) and they stated they provided treatments to the wound on the sacrum without an order but did not document it and did not notify the provider. During an interview on 04/16/25 at 2:43 PM, LPN8 stated he was assigned to R170 on 03/06/25 and performed a skin check on her legs so he did not know she had a sacral wound. During an interview on 04/16/25 at 3:36 PM, LPN12 verified she was assigned to R170 and observed the sacral wound when she completed the skin assessment on 03/10/25. LPN12 stated there was no treatment order in place. LPN12 stated she notified the nurse practitioner and informed the ADON. LPN12 also stated the sacral wound was not passed onto her in nursing report and she did not see alert charting on it in the progress notes. LPN12 stated R170 was placed on the wound rounds on 03/12/25. During an interview on 04/16/25 at 3:50 PM, the Wound Physician stated he was not aware that there were no treatments in place for R170's wound on her sacrum until 03/11/25. The Wound Physician confirmed he saw R170 on 03/12/25 and on 03/19/25, the sacral wound was unstageable, and he debrided it. During an interview on 04/17/25 at 5:34 PM, the Director of Nursing (DON) 1 stated she was informed by the ADON that LPN12 reported to her that R170 had a wound to her sacrum without treatment orders and that LPN12 reported it to the Nurse Practitioner.

Based on observation, record review, and interview, the facility failed to administer medications timely for two of five residents (Resident (R) 41 and R145) reviewed for medication administration out of 49 sampled residents. This had the potential to result in adverse health outcomes. Findings include: 1. Review of R41's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R41 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD), asthma, atrial fibrillation, and constipation. Review of R41's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/25 and located in the MDS tab of the EMR, revealed R41 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Review of R41's Order Summary Report, dated 04/15/25 and located in the Orders tab of the EMR, revealed R41 was to receive the following medications: Acetaminophen 325 milligrams (mg) two tabs three times a day for pain Potassium chloride 20 milliequivalent (mEq) twice daily for hypertension Cyanocobalamin (vitamin B12) 500 micrograms (mcg) daily for supplement Diltiazem HCl extended release (ER) 180mg daily for hypertension Losartan potassium 100mg daily for hypertension Isosorbide mononitrate 30mg daily for hypertension Apixaban 2.5mg twice daily for atrial fibrillation Benzonatate 100mg three times daily for cough Cholecalciferol (vitamin D3) 50mcg daily for supplement Docusate sodium 100mg twice daily for constipation Sodium chloride 1 gram (gm) three times daily for hyponatremia Cetirizine 10mg daily for allergy symptoms Olopatadine HCl ophthalmic solution 0.2% one drop to each eye daily for allergies Breo Ellipta inhalation daily for asthma Review of R41's Medication Administration Record (MAR), located in Orders tab of the EMR, revealed the potassium, vitamin B12, diltiazem, vitamin D3, sodium chloride, cetirizine, olopatadine, and Breo Ellipta were scheduled for 9:00 AM. The acetaminophen, losartan potassium, isosorbide mononitrate, apixaban, benzonatate, and docusate sodium were scheduled at 8:00 AM. During an interview on 04/15/25 at 9:30 AM, LPN8 stated he had to administer medications on two floors due to one floor only having one nurse, instead of its normal two nurses. LPN8 stated he started with the more complicated residents who had blood sugar checks and insulin orders. During an observation on 04/15/25 at 10:15 AM, Licensed Practical Nurse (LPN) 8 started to administer R41's morning medications. During an interview on 04/15/25 at 10:25 AM, R41 stated she did not really pay attention to the timing of her medications. During an interview on 04/15/25 at 10:31 AM, LPN13 stated a nurse called off. The facility tried to find another nurse replacement but was unable. LPN13 stated this happened about every two weeks. The two nurses from the other side of the hall floated over to administer medications. Medications were to be administered from an hour before until an hour after their scheduled times, which was difficult when nurses floated. During an interview on 04/15/25 at 3:06 PM, LPN8 stated he was behind that morning due to administering medications in two areas. He felt the morning medication pass should be completed by around 10:00 AM. 2. Review of R145's admission Record, located under the Profile tab of the EMR, revealed R145 was admitted to the facility on [DATE] with diagnoses that included gastrostomy (feeding tube) status and persistent vegetative state. Review of R145's admission MDS, with an ARD of 03/19/25 and located in the MDS tab of the EMR, revealed staff were unable to determine R145's BIMS score. Review of R145's Order Summary Report, dated 04/15/25 and located in the Orders tab of the EMR, revealed R145 was to receive the following medications: Enoxaparin sodium injection daily for deep vein thrombosis (DVT) prophylaxis (prevention) Famotidine 20mg every twelve hours for GERD Review of R145's MAR, located in Orders tab of the EMR, revealed the medications were scheduled for 8:00 AM. During an observation on 04/15/25 at 10:05 AM, LPN20 administered R145's medications. During an interview on 04/15/25 at 10:19 AM, LPN20 reported medications should be given one hour before and one hour after they were ordered. LPN20 stated the medications were due to 9:00 AM, so they were late but were not real late. During an interview on 04/16/25 at 6:00 PM, Director of Nursing (DON) 1 stated she expected medications to be given from one hour before until one hour after their scheduled times. The facility had no policy regarding medication administration.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of less than five percent during medication administration. The facility had two errors in twenty-six opportunities, due to not properly administering medicated eye drops and not priming an insulin pen. This resulted in a seven percent error rate and affected two (Resident (R) 41 and R64) out of five residents observed. Medication errors have the potential to result in adverse health outcomes. Findings include: 1. Review of the facility's policy titled, Eye Drop Administration revised August 2020, revealed, Instill the prescribed number of eye drops into the pouch near the outer corner of the eye.Instruct the resident to close their eyes slowly to allow for even distribution over the surface of the eye. The resident should refrain from blinking or squeezing their eyes shut. While the eye is closed, use one finger to compress the tear duct in the inner corner (inner canthus) of the eye for 1-2 minutes. This reduces systemic absorption of the medication. Alternatively, the resident may keep their eyes closed for approximately three minutes . Review of R41's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R41 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD), and asthma. Review of R41's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/25 and located in the MDS tab of the EMR, revealed R41 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Review of R41's Order Summary Report, dated 04/15/25 and located in the Orders tab of the EMR, revealed R41 was to receive olopatadine HCl ophthalmic solution 0.2% one drop to each eye daily for allergies. During an observation on 04/15/25 at 10:15 AM, Licensed Practical Nurse (LPN) 8 instilled one drop of the olopatadine HCl ophthalmic solution into each of R41's eyes. LPN8 blotted each eye with a tissue following administration but did not compress the tear duct nor ask R41 to keep her eyes closed or to compress the tear duct in the inner corner of the eye. During an interview on 04/15/25 at 3:06 PM, LPN8 stated he knew to wait for at least five minutes between different types of eye drops and to wipe with a tissue from inner eye to outer eye to prevent any dripping. He had not been taught about putting any pressure on the tear duct. During an interview on 04/17/25 at 5:32 PM, the Staffing Coordinator stated staff were to apply a little pressure at the corner of the eye after administering the eye drop medication. During an interview on 04/18/25 at 11:07 AM, Director of Nursing (DON) 1 reviewed the Eye Drop Administration policy and stated she expected staff to follow it and to instruct or assist residents to close their eyes slowly to allow for even distribution over the surface of the eye and use one finger to compress the tear duct in the inner corner of the eye for 1-2 minutes. 2. Review of the Admelog Solostar Pen Instructions for Use, dated November 2019, accessed at https://products.sanofi.us/admelog/Admelog_Solostar_Pen_IFU.pdf on 04/16/25, revealed . Step 1: check your pen .1B Pull off the pen cap .1C check that the insulin is clear . 1D wipe the rubber seal with an alcohol swab . Step 2: Attach a new needle . Step 3: Do a safety test . 3A Select 2 units by turning the dose selector until the dose pointer is at the 2 mark. 3B press the injection button all the way in. when insulin comes out of the needle tip, your pen is working correctly . Review of R64's undated admission Record located in the EMR under the Profile tab, revealed R64 was admitted to the facility on [DATE] with a diagnosis of type 1 diabetes mellitus (DM) with hyperglycemia. Review of R64's Physician Orders, dated 01/21/25, located in the EMR under the Orders tab, revealed an order for Admelog SoloStar (a rapid acting insulin) 100 unit/milliliters (ML) solution pen-injector inject 10 units subcutaneously before meals for DM. During an observation on 04/15/25 at 12:46 PM, Registered Nurse (RN) 6 retrieved R64's insulin pen (a pen contains the vial of insulin inside the pen and has a mechanism where the dose to be administered is set on a dial at the top of the pen, and only that amount can then be injected) from the medication cart, wiped the top with an alcohol wipe, attached a needle to the pen then dialed the dose to 10 units. RN6 carried the pen to R64's room. RN6 washed her hands, applied gloves, observed R64's left side of the abdomen, cleansed her abdomen with an alcohol wipe, gently inserted the pen needle into the flesh, injected the dose, then removed the needle after ten seconds. Next, RN6 carried the pen to the medication cart, disposed of the needle, and performed hand hygiene. During an interview on 04/15/25 at 12:51 PM, RN6 confirmed she did not prime the pen with two units to ensure the needle was working. RN6 stated she did not prime the insulin pens and was not trained to do so. During an interview on 04/18/25 at 10:07 AM, the Staffing Coordinator stated she reviewed insulin pen administration on day 3 of orientation and the nurses completed the competency afterwards. The Staffing Coordinator also stated she would make medication administration observations on a schedule but did not know the schedule yet since she began employment on 04/01/25. The Staffing Coordinator indicated that after the needle was applied to the insulin pen, it should be dialed to two units and then push the plunger to ensure that it worked. During an interview on 04/17/25 at 6:49 PM, DON1 stated she expected the nursing staff to administer insulin via the manufacturer's directions and the insulin pen should be primed with two units after attaching the needle to ensure it worked.

Based on interview, record review, and policy review, the facility failed to ensure one of four sampled residents reviewed for hospitalization (Resident (R) 162) and R162's representative were notified of the reasons in writing for R162's transfer to the hospital on [DATE]. Additionally, there was no evidence that the Ombudsman was notified of the transfer/discharge. This failure placed all residents at risk of not being informed of their appeal rights and process after they are discharged from the facility. Findings include: Review of the facility's policy titled, Resident and Ombudsman Notification of Transfer or Discharge, dated 01/03/25 revealed, It is the policy of [Corporation name] to provide residents/resident representatives and the ombudsman with a notice of transfer/discharge as required by Center for Medicare & Medicaid Services (CMS) . Review of R162's undated admission Record in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R162's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/29/24 in the EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated the resident was severely cognitively impaired. Review of R162's Nurse's Note, dated 10/10/24 and located in the resident's EMR under the Progress Notes tab revealed the resident had a fall. Review of R162's Nurse's Note dated 10/14/24 located in the resident's EMR under the Progress Notes tab revealed, Daughter wishes for patient to be sent to ER [emergency room] for eval. 911 was called, NP called report to ER [Emergency Room]. 911 arrived to facility at 1221 [12:21 PM], was transported to ER with all appropriate paperwork. A request was made on 04/18/25 of administration for R162's transfer notice provided to the resident, responsible party, and ombudsman; no evidence of the resident, responsible party, or ombudsman notification was provided as of the survey exit on 04/18/25. During an interview on 04/17/25 at 11:11 AM, the admission Director (AD) stated she completed the bed hold notices when residents were sent to the hospital but had nothing to do with the transfer/discharge notices. The AD stated she thought nursing staff might have provided the transfer/discharge notices to the resident/responsible parties. During an interview on 04/18/25 at 9:24 AM, Social Service (SS) 1 stated this was her second week of employment and she had not been completing the transfer notices for residents going to the hospital and did not know who was responsible. During an interview on 04/18/25 at 10:50 AM, Director of Nursing (DON) 1 stated the facility did not complete a transfer/discharge form that was provided to the resident or responsible party for emergent transfers to the hospital. The DON stated families/responsible parties were notified by phone of transfers by nursing; however, nothing was provided in writing. During an interview on 04/18/25 at 11:40 AM, Licensed Practical Nurse (LPN) 19 stated she contacted families when residents were transferred to the hospital; however, did not provide anything in writing to the resident or responsible party/family. During an interview on 04/18/25 at 1:19 PM, LPN18 stated when a resident was sent to the hospital, the family was called. A transfer/discharge form was not provided in writing to the resident or responsible party/family.

Based on observation, interview, and record review, it was determined that for five (R2, R3, R4, R5, and R6) out of five residents reviewed for respiratory care, the facility failed to ensure that respiratory care, including tracheostomy care and respiratory mouth care, was provided consistent with professional standards of practice and the comprehensive person-centered care plan. Findings include: 1. Review of R2's clinical record revealed: 8/3/23 - R2 was admitted to the facility with diagnoses including acute respiratory failure with hypoxia, and tracheostomy. R2 was dependent on the staff for all activities of daily living. 8/4/23 - R2's respiratory care plan documented, The resident [R2] has a tracheostomy. The interventions included, Trach care per order . Provide good oral care . 8/4/23 - R2's respiratory treatment administration record documented, Respiratory to perform mouth care every shift Trach care every shift. A review of R2's respiratory TAR revealed the following: 6/6/24 7:00 PM - R2's respiratory TAR lacked evidence of tracheostomy and respiratory mouth care. 6/9/24 7:00 PM - R2's respiratory TAR lacked evidence of tracheostomy and respiratory mouth care. The facility failed to provide tracheostomy and respiratory mouth care for two out of 24 opportunities. 2. Review of R3's clinical record revealed: 12/17/22 - R3 was admitted to the facility with diagnoses including acute and chronic respiratory failure, seizure disorder, ventilator dependence, and persistent vegetative state. R3 was completely dependent on staff for all activities of daily. 2/16/23 - R3's respiratory care plan documented, The resident is ventilator dependent r/t [related to] Respiratory Failure. The interventions included, Trach care per order. 9/26/23 - R3's respiratory treatment record documented, Respiratory to perform mouth care, Trach care every shift. 12/14/25 12:15 PM - A review of R3's respiratory TAR revealed the following: 6/9/24 7:00 PM - R3's respiratory TAR lacked evidence of tracheostomy and respiratory mouth care The facility failed to provide tracheostomy and respiratory mouth care for one out of a total of 60 opportunities. 3. Review of R4's clinical record revealed: 8/22/23 - R4 was admitted to the facility with diagnoses including left sided paralysis status post stroke, chronic respiratory failure and tracheostomy. R4 was dependent on staff for all activities of daily living. 8/23/23 - R4's respiratory care plan documented, Has a tracheostomy . The interventions included, Monitor/document respiratory rate, depth and quality. Check and document q [every] shift as ordered. 5/17/24 - R4's physician's orders documented, Trach care every shift, Respiratory to perform mouth care every shift. A review of R4's respiratory TAR revealed the following: 6/6/24 7:00 PM - R4's respiratory TAR lacked evidence of tracheostomy care. 6/9/24 5:00 PM - R4's respiratory TAR lacked evidence of respiratory mouth care, and tracheostomy care at 7:00 PM. 6/17/24 5:00 PM - R4's respiratory TAR lacked evidence of respiratory mouth care, and tracheostomy care at 7:00 PM. 6/18/24 5:00 PM - R4's respiratory TAR lacked evidence of respiratory mouth care, and tracheostomy care at 7:00 PM. 6/23/24 1:00 PM - R4's respiratory TAR lacked evidence of respiratory mouth care. The facility failed to provide tracheostomy and respiratory mouth care for four out of 60 out of opportunities. 4. Review of R5's clinical record revealed: 8/25/23 - R5 was admitted to the facility with diagnoses including chronic obstructive pulmonary failure, acute respiratory failure, and tracheostomy. 2/23/24 - R5's care respiratory care plan documented, .Has a tracheostomy . The interventions included, . Trach care per orders . 6/1/24 - R5's respiratory treatment record documented, Trach care every shift. Respiratory to perform mouth care two times a day. A review of R5's respiratory TAR revealed the following: 6/6/24 7:00 PM - R5's respiratory TAR lacked evidence of tracheostomy and respiratory mouth care. 6/9/24 7:00 PM - R5's respiratory TAR lacked evidence of tracheostomy and respiratory mouth care. 6/17/24 7:00 PM - R5's respiratory TAR lacked evidence of tracheostomy and respiratory mouth care. The facility failed to perform tracheostomy and respiratory mouth care for three out of total 60 opportunities. 5. Review of R6's clinical record revealed: 12/6/22 - R6 was admitted to the facility with diagnoses including anoxic brain damage, persistent vegetative state, acute and chronic respiratory failure, and tracheostomy. R6 was completely dependent on staff for all activities of daily living. 12/6/22 - R6's respiratory care plan documented, .Resident has a tracheostomy r/t [related to] impaired breathing mechanic . The interventions included, Suction as necessary. Trach care per order. 4/24/24 - R6's respiratory TAR documented, Trach care every shift, and respiratory to perform mouth care 2 times a shift. A review of R6's respiratory TAR revealed the following: 6/6/24 7:00 PM - R6's respiratory TAR lacked evidence of tracheostomy and respiratory mouth care. 6/9/24 7:00 PM - R6's respiratory TAR lacked evidence of tracheostomy and respiratory mouth care. 6/17/24 7:00 PM - R6's respiratory TAR lacked evidence of tracheostomy and respiratory mouth care. 6/18/24 7:00 PM - R6's respiratory TAR lacked evidence of tracheostomy and respiratory mouth care. The facility failed provide tracheostomy and respiratory mouth care for a total of four out of 60 opportunities. 2/14/25 2:30 PM - During an interview the Surveyor asked E6 (RT) which department provided tracheostomy and respiratory mouth care for the residents. E6 stated, Respiratory therapy. 2/16/25 2:00 PM - Findings were confirmed with E3 (CNO.) 2/17/25 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (CNO), E10 (Corp. Nurse) and E11.

Based on interview and record review, it was determined that for two (R5 and R19) out of four residents reviewed for physician visits, the facility failed to ensure that the physician reviewed R5's total program of care including medications.R5's Eliquis (anticoagulant-medication that works to prevent clotting of blood) was not re-started following R5's outpatient procedure on [DATE]. The facility's failure to ensure the physician/providers had a process to track residents on anticoagulants placed R5 in immediate jeopardy (IJ) of a serious adverse outcome. R5 had chronic atrial fibrillation, which placed him at risk for developing clots; R5 has been prescribed eliquis since [DATE] in order to prevent the development of clots. Due to this failure, R5, whose anticoagulant (Eliquis) had been discontinued pre-operatively beginning [DATE] did not receive his Eliquis (anticoagulation) from [DATE] through [DATE]. On [DATE], R5 was sent to the hospital with complaints of abdominal pain and nausea and was found to have significant blood clots impacting several organ systems. R5 was placed on comfort care and died the following day on [DATE]. The immediate jeopardy is being cited as past non compliance with an abatement date of [DATE]. For R19, the facility failed to ensure the provider was reviewing and responding to R19's clinical lab work. Findings include: Eliquis (apixiban) Drug Package Insert .Black Box Warning: WARNING: (A) PREMATURE DISCONTINUATION OF ELIQUIS INCREASES THE RISK OF THROMBOTIC EVENTS . 2.3 Temporary Interruption for Surgery and Other Interventions- ELIQUIS should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding. Eliquis should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled. Bridging anticoagulation during the ,d+[DATE] hours after stopping Eliquis and prior to the intervention is not generally required. Eliquis should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established .5.2 Bleeding- . The pharmacodynamic effect of Eliquis can be expected to persist for at least 24 hours after the last dose, i.e. for about two drug half-lives . Bristol [NAME] Squibb revised [DATE]. Review of R5's clinical record revealed: [DATE] - R5 was admitted to the facility with diagnoses including but not limited to stroke, heart failure and atrial fibrillation. [DATE] - E6 (MD) ordered, Eliquis (anticoagulant) tablet 5 mg (milligram) Give 1 tablet by mouth two times a day for Afib (atrial fibrillation). ,d+[DATE] - Pre-operative paperwork was received by the facility from an ENT (Ear, Nose and Throat) Surgeon regarding R5's upcoming surgical procedure scheduled for [DATE]. An instruction sheet provided to the patient from an ENT surgery center stated, .Unless otherwise directed, we must ask you to avoid any of these medications for at least two weeks prior to surgery. If any of these medications have been prescribed for you by your family doctor, please notify them of your pending surgery. A list of medications included with the paperwork and eliquis was circled. [DATE] - E6 (MD) gave a verbal order to E13 (RN) to discontinue Eliquis,give 1 tablet . two times a day for afib until [DATE] 23:59. [DATE] was 15 days prior to R5's surgical date of [DATE]. [DATE] 8:00 PM - R5's Medication Administration Record (MAR) documented R5's last dose of Eliquis. [DATE] - An operative report documented, R5 underwent an outpatient surgical procedure with the a right ear. R5 tolerated the procedure well and returned to the facility. [DATE] 3:40 PM - R5's Discharge Instructions from the procedure documented no changes to R5's medications including Eliquis, specifically the term unchanged was used with regards to R5's Eliquis on this document. [DATE] 5:32 PM - A nursing progress note documented that R5 returned to the facility without incident. [DATE] 1:00 AM - E7's (NP) progress note documented, .History of Present Illness: Pt with decline in functions, constantly c/o (complaint of) dizziness . Chart, labs, meds reviewed . Plan: .Dizziness - Possibly dt (due to) meds. Meds reconciled and made changes today .A-fib- cont (continue) eliquis, sotalol . [DATE] - A nursing progress note documented Resident requested to be sent out to the hospital for abdominal pain and nausea. (E7) was made aware and approved. [DATE] 11:48 AM - An Emergency Department physician record documented R5 had atrial fibrillation on Eliquis presenting from a nursing facility with altered mental status and green stool. He is not following commands .tender when he pushes abdomen and nods yes when asked if he is tender. A CT scan (imaging test that takes detailed pictures of the inside of the body) was performed and the results determined, R5 had an occlusion of the SMA with signs of ischemia (an inadequate blood supply to a body organ), complete occlusion of the common illiac artery, left external iliac artery, and left femoral artery and a new infarct of the kidney and spleen (a blood clot in the intestines, three arteries that bring blood to the legs, and blood clots in the arteries that bring blood to the kidneys and spleen). [DATE] - A hospital History and Physical report documented He has not been taking his Eliquis .seen by vascular surgery team and underwent an exam of blood vessels by taking an x-ray and a surgical procedure to remove blood clots from an artery or vein. Following the procedure R5's heart rate was in the 140's (normal range is ,d+[DATE] beats per minute), rapid breathing greater than 20 breaths per minute (normal range is ,d+[DATE] breaths per minute), and a lack of oxygen in the tissues to sustain bodily functions. R5 was admitted to the ICU (intensive care unit). [DATE] - A Discharge Summary documented, R5 in collaboration with family members have elected to proceed with comfort measures (care that helps or soothes a person who is dying) .they declined hospice and would like to stay in the unit during his dying process. [DATE] - Review of Certificate of Death established R5 was pronounced deceased at 3:53 PM. Documented cause of death: Mesenteric ischemia, Superior Mesenteric Artery Occlusion (inadequate blood flow to the small intestine), and Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). [DATE] 10:30 AM - An interview was conducted with E1 (NHA), E2 (DON), E5 (RN,CNO), E11 (COO) regarding the events leading up to R5's death. E1, E2, and E5 confirmed that on [DATE] when R5 returned from his outpatient procedure that Eliquis was not re-started and they stated that no medication reconciliation was done as the procedure was performed as a same-day procedure. They confirmed that R5 had been taking the medication since 2020 for A-fib. [DATE] 1:45 PM - During an interview with E6 (MD), this Surveyor asked E6 why was R5's Eliquis not re-started upon his return to the facility from his procedure? E6 replied It should have been. E6 also confirmed that she had given a verbal order to E13 (RN) to discontinue the medication on [DATE] and also confirmed that it should have been an order to hold and resume upon return. [DATE] 11:55 AM - During an interview, E7 (NP) confirmed that she had seen R5 on [DATE]. E7 stated, I have been seeing this resident for five years, I discontinued his psychiatric medicines because he was fatigued and dizzy. I thought this was secondary to his psych. medications. When asked about her note regarding Eliquis and if she had reviewed the meds, E7 replied that she didn't know Eliquis had been discontinued. E7 stated she had reviewed R5's medicine list in Gerimed, the electronic application that E6 (MD) has her NPs document in and the Eliquis was still listed there. When E7 was asked if Gerimed communicates in real time with Point Click Care (the electronic application used by the facility to order and document in a resident's record within the facility) to update medicines, E7 stated' No, I have to update the meds. This application (Gerimed) doesn't automatically update; updates are done manually. When asked if she had looked at the discharge summary, E7 replied If I looked at it, I would have signed it. [DATE] 12:17 AM - During an interview, E7 confirmed that the discharge summary for the [DATE] procedure in R5's clinical record was not signed and she had not looked at it. [DATE] - Review of all documentation of the corrective action plan that was abated on [DATE] included: - Timely reporting to State Agency; - An immediate QAPI plan of action initiated; - Education of all nursing staff, including providers; - A house sweep with a 90 day lookback of all residents taking blood thinners; - A 30 day lookback of care plans of those residents taking blood thinners, then monthly audits conducted through [DATE]; - A 30 day lookback at all consults for outpatient procedures; - System changes initiated for all residents returning from outpatient procedures. The nurse will notify the unit manager, who will take it to the provider. If clarification is needed, the provider will contact the outside entity. For R5, the facility failed to resume an anticoagulant medication used to treat atrial fibrillation and prevent blood clots upon return from a same day outpatient procedure, causing an adverse outcome and ultimately death.

Based on interview, record review and review of other facility documentation, it was determined that for one (R4) out of four residents reviewed for medication errors, the facility failed to ensure R4 received the correct dose of NPH (Neutral Protamine [NAME]) insulin on 9/7/23. The facility's failure placed R4 at risk for a serious adverse outcome, hypoglycemia and diabetic coma. An IJ was identified and due to the facility's corrective measures following the incident on 9/7/23 at approximately 5:00 PM this is being cited as past non-compliance with an abatement date of 9/8/23. Findings include: A facility policy Blood Glucose Monitoring last revised 11/12/21, reviewed 1/20/23 documented, It is the policy of Cadia Healthcare to provide safe blood glucose monitoring . verify the resident's order . obtain blood sample, check results .document results in Medical record and administer Review of R4's clinical record revealed: 3/24/23 - R4's most recent admission to the facility included diagnoses of but not limited to stroke, tracheostomy and diabetes. 8/2/23 - A physician order written by E6 (MD) documented, NPH Insulin 100 UNIT/ml (means there are 100 units of insulin in each millimeter of insulin). Inject 15 units subcutaneously two times a day for diabetes, at breakfast and dinner. 9/7/23 - A facility investigation documented, at approximately 5:00 PM, R4 was inadvertently administered 100 units of NPH insulin by E4 (LPN) instead of the prescribed 15 units. E4 immediately self-reported the error and R4 was given glucagon (an emergency medicine used to treat severe hypoglycemia [low blood sugars] in diabetes) and orange juice via peg tube. 911 was called and EMS transported R4 to the hospital. 9/7/23 5:54 PM - An ED Physician Record documented, R4 arrived .from the facility for evaluation of incorrect medication administration .blood glucose initially 324 in the emergency department . anticipate patient will require admission for observation. Discussed case with pharmacy who reports that NPH has a bell-curve (a graph after administration and can cause effects up to 24 hours afterwards.) onset with peak onset 4 hrs - 12 hours 9/7/23 6:28 PM - E18 (ED MD) documented in the ED Teaching Physician Record . (R4) presents after an overdose administration of her insulin .Patient was given 100 units of NPH just prior to the arrival at 4:55 PM. She was given glucagon as well as orange juice via her PEG tube immediately afterwards .Iatrogenic (a medical injury caused in the process of medical treatment) insulin overdose . 9/8/23 6:58 AM - E20 (MD) documented on a hospital Admission History & Physical .accidental insulin overdose . initial blood glucose 290 on BMP (basic metabolic panel) now trended down to 80 most recently . lactate 3.7 . She was started on D5LR (a solution that is a source of water, glucose, and electrolytes) in the ED and rate has been increased to 200 ml (milliliters)/ hr .Assessment/Plan: Accidental overdose of insulin: monitor blood glucose every 2 hours x 4, then switch to 4 hours .Diabetes - holding diabetic medications due to an accidental insulin overdose . 9/15/23 6:44 PM - On R4's Hospital Discharge Summary, E21 (DO) documented .admitted for hypoglycemia .accidental overdose of insulin. 10/12/23 12:05 PM - A Surveyor observed insulin administration to a resident by E11 (LPN) prior to lunch being served, which revealed right resident, right medication, right dose, right route, right time. 10/13/23 10:30 AM - During an interview E1 (NHA), E5 (RN, CNO), and E10 (COO) all confirmed that R4 had been administered the wrong dose of insulin on 9/7/23 and the nurse immediately reported the error and R4 was sent to the hospital. E2 immediately educated E4 (LPN) with regards to the eight rights of medication administration, verifying orders and due to E4 being a new nurse she stated that when administering insulin to have another nurse double check the order with her. E2 stated she went over the insulin competency with E4 and had her return demonstrate the nine listed tasks. Based on this event, the facility initiated education for all staff nurses on 9/8/23, which included: insulin types, onset, peak and duration, eight rights of medication administration, selecting the correct syringe, and return demonstration of drawing up the medication and verifying the order. 10/13/23 1:25 PM - During an interview, E2 (DON) confirmed that by 9/8/23 that all nurses had completed the competencies/education regarding insulin. 10/17/23 1:45 PM - During an interview, E11 (LPN), E12 (RN), and E14 (RN) all confirmed they had completed the competencies/education regarding insulin that the facility implemented in response to the medication error. The survey team reviewed and confirmed the corrective actions were completed on 9/8/23. 10/17/23 3:12 PM- Findings were reviewed during the Exit conference with E1 (NHA), E2 (DON), E5 (CNO), E15 (Corporate consultant) and E16 (Corporate nurse).

Based on observations, interviews and reviews of clinical records, facility documentation and other sources as indicated, it was determined that the facility failed to maintain an infection prevention and control program to protect the residents against an outbreak of norovirus (a highly contagious infection that can cause a sudden onset of severe vomiting and diarrhea) and they failed to have a system in place to control a contagious disease to residents, staff and visitors. For three (R52, R167 and R417) out of nine sampled residents, the facility failed to actively adhere to contact precautions and hand hygiene among healthcare personnel, residents, and visitors in patient care areas affected by outbreaks of norovirus gastroenteritis, including a process to identify the residents who were symptomatic with signs and symptoms of norovirus as per CDC guidance. The facility's system failure put all residents, including R52, R167 and R417 at immediate jeopardy (IJ) of a serious adverse outcome by not having a method of identifying residents that required contact precautions as it relates to Norovirus, not providing staff the necessary education and PPE (Personal Protective Equipment) to use for contact precautions while delivering resident care and lack of evidence of staff surveillance as per CDC guidance. The IJ was identified on 2/16/23 at 4:11 PM and was abated on 2/20/23 at 10:19 AM. In addition, the facility failed to use infection control precautions for R29 during wound care. Findings include: The facility policy titled, Standard and Transmission Based Precautions, effective June 2013 and revised 1/27/23 documented, 'Contact Precautions' -applies to all residents infected or colonized with a MDRO (multidrug-resistant organisms or bacteria that resist treatment with more than one antibiotic) in the following situations: presence of acute diarrhea . c. diff (or clostridium difficile, a bacterial overgrow that releases toxins that attack the lining of the intestines) . norovirus . Special Situations: Organisms likely to have spores like Clostridium difficile and some diseases with ongoing transmission like Norovirus and Influenza may require special contact precautions. In addition to contact precautions, perform hand hygiene using soap and water and use a hypochlorite solution (e.g., bleach) for environmental cleaning . Resident Care Equipment and Articles - cleaned and disinfected after use . The CDC's Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, last updated 2/15/17, documented, . The Summary of Recommendations includes recommendations organized into the following categories: -Patient Cohorting and Isolation Precautions . Avoid exposure to vomitus or diarrhea . During outbreaks, place patients with Norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients . Consider longer periods of isolation or cohorting precautions for complex medical patients (e.g., those with cardiovascular, autoimmune, immunosuppressive, or renal disorders) as they can experience protracted episodes of diarrhea and prolonged viral shedding. Patients with these or other comorbidities have the potential to relapse, and facilities may choose longer periods of isolation based on clinical judgment . Staff who have recovered from recent suspected norovirus infection associated with an outbreak may be best suited to care for symptomatic patients until the outbreak resolves . -Hand Hygiene . Actively promote adherence to hand hygiene among healthcare personnel, patients and visitors in patient care areas affected by outbreaks of norovirus gastroenteritis . During outbreaks, use soap and water for hand hygiene after providing care or having contact with patients suspected or confirmed with norovirus gastroenteritis . -Personal Protective Equipment . If norovirus infection is suspected, adherence to PPE use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e. gowns and gloves upon entry) to reduce the likelihood of exposure to infectious vomitus or fecal material . Use a surgical or procedure mask and eye protection or a full face shield if there is an anticipated risk of splashes to the face during the care of patients, particularly among those who are vomiting . -Education . Provide education to staff, patients, and visitors, including recognition of norovirus symptoms, preventing infection, and modes of transmission upon the recognition and throughout the duration of a norovirus gastroenteritis outbreak . -Active Case-Finding . Begin active case-finding when a cluster of acute gastroenteritis cases is detected in the healthcare facility. Use a specified case definition, and implement line lists to track both exposed and symptomatic patients and staff. Collect relevant epidemiological, clinical, and demographic data as well as information on patient location and outcomes . -Communication and Notification . Provide timely communication to personnel and visitors when an outbreak of norovirus gastroenteritis is suspected and outline what policies and provisions need to be followed to prevent further transmission . (https://www.cdc.gov/infectioncontrol/guidelines/norovirus/) According to the facility's completed form entitled Gastroenteritis Data Collection Line Listing for Patients, from 1/31/23 to 2/15/23, 46 residents were documented with gastrointestinal (GI) symptom(s) on both floors of the facility. Observations and clinical record reviews of three current residents with recent GI symptoms identified on the GI Line Listing revealed: 1a. Review of R167's clinical record revealed the following: 2/9/23 - R167 was admitted to the facility. 2/13/23 5:47 PM - Review of the Electronic Medication Administration Record (eMAR) revealed that R167 was administered a medication to treat diarrhea and another medication to treat nausea and vomiting. Subsequently, the eMAR documented that these medications were effective in treating the diarrhea, as well as the nausea and vomiting. 2/14/23 8:45 AM - A Physician Order was written to chart GI symptoms, which included to monitor for nausea, vomiting, and diarrhea every shift for three days. 2/15/23 3:30 PM - An interview with R167 revealed that he had nausea yesterday on 2/14/23, but denied nausea, vomiting and/or diarrhea today. An observation of the exterior door into R167's room revealed that there was no signage indicating that R167 was on contact precautions and there was no PPE hanging on his door for staff and visitors to apply prior to entering the room. 2/16/23 3:40 PM - An interview with the assigned nurse E8 (LPN) revealed that R167 was not on contact precautions. The facility failed to ensure R167 had contact precautions implemented (including PPE and signage) and the facility failed to ensure that staff were aware of the precautions to follow during an outbreak in the facility. 46134 1b. Review of R417's clinical record revealed the following: 2/8/23 - R417 was admitted to the facility. 2/14/23 3:26 PM - A progress note by E24 (NP) stated that R417 was experiencing loose stools and had orders for medications to treat diarrhea and nausea and vomiting. 2/15/23 3:45 PM - An interview was done with E6 (CNA) and E7 (CNA). E6 stated that a stomach bug is growing and growing and it is hard to make sure that you don't catch it. E6 and E7 both stated they do not know when residents are positive for a stomach virus and that they ask the Nurses to find out information about residents because the Nurses do not automatically tell them. E6 and E7 added that it is hard to tell who has a stomach virus because some residents are on laxatives and it is hard to know the difference when the residents have loose stools. 2/16/23 9:00 AM - A review of the facility's infection control tracking document for gastroenteritis documented that R417's last episode of diarrhea was on 2/15/23 at 2:00 PM. 2/16/23 11:00 AM - An observation of R417's exterior room door lacked evidence of contact precautions signage and the presence of PPE for staff and visitors to apply prior to entering R417's room. 1c. Review of R52's clinical record revealed the following: 12/23/22 - R52 was admitted to the facility. 2/14/23 3:15 AM - A nurses note in the electronic medical record (EMR) revealed that R52 was being monitored for GI symptoms. 2/14/23 2:00 PM - A nurses note in the EMR revealed that R52 was experiencing loose stools and a new order was received for a medication to treat R52's diarrhea. R52's onset of diarrhea was noted on the facility's Gastroenteritis: Data Collection Line Listing. 2/16/23 11:00 AM - While PPE was present outside of R52's door as the resident was already on enhanced barrier precautions, an observation of R52's exterior door revealed the absence of contact precautions signage to inform staff and visitors to apply the PPE prior to entering the room. According to the facility's Gastroenteritis: Data Collection Line Listing, R52's last episode of diarrhea was on 2/16/23 at 8:30 AM. 2/16/23 4:11 PM - Based on observations, interviews, review of facility documentation and other sources, an Immediate Jeopardy was called and reviewed with facility leadership including E1 (CNO), E2 (NHA), E3 (DON) and E26 (VPO). 2/16/23 7:02 PM - It was confirmed by Surveyors that the affected three resident rooms had contact precautions signage and PPE in place for staff and visitors on what was required prior to entering the rooms. The facility started staff education that was ongoing around the clock and through an electronic module available to staff. In addition, a CDC sign for norovirus was posted at the receptionist desk educating visitors on what precautions were required during the outbreak. 2/16/23 7:30 PM - E2 submitted an acceptable Abatement Plan signed, dated, and timed 2/16/23 at 7:29 PM. 2/17/23 4:00 PM - E1 was advised by the Surveyor to send via email evidence of staff education once completed. 2/17/23 5:40 PM - In an email correspondence, E2 sent proof of staff education status as of 2/17/23 at 5:30 PM and stated, continuing to educate staff. 2/20/23 10:19 AM - The date and time E2 stated that staff in-service was completed. 40264 2. The facility failed to provide evidence of an infection control surveillance program that included monitoring staff for GI signs and symptoms. The CDC's Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, last updated on 2/15/17, documented . The Summary of Recommendations includes recommendations organized into the following categories: -Staff Leave and Policy . Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Once personnel return to work, the importance of performing frequent hand hygiene should be reinforced, especially before and after each patient contact . 2/14/23 12:17 PM - An interview with E9 (LPN) stated that a GI illness started on the second floor last weekend and then spread to the first floor residents. E9 stated that she believed a random test was done, but she was not sure if the residents were tested specifically for Norovirus. 2/15/23 3:00 PM - E3 (IC/DON) provided the survey team with copies of the correspondence from the State of Delaware Department of Public Health (DPH). This included the Gastroenteritis Data Collection Line List. DPH recommended 2-3 resident stool samples for testing. E3 also stated that the official start of the outbreak was 2/8/23 when the facility received notification of a positive test for norovirus. 2/16/23 10:35 AM - A joint interview with E1 (CNO), E2 (NHA) and E3 revealed that DPH sent an email for the facility to call DPH to go over the results and recommendations when the positive norovirus test came back on 2/8/23. According to E1 and E3, the recommendations included to quarantine (resident) cases in their room .if .any more staff please exclude them until .(diarrhea) symptoms have resolved .isolating precautions .cohorting or exclusion for staff . 2/16/23 10:45 AM - An interview with E3 confirmed that an infection control line listing was not initiated for staff. It was further revealed there were sporadic staff cases based on who called out sick. E3 stated that symptomatic staff could not come back to work until they were without nausea, vomiting, diarrhea and/or fever for 48 hours. E3 stated that she'll start creating the staff line list using the DPH template. 47114 3. Review of the facility policy and procedure, revised 6/2/2021, titled Infection Control Hand Hygiene included, .it is the policy of Cadia Healthcare to help control the spread of infection through hand hygiene, wash hands thoroughly, using rigorous scrubbing action for at least 20 seconds . Review of When and How to Perform Hand Hygiene included .after touching a patient or the patient's immediate environment, after contact with blood, body fluids or a contaminated surface. https://www.cdc.gov/handhygiene/providers/index.html. 2/20/23 9:55 AM - During an observation, R29's breakfast tray and a urinal containing urine were on the bedside table. E14 (LPN) placed dressing supplies on the unclean bedside table and then picked up R29's breakfast tray and left the room. E14 then picked up the urinal from the bedside table and emptied it in the bathroom and washed her hands for five seconds. E14 placed a blue pad on the bedside table to create a clean field, then picked up the dressing supplies that had been placed on a dirty bedside table, and put them on the blue pad causing contamination of the clean field. E14 then put on clean gloves and opened the treatment supplies that had been contaminated causing the nurses gloves to no longer be clean. The nurse proceeded to complete the dressing change with gloved hands that were contaminated. 2/21/23 11:00 AM - The Surveyor asked E1 (CNO) for a policy and procedure for wound care, and E1 replied, No, we don't have a policy and procedure for wound care. 2/21/23 2:11 PM - During an interview with E14 she stated, I put the dressings on the table and put the dressings on top of the pad. 2/23/23 - Findings were reviewed with E1 (CNO), E2 (NHA) and E3 (DON) during the exit conference beginning at 2:15 PM.

Based on record review, interview, and review of other facility documentation, it was determined that for two (2) (R51 and R84) out of four (4) sampled residents reviewed for hospitalization and one (1) (R209) out of three (3) sampled residents for nutrition, the facility failed to ensure that residents received the treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. For R51, the facility failed to notify the physician/nurse practitioner of refusal of ordered labs, failed to re-educate R51 about the health risks of refusing labs, and failed to re-attempt to obtain the labs during a 39 day span. The facility failed to adequately assess and monitor the amount of blood loss from R51's wounds. This failure resulted in harm when R51 was hospitalized from [DATE] to 8/3/19 for blood [MEDICAL CONDITION] and treatment for [REDACTED]. For R84, the facility failed to identify and treat a right foot wound on a resident that was susceptible to chronic wounds and infections until it was infested with maggots on 6/24/19 requiring hospital evaluation and treatment. For R209, the facility failed to follow the resident's plan of care to obtain a weight on 7/24/19 as per a 7/17/19 physician's orders [REDACTED]. Findings include: A facility policy entitled Refusal of Medications and Treatments (last revised 1/18/19) included: Documentation pertaining to a resident's refusal of medication, treatment, or procedures should include: -What the resident is refusing. -The reasons for the refusal, if known. -Advising, educating the resident/responsible party about risks/consequences of refusal (i.e.: deterioration in condition). -Physician notification and response. -Steps that were taken to address the resident's concerns and alternatives that were offered. -For on-going refusals documentation should include: All the efforts made by the facility and the care team to render care; and encourage compliance and consideration of alternatives. The resident's care plan should address the refusals, non-compliance/non-adherence to the recommended care; and the approaches implemented to address the refusals. Review of R51's clinical record revealed: 10/17/14 - R51 was admitted to the facility with [MEDICAL CONDITION], chronic [MEDICAL CONDITION] and dependence on mechanical ventilation related to a motor vehicle accident. 4/19/19 - An annual MDS assessment documented that R51 was independent with decisions. 6/1/19-7/24/19 - R51's nursing progress notes lacked evidence of assessing and monitoring the resident's blood loss from his wounds. 6/13/19 - R51's physician orders [REDACTED]. 6/13/19 - R51's lab results revealed that R51's Hemoglobin was 7.0, and Hematocrit was 21.4. (Normal Hemoglobin and Hematocrit lab values per the facility contracted lab results were: Hemoglobin 13.5-17.5 and Hematocrit 37.5-55.5.) 6/14/19 - R51's physician orders [REDACTED]. Folate, and B12 level. Repeat H&H (Hemoglobin and Hematocrit) in one week. Special Instructions: low Hemoglobin. 6/15/19 - Although it was noted on the facility's contracted lab log that R51 refused to have the 6/14/19 ordered labs drawn (the following day) and the lab tech advised the facility nurse, R51's clinical record lacked evidence that: R51 refused the ordered labs to be drawn; that the facility educated R51 of the risks of refusing labs related to critical lab values; that the physician/practitioner was consulted about R51's refusal for the ordered labs; that any steps were taken to address R51 to feel more comfortable/compliant for lab draws (such as a familiar staff member was present during the procedure). The physician orders, nursing and physician/practitioner progress notes also lacked evidence of re-attempting to obtain labs from R51 after the 6/15/19 refusal. 6/21/19 - R51's physician's orders [REDACTED]. 6/21/19 - It was noted on the facility contracted lab log that R51 refused to have the ordered labs drawn and that the tech notified the facility nurse. The facility's daily report and midnight census report documented that R51 refused ordered labs and stated the NP was notified. Although this information was recorded on in-house tools, R51's clinical record lacked evidence of R51's refusal to have the ordered labs drawn, re-education of consequences of refusal on resident's health status, that the physician or nurse practitioner was consulted, any steps that were taken to address the resident's concerns and alternatives that were offered, or a re-attempt to obtain the ordered labs. The facility lacked evidence of a system to ensure that the refusals that were noted on the contracted lab sign-off sheet were documented in the clinical record, and a method to ensure that the physician or nurse practitioner was consulted when blood draws were refused. Review of R51's physician orders [REDACTED]. The lab orders for 6/14/19 and 6/21/19 were one time orders which resulted in not attempting to obtain another H&H in a timely fashion. 6/21/19 - The lab result from the contracted lab documented that the lab draw was refused, however, the lab sheet lacked evidence that a practitioner reviewed the result sheet or was consulted related to the refusal of the lab. The lab result paper hard copy provided by the facility was unsigned and undated. 6/22/19 - Again it was noted in the contracted lab log that R51 refused to have (H&H) Hemoglobin and Hematocrit blood tests and that the tech told nurse. The clinical record lacked evidence of consultation with the physician or nurse practitioner and further re-attempts to obtain the labs. 7/23/19 - Although a progress note written by E4 (NP) documented that R51 refused labs, the practitioner's notes and review of the (MONTH) 2019 orders lacked evidence of E4's knowledge of the particular dates and labs that R51 refused, and any re-attempts to obtain R51's labs. R51 was compliant with having labs drawn on 6/13/19 and 7/24/19, one day after the 7/23/19 nurse practitioner's progress note documented that R51 refuses labs. 7/24/19 - R51's physician orders [REDACTED]. The clinical record lacked evidence of consultation with the physician or nurse practitioner regarding the status of R51's labs and R51's refusal to consent to lab draws on 6/15/19 and 6/21/19 until 7/24/19 when the labs were re-ordered by E4 (NP), 39 days after the initial refusal on 6/15/19. 7/24/19 - R51's lab results revealed a Hemoglobin of 6.0 and a Hematocrit of 18.5 (down from a Hemoglobin of 7.0 and a Hematocrit of 21.4 on 6/13/19). 7/24/19 4:30 PM - A nursing progress note documented that (R51) was sent to the ER for a critical Hemoglobin of 6.0 and a Hematocrit of 18.5. 7/24/19 5:57 PM - A progress note written by E5 (NP) lacked evidence of knowledge of the resident's previous refusals of the 6/15/19 and 6/21/19 ordered lab draws. 7/24/19 - A hospital record History and Physical physician's note revealed: (R51) is a [AGE] year old male patient with past medical history of [REDACTED].>ventilatory (sic) dependent, [MEDICAL CONDITION] secondary to motor vehicle accident, . chronic [MEDICAL CONDITION], .chronic decubitus ulcer who was sent from his long-term skilled nursing facility for low hemoglobin of 6.0. He was found to have blood oozing from his wounds. Acute on (sic) chronic blood loss [MEDICAL CONDITION]. This is likely secondary to blood loss from patient's wound. Homeostasis was achieved. Patient received 1 unit of blood transfusion. Monitor H&H (Hemoglobin and Hematocrit). 7/24/19 - A hospital record physician's note included: Skin: Numerous decubitus ulcers on his backside, with thick granulation tissue, with 2-3 areas of persistent bleeding with minimal agitation. I injected with [MEDICATION NAME] with [MEDICATION NAME], attempted silver [MEDICATION NAME] cautery but defaulted to hot dressing followed by 4 x 4's. This seemed to abate the bleeding. When he first came in .posterior dressings were changed and we discovered numerous clots. 8/1/19 3:40 PM - R51's hospital discharge summary included: He presents in a setting of [MEDICAL CONDITION] and bleeding from his chronic wounds sent from his long-term skilled nursing facility. Patient's [MEDICAL CONDITION] has been treated with 3 total units of blood throughout his stay. 8/3/19 - R51's discharge [DIAGNOSES REDACTED].) chronic blood loss [MEDICAL CONDITION] bleeding from wound and multiple wounds. 8/26/19 1:35 PM - During an interview with E6 (Corporate Nurse), it was confirmed that there were physician orders [REDACTED]. 8/27/19 10:10 AM - During an interview with E7 (RN, UM), it was confirmed that the clinical record lacked evidence of refusals of labs in the progress notes for 6/15/19 and 6/21/19, and there were no lab results for those dates. E7 confirmed that the same labs (from 6/15/19 and 6/21/19) were re-ordered on [DATE]. 8/27/19 10:34 AM - During an interview, E4 (NP) reported that R51 often refused care, but did not know if E51 had refused the labs or not on 6/15/19 and 6/21/19. E4 stated that the labs were re-ordered related to lack of evidence of lab results for 6/15/19 and 6/21/19 in the medical record. 8/27/19 10:46 AM - During an interview, E3 (ADON) reported that sometimes the lab tech would go to nursing and report refusals for lab draws to see if staff can go in and explain the need for the labs, and encourage the resident to let the labs be drawn. The clinical record lacked evidence of that approach/intervention and/or that the nurse consulted the physician/practitioner. E3 added that the lab techs do not always report refusals to the nurse and the lab tech will make note of the refusals in the lab sign-off log. E3 confirmed that it was the expectation of facility nurses to re-attempt to complete the labs, consult the physician/practitioner, and complete a nursing progress note. 8/27/19 11:10 AM - During an interview with E1 (NHA) and E2 (DON), E2 presented the surveyor with physician, nurse practitioner and nursing progress notes, and stated there was documentation that R51 refused care and labs at times, but confirmed there were no specific dates of the lab refusals. E2 reported that it was common for R51 to refuse care. E2 confirmed there was a lack of evidence of R51's refusal of labs, physician/nurse practitioner notification, and interventions to re-attempt the lab draws in the nursing progress notes on 6/15/19 and 6/21/19. Review of the resident record revealed lack of evidence of any orders to re-attempt to draw the 6/15/19 and 6/21/19 ordered labs. E2 reported that E4 (NP) was at the facility every day, and staff report those things directly to E4 when at the facility. The clinical record lacked evidence that R51's refusals of the 6/15/19 and 6/21/19 labs were reported to E4 and or any other physician or nurse practitioner until 7/24/19 when E4 gained knowledge that there were no lab results for those days. The facility failed to notify the physician/nurse practitioner of R51's refusal of ordered labs, failed to re-educate R51 about the health risks of refusal of labs, failed to obtain further orders after the refusal of labs, failed to re-attempt to obtain the labs, and failed to accurately assess and monitor R51's blood loss from the resident's wounds (from 6/1/19-7/24/19) which resulted in R51's hospitalized from [DATE] to 8/3/19 for blood [MEDICAL CONDITION] and treatment for [REDACTED]. 2. Review of R84's clinical record revealed: 1/5/17 - R84 was admitted to the facility. 4/28/19 - R84 was care planned for actual MASD of right posterior thigh to buttock and left posterior thigh (back of thigh) with approaches that included skin checks every 2 hours and turn and reposition every 2 hours and as needed. 6/24/19 - Review of R84's clinical record lacked evidence that a skin integrity issue and/or wound was identified on R84's right foot or if a current treatment was in place. 6/24/19 at 1:58 AM - Review of the CNA Point of Care History report revealed that E50 (CNA) signed off that he/she completed Skin checks every 2 hours and report any changes to the nurse AND Turn and Reposition every 2 hours during the 11 PM to 7 AM shift. It was unclear how E50 could sign off both of these tasks as Done only 3 hours after his/her 8 hour shift started. 6/24/19 at 11:41 AM - A nurse's note stated, Resident noted with maggots to right foot during am/wound care at 1000 am. Right foot flushed by wound nurse. E48 (MD's name) at facility and informed of new development. E4 (NP's name), examined resident with this nurse. One maggot still visible. Right lower extremity red with increase [MEDICAL CONDITION] (swelling) Received order to send to ER for evaluation for maggots .to right foot . 6/24/19 at 4:22 PM - E4's (NP) progress note stated, .Asked to eval (evaluate) due to increase [DIAGNOSES REDACTED] (redness) and drainage ble .Maggots found in wound right foot . 6/24/19 at 7:41 PM - The hospital record's history and physical stated, .Patient is coming from a nursing home where (he/she) was found today to have maggots in (his/her) feet .(R84) has chronic wounds on her lower extremities secondary to bedbound state . 6/24/19 at 7:45 PM - The hospital record progress note stated, .Wound noted to bottom of R (right) foot, 6 cm x 3.5, red, hypergranulation tissue (excessive granulation filling a wound bed; tissue is raised) noted, area just above, yellow necrotic (dead tissue) skin flap, 14 maggots removed from this . 6/25/19 at 12:13 PM - The hospital's infectious disease consult stated, .Maggots in wounds .Patient has had difficulties with immobility, progressive lower body/LE (lower extremity) [MEDICAL CONDITION] and stasis ulcerations (venous wounds due to abnormal veins). Chronic ulceration right plantar lateral foot and right lateral calf more recently noted. (He/she) subsequently noted maggots on (his/her) feet yesterday .Patient notes that since admission overnight 18 more maggots were removed from (R84's) foot. (He/she) states 'I know there are flies around, I have a fly sweater (sic) at my bedside.' .Right foot .moderate-copious serous drainage .Assessment/Plan .Infestation, maggots .Important to keep wounds with drainage covered to prevent ongoing infestation .Additional Recommendation or Comments .admitted with progressive stasis ulcerations/maggot infestation, super infection (previous infection and develops another strain of infection on top of the first one) suspect right lower extremity/plantar foot . 9/3/19 at 8:30 AM - Findings were reviewed with E1 (NHA) and E2 (DON). The facility failed to identify and treat a right foot wound on a resident that was susceptible to chronic wounds and infections until it was infested with maggots on 6/24/19 requiring hospital evaluation and treatment 9/4/19 at 7:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON) and E3 (ADON). 3. Review of R209's clinical record revealed: 6/21/19 - R209 was admitted to the facility for short-term rehabilitation. 6/29/19 - R209 was care planned for potential for alteration in hydration with an approach to obtain weights as ordered. 7/17/19 - A physician's orders [REDACTED]. 7/24/19 - Review of R209's clinical record lacked evidence that the resident's weight was taken on Wednesday, 7/24/19. 9/3/19 at 8:30 AM - Findings were reviewed with E1 (NHA) and E2 (DON). The facility failed to follow R209's plan of care to obtain a weight on 7/24/19. 9/4/19 at 7:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON) and E3 (ADON).

Based on record review, interview and review of other facility documentation as indicated, the facility failed to ensure that advanced directives for one (R49) out of 29 initial pool residents, were accurate and congruent in all facility documents. The electronic facesheet with code status display ribbon, documented R49 as a (DNR, do not resuscitate), conversely current physician's orders [REDACTED]. The code status as recorded in two different documents did not match. This discrepancy put R49 at immediate jeopardy (IJ) of not having a confirmed, accurate code status in the event of an emergency. Facility nursing staff were unable to articulate which code status was accurate and stated they would refer to the code status documented in books on top of the emergency crash carts. The code status books were obsolete, no longer in use. 12 out of 15 nursing staff interviewed provided inaccurate or uncertain information on how to identify a resident's code status, placing residents in immediate jeopardy. The IJ was identified at 2:10 PM on 9/18/18 and abated at 7:00 PM on 9/18/18. Findings include: The facility policy on advanced directives which includes code status, last revised 9/29/17, indicated that the facility will review advance directives with resident/representative at a minimum, annually during the resident's care plan meetings , to ensure that all caregivers and interested parties are aware of the resident's advance directives. Review of R49's clinical record revealed: 9/18/18 at 1:42 PM - During the initial pool record review for R49 the face sheet on the electronic medical record documented R49 as a DNR in red; review of R49's current physicians orders documented R49 as a full code as of 7/23/18. During an interview on 9/18/18 at 2:12 PM with E18 (RN), when shown R49's code status according to the electronic face sheet E18 confirmed that R49's code status was documented as a (DNR) on the electronic face sheet. E18 also stated to be sure we can also find it in the orders also and a quick reference is the report sheet. E18 checked R49's orders and confirmed they did not match the electronic face sheet code status. The code status for R49 was not documented on the report sheet. During an interview on 9/18/18 at 2:15 PM with E21 (RN) it was reported that when the resident code status does not match, the nurse should listen to the most current code status that is documented in the computer. During an interview on 9/18/18 at 2:20 PM when asked what is the next step when the face sheet and orders do not match, where is code status found, E18 (RN) stated we would look at the code status book located on the emergency crash carts. The surveyor accompanied E18 and there was no code status book located on the emergency crash cart. During an interview on 9/18/18 AT 2:21 PM with E15 (RN) it was reported that the resident code status information could be found at the code status book, located on the emergency crash carts. E15 attempted to show the book to the surveyor, and when the code status information was not there, E15 asked E7 (RN) unit manager for the book and was told they changed that and don't put them in there anymore. During an interview on 9/18/18 at 2:22 PM with E7(RN) it was reported that the resident code status had been removed from books on the emergency crash carts for 2 or 3 months and that education was performed notifying the direct care staff. Documentation of this education was requested from E3 (ADON) and was not received from the facility. During an interview on 9/18/18 at 2:34 PM with E16 (RN) it was reported that resident code status could be located on the EMAR, and the code book on the emergency crash carts. E7 (RN) had previously confirmed code status books were no longer in use. During an interview on 9/18/18 at 2:36 PM with E17 (RN) it was reported that resident code status could be located in the software right under the residents name, additionally we can go to the emergency crash cart but that's too far away, but if I had to run on another unit then I would hit the emergency code cart first for code information. E17 accompanied the surveyor to the emergency crash code cart and was unable to locate a book with the resident code status information. During an interview on 9/18/18 at 2:38 PM with E11 (RN) , when asked where resident code status information was located, E11 stated I'll show you, typically we go to the orders, and then if its not there, I'm not sure but any of the patient's you can find in their physicians orders. E11 was unaware of whether resident code status information could be located in a book on the emergency crash carts. During an interview on 9/18/18 at 2:47 PM with E8 (RN) unit manager, it was reported that the resident code status can be found in the computer system and they(nurses) can look and see if it was scanned in from the paper medical record. If the two are not congruent in code status E8 stated we have to pull the original or they can go to the patient, or call the family and verify; that is rare but these things happen with scanning. During an interview on 9/18/18 at 2:54 PM with E13 (LPN) it was reported that code status could be found on the electronic face sheet and on the software on the very first screen across the top. Resident code status was observed as documented in those areas. During an interview on 9/18/18 at 2:56 PM with E14 (LPN) it was reported that the resident code status can be located in the software, in the file code status comes up automatically and the shift report sheet, but the EMR is more up to date or reliable. E14 explained during a code staff should rely on the EMR and go to look at it first before calling a code. E14 was unsure if the code status could be found anywhere else. During an interview on 9/18/18 at 3:04 PM with E22 (RN) unit manager it was confirmed that the facility was aware of a code status discrepancy for R49. E22 stated we are looking into that. It should not have been changed and we have the medical record clerk looking into it. E22 was asked how soon the facility would have an answer about R49's code status and E22 responded by the end of the day today, I don't know what time but within the next hour to find out exactly where the ball dropped. E22 stated that if R49 was to go into [MEDICAL CONDITION] at present while awaiting code status verificationI would expect a full code response without confirmation of code status. During an interview on 9/18/18 at 3:30 PM with E23 (RN) it was reported that the resident code status could be found in the face sheet and I print it out on the report sheet, It's also supposed to be on the crash cart. During an interview on 9/18/18 at 3:32 PM with E24 (RN) it was reported that the resident code status could be found from the face sheet , or under the orders they used to have it on the crash cart in the hard copies but nowadays I don't think they do it anymore. During an interview on 9/18/18 at 3:36 PM with E26 (LPN) it was reported that the resident code status could be found in the software under resident documents. Record review determined resident code status is documented in the resident documents section. During an interview on 9/18/18 at 3:42 PM with E25 (LPN) it was reported that the resident code status could be found in the computer on the electronic face sheet, and they have a book of code status names at the nurses station. The code status books had previously been confirmed as no longer in use by E7. 9/18/18 at 4:09 PM - E1 (NHA) and E5 (Director of Clinical Service) were notified by the survey team that during initial pool record review, it was identified that R49, did not have consistent advance directives related to code status in her medical record and that nursing staff were unable to consistently state where the accurate code status could be found. During an interview on 9/18/18 at 5:42 PM with E1 (NHA) and E5 (DCS) it was reported that an abatement plan had been intiated and that global education related to resident emergency code status, location of code status, and protocol for determining code status was being implemented. 9/18/18 at 6:30 PM - E5 (DCS) confirmed that an audit was completed of all residents and the correct code status was verified with no additional errors. 9/18/18 at 7:00 PM - E1 (NHA) and E5 (DCS) provided the survey team with updated policies and an action plan for continued training and confirmed abatement regarding this issue. Abatement was called at 7:00 PM on 9/18/18. The facility failed to ensure that: -advanced directives/code status for all residents were accurate and congruent in all facility documents. -facility nursing staff were able to articulate how to find the code status for all residents. These findings were reviewed during exit conference on 9/28/18 at 3:00 PM with E1 (NHA), and E2 (DON).

Based on observation, record review and interview, it was determined that for one (R121) out of 54 sampled residents, the facility failed to implement appropriate transmission-based precautions, which placed a frail resident at risk of contracting [MEDICAL CONDITIONS], a potentially life-threatening bacterial infection when cohorted with another resident (R362) with a current [DIAGNOSES REDACTED]. The facility infection control policy dated (MONTH) 15, (YEAR) states as follows: Instituting transmission-based precautions: - Obtain a physician's orders [REDACTED]. - Relocate the resident as appropriate to a private room Contact precautions: - Used for residents that have an infection that can be spread by contact with the other person's skin, mucous membranes, feces, vomit, urine, wound drainage or by contact with equipment of environmental surfaces that may be contaminated by the patient/resident or by his/her secretions and excretions; In addition to standard precautions: .Organisms likely to have spores like [MEDICAL CONDITION] and some diseases with ongoing transmission like Norovirus may require special precautions. Review of clinical records for both R121 and R362 revealed the following: R121's record revealed: 5/21/18 - R121 arrived at the facility for rehabilitation after a [MEDICAL CONDITION]. 5/21/18 - Hospital records (provided to the facility upon admission) revealed that R121 suffered a [MEDICAL CONDITION] and underwent a [PR[NAME]EDURE] times 3. During hospitalization , R121 contracted [MEDICAL CONDITION] Sensitive Staphylococcus Aureus bacteremia for which R121 received intravenous antibiotics through a tunneled catheter (PICC line). 6/9/18 - around 4:00 PM - R 121 was transferred to a different room. R362 's record revealed: 6/8/18 - Intra-agency discharge orders from transferring facility dated 6/8/18 reflect R362 has [MEDICAL CONDITIONS] and need for precautions. 6/8/18 - Arrived at the facility at 4:26 PM. 6/8/18 - Review of computerized records reflects there was no order for contact precautions, but that R362 was being administered antibiotic for treatment of [REDACTED]. 6/9/18 11:10 AM - Physical Therapy orders that note [MEDICAL CONDITION]+ contact precautions for R362. 6/21/18 - Laboratory report on record indicating presence of active [MEDICAL CONDITION] for R362. 6/9/18 - F1 (R121's family member) filed a Resident Concern / Compliment Form that reported, (R362 name) has contagious [MEDICAL CONDITION] - he told me that. I am concerned that he and my husband are using the same toilet seat and bathroom. He leaves a pink residue on the seat. I asked both him and my husband to use disinfectant wipes on the seat before and after using the seat. 9/27/18 4:15 PM - Interview with E27 (infection control nurse) and E28 (IT staff) at which time it was stated that residents with [MEDICAL CONDITION] should not be cohabitated with anyone with open areas or a decreased immune system. 9/27/18 approximately 5:30 PM - Interviews with E1 (NHA), E2 (DON), and E5 (Corporate Executive Nurse) revealed that although R362 tested positive for [MEDICAL CONDITION] on 6/7/18 while still at the hospital, the facility was not aware of this new diagnosis, as it did not receive any updates from hospital prior to his arrival on 6/8/18. This explanation was provided despite the fact that a 6/8/18 Intra-agency discharge order from the transferring facility documented a [DIAGNOSES REDACTED]. It was confirmed that R362 and R121 were roommates until approximately 4:00 PM on 6/9/18. The facility alleges proper infection control precautions were in place. 9/27/18 - The facility's infection control program was reviewed. Survey staff checked the currently infected residents to make sure they were properly isolated. No compliance issues were identified. All affected residents were isolated in private rooms. 9/28/18 at 9:05 AM - Interview with E32 (RNAC) who was the Manager on Duty for 6/9/18 revealed that she was unaware of the family member having concerns with the roommate having an infectious [MEDICAL CONDITION]. It was also confirmed that R121 did use the bathroom. E32 stated R362 had a bedside commode. No information could be found indicating what precautions were put in place when these two residents, who should not have been cohabitated, were together for 24 hours. There was no evidence that education was conducted with R121, R362 or their families. There was no evidence that precautions were implemented to prevent cross contamination between the residents. 10/2/18 9:49 AM - Interview with F1 (R121's family member) revealed: R362 arrived on 6/8/18 in the late afternoon; there was no isolation cart or warning sign placed at the door; there was no education with R121 or their family concerning precautions; there was no yellow bagged linen bins or red bagged trash bins in the room. -- When F1 expressed concern to the nursing supervisor, the (former) DON (E3), was called and is reported to have said just be extra careful with hygiene. -- Before leaving on 6/8/18, F1 reported they were out of wipes to clean the toilet and requested the room be resupplied. -- On 6/9/19 when F1 arrived in the morning, there were no wipes. -- On 6/9/18, F1 verbalized concern again and was told to fill out a concern form. -- R362 was observed by F1 using the shared bathroom on 6/8 and 6/9/18. -- R362 verbalized to F1 s/he was having diarrhea and revealed s/he has a contagious [MEDICAL CONDITION]. -- R121 moved to another room on 6/9/18 around 4:00 PM. -- After R121 moved from the room, the sign and isolation cart was put up in front of room. 10/2/18 3:56 PM - Interview with E11 (RN) revealed that s/he worked 6/8/18 3 -11 PM shift. -- E11 stated that s/he was aware that R362 had [MEDICAL CONDITION]; an isolation cart was placed outside the room; a gray stool was put over the toilet since both residents were using the bathroom. E11 could not explain the purpose of the stool. -- Aides were informed to use hand washing and not alcohol sanitizer. -- E11 also revealed that F1 (R121's family member) did approach her/him and asked a lot of question about R362 and his/her condition, but no information was shared. -- F1 was told that due to HIPPA, no information could be shared. 10/4/18 12:00 PM - Interview with F2 (R362's family) revealed: R362 had a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. -- No precaution signage or protective equipment was available during the first couple of days of R362's admission. -- Although there was a bedside commode in the room, it was pushed in the corner with no instruction to use it instead of the bathroom. -- Soiled linens were put in the corner of the room by F2 because there was no receptacle for them; staff were in the room providing care without protective equipment during the first few days. -- After the signage and equipment were put in place, staff entered fully-garbed. -- No instruction was provided to use handwashing instead of the hand sanitizer dispensers located in the halls (F2 stated she did not go in the bathroom and cleansed her hands with the hand sanitizer during her visits). Based on the foregoing circumstances, it was determined that the facility failed to meet professional standards in the area of comprehensive transmission-based precautions and placed a deconditioned resident (R121) at risk for contracting [MEDICAL CONDITION], a potentially life threatening bacterial infection, in the same room with a resident (R362) with active [MEDICAL CONDITION]. Although R121 did not contract the infection, s/he was at risk for about 24 hours while sharing a room and bathroom with an infected resident experiencing ongoing diarrhea for an active [MEDICAL CONDITION] infection. The facility placed R121 at immediate jeopardy of contracting a [MEDICAL CONDITION] infection on 6/8/18 when he was admitted to the facility. The immediate jeopardy was abated on 6/9/18 at 4:00 PM when R121 was moved out of the room and isolation precautions were initiated for R362. These findings were reviewed during the exit conference on 9/28/18 at 3:00 PM with E1 (NHA), and E2 (DON).

Based on observations, interviews and record reviews, it was determined that for 2 (R71 and R61) out of the 54 sampled residents the facility failed to ensure adequate supervision and assistive devices to prevent falls. R71 was left unattended in the dining area in a standard chair. When R71 tried to transfer to her wheelchair, she fell , resulting in harm when her right arm was broken. The facility failed to initiate interventions for an identified posture issue for R61 resulting in a fall. Findings include: 1. The following were reviewed in R71's clinical records: 6/18/18 - R71 was admitted to the facility for rehabilitation with ambulatory dysfunction. Hospital record shows that prior to the LTC facility admission, R71 had a history of [REDACTED]. R71 was then admitted to the hospital on [DATE] for [MEDICAL CONDITION] Fibrillation and was noted to be a fall risk. -- Per the Physician Rounds Report dated 4/18/18, R71 was a high risk for injury should she fall. 6/19/18 - Baseline Care Plan record documents the reason for admission to LTC Skilled Services as: -- difficulty walking -- injured right shoulder -- PT/OT screening The Baseline Care Plan also documented: -- cognitive risks -- preference for meals in dining room -- uses wheelchair -- safety considerations for history of falls 6/19/18 - R71 was started on the Physical Therapy caseload. 6/20/18 - Care Planned for Cognitive Loss/Dementia Chronic/Progressive decline in intellectual function as evidenced by: -- deficits in memory -- decision making -- thought process with interventions to anticipate needs and -- provide cueing and prompting as needed for ADLs 6/25/18 - Admission MDS assessment indicated that R71 has severe confusion, was an extensive 2 person assist with transfer and bed mobility; and needed extensive 1 person assist with walking and locomotion. 6/28/18 - In a Care Plan for Potential for Falls related to decreased mobility, weakness, cognitive impairment and fall history, the facility failed to indicate the need for staff supervision with transfer and mobility. 6/28/18 - Care Plan for Communication documented that R71 has difficulty understanding and communicating with others related to cognitive impairment. 7/23/18 - Physical Therapy Discharge Summary stated R71 was discharged from Physical Therapy caseload. The Patient Progress and Response to Treatment form documented .Patient made good progress with therapy however independent level not achieved due to significant dementia with very poor carryover. Patient S/SBA (Supervision/Stand by assist) level with bed mobility and SBA level with transfers. Requires maximum verbal and tactile cues for safety and exhibits impulsive behavior at times that further impacts safety Patient continues with high fall risk as evidenced by Timed Up and Go test score with is further impacted by poor safety awareness. Patient will require 24 hour assist due to high fall risk , poor endurance and very low safety awareness Patient currently at w/c (wheelchair) level for mobility with supervision . 8/8/18 9:17 AM - As per Incident Report dated 8/8/18 and completed on 8/14/18 by ADON (E4), Patient found on floor at 0917 (9:17 AM) by members of therapy in the dining room. Patient assessed and no bruises just no ROM (Range of Motion) in right arm. Patient grimaced when moved back to w/c (wheelchair). No change in baseline neuro. Vitals taken: 138/90, 78, 20, 96% on room air. Daughter called at 0927 (9:27 AM). NP notified at 0928 (9:28 AM). Patient given Tylenol 325 mg x 2 tabs at 10:25 (10:25 AM). With partial relief noted. EMS arrived at 12:10 (12:10 PM) and patient given 2 more tabs of 325 mg (Tylenol) per NP orders at 1200 (12:00 PM). Patient left to (Hospital Name) for evaluation and treatment. -- R 71 was in the dining room. -- Attempted to move from standard chair to a wheelchair. -- fell . -- Last toileted at at 8:00 AM. -- No assistive device in use. -- Fall risk: 10.0. -- Fall witnessed by another resident. Statement from the fell ow resident RSS1 on 8/8/18, Resident (R71) was getting up from a regular chair to a wheelchair in the Dining Room, when she fell to the floor and landed on her right side.was saying her right shoulder was having pain. 8/9/18 8:26 AM - Review of the Progress Notes dated 8/9/18 written by ADON (E4) . IDT follow - up for fall event (MONTH) 8, (YEAR) (8/8/18)--- This ADON spoke with the patient in the dining hall this morning. We discussed the fall details and education was provided. Patient stated, I know that if I need help I need to call someone by pushing the call bell or telling someone. 9/28/218 10:00 AM - Review of Progress Notes dated 8/8/18 6:19 PM indicated that R71 returned from hospital ED with a new [DIAGNOSES REDACTED]. Right arm sling was to be worn at all times except for hygiene. 9/28/18 11:50 AM - Interview with Rehab Manager (E9) and DON (E2). Both said that R71 was a contact guard assist for transfers around the time of the accident. The fall took place in the Dining Room, a common area that is usually not supervised by Nurses and CNAs. R71 was in the dining room unattended when she attempted to independently transfer from the standard chair to the wheelchair that caused her to fall which resulted in a broken right arm. Despite the history of a fall at home resulting in an injury and hospitalization and despite being classified at the hospital as a fall risk with a high risk of injury, the facility failed to: -- Develop a Fall Care Plan to incorporate Supervision -- Incorporate the Physical Therapy recommendations into the Nursing Care Plan & Intervention During an interview on 9/24/18 at 12:01 PM with E4 ADON it was confirmed that the fall on 7/19/18 was postural. E4 was unsure of when she became aware of R61's postural deficits and stated PT would have been working with R61 and that information is shared during daily morning meetings. R71 who was identified as a fall risk and as having weakness, and poor sitting balance experienced a preventable fall on 7/19/18 as a result of the facility failed to implement interventions related to posture, and balance to prevent falls. These findings were reviewed during the exit conference on 9/28/18 at 3:00 PM with E1 (NHA), and E2 (DON). 2. The following were reviewed in R61's clinical record: 7/11/18 R61 was admitted to the facility with multiple [DIAGNOSES REDACTED]. 7/11/18 -The following fall precautions were implemented for R61, a low bed, and non-skid foot wear. 7/11/18 - An admission fall assessment documented R61 as a high risk of falls with a score of 14, any score greater than 10 being a high risk. 7/12/18 - E36 (PT) documented the following: R61's sitting balance poor . currently presents with significant weakness decreased sitting tolerance and balance, decreased standing tolerance and balance, decreased endurance, difficulty following 1 step commands, and decreased safety and independence with bed mobility, transfers, and wheelchair mobility. 7/19/18 - A facility incident report documented R61 fell out of her wheelchair onto her left side. The investigative summary on that same incident report documented Patient found to have decreased postural support causing the patient to fall out of the wheelchair. The facility failed to initiate interventions for an identified posture issue for R61 resulting in a fall. These findings were reviewed during the exit conference on 9/28/18 at 3:00 PM with E1 (NHA), and E2 (DON

Based on closed record review, interview and review of other facility documents as indicated, it was determined that the facility failed to ensure that for one resident (R5) out of seven (7) sampled, who entered the facility without pressure sores did not develop a pressure sore unless the individual's clinical condition demonstrates that it was unavoidable. According to R5's admission Minimum Data Set (MDS) assessment, dated 10/8/11, R5 was at risk for developing pressure ulcers but had no unhealed pressure ulcer(s) at Stage 1 or higher. However, on 10/17/11, R5 was discovered with an unstageable pressure ulcer on his right heel. Findings include: The facility's policy entitled. "Pressure Ulcer Prevention and Management" stated "Purpose: To identify individuals at risk for skin breakdown and develop an ongoing plan of care for prevention, recognition and treatment of [REDACTED]..2. Upon admission to the facility and weekly afterwards, the nurse will complete a skin assessment on the skin rounds form...5d. Off load heels when in bed...Wound Identification Procedure: 1. Residents will have a total body skin check upon admission and thereafter weekly. In addition, the assigned CNA (Certified Nurse Aide) checks skin daily and reports unrelieved redness or breakdown to the nurse. 2. When a skin condition is identified (other than Stage I Pressure Ulcer), Nursing will:..d. Complete wound assessment weekly, document wound appearance; include location, size, type, odor, and drainage using the Weekly Wound Assessment sheet...Wound care Team Procedure: Responsibilities: Nursing team will measure and evaluate wound weekly..." R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Admission Assessment, dated 10/1/11 and completed by the admitting nurse did not identify any skin conditions other than the PEG (percutaneous endoscopic gastrostomy) tube site. Additionally, the admission nurse's note, dated 10/1/11 and timed 11:00 PM, did not note any concerns with R5's skin condition. A second nurse's note dated 10/2/11 and timed 12:00 PM stated "(Patient) reassessed per (treatment) nurse. No skin problems noted." A Braden Scale (for predicting pressure sore risk) was completed on 10/1/11 and identified R5 as being at High Risk for developing pressure sores with a score of 16 (16 or less considered High Risk). On 10/1/11 a care plan for the problem "At risk for alteration in skin integrity related to: impaired mobility" was developed and included the interventions "Apply moisturizers to skin as needed, Monitor skin condition with (Activities of Daily Living-ADL) care daily, report abnormalities, Off load heels/derma savers as necessary..." On 10/10/11, the care plan for potential for pressure ulcers was updated to include the interventions "pressure reducing mattress to bed, pressure reducing cushion to wheelchair when (out of bed), turn and reposition (every 2 hours & PRN (as needed), Weekly skin checks on shower days, ensure measures are taken to prevent/reduce potential shearing or friction during transfers, repositioning, etc., Skin checks (every) 2 hours..." Review of the treatment administration record (TAR) from 10/2/11 through 10/31/11 revealed that staff nurses were signing off that they were off loading R5's bilateral heels while he was in bed with two pillows. Additionally, review of the CNA Flow Sheet from 10/1/11 through 10/31/11 revealed the CNAs were signing off on each shift that they were completing skin checks every 2 hours, turning and repositioning every 2 hours and reporting any skin changes to the nurse. The admission MDS assessment, dated 10/8/11, stated R5's cognitive skills for daily decision making were severely impaired - never/rarely made decisions and that he had no behavior problems. This same MDS stated R5 was totally dependent on two staff for bed mobility, transfers, toilet use, and bathing, and totally dependent on one staff person for locomotion on and off the unit, dressing, eating, and personal hygiene. R5 did not walk in his room or in the corridor during the assessment time period and had a functional limitation in range of motion of both his upper and lower extremities. The MDS stated R5 was at risk for developing pressure ulcers and had no unhealed pressure ulcer(s) at Stage 1 or higher. Review of the weekly Skin Rounds sheet revealed that on 10/3/11, R5 had a weekly skin assessment completed which stated that there were no skin issues noted. The next weekly skin assessment was due to be completed on 10/10/11. The facility failed to complete the assessment on 10/10/11. On 10/17/11, the Skin Rounds sheet stated "(Large) blister at (Right) heel 3.9 x 3.7 hard. No drainage skin prep applied." The corresponding nurse's note, dated 10/17/11 and timed 10:15 AM stated "...shower given...skin (check) done, large blister area noted to (right) heel 3.9 x 3.7 cm, area dry intact..." A second nurse's note, dated 10/17/11 and timed 2:00 PM, stated "(Right) heel unstageable pressure 3.9 x 3.7 x UTD (unable to determine) depth, Red/black wound base, no drainage, intact surrounding tissue dry + intact..." Despite CNAs documenting that skin checks were being completed every two hours and reporting changes to the nurse, the heel wound was not identified until it was unstageable. On 10/17/11 physician's orders [REDACTED]. Review of the Skin Rounds sheet and Weekly Wound Assessment sheet revealed that the facility failed to complete both of these assessments on the next due date, 10/24/11. A Wound Evaluation Form completed by the Nurse Practitioner (NP), dated 11/1/11 stated the right heel pressure ulcer's initial Stage was "UTD/Necrosis," the visual Stage was "UTD, DTI (Deep Tissue Injury-Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.)" measuring 3.2 x 3.0 x 0 with a black wound bed and that the wound had improved. A Wound Evaluation Form, dated 11/8/11 stated this wounds visual Stage remained "UTD/DTI" measuring 3 x 2.5 x 0 with a black wound bed and that it had improved. This was the last measurement completed in the facility, as R5 was transferred to another rehabilitation facility on 11/14/11. Although the facility documented off loading of the heels, turning and repositioning every 2 hours and that CNAs were checking R5's skin for changes every two hours, the facility failed to identify changes to R5's skin until the heel wound was unstageable. The facility failed to complete weekly skin rounds and weekly wound assessments as per policy. On 2/3/12 at 12:45 PM, E4 (Physical Therapist) was interviewed and confirmed that she treated R5 during his stay at the facility. E4 stated the resident was not ambulatory and was mostly at the parallel bars to increase standing balance but required the assistance of two staff. E4 stated R5 was also placed in a stander because the staff could not hold him up for a prolonged period of time and she also worked with him on wheelchair mobility and he would have worn sneakers then. E4 stated that the resident wore black sneakers to therapy and at times wore non-skid socks. During an interview on 2/3/12 with E1 (Administrator, E2 (Director of Nursing) and E3 (Chief Operating Officer), E2 stated that she believed that R5 had a "blood blister" on his right heel. It was also stated that R5 wore sneakers and that may have been the cause of the wound. There was no supporting documentation found in the clinical record that sneakers caused the right heel wound.

Based on closed record review and interview, it was determined that the facility failed to ensure that three (R1, R2 and R3) out of 12 sampled residents were free from significant medication errors. R3 failed to receive [MEDICATION NAME] for 4 consecutive doses and also failed to receive [MEDICATION NAME] 225 mg tablets for 2 consecutive doses following admission. As a result R3 was found to be in "uncontrolled Afib ([MEDICAL CONDITION])" with a heart rate of 180 (normal range is 60-100 beats/minute). R3 stated "I feel like I want to die". R3 was sent to the hospital emergency room via 911 and was subsequently admitted to the hospital for treatment. R1 failed to receive medication according to the physician ordered parameters resulting in multiple medication errors. R2 failed to receive eight doses of [MEDICATION NAME]. Findings include: 1. R3 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. According to R3's "Admission Assessment" dated 6/4/11, this resident was totally dependent on staff for all activities of daily living (ADLs). R3's level of consciousness/mental status was "alert with intermittent confusion". R3's discharge medication orders from the hospital on [DATE] included: [MEDICATION NAME] (to treat heart rhythm disorder) 60 mg tablet four times a day Hold for systolic blood pressure (SBP) < (less than) 90 and heart rate (HR) < 60 and [MEDICATION NAME] (to treat irregular heartbeat, maintain a normal heart rate) 225 mg tablet every 8 hours. According to the hospital's "Medication Reconciliation Order Sheet for Extended Care Facilities" the [MEDICATION NAME] was last administered in the hospital on [DATE] at 12:22 PM (next dose due at 6:00-6:30 PM in the facility) and [MEDICATION NAME] was given at 4:00 PM (next dose due at 12:00 AM on 6/5/11). R3 arrived at the facility on 6/4/11 at 6:15 PM. Facility staff failed to follow facility protocol of informing the Pharmacy of the need for prompt delivery of this resident's clinically significant medications ([MEDICATION NAME] and [MEDICATION NAME]) and failed to request delivery within four hours. As a result, these clinically significant medications were not delivered by the Pharmacy until 6/5/11, between 6:00- 6:30 PM, resulting in a 24 hour delay. An interview with E2 (DON) and E4 (Clinical Service Consultant) on 8/10/11, revealed that these medications were not included in the facility's emergency box. R3's 6/11 Medication Administration Record (MAR) listed12 routine and 3 PRN (as needed) medications prescribed on 6/4/11 which included [MEDICATION NAME] and [MEDICATION NAME]. As a result of this breakdown in communication by the nursing staff responsible for communicating the need for the timely delivery of these medications with the Pharmacy and by not following facility policy and procedures, the [MEDICATION NAME] was not available to be administered on 6/4/11 at 6:00 PM and on 6/5/11 at 12:00 AM, 6:00 AM and 12:00 PM. In addition, after the medication was delivered to the facility on [DATE] (Sunday) between 6-6:30 PM, R3's MAR revealed that the [MEDICATION NAME] was not administered to the resident at that time. E6 (LPN) wrote on the MAR that "patient request medication ([MEDICATION NAME]) wait for 1 hour secondary to [MEDICATION NAME] administration (medication for pain)". However, R3's MAR revealed that E6 signed off and circled to indicate that the [MEDICATION NAME] was not administered and there was no evidence indicating that E6 went back and administered the 6:00 PM dose of [MEDICATION NAME] on 6/5/11. Altogether, R3 failed to receive [MEDICATION NAME] for 4 consecutive doses since admission. The [MEDICATION NAME] 225 mg tablet prescribed to be given every 8 hours was also not administered at 12:00 AM and 8:00 AM ( 2 consecutive doses) on 6/5/11. Interview with E4 (Clinical Services Consultant) on 8/10/11 at 3:30 PM confirmed this finding. E6 no longer worked in the facility and therefore was not available for interview. A nurse's note, dated 6/5/11 and timed 8:30 PM stated that the "APN" (Advance Practice Nurse) on call for R3's attending physician came in to assess the resident and discovered that the resident was in "uncontrolled Afib ([MEDICAL CONDITION])" with a heart rate of 180 (normal range is 60-100 beats/minute). R3 stated "I feel like I want to die". R3 was sent to the hospital emergency room via 911 and was subsequently admitted to the hospital for treatment. The hospital admission record stated that R3 had "[MEDICAL CONDITION] Fibrillation with RVR (Rapid Ventricular Rate)" and was given [MEDICATION NAME] which decreased his heart rate from the 150's to the 120's. R3 returned to the facility on [DATE] for Rehabilitation services with [DIAGNOSES REDACTED]. In an interview with E11 (Medical Director/attending physician) on 8/11/11, he stated that the most level of harm R3 would have for the missed doses of [MEDICATION NAME] would be "symptomatic", that is, A-Fib/rapid heart rate" and not fatal. While R3 did not experience a fatality R3 was discovered on 6/5/11 by the APN in uncontrolled Afib with a heart rate of 180 and also stated "I feel like I want to die". Additionally the form entitled " emergency physician record" documented the chief complaint as heart racing, with fast pounding heart beat, dizziness and weakness associated with light headedness, shortness of breath and cough. The hospital admitting physician's H & P for the 6/6/11 admission also stated R3 stated he was feeling "sloppy in his stomach". This finding was acknowledged by E1 (Administrator), E2 (DON) and E3 (ADON) and E4 (RN) on 8/17/11. 2. R1 was originally admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED].> (greater than) 125, diastolic blood pressure (DBP) > 75. Although R1 had multiple hospitalization s between 4/10 through 9/10, readmission orders [REDACTED]. Review of medication administration records (MAR) from 4/27/10 through 9/10 revealed multiple errors in the administration of the [MEDICATION NAME]. Facility nursing staff was at times holding the medication when it should have been given or giving the medication when it should have been held according to the ordered parameters. On 10/5/10 a new order was written which stated R1 was to receive [MEDICATION NAME] 10 mg twice a day (BID) Hold SBP > 110, DBP > 70. This order remained in effect through 3/7/11. Review of MARs from 10/5/10 through 2/15/11 revealed that again facility nursing staff was at times holding the medication when it should have been given or giving the medication when it should have been held. During an interview with E11 (R1's physician) on 8/11/11, he stated that the multiple errors did not harm the resident. Findings were reviewed during the exit conference on 8/17/11 and acknowledged by the facility's administrative staff. 3. Review of R2's closed record revealed the resident was to have been admitted to the facility on [DATE]. However, R2 did not arrive from the hospital until 4/12/11. R2's [DIAGNOSES REDACTED]. On 4/11/11, the facility received a fax of R2's "Medication Reconciliation Order Sheet for Extended Care Facilities" from the hospital. Included on this list was an order for [REDACTED]. When R2 arrived at the facility on 4/12/11, a second medication reconciliation Sheet came with her. This second order sheet stated R2 was to have [MEDICATION NAME] 20 mg daily. The words "every other day" had been crossed off and "daily" was written instead. The order for the [MEDICATION NAME] 20 mg daily was transcribed onto a medication administration record (MAR). R2 received [MEDICATION NAME] 20 mg daily through the end of 4/11. The monthly pre-printed physician order [REDACTED]." The facility failed to correct this pharmacy transcription error on the 5/11 monthly POS and MAR during the monthly recapitulation of physician's orders [REDACTED]. The MAR revealed that on 5/18/11, E16 (nurse) yellowed out the [MEDICATION NAME] 20 mg every other day and wrote "change see next sheet." E16 rewrote the [MEDICATION NAME] 20 mg every other day on a new MAR and drew boxes on the days for it to be given (every other day). During an interview with E16 on 8/16/11, she stated that when she saw the "error," she did go back to the original orders from the hospital that were dated 4/11/11 which stated [MEDICATION NAME] 20 mg every other day. E16 stated that she had not seen the second order sheet that had arrived with R2 on 4/12/11 which had "every other day" crossed off and "daily" written in. E16 acknowledged that she did not notify the physician at this time, nor did she complete a medication incident report. Nursing staff administered the [MEDICATION NAME] 20 mg every other day from 5/19/11 through 6/3/11 resulting in R2 not receiving a total of eight (8) doses. According to a nurse's note, dated 6/5/11, R2's family member expressed concern over increased swelling of R2's lower extremities and that the physician was called. Additionally, the note stated that the nurse practitioner called back, ordered a dose of [MEDICATION NAME] 20 mg be given to the resident and that the [MEDICATION NAME] order would be clarified with R2's physician in the morning. On 6/6/11 an order was written for [MEDICATION NAME] 20 mg daily. The facility failed to correctly complete monthly recapitulation of physicians orders, failed to notify the physician of a perceived medication error and failed to complete a medication incident report. Subsequently, R2 was not given eight (8) doses of [MEDICATION NAME] 20 mg. Findings were acknowledged by administrative staff during the exit conference on 8/17/11.

Based on observation, record review, interview and review of other documentation as indicated, it was determined that the facility failed to provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 (R5) out of 13 sampled residents. The facility failed to remove the tourniquet after restarting R5's IV (intravenous) on 10/18/10. The tourniquet remained in place on R5's left upper arm until the 3-11 shift nurse discovered it approximately 12 hours later. Consequently, R5 had swelling and pain in his left arm and hand, he developed bruising to the arm as well as circumferential stage 2 wounds (blisters) where the tourniquet was, which later became scabbed areas. R5 also received his evening antibiotic intramuscularly, which is painful and often requires the administration of multiple injections. Additionally, the facility failed to discover the tourniquet/arm swelling during every 2 hour skin checks. Findings include: Search for a facility procedure on IV insertion was unsuccessful. On www. mrprotocols.com/sset/iv.html an article entitled "Starting Intravenous Lines", stated, "...Apply a tourniquet high on the upper arm. It should be tight enough to indent the skin without causing patient discomfort... If you cannot see any veins popping up from distention caused by the tourniquet... Once the angio catheter (type of IV catheter) is advanced in the vein up to the hub, release the tourniquet, apply gentle pressure over the vein to collapse it...". R5 was admitted to the facility in August 2009 with [DIAGNOSES REDACTED]. R5 also had a history of [REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 10/18/10, revealed that R5 was not oriented to the current year. He was non-ambulatory and dependent on staff for activities of daily living. Care plan review revealed the problems "Chronic/Progressive decline in intellectual functioning characterized by; deficit in memory, judgement, decision making and thought process related to: short term memory loss, dementia" and "Impaired communication R/T (related to) impaired cognition, short term memory loss, may miss part/some of message, dementia", dated 8/4/10. Additionally on 8/4/10, a care plan was developed for "at risk for alteration in skin integrity related to pain, incontinence, impaired mobility...". Interventions included: monitor for and report any [MEDICAL CONDITION], turn and reposition every 2 hours, skin checks every 2 hours and report abnormalities. Observation of R5 on 2/22/11 confirmed that he was unable to answer questions and speech was unintelligible. Nurses's notes revealed: 10/18/10 (3 PM)- receiving IV Cefepine (antibiotic) for an upper respiratory infection and E5 (unit manager) restarted the IV in the left arm. 10/18/10 (11:40 PM)- "... went into... room to hang IV checking his L (left) hand, I found a tourniquet on his upper arm. Hand noted swollen and site where the tourniquet was noted irritated. MD notified and N/O (new order) obtained 1) Cefepine 1 gm (gram) IM (intramuscularly- injection into muscle) x1 (one time) tonight. 2) elevate L arm. 3) no blood draws or IV's on L arm. 4) venous doppler on L upper arm to R/O (rule out) [MEDICAL CONDITION] ([MEDICAL CONDITION] or blood clot) on 10/19/10...". The venous doppler study was negative for a [MEDICAL CONDITION]. 10/19/10 (4:30 PM)- "... L arm [MEDICAL CONDITION] (swelling) persists c (with) discoloration..." 10/20/10 (7 AM)- "... L arm swelling decreasing. Some discoloration noted tourniquet site..." 10/20/10 (11 PM)- "... Blister on L upper (arm) cleaned & [MEDICATION NAME] (antibiotic ointment) applied. Pt. on routine [MEDICATION NAME] (narcotic for moderate to severe pain) for B/L (bilateral) extremities...". 10/25/10 (3:20 PM)- "... (no) discoloration noted (left arm) except healing area where tourniquet was applied...". R5 completed antibiotic for pneumonia. 10/28/10 (3:30 PM)- "... Bruise upper L arm resolving. (No) open areas. (No) [MEDICAL CONDITION] Sm. scab intact..." E2 (Director of Nursing) was interviewed by a DLTCRP investigator on 10/29/10. E2 stated that initially, there were some blisters, but there is now just a little bit of scabbing and peeling. A physician progress notes [REDACTED]. (No) open areas. Sl (slight) (increased) discoloration of area immediately distal to above, corresponds to tourniquet site... St II wd (wound) L arm 2 (secondary to) tourniquet (prolonged)... monitor closely...". Review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Without the routine administration of these pain medications, R5 would have likely experienced more pain in his left arm and hand. Review of October 2010 CNA (certified nurses aides) Flow Sheets documented (including 10/18) that skin checks were done every 2 hours and changes were to be reported to the nurse. There were no comments written on the back of the form. E35 (CNA) was interviewed on 2/23/11. E35 was the 7-3 shift CNA assigned to the resident on 10/18/10. She stated that the IV had not been restarted yet when she did R5's AM care. E35 confirmed that R5 was dependent for care, including being turned, but stated that she did not see a tourniquet on R5's arm on 10/18/10. When asked how E35 does skin checks, she stated that she checks the residents bottom, not the top. E5 (unit manager) that restarted R5's IV on 10/18/10 wrote in a statement, dated 10/19/10, "... I inadvertently forgot to take off the tourniquet. This was missed also by the primary nurse because the tourniquet was concealed beneath the sleeve of the gown...". E5 was unavailable for interview as her last day in the facility was 2/21/11. The facility failed to remove the tourniquet after restarting R5's IV on 10/18/10 and it remained in place for approximately 12 hours, which resulted in harm that included pain, swelling, bruising and the development of wounds to the left upper extremity. Facility staff failed to find the tourniquet/left arm swelling until the 3-11 nurse went to hang R5's IV antibiotic that night, despite documentation of skin checks every 2 hours, that admitted ly failed to include the upper part of R5's body.