Every finding on record at Cadia Rehabilitation Renaissance

Based on record review and interview, it was determined that for one (R13) out of forty-five residents in the investigative sample, the facility failed to provide services that meet professional standards of quality by having Licensed Practical Nurses (LPN) complete post fall assessments. Findings include:Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . RN . Post Fall Assessment & Documentation . updated 10/11/24.Review of R13's clinical record revealed:3/17/26 - R13 was admitted to the facility. 6/24/26 11:20 AM - A facility reported incident documented that R13 had a witnessed fall when standing up from wheelchair, lost balance, and fell making contact with a chair on the left side and shoulder while outside on the patio with activities. 6/24/26 11:20 AM - A witness statement documented that R13 was sitting on the ground on the patio with left side leaning against an outdoor chair. The statement further documented that R13 was assessed by E20 (LPN) for range of motion (ROM), vital signs and neurological checks were initiated. 6/24/26 12:13 PM - A post fall assessment was completed by E20 in the EMR (electronic medical record). There was no evidence in the clinical record that the RN on duty was called to assess the resident.6/24/26 1:00 PM - A provider progress note documented that E8 (NP) assessed R13 post fall. The progress note documented that R13 was complaining of pain in the left shoulder and had limited ROM. The progress note further documented that E8 ordered an x-ray of R13's left shoulder. 8/13/26 12:40 PM - During an interview, E20 stated she completed the post fall assessment on 6/24/26 after R13 fell outside on the patio. E20 stated the expectation is for the LPN to complete the assessment if assigned to the resident and notify the RN Unit Manager if they are available. 8/13/26 1:00 PM - During an interview, E12 (RN) stated the expectation was the post fall assessment could be started by an LPN but an RN should be present during assessment and cosign the assessment upon completion. E12 confirmed that E20 completed the aforementioned assessment. 8/17/26 2:50 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on observation, interview, and record review, it was determined that for two (R16 and R27) out of two residents reviewed for respiratory care, the facility failed to ensure the respiratory equipment was stored in plastic bagging when not in use. Findings include: 1. R16 was admitted to the facility with the following diagnoses, including but not limited to, pneumonia, shortness of breath, and chronic obstructive pulmonary disease. 7/23/26 – A review of R16's physician's orders documented Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 mL, to be inhaled orally every eight hours as needed for wheezing/shortness of breath for 14 days, and 3 mL to be inhaled orally three times a day for shortness of breath/wheezing. 8/10/26 at 9:25 AM – An observation revealed R16's nebulizer machine sitting on the nightstand, with the nebulizer mask attached to the tubing. The mask was dated and lying in the drawer, with the drawer closed. A plastic bag was observed lying next to the nebulizer machine. 8/11/26 at 10:41 AM – A second observation revealed R16's nebulizer mask and tubing stored in a plastic bag. 8/12/26 at 10:11 AM – A third observation revealed R16's nebulizer mask lying on the bedside table and not enclosed in a plastic bag. 8/12/26 at 10:17 AM – During an interview and observation, E12 (RN, UM) confirmed that R16's nebulizer mask was not placed in protective bagging. The surveyor asked E12, What is the facility's policy for respiratory equipment when not in use? E13 stated, It should be in a bag. I will speak to the nurse; this will be taken care of. 2. R27's clinical record revealed: 7/30/26 – R27 was admitted to the facility. 7/30/26 7:24 PM – A physician's order for R27 documented to apply the CPAP at bedtime and as needed for naps. 8/2/26 – An admission Minimum Data Set (MDS) documented R27 as cognitively intact with a BIMS score of 14. 8/10/26 10:54 AM – An observation revealed R27's CPAP mask and tubing lying on the bedside table, on top of the CPAP machine. R27 stated that she did not receive a bag for storing the mask. 8/10/26 11:07 AM – During an interview, E6 (RN) stated that respiratory equipment, including a CPAP mask, goes into a clear, gallon-sized bag. 8/10/26 11:10 AM – During an interview, E17 (CNA) confirmed that the CPAP was lying on the bedside table and was not placed in a storage bag. 8/17/26 2:50 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on observation, interview and review of facility documents it was determined that the facility failed to ensure dishes and utensils were cleaned under sanitary conditions. Additionally, the facility failed to ensure cleanliness of food storage areas and properly store items in facility unit refrigerators. Findings include: 1. 8/19/25 9:36 AM - 9:41 AM - During a follow up visit to the kitchen, the dish washer was observed as having a water temperature of 135 degrees during the wash cycle. The digital screen that displayed the dish cycle temperatures, flashed red and [alarmed] kitchen staff that the temperature was below 150 degrees. 8/19/25 9:43 AM - During an interview, E15 (FSD) confirmed the wash cycle for the temperature did not meet the minimum 150 degrees. E15 stated, I just saw the alarm, so I went and talked to maintenance, and they think one of the boilers temperatures was turned down. 8/19/25 10:00 AM - Review of the facilities dish machine temperature logs revealed the following dates when dish washing temperatures failed to meet the minimum of 150 degrees:June 2025 - 6/5, 6/26 and 6/29.July 2025 - 7/5, 7/11, 7/15, 7/16, 7/27 and 7/28.August 2025 - 8/1, 8/2, 8/3, 8/8, 8/9 and 8/14. 8/19/25 11:26 AM - During an interview, E15 (FSD) confirmed the temperature logs and stated that they had a contractor out on 8/12/25 and the temperatures met requirements that day. 2. 8/19/25 10:35 AM - During inspection of the facilities unit refrigerators a plastic food storage container that contained rice and broccoli was observed on the shelf, unlabeled and undated. The finding was immediately confirmed by E14 (unit clerk). 3. 8/19/25 11:23 AM - During a follow up visit to the kitchen, an area of fuzzy, black spotted substance was observed on the wall surrounding the light switch of the dry storage room. E15 (FSD) immediately confirmed the finding. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.

Based on interview, and record review it was determined that for two (R118 and R120) out of nine residents sampled for discharge and hospitalization the facility failed to send the required notification to the Ombudsman of transfer discharge. Findings include:1. A review of R118's clinical record revealed: 6/16/25 - R118 was admitted to the facility with diagnoses including complete obstruction of the intestines and acute kidney failure. 7/22/25 10:55 AM - Review of R118's progress note documented R118 was admitted to the hospital. 8/22/25 12:20 PM - During an interview E17 (SW) reported the Ombudsman was notified quarterly of resident discharges and transfers. E17 then stated, I was out on medical leave, and my assistant was not sending them out so now I am sending it out for July and August prior to me going out on medical leave I was sending them out monthly. Surveyor requested documentation of required notification for the previous months. 8/22/25 1:15 PM - E11 confirmed the required notification of R118's transfer to the hospital was not submitted to the Ombudsman. 2. A review of R120's clinical record revealed: 4/14/25 R120 was admitted to the facility with diagnoses including lower back stress fracture and left rib fracture. 7/23/25 - R120's clinical record documented R120 was discharged to home. 8/22/25 12:20 PM - An interview with E17 (SW) revealed there was no notification to the Ombudsman for R120's planned discharge to home from the facility. 8/22/25 1:15 PM - E11 (CNO) confirmed that the required notification to the Ombudsman for R120's discharge to home was not sent. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.

Based on record review and interview it was determined that the facility failed to ensure accuracy of the medication reconciliation documentation for a controlled drug. Findings include: 8/3/25 - A controlled drug administration record for R123 documented that the facility received thirty morphine capsules from the pharmacy. 8/5/25 - The controlled drug administration record for R123's morphine revealed that E12 (LPN) administered one of the capsules to R123 and documented that twenty-nine capsules remained. 8/6/25 - The controlled drug administration record for R123's morphine indicated that E12 (LPN) witnessed E13 (RN) destroy a remaining amount of twenty-four of R123's morphine capsules. The controlled drug administration record had previously documented a remaining amount of twenty-nine capsules, a five-capsule deficit. The clinical record and drug administration record lacked clarification to account for the five-capsule deficit. 8/20/25 1:38 PM - During an interview, E11 (CNO) stated that the facility had not identified any medication reconciliation discrepancies regarding medications received from the pharmacy for R123. 8/20/25 1:45 PM - During an interview, E12 (LPN) denied knowledge of the five capsule deficit documented on the controlled drug medication administration record for R123's morphine capsules. When shown the record, E12 confirmed witnessing the destruction of the medications, and stated I don't remember there being an error. 8/20/25 1:53 PM - During an interview, E13 (RN) confirmed his signature on the controlled drug medication administration record for R123's morphine capsules. E13 confirmed the five capsule discrepancy and stated, I think it's just a typo. 8/20/25 2:26 PM - During an interview E11 (CNO) confirmed the discrepancy on the controlled drug administration record for R123's morphine and stated, it was a clerical error. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.

Based on interview, and record review it was determined for one (R10) out of four residents sampled for PASARR review the facility failed to ensure a referral for a new PASARR Level I and II screening occurred by or before the sixth (60) day. R10 remained in the facility beyond the authorization time frame. Findings include:Review of R10's clinical record revealed: 6/5/25 - A review of R10's Notice of PASARR Level I Screen Outcome documented PASARR Level Determination Convalescence Categorical Approval Period 60 days. Suspected or confirmed PASARR Condition(s): (MH) Mental Health Disability. A 60 day or less stay in the NF is authorized rescreening must occur by or before the 60 days if the individual is expected to remain in the NF (Nursing Facility) beyond the authorization timeframe. 6/12/25 - R10 was admitted to the facility with diagnoses including but not limited to post traumatic stress disorder and anxiety. 8/22/25 10:02 AM - An interview with E17 (SW) confirmed R10's PASARR rescreening had not been submitted. E17 stated, I thought [R10's] approval was for ninety (90) days, so it needs to be submitted I'll initiate it. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.

Based on observation, interview, and record review it was determined that for one (R37) out of four sampled residents reviewed for ADL(s) the facility failed to provide nail care. Findings include: Review of R37's clinical record revealed: 1/2/24 - R37 was admitted to the facility with diagnoses including a stroke and right-side weakness. 4/1/25 - R37's care plan for self-care deficit documented assist with daily hygiene, eating, toileting, dressing, grooming and oral care as needed. R37's care plan lacked evidence of refusing nail care. 6/25/25 - A quarterly MDS assessment revealed R37 required moderate assistance for personal hygiene and grooming. 8/18/25 9:50 AM - An observation of R37's fingernails on both hands were very long with dark encrusted debris underneath each fingernail. 8/19/25 10:42 AM - A second observation revealed R37 had not been provided nail grooming. 8/20/25 9:34 AM - A third observation of R37's nails on both hands remained long in length with dark encrusted debris under the nails on both hands. 8/21/25 9:53 AM - A fourth observation revealed R37's nails were still long with dark debris underneath all fingernails on both hands. 8/21/25 10:16 AM - During an interview, E19 (CNA) confirmed that according to the shower record that R37 should have received nail care on 8/17/25 during the 3:00 PM to 11:00 PM shift. 8/21/25 2:05 PM - During an interview and observation E18 (LPN) confirmed R37's nails needed to be cut, filed and cleaned. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.

Based on observation, interview, and record review it was determined for one (R37) out of three residents sampled for range of motion and mobility, the facility failed to provide a right wrist splint to prevent contractures for R37. Findings include: A facility policy titled Range of Motion Contracture Management revised 1/2/25 documented . To prevent the decline in range of (ROM), influencing a resident's ability to participate in functional activities Cross Refer F657 A review of R37's clinical record revealed: 1/2/24 - R37 was admitted to the facility with diagnoses including but not limited to stroke and right-side weakness. 1/3/24 - R37's documented splint/brace/device see RNP task for details. Review of the RNP task sheet revealed [R37's] splint is to be applied on the 7AM-3PM, 3PM-11PM and the 11PM-7AM shifts. 10/8/24 - R37's care plan for actual contractures and potential for further contractures related to decreased mobility, right spastic hemiplegia (stiff muscles and poor motor control) following stroke revealed the intervention resting right hand splint initiated 2/19/24. 2/25/25 - The facility range of motion assessment revealed R37's right wrist range was severe reduced range of motion reduction attributed to actual contracture and tone. 8/18/25 11:14 AM - R37 was observed lying in bed. R37's splint for the right/wrist and hand was laying in the resident's wheelchair. 8/19/25 10:00 AM - A second observation revealed R37 was in bed and was not wearing a splint. The splint was observed laying on R37's wheelchair. 8/20/25 9:53 AM - During an interview E19 (CNA) stated, since I have been working here, I have never seen [R37] with a brace I know that [R37's] is right arm is weak, but I have never seen him with a brace. 8/20/25 11:13 AM - R37's RNP task for splint placement was documented by E19 CNA that the splint had been applied. R37 was not wearing the splint during this observation. 8/20/25 11:15 AM - R37 was not wearing a splint to the right hand. R37's splint was laying on the wheelchair. 8/20/25 1:55 PM - R37 was not wearing the splint to the right hand. R37's splint was laying on the wheelchair. 8/20/25 2:00 PM - During an interview E18 (LPN) reported and stated, [R37] does not wear the splint. E18 reported [R37] always refuses to wear the splint. 8/21/25 2:05 PM - During the interview E18 observed and confirmed R37's splint was sitting on the wheelchair. E18 picked up the splint and applied it to R37's right wrist. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.

Based on interview and record review, it was determined for two (R20 and R61) out of five sampled residents for unnecessary medications, the facility failed to document a rationale for disagreeing on a monthly medication regimen review (MRR) recommendations. The Findings include:1.7/6/25 – R20 was admitted to the facility. The following recommendations were unanswered with a rationale: 12/31/24 – The pharmacist recommended: Could Trazodone GDR be considered with an insomnia diagnosis? The provider checked disagree, but no rationale was documented. 1/29/25 – The pharmacist noted: Clonazepam 0.5 mg tab order omits 0.5 mg tab = 2.5 mg. Neither agree nor disagree was selected, but documentation was noted. 3/30/25 – The pharmacist recommended: Could clozapine GDR be considered? Disagree was checked, but no rationale was documented. 4/28/25 – The pharmacist suggested monitoring for ASA/Clopidogrel for bruising/bleeding. Disagree was checked, with no rationale provided. 5/4/25 – The pharmacist recommended: Please evaluate resident tolerability to Amoxicillin with penicillin allergy. Please evaluate resident tolerability to Aspirin with Excedrin allergy. Neither agree nor disagree was selected, but documentation was noted. 7/6/25 – The pharmacist recommended: Please evaluate resident tolerability of Aspirin with allergy to Excedrin, and please clarify diagnosis of 'psych disorder' per CMS. There was no documentation from the provider in response. 7/25/25 – The pharmacist recommended: 7/6 olanzapine psyche disorder dx will trigger MDS inappropriate use on the quality indicator report. Please review dx and usage in considering a GDR. Risk vs. benefit analysis suggested with methocarbamol per Beers. Neither agree nor disagree was checked, but no rationale was documented. 8/22/25, 10:02 AM – During an interview, E7 (NP) confirmed she reviews the pharmacist's recommendations. E7 stated she consults the pharmacist when a GDR is suggested. For psychiatric medication changes, she contacts E27 (Psych NP) to discuss whether changes are appropriate. E7 also confirmed that when a provider disagrees with a recommendation, a rationale should be documented. 8/22/25, 2:25 PM – During an interview, E11 (CNO) confirmed that the facility attending physician failed to document the action taken or not taken in response to identified irregularities. 2.Review of R61's clinical record revealed: 10/13/23 – R61 was admitted to the facility. 7/1/25 - A MRR for R61 documented, lorazepam that a dose reduction GDR be considered. 7/1/25 – A MRR for R61 documented lorazepam 0.5 mg tab by mouth two times a day, should be considered for GDR. There was no rational documented. 8/22/25 10:15 AM - During an interview with E7, (NP) stated she reviews the monthly GDR recommendations. E7 discusses the findings with the psychiatric nurse practitioner. E7 then documents her rationale on the pharmacy GDR form and in the electronic medical record. 8/22/25 1:45 PM - During an interview, E3 (DON) stated that quarterly reviews of the Medical Record Review (MRR) are conducted. Following these reviews, the findings are discussed with the medical director. E3 confirmed that the medical director did not include a rationale for lorazepam. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.

Based on record review and interview it was determined that for one (R123) out of four residents reviewed for abuse the facility failed to ensure an allegation of misappropriation of resident property was reported to the state agency within the required time frame. Findings include: 1. The facility policy on abuse last updated January 3, 2025, indicated, All alleged incidents involving misappropriation shall be reported to the NHA/designee immediately .Incidents involving reasonable suspicion of criminal conduct are reported to the applicable state agency within eight hours or withing two hours if the conduct causes serious bodily harm. 1. Review of R123's clinical record revealed: 7/20/25 11:30 AM - A statement written by E12 (LPN) documented, At 10:45 AM I counted .however six [purple tablets] were missing. I recognized the discrepancy. Nursing supervisor [E9 (RN)] was immediately made aware, and she immediately made E2 (former DON) aware. 8/7/25 - E2 (former DON) submitted an incident report to the state agency that alleged [R123] bought in home medications upon admission .six purple pills noted on count sheet. It was noted that the six purple pills were missing. The incident report documented that the incident occurred on 7/19/25 nineteen days prior to the day the allegations were reported. 8/21/25 11:36 AM - During an interview, E9 (RN supervisor) stated, On July 20th on a Sunday and [E12(LPN)] said the count was incorrect, she said the six purple pills weren't there. E9 then confirmed that she notified E2 (DON) and that E2 was the person responsible for reporting. 8/21/25 11:45 AM - During an interview, E2 (former DON) confirmed recognizing the incident as an allegation of misappropriation of resident property and stated, I was delayed in reporting it because I was doing the investigation. 8/21/25 12:59 PM - During an interview, E1 (NHA) confirmed the delayed reporting. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (CO), and E11 (CNO) during the exit conference.

Based on observation and interview it was determined that for two out of three medication carts reviewed the facility failed to ensure opened medications were labeled with an open date. For one out of three medication carts reviewed the facility failed to ensure that insulin was stored in accordance with manufacturer's instructions regarding temperature. Lastly, the facility failed to ensure that medications in the facility were labeled in accordance with currently accepted professional principles when they accepted and stored unidentifiable medications then failed to ensure safe and secure storage of those medications. Findings include: 1a. 7/13/25 - A controlled substance record was created for R123 by E23 (RN) and E24 (RN) that documented six purple pills were received from R123. 7/20/25 11:30 AM - A statement written by E12 (LPN) documented, At 10:45 AM I counted .however the six [purple tablets] were missing. I recognized the discrepancy. Nursing supervisor [E9 (RN)] was immediately made aware, and she immediately made E2 (former DON) aware. 8/7/25 - E2 (former DON) submitted an incident report to the state agency that alleged [R123] bought in home medications upon admission .six purple pills noted on count sheet. It was noted that the six purple pills were missing. 8/20/25 1:38 PM - During an interview, E11 (CNO) stated We implemented a new medication from home sheet for counting medications from home. They are counted then placed into the cart until the DON takes possession, then they are counted again and placed in the locked drawer in the DON office. E11 stated that E2 (former DON) was interviewed regarding the six missing tablets and that E2 reported she may have left the keys on her desk at times. 8/20/25 2:01 PM - During an interview, E24 (RN) confirmed that R123 bought in six purple pills to the facility. E24 stated, E23 (RN) asked me to be a witness. R123 had multiple bottles of medications. After a few days we got tired of counting them and we gave them to [E2 (former DON)]. 8/21/25 11:45 AM - During an interview, E2 (former DON) denied knowledge of the whereabouts of the missing six purple pills. E2 stated, The staff bought me meds in a Ziplock bag inside was pill bottles and said that her family would pick them up. I put them in my drawer and locked them up. I never counted them. Later the staff said they [R123's family] wanted them and came in on a Saturday to get them but they didn't get them. At no time did I touch the pills, open them, or count them I just locked them in my office drawer. When [E12 (LPN)] returned them, she said there was some purple pills missing. I asked [E12] for a statement. She did verbally tell me there were purple pills in the bottle and they were not there at that point. Everyone has access to my office. My keys are always in my top desk drawer so anyone can go in. So, what happened to the pills I have no clue. The six purple pills bought to the facility from home by R123 were stored by the facility. The facility was unable to safely secure the medications as evidenced by the medications were unable to be located as of 7/20/25. 1b. 7/13/25 - A controlled substance record was created for R123 by E24 (RN) who hand wrote Morphine 30 mg six purple pills were received from R123. 8/20/25 1:45 PM - During an interview, E12 (LPN) confirmed visualizing the medications accepted and stored by the facility from R123 and that the six purple pills were unlabeled. E12 stated, There were three bottles of Percocet, and one bottle had six morphine mixed in with the Percocet. When asked how staff identified the six purple pills, E12 stated, By visually identifying and at the time she was on the same medication from the pharmacy, same color and size. 8/20/2025 2:01 PM - During an interview, E24 (RN) confirmed the facility accepted and stored unlabeled medications from R123. E24 stated, I believe it was all labeled oxy but [R123] had a card of morphine from our pharmacy, and we visually matched the six purple pills and they were an identical match when we looked at them. 8/20/25 2:26 PM - During an interview, E11 (CNO) confirmed the facility accepted and stored unlabeled medications from R123. E11 stated, we can't assume what they [the medications] are but we can't get rid of them because they are the residents property. 8/21/25 11:32 AM - During an interview, E25 (LPN) confirmed the facility received and stored six purple pills from R123. E25 stated, There were six purple pills mixed in with the bottle of oxycodone. We took them for safety; we counted the medications in front of [R123]. When asked how staff determined what the six purple pills were due to the bottle being unlabeled E25 stated, [R123] was cooperative and telling us what the medication was. The facility accepted and stored unidentifiable/unlabeled medication as evidenced by the acceptance of six purple pills not in their original container received from R123. 2. 8/19/25 10:48 AM - During inspection of a [NAME] unit medication cart, one opened bottle of aspirin, and one opened bottle of Colace were observed without open dates. E21 (LPN) immediately confirmed the finding. 8/19/25 12:27 PM - During inspection of a [NAME] unit medication cart, one opened bottle of aspirin, and one open bottle of Tylenol were observed without open dates. E16 (LPN) immediately confirmed the finding. 8/19/25 3:03 PM - During inspection of a Rehoboth unit medication cart, an unused Humalog insulin pen was observed in a medication cart. The pharmacy labeled the insulin pen with manufacturer's instructions that directed the insulin pen to be refrigerated until opened. E24 (RN) immediately confirmed the finding. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.

Based on record review and interview, it was determined that for one (R106) out of one resident reviewed for lab services, the facility failed to promptly notify the ordering medical practioner of abnormal laboratory results. Findings include:Review of R106's clinical record revealed: 6/6/25 - R106 was admitted to the facility. 7/10/25 5:50 AM - A nursing progress note documented for R106 that a urine sample was collected and a dipstick resulted in positive blood and leukocytes. The nursing note further documented that a lab order to do urinalysis (UA) and culture and sensitivity (C&S) was placed, waiting to be picked up and that the NP was notified in the book. 7/10/25 12:01 PM - A physician's progress note documented that R106 complained of burning with urination, an in-house urine dipstick was positive for blood and leukocytes, and the lab picked up the urine in the morning, awaiting a culture and sensitivity. 7/12/25 1:19 PM - The lab results revealed the urine culture was positive for a urinary tract infection (UTI) with a positive growth of greater than 100,000 colony forming units of Escherichia coli (a type of bacteria). 7/12/25, 7/13/25 and 7/14/25 - The clinical record lacked evidence that R106's UTI was addressed for three days after the positive results were available. 7/15/25 11:34 AM - A physician's order was written for cefuroxime axetil (antibiotic) 500 mg, give 500mg by mouth stat for UTI. 7/15/25 9:00 PM - The medical administration record for R106 documented cefuroxime as not available. 7/16/25 9:00 AM - The medical administration record for R106 documented cefuroxime as administered. 7/16/25 9:54 AM - A nursing progress note documented for R106 that the pharmacy did not process the cefuroxime due to a resident's allergy. Two doses of cefuroxime were sent to a local pharmacy for the facility to pick up.There was an additional one day delay making it four days before the urine culture results were reviewed and R106 received antibiotics. 8/22/25 10:10 AM - During an interview, E22 (LPN) stated that the outside lab urine culture results are automatically uploaded into a resident's chart, and staff need to be aware to keep checking the chart for the results. When the results appear in the chart, they notify the provider. 8/22/25 10:15 AM - During an interview, E18 (LPN) stated that the outside lab will call the facility for a positive lab result and during weekend hours, the facility will contact the on-call provider. 8/25/25 11:23 AM - During an interview, E23 (UM) stated that the outside lab urine culture results are uploaded to the resident's charts. The outside lab generally does not call for positive urine culture results. E23 confirmed that there was a delay in notifying the provider about the culture results for R106. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.

Based on observation, interview and record review it was determined for one (R37) out of two residents sampled for care plans the facility failed to develop and implement a comprehensive person-centered care plan to address R37's refusal to wear a splint/brace for right hand/wrist contractures. A review of R37's clinical record revealed: 1/2/24 - R37 was admitted to the facility with diagnoses including but not limited to stroke and right-side weakness. 1/3/24 - A review of R37's orders documented splint/brace/device see RNP task for details. 10/8/24 - A review of R37's care plan for actual contractures and potential for further contractures related to decreased mobility, right spastic hemiplegia (stiff muscles and poor motor control) following stroke revealed the intervention resting right hand splint initiated 2/19/24. Review of R37's care plan lacked evidence of the resident refusing to wear the splint. 8/20/25 9:53 AM - E19 (CNA) was interviewed and reported R37 had weakness to the right arm but had never seen or known R37 to have a worn a splint. 8/20/25 2:00 PM - During an interview E18 (LPN) reported and stated, [R37] does not wear the splint [R37] always refuses to wear the splint. In addition, E18 confirmed R37 had not been care planned for refusing to wear the splint. 8/25/25 2:10 PM - Findings were reviewed with E1 (NHA), E10 (COO) and E11 (CNO) during the exit conference.

Based on observation, interview, and record review, it was determined that for one (R15) out of one resident reviewed for abuse, the facility failed to protect residents by not suspending the accused staff member pending the outcome of the investigation. Findings include: A facility policy titled Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, .Allegations of resident abuse shall be reported to the appropriate state regulatory authority within two hours .the named person accused of the act will be immediately suspended pending outcome of the investigation . Review of R15's record revealed: 5/16/25 at approximately 9:10 PM - A facility investigation documented that E8 (CNA) informed E11 (LPN, supervisor) that E10 (CNA) had pushed R15. E11 instructed E8 to write a statement and place it under the DON's door. 5/17/25 - The facility provided investigation packet documented the following: a statement written by E10 accused, wrote the accusation of rough is untrue. statement written by E18 (RN part time supervisor) wrote R15 was thoroughly checked by from head to toe and there were no bruising/skin issues noted. statement written by E11 wrote that at the time of the incident she was providing care to a resident on another unit and remembers E8 telling her about the allegation. Interviews and skin checks performed on R15 and the other residents that were assigned to E10 the evening prior by E2. No issues or concerns were noted. 5/30/25 - at approximately 2:00 PM - During a telephone interview, E11 confirmed the accused was not immediately suspended pending outcome of the investigation. 5/30/25 9:10 AM - During an interview, E2 (DON) stated she was made aware of the incident the following day and went to the facility to conduct an investigation about the allegation of abuse. E2 stated I completed the investigation, E10 wasn't suspended because it was determined there was no abuse. E10 was allowed to continue to work his scheduled shifts providing resident care the remainder of the shift on 5/16/25 following the allegation without suspension and continues to work at the facility. 6/2/25 2:45 PM - Findings were reviewed with E1 (NHA), E2, E3 (CNO), and E4 (COO) during the exit conference.

Based on interview and record review, it was determined that the facility failed to report an allegation of abuse to the state agency for one of one resident (R15) reviewed for abuse. Findings include: A facility policy titled Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, .Allegations of resident abuse shall be reported to the appropriate state regulatory authority within two hours .the named person accused of the act will be immediately suspended pending outcome of the investigation . Review of R15's clinical record revealed: 1/15/25 - R15 was admitted to the facility with diagnoses including Alzheimer's disease and Dementia with unspecified severity of behavioral disturbance. 1/21/25 - An admission MDS documented a BIMS score of 00, indicating R15 was severely cognitively impaired. 5/16/25 at approximately 9:10 PM - A facility investigation documented that E8 (CNA) informed E11 (LPN, supervisor) that E10 (CNA) had pushed R15. E11 instructed E8 to write a statement and place it under the DON's door. 5/29/25 1:55 PM - During a telephone interview, E8 stated she saw E10 in the doorway between two units. E8 reported that R15, who wears a wander guard bracelet and frequently sets off the alarmed door, was grabbed by E10, turned around, and pushed. 5/30/25 8:50 AM - During a telephone interview, E9 (CNA) stated she witnessed E10 push R15 away from the door. E9 wrote a statement and was also told by E11 to place it under the DON's door. 5/30/25 9:05 AM - During an interview, E7 (RN/UM) stated she was on call on 5/17/25. Upon arriving at the facility, she was informed of the incident by E8. E7 notified E2 (DON), who arrived at the facility at approximately 3:00 PM and began an investigation. 5/30/25 9:10 AM - During an interview, E2 (DON) stated she became aware of the incident the previous evening and came to the facility the next day (Saturday) to investigate. E2 stated, I didn't know it wasn't reported. 5/30/25 approximately 2:00 PM - During a telephone interview, E11 confirmed that E8 had reported the allegation to her and that she instructed E8 to write a statement and leave it under the DON's door. E11 acknowledged she had not read the statement and did not report the allegation to the state agency. E11 further confirmed that the accused staff member was allowed to continue working on the unit. 5/30/25 3:02 PM - During an interview, E10 (CNA) stated he was sitting between the units and continually redirecting R15. E10 stated, I didn't push him. I was trying to re-direct him away from the door. There was no evidence the facility reported R15's allegation of abuse. 6/2/25 2:45 PM - Findings were reviewed with E1 (NHA), E2, E3 (CNO), and E4 (COO) during the exit conference.

Based on observation, interview, document review, and policy review, the facility failed to develop and implement infection control protocols for 1. failed to ensure COVID19 infection control processes were followed by facility staff within a secured unit and soiled PPE was not kept out of reach for resident (Resident (R) 89); and 2. infection control was maintained during wound care for R104. These failures had the potential to affect all 116 residents in the facility. Findings include: Review of the facility's policy titled, COVID-19, initiated March 23, 2020, and last revised October 19, 2022, revealed The DON and the Infection Control Preventionist (IP) will conduct monitoring and surveillance in the facility for early detection and recognition of potential outbreaks of Coronavirus including all respiratory infections. 1. During an observation on 09/16/24 at 9:40 AM, a sign was posted on the outside of the secured 300-unit doors, near the main dining room. An isolation cart was placed in front of the door as a donning station. The sign documented, Stop. Everyone in our facility must follow these precautions .Contact Precautions. Everyone must wash their hands, including before entering the room and when exiting the room. Providers and staff must also put on gloves before entering the room and discard gloves when exiting the room .must put on a gown before entering the room and discard the gown before exiting the room .must use dedicated or disposable equipment, and they must clean and disinfect reusable equipment before use on another person. Droplet Precautions. Everyone must wash their hands, including before entering the room and when exiting the room. Everyone must make sure their eyes, nose and mouth are full covered before entering the room and remove face protection before exiting the room. The same sign was posted on the second entrance doors to the secured 300-unit off of the 200-unit hallway. Both isolation carts contained gowns, gloves, and masks. Neither station stocked eye protection. During an interview on 09/16/24 at 9:43 AM, Activity Aide (AA) stated that a staff member who worked on the secured 300 unit had tested positive for COVID on 09/14/24. She said that the secured 300 unit was now on precautionary isolation. Both entrances to this unit had donning PPE (Personal Protective Equipment) carts outside the doors to the unit. AA said that all staff were required to wear full PPE when entering the secured unit, which included a gown, face shield, N95 mask, and gloves. She said residents had been tested on [DATE] and were negative. During an interview on 09/16/24 at 12:55 PM, the Infection Preventionist (IP) stated that two staff tested positive the prior week. She said they were now testing residents on the secured 300-unit, and no one was symptomatic. She said they had placed the residents in the secured unit on quarantine. The doffing station was posted on the inside doors to the secured 300-unit. There were two doffing bins, one for reusable gowns and one for disposable gowns and gloves. Neither bin had a lid to prevent easy access to residents on the secure unit. There were no sanitizing wipes to clean off eye protection, nor a place to store the eye equipment. IP confirmed there was no established cleaning and storing process for eye protection after doffing PPE. She confirmed there was no easily accessible hand sanitizer at the doffing station after doffing PPE. During an observation on 09/17/24 at 12:15 PM, the isolation cart for the secured 300-unit off of the 200-unit hallway contained no eye protection. On 09/17/24 at 12:17 PM, the isolation cart for the main secured 300-unit contained one pair of goggles. During an observation on 09/18/24 at 11:15 AM on the secured 300-unit, the main entrance isolation cart had no eye protection present. Central Supply (CS) was observed bringing newly washed reusable gowns to the isolation cart. CS confirmed there was no eye protection face shields or goggles present in the cart. She knocked on the door to the secured 300-unit and requested eye protection from LPN1, working in the unit. LPN1, observed only wearing prescription glasses, handed a pair of goggles to CS. LPN1 said she was not wearing goggles because she was working on the medication cart, and not near the residents. LPN1 said the nursing staff on the secured 300-unit were still figuring the PPE requirements out. Staff were observed not wearing gloves on the unit. On 09/18/24 at 11:35 AM, Resident (R) 89 was observed ambulating down the secured 300-unit hallway, to the exit, connected to the 200 hallway. She was observed pulling doffed gowns out of the doffing bins (no lids) with bare hands. AA was observed redirecting the resident away from the open bins, removing the gowns from her hands, and returning them to the bin. The resident was escorted back down the hallway without hand sanitizing. AA confirmed that the facility did not put lids on the doffing bins, and she had to redirect the resident after touching the gowns. During an observation on 09/18/24 at 12:58 PM, two meal carts were observed pushed out of the secured unit after lunch by dietary staff. The meal carts were not cleaned prior to exiting the unit. During an observation on 09/18/24 at 1:15 PM, the laundry cart was observed pushed out of the secured unit by laundry staff. The cart was not cleaned prior to exiting the unit. The laundry staff were observed wearing eye protection off of the unit without cleaning or removing them. During an observation on 09/19/24 at 8:00 AM, no eye protection was found in either isolation cart. During an interview and observation on 09/19/24 at 12:00 PM with the IP, she confirmed that the isolation carts should always have eye protection, and staff were to wear them on the unit. She confirmed there was no doffing station to clean or store eye protection. The IP said that the doffing bins were supposed to have lids on them, and was surprised none of them had any. She confirmed all staff should be following both droplet and contact PPE precautions according to the posted sign on the doors. She stated that the signs could be confusing, and that the signs did not specify gloves to only be worn while providing cares and touching food. She said that she was not sure what the correct process should be for meal carts and laundry carts that would come on and off the units, as it had not been discussed. During an interview on 09/19/24 at 1:41 PM, the Staff Development Coordinator (SDC) said the isolation carts would be set up by IP, and stocked by CS. She said that if a cart was empty or missing PPE, the supervisors could restock items. She said the carts should always have gowns, N95 masks, hand sanitizer, eye gear, and regular surgical masks for visitors. She stated that when staff doff inside the secured unit, they were educated to take off their gloves, they take off their gown to dispose of in the correct bin, then hand sanitize. She said staff should doff and clean the eye protection. Doffing bins should have lids on them, especially for wandering residents. She confirmed that laundry bins and meal carts should be wiped down on the outside before leaving the secured unit. 32513 2. Review of the Admission Record located in the Profile tab of the EMR revealed R104 was admitted to the facility on [DATE] with a diagnosis of a stroke and a sacral pressure ulcer. Review of R104's admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/07/24 revealed R104 had a staff assessed Brief Interview of Mental Status (BIMS) which indicated R104 was severely impaired in cognition. The assessment further revealed that R104 had an unstageable pressure ulcer that was present upon admission to the facility. Review of the Physician Orders located in the Orders tab of the EMR revealed, Metronidazole [an antibiotic] 500mg three times daily from 09/13/24 to 09/23/24 for wound infection. During a wound care observation on 09/18/24 at 10:15 AM, Licensed Practical Nurse (LPN) 4 donned PPE (personal protective equipment) to perform the wound care. LPN 4 removed the soiled dressing and packing from the sacrum and then removed her soiled gloves, used hand sanitizer, and donned new gloves. After LPN 4 donned new gloves, she obtained gauze and cleaned fecal material on R104's buttocks, then proceeded to clean the wound. Without removing the soiled gloves or performing hand hygiene, LPN 4 obtained the prescribed ointment, put it on her the same gloved fingers and coated the wound bed with the ointment, as prescribed, and then placed the calcium alginate into the wound bed. During the wound care, LPN 4 was asked if she had changed gloves prior to putting the ointment into the wound bed with her gloved hands. LPN 4 stated, No, I should have changed gloves after cleaning him up and before placing the santyl and calcium alginate. LPN 4 was asked if there was anything else she could have used, instead of her fingers, to apply ointment to the wound bed. LPN4 stated, Yes, I could have used Q-tips. LPN 4 finished wound care removed her soiled gloves and washed her hands. During an interview on 09/18/24 at 1:35 PM, the Director of Nursing (DON) was told about the wound care observation and was asked what her expectation was regarding providing wound care in a manner that prevents infection. The DON stated, After LPN4 had cleaned up the resident, she should have changed gloves, put on new gloves and either used a Q-tip or tongue depressor as he has a large wound.

Based on interviews and record review, the facility failed to ensure the arbitration agreement provided for the selection of a neutral arbitrator without stipulations and the selection of a venue that is convenient for three (Residents (R)11, R43, and R89) of three residents reviewed for arbitration in a total sample of 34 residents. This placed residents at risk not having the opportunity to choose an arbitrator or venue. Findings include: Review of the facility arbitration agreement, dated 01/01/24, provided by the facility in the admission packet revealed All arbitrators must be a retired state or federal court judge or a member of the state bar with at least ten (10) years of experience as an attorney. There was no mention of a venue that is convenient to both parties. 1. Review of R11's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 07/25/24, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE]. R11 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R11's cognition was intact. Review of R11's binding arbitration agreement, signed by R11 on 09/10/24, provided by the facility, revealed no mention of the selection of a venue or a neutral arbitrator. Stipulations were placed upon the arbitrator that included All arbitrators must be a retired state or federal court judge or a member of the state bar with at least ten (10) years of experience as an attorney. 2. Review of R43's significant change MDS with an ARD date of 07/25/24, located in the MDS tab of the EMR, revealed an admitted [DATE]. R43 had a BIMS score of 13 out of 15 indicating R43's cognition was intact. Review of R43's binding arbitration agreement, signed by R43 on 05/10/21, provided by the facility, revealed no mention of the selection of a venue or a neutral arbitrator. Stipulations were placed upon the arbitrator that included All arbitrators must be a retired state or federal court judge or a member of the state bar with at least ten (10) years of experience as an attorney. 3. Review of R89's admission MDS with an ARD date of 08/15/24, located in the MDS tab of the EMR, revealed an admitted [DATE]. R89 had a BIMS score of two out of 15 indicating R89's cognition was severely impaired. Review of R89's binding arbitration agreement, signed by R89's RP on 09/05/24, provided by the facility, revealed no mention of the selection of a venue or a neutral arbitrator. Stipulations were placed upon the arbitrator that included All arbitrators must be a retired state or federal court judge or a member of the state bar with at least ten (10) years of experience as an attorney. During an interview on 09/19/24 at 9:46 AM, the Admissions Coordinator (AC) was asked about the arbitration agreement. The AC stated the document was in the admission packet and she explained it with the other paperwork. When asked the AC stated she did not discuss the right to neutral arbitrator and an agreed upon venue. The AC was asked if she ever read the facility's arbitration agreement herself. The AC stated, No. During an interview on 09/19/24 at 11:22 AM, the Administrator was asked about the binding arbitration agreement and the missing components of the selection of a venue and a neutral arbitrator as well as placing stipulations on what arbitrator could be used such as all arbitrators must be a retired state or federal court judge or a member of the state bar with at least ten (10) years of experience as an attorney. The Administrator stated she would look into it. During a follow-up interview on 09/19/24 at 12:34 PM, the Administrator provided an arbitration agreement, dated 01/01/24. However, this agreement was dated and contained the same information as the agreement found in the admission packet.

Based on interviews, record review, and review of the facility arbitration agreement, the facility failed to thoroughly explain the binding arbitration agreement to residents or their representative and provide an arbitration agreement that granted the resident or their representative the right to rescind the agreement within 30 days of signing it and communicate with federal, state, local officials and the ombudsman for three (Residents (R)11, R43, and R89) of three residents reviewed for arbitration in a sample of 34. This failure denied residents the opportunity to fully understand what the agreement meant and the ability to rescind the agreement within 30 days of signing. Findings include: Review of the facility arbitration agreement, dated 01/01/24, provided by the facility in the admission packet revealed .(3) this Agreement may be rescinded by written notice sent to the other party via Certified Mail, return receipt requested, within twenty-one (21) days of the date upon which it is signed. Rescission or waiver of this Agreement can only be effected in writing. If this Agreement is not rescinded within thirty (30) days of the date upon which it is signed, it is binding upon the parties in all matters regarding care and services provided to the Resident by the Facility, regardless of subsequent discharges and readmissions. The agreement did not include the resident, or their representative may communicate with federal, state, local officials and the ombudsman. 1. Review of R11's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 07/25/24, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE]. R11 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R11's cognition was intact. Review of R11's binding arbitration agreement, provided by the facility, revealed R11's name and signature, dated 09/10/24. R11's arbitration required the agreement be rescinded by written notice sent to the other party via Certified Mail, return receipt requested, within twenty-one (21) days of the date upon which it is signed. The agreement did not include the resident, or their representative may communicate with federal, state, local officials and the ombudsman. During an interview on 09/19/24 at 9:46 AM, the Admissions Coordinator (AC) stated the document was in the admission packet and she explained it with the other paperwork. AC stated, if the resident's BIMS score was a 13 to 15, it was okay for the resident to sign it, otherwise the RP [resident representative] signed it if the resident's mental capacity isn't there. The AC stated she summed the agreement up by telling them, If they and the facility had a disagreement they [the facility] like to use an arbitrator. The AC stated if they ask about it further, she told them a third party was used but that was all she told them. The AC stated she was not aware of the 30-day time frame to rescind the agreement. On 09/19/24 at 10:29 AM, R11 was asked if she signed an arbitration agreement. R11 responded by asking what that was. The surveyor explained that it was a binding agreement that was used in case she had a dispute with the facility, and they would use an arbitrator instead of going to court. R11 stated, No [she did not sign] The document with her signature, dated 09/10/24, was shown to R11. R11 looked at the document and her signature. 2. Review of R43's significant change MDS with an ARD date of 07/25/24, located in the MDS tab of the EMR, revealed an admitted [DATE]. R43 had a BIMS score of 13 out of 15 indicating R43's cognition was intact. Review of R43's binding arbitration agreement, provided by the facility, revealed R43's name and signature, dated 05/10/21. R43's arbitration required the agreement be rescinded by written notice sent to the other party via Certified Mail, return receipt requested, within twenty-one (21) days of the date upon which it is signed. The agreement did not include the resident, or their representative may communicate with federal, state, local officials and the ombudsman. During an interview on 09/19/24 at 2:00 PM, R43 was asked about signing an arbitration agreement. R43 was shown the 05/10/21 arbitration agreement. R43 confirmed he signed it, but stated it was not explained to him so that he understood what he was signing. 3. Review of R89's admission MDS with an ARD date of 08/15/24, located in the MDS tab of the EMR, revealed an admitted [DATE]. R89 had a BIMS score of two out of 15 indicating R89's cognition was severely impaired and had diagnoses of dementia, osteoporosis, and hypokalemia, and received hospice care. Review of R89's binding arbitration agreement, provided by the facility, revealed R89's name and signature, dated 09/04/24. R89's arbitration required the agreement be rescinded by written notice sent to the other party via Certified Mail, return receipt requested, within twenty-one (21) days of the date upon which it is signed. The agreement did not include the resident, or their representative may communicate with federal, state, local officials and the ombudsman. During an interview on 09/19/24 at 11:22 AM, the Administrator was asked. about the missing components such as communicating to federal, state, local officials and the ombudsman in the agreement, the 21- days verses the 30-days rescinding timeframes, and the AC's limited explanation and failing to inform residents and their RP the agreement was binding. During a follow-up interview on 09/19/24 at 12:34 PM, the Administrator provided an updated arbitration agreement, dated 01/01/24, that contained the same information as the agreement found in the admission packet.

Based on observation, interview, record review, and review of the facility's resident rights, the facility failed to ensure 1. residents were provided a homelike environment during meals for eight of eight residents (Resident (R) 46, R8, R25, R32, R36, R83, R111, R32, and R168) during dining; 2. privacy bags covered urinary catheter bags for R51; 3. and privacy with shower schedules was maintained. This failure placed the residents at risk of an undignified dining experience. Findings include: Review of the facility's Resident Rights, dated 06/01/24 revealed To promote the interest and well-being of the residents in long-term care facilities, all facilities must treat residents in accordance with the following resident rights: (1) Each resident shall have the right to receive considerate, respectful .services .recognizing each person's basic personal .which include dignity and individuality . 1. Residents were not served meals in a homelike environment. a. Review of R46's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included metabolic encephalopathy and unspecified dementia. Review of R46's Medicare 5- Day Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/21/24 revealed a Brief Interview for Mental Status (BIMS) could not be completed as the resident was rarely/never understood. The facility assessed the resident to have short and long-term memory problems and assessed the resident to be moderately cognitively impaired in skill for daily decision making. b. Review of R8's undated Admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included Bell's Palsy and Parkinson's Disease. Review of R8's quarterly MDS with an ARD of 07/24/24 located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired. c. Review of R25's undated Admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included vascular dementia. Review of R25's quarter MDS with an ARD of 07/17/24 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of eight out of 15 which indicated the resident was moderately cognitively impaired. d. Review of R32's undated Admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit. Review of R32's quarterly MDS with an ARD of 07/17/24 and located in the resident's 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. e. Review of R36's undated Admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit. Review of R36's significant change in status MDS with an ARD of 07/16/24 revealed the facility assessed the resident to have a BIMS score of zero out of 15 which indicated the resident was severely cognitively impaired. f. Review of R83's undated Admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia. Review of R83's admission MDS with an ARD of 08/01/24 and located in the resident's EMR under the Profile tab revealed a BIMS could not be completed on the resident as the resident was rarely or never understood. Staff assessed the resident to have short and long term memory problems, and the resident was severely cognitively impaired in skills for daily decision making. g. Review of R111's undated Admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia. Review of R111's admission MDS with an ARD of 09/01/24 located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired. Observation on 09/16/24 at 12:53 PM, of the lunch meal in the [NAME] dining room revealed the above seven residents in the dining room eating their lunch meal. Continued observation revealed all seven residents' meals were served on the dining room tables with the plates left on the plate warmer bottoms and the plate warmers/plates left on the serving trays. The residents' desert of emerald pear gelatin was in a round Styrofoam container and not on a regular dish. During an interview on 09/16/24 at 1:15 PM, Certified Nurse Aide (CNA) 3 stated residents' lunch meal should not have been left on the serving trays and plate warmer bottoms. CNA3 also stated the residents' desert should not have been served to them in a Styrofoam container. When asked why the residents should not have been served their meal this way, CNA3 stated it was not homelike and she would not want to eat off of a serving tray at her home. h. Review of R32's Admission Record, located under the Profile tab in the electronic medical record (EMR) revealed R32 was admitted on [DATE] with diagnoses that included transient ischemic cerebral attack, generalized muscle weakness, and depression. Review of the quarterly MDS, with an ARD of 07/17/24, revealed a BIMS score of 11 out of 15 which indicated the resident had moderate cognitive impairment. R32 was identified on the quarterly MDS to be able to feed herself with set up assistance. Review of R32's Care Plan, revised on 07/29/24, revealed The resident has an ADL (activity of daily living) self-care performance deficit r/t (related to) limited mobility. Assist with hygiene, grooming, toileting, dressing, oral care, and eating as needed. During an observation, on 09/16/24 at 12:19 PM, of the assisted dining located in the activity room, R32 was waiting to be served lunch. At 1:10 PM, The lunch meal was served to R32 on the meal tray and with the bottom insulator left under the plate. Towels were placed R32's neck as a clothing protector. On 09/16/24 at 1:20 PM, CNA4 was seated between two residents, with her back to R32. During the meal, R32 was observed to hold both hands up, chest high, fingers apart. No staff came to assist R32. During an observation on 09/17/24 at 12:41 PM, R32 was served lunch by the Assistant Director of Nurses (ADON). The ADON left the bottom half of the insulator under the plate. R32 was observed to have her hands held up, out in front of her. R32 started to ask CNA5 a question, CNA5 stated You want a napkin, I'll get it. R32 was provided with a paper towel. During an observation, on 09/18/24 at 1:23 PM, R32 was seated at the table, with her hands in the air in front of her. R32 had a napkin in her left hand. When asked why she held her hands up, R32 stated I like to have my hands clean. See my nails, they look dirty. The resident's index finger was observed to have dirt under the nail. When asked if she was offered a washcloth before or after meals to clean her hands, R32 stated, I would like that very much. I don't get that. You have to ask. When asked if she was routinely offered a washcloth or hand wipe before or after meals, R32 said, No. During an interview, 09/18/24 at 1:30 PM, CNA5 stated, She always does that with her hands. She always wants a napkin. When asked if the resident is offered a washcloth or hand wipe before or after meals, CNA5 stated, No we don't do that, we always wash their hands when we get them up. During an interview, on 09/19/24 at 9:03 AM, CNA3 stated, She just does that, that's her. During an interview, on 09/19/24 at 9:04 AM, R32 was asked about holding her hands up and stated, I like to have my hands clean, but I have to ask, I don't get a washcloth at meals. i. Review of R168's Admission Record, located in the EMR under the Profile tab, revealed an initial admitted [DATE] and readmission of 02/07/24 with diagnoses that included major depressive disorder, recurrent; obsessive compulsive disorder; and adult failure to thrive. Review of R168's significant change MDS, with an Assessment Reference Date (ARD) of 08/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R168 had moderate cognitive impairment. On 09/16/24 at 12:56 PM, R168 was observed in her room, sitting in a chair in her room, eating lunch. The only utensil present was a spoon. Review of R168's care plan, updated 02/08/24, located under the RAI tab in the EMR, revealed [R168] has a safety hazard to self as evidenced by recent suicidal thoughts and attempt; resident readmitted after stay at psychiatric facility. [R168] will remain safe in her own environment and will verbalize any feelings or thoughts about harming herself to staff immediately. Allow [R168] to vent her feelings and encourage her to talk about her concerns and thoughts. Encourage [R168] to participate in activities of choice. Medications as ordered, report effectiveness, SE [side effects], or adverse reactions. Provide [R168] with finger foods, and not giving her utensils until evaluated by IDT [Interdisciplinary Team]. During an interview on 09/19/24 at 12:02 PM, the Social Service Director (SSD) said she was not aware of the care plan that specified finger foods only. During an interview, on 09/19/24 at 1:04 PM, R168 stated, I don't get finger foods, what is that? I only get a spoon to eat with. I keep asking for the rest, a knife and fork. some foods are hard to eat with a spoon. I'm fine, I can have silverware. Review of a list of finger food meals, provided by the Dietary Manager (DM), revealed three names on the list, and did not include R168. During an interview, on 09/19/24 at 3:15 PM, the Administrator stated, the care plan needs to be updated to the current treatment provided, the accuracy of type of diet and utensils provided. During an interview on 09/19/24 at 12:12 PM, the Social Service Director (SSD) stated she hated the way it looked when residents were served their meal on trays. The SSD also stated it was not a dignified meal nor was it a homelike environment. During an interview, on 09/19/24 at 12:30 PM, the Administrator said they had no policy on dignity or dignity and dining. The Administrator stated, We will have to educate the staff. We've had the placemats, I purchased them, they know not to leave trays under the meals or insulators under the plate. We will need to educate to wash hands before and after meals not just when getting them up. During an interview on 09/19/24 at 1:33 PM, Registered Nurse (RN) 2, who was the [NAME] Unit Manager, stated the CNAs were well aware they should not be leaving the meal on the trays. During an interview on 09/19/24 at 2:15 PM, the Administrator stated it was her expectation the residents' lunch meal would have been served in a homelike environment. 36190 2. Review of R51's quarterly MDS with an ARD date of 06/19/24, located in the MDS tab of the EMR, revealed an admitted [DATE]. R51 had a BIMS score of four out of 15 indicating R51's cognition was severely impaired and had diagnoses of Alzheimer's disease, dementia, and a neurogenic bladder, and had an indwelling catheter. Review of R51's care plan, revised 11/09/23, located in the EMR under the Care Plan tab revealed The resident has Indwelling Catheter: Neurogenic bladder. An intervention included Catheter care as ordered. Review of R51's order, dated 11/09/23, located in the EMR under the Order tab revealed Catheter Care q [every] shift, every shift. On 09/16/24 at 10:21 AM, R51 was asleep in bed wearing a hospital gown and a catheter drainage bag half full of urine hanging from the bedframe. R51's door was open and the urine in the bag was visible from the hall. One of the entrances and exits to the unit was in proximity and visitors were observed passing by R51's room. On 09/17/24 at 11:34 AM, R51 was asleep in bed wearing a hospital gown and a catheter drainage bag half full of urine hanging from the bedframe. R51's door was open and the urine in the bag was visible from the hall. One of the entrances and exits to the unit was in proximity and visitors were observed passing by R51's room. On 09/18/24 at 12:17 PM, R51 was awake in bed with his lunch tray and a catheter drainage bag hanging on the bedframe. The bag contained urine that was visible from the hallway. R51 was asked about his care and R51 had no response. During an interview on 09/18/24 at 12:31 PM, Licensed Practical Nurse (LPN)1 was asked about R51's catheter drainage bag with urine visible from the hall and entrance and exits door nearby where visitors could observe. LPN1 stated she thought privacy bags were only when residents left their room. LPN1 stated when she came to the facility to work, this facility required staff to use privacy bags. LPN1 confirmed the CNA should have used a privacy bag for R51. At this time LPN1 turned the urine side of the bag to the private side of the bag, making it not visible anymore. During an interview on 09/19/24 at 7:21 AM, the Director of Nurse (DON) was asked about R51's urine being visible in the catheter drainage bag from the hall. The DON stated staff should be using a Fig Leaf urinary drain bag that hides R51's urine from view. 26446 3. During an observation on 09/16/24 at 9:33 AM, a large whiteboard was observed near the nurse station on the 200 hallway in the common area. Written on the whiteboard for September 15, 2024, was a list of staff and room assignments. On the whiteboard Showers was documented with a list of the residents assigned to receive showers on that date. Staff had documented done and refused next to individual resident beds. An additional note written on the whiteboard documented PS Check Behaviors Books before end of shift. During an interview on 09/19/24 at 2:26 PM, the Administrator stated that showers should be recorded in the resident record, and documenting refused was not appropriate to be written in a common area.

Based on interview, record review, and review of the facility's resident rights, the facility failed to honor a resident's right to 1. choose their preferred method of transferring for one of 34 sampled residents (Resident (R) 43) and 2. choose to go outside for one of 34 sampled residents (R42). This failure placed the residents at risk for psychosocial harm by diminishing their independence. Findings include: Review of the facility's Resident Rights, dated 06/01/24 revealed To promote the interest and well-being of the residents in long-term care facilities, all facilities must treat residents in accordance with the following resident rights: .(6) Each resident may refuse medication or treatment and must be informed of the medical consequences of all medication and treatment alternatives .(21) Each resident has the right, personally, through other persons, or in combination with others to do any of the following: a. Exercise the resident's own rights .(31) Each resident shall be free to make choices regarding activities, schedules, health care, and other aspects of the resident's life that are significant to the resident . 1. Review of R43's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acquired absence (amputation) of right and left leg below the knee. The Admission Record identified R43 as being his own responsible party. Review of R43's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/24 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The facility also assessed the resident to need partial/moderate assistance for transferring to and from a bed to a chair. Review of R43's Care Plan revised 09/09/22, located in the resident's EMR under the Care Plan tab revealed a problem of [Resident's Name] has an ADL self-care performance deficit r/t [related to] balance concerns with a goal of The resident will maintain current level of function through the review date and interventions which included Assist with bed mobility and transfers per orders .Hoyer lift . Encourage the resident to participate to the fullest extent possible with each interaction . Review of R43's care conference Progress Note, dated 05/29/24 and located in the resident's EMR under the Progress Notes tab revealed [Resident Name] .does not want to use a hoyer lift [mechanical lift], and that is the recommendation for safety to transfer himself . During an interview on 09/16/24 at 11:29 AM, R43 stated he was scared to use a mechanical lift for transfers and the facility would not assist him with transfers any other way. R43 stated he had a family member bring him a transfer board, so he did not have to use the mechanical lift. During an interview on 09/18/24 at 10:00 AM, the Certified Occupational Therapy Assistant (COTA) stated he remembered when R43 got his own transfer board because he did not want to use the mechanical lift and would use the board to transfer himself from the bed and not use the mechanical lift. The COTA also stated R43 had been noncompliant with therapy's recommendations and safety measures and in May of 2024, the facility removed his transfer board from his room for safety reasons. The COTA further stated R43 had not been assessed for any other transfer devices including the slide board because it was not safe for him to use on his own. The COTA stated therapy was resident driven; however, it was the facility's protocol for residents not to independently use the boards. During an interview on 09/18/24 at 10:41 AM, the Director of Nursing (DON) stated if the therapy department assessed R43 for the use of the transfer board and determined it to be an unsafe practice and the resident was educated on why it was unsafe, then his decision to use the transfer board instead of the mechanical lift should be honored. During an interview on 09/19/24 at 11:55 AM, the Social Service Director (SSD) stated R43 was set in his ways and she believed the mechanical lift issue came from fear. The SSD also stated during discussions about the resident refusing to use the mechanical lift, she voiced R43 had the right to make the decision not to use the mechanical lift even if it was a bad decision. The SSD further stated R43 was able to understand the risks versus the benefits. During an interview on 09/19/24 at 1:08 PM, Registered Nurse (RN) 2 stated therapy directed R43's transfer status and nursing could not do anything against what therapy determined the resident's transfer status to be. RN2 stated nursing staff were directed they could not assist the resident with transfers unless it was using the mechanical lift. During an interview on 09/19/24 at 1:57 PM, the Administrator stated residents were allowed to exercise their right of self-determination. The Administrator also stated the resident's choice should have been honored. 2. Review of R42's Admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R42 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included depression. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/24, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R42 was cognitively intact. Review of R42's Care Plan, updated 07/31/24, located under the Resident Assessment Instrument (RAI) tab revealed R42 had a Care Plan, dated 07/31/24, for (R42) is independent for meeting emotional, intellectual, physical, and social needs. She has little interest or pleasure in doing things. (R42) will engage self in independent activities as she chooses by next review. Activities will provide one on one room visits when (R42) does not attend activities or do independent leisure activities. During an interview, on 09/16/24 at 11:18 AM, R42 said she did not attend the group activities, she liked to be in her room or outside. During an interview on 09/16/24 at 12:54 PM, R42 stated, It was the best when I had therapy, and the therapist took me outside. We even walked by my window so I could look in. During an interview on 09/16/24 at 3:55 PM, R42 stated I really could use a Diet Pepsi. I'd like to go sit on the deck and drink it, get some vitamin D. R42 denied having opportunities to sit outside stating, I just look out my window. During an interview on 09/18/24 at 12:45 PM, R42 stated, They really have stupid rules around here. CNA's [certified nursing assistants] can only have 10 minutes outside with me. Sometimes Activities would go with, but not for a long time. They say I can't go out alone, you have to have a key card to get out and in. There is one CNA [CNA5] that is very good at everything. She will get me my Diet Pepsi and sit with me after her shift, for 10 minutes, if she has time sometimes. During an interview on 09/19/24 at 8:55 AM, three staff members were asked if R42 was permitted to go outside on the deck. All three, CNA3, CNA4, and CNA6, said No, in unison. When asked, Why, CNA6 stated, They can't go out without supervision, we don't have time. During an interview on 09/19/24 at 11:37 AM, the Activity Coordinator/Temporary Activity Director (AD) stated, R42 has a right to go outside. Yes, the door is locked. Activities generally takes the lead on that. I'm sure the prior AD took her out. I will take [R42] out, we can do that during our one-to-ones. During an interview on 09/19/24 at 12:50 PM, R42 stated, I like the back deck. I'd like to go outside again. I don't know what they think that I'm going to jump off? During an interview, on 09/19/24 at 1:45 PM, the Administrator said, The resident can go outside, she may need supervision. We will have to educate the staff.

Based on interview, record review and review of other facility documentation, it was determined that for two (R1 and R2) out of two residents reviewed for abuse, the facility failed to ensure the protection of all residents from alleged sexual abuse. The facility's failure placed all residents at risk for a serious adverse outcome, by not immediately protecting the resident and allowing the CNA to continue providing care for other residents. An IJ was identified on 6/17/24 and due to the facility's corrective measures this is being cited as past non-compliance with a compliance date 6/14/24. Findings include: A facility policy titled Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and reasonable Suspicions of Crime revision date 1/12/23 included it is the policy of Cadia Healthcare to protect residents and prevent occupancies of abuse . all alleged incidents abuse .shall be reported to the NHA or designee immediately . the accused . will be immediately suspended .allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours of the allegation. 1. Review of R1's clinical record revealed: 7/5/22 - R1 was admitted to the facility with a diagnosis of dementia with severe cognitive impairment. 6/10/24 - A witness statement documented between 6:00 - 6:30 PM, E8 (CNA) heard R1 screaming, E8 knocked on the door and asked E9 (agency CNA) if everything was ok? E9 responded everything was ok. E8 entered the room and saw R1 crying and the resident said, rape, E8 immediately reported this to E4 (LPN). 2. Review of R2's clinical record revealed: 3/11/24 - R2 was admitted to the facility with a diagnosis of Alzheimer's disease, unspecified, and dementia with severe cognitive impairment. 6/10/24 - A witness statement documented at 8:00 PM E9 (agency CNA) went to put R2 to bed. E10 (CNA) heard R2 screaming, re-entered the room and brought R2 into the hallway. R2 was saying he raped me. 6/11/24 3:15 PM - A nurse practitioner progress note documented R1 and R2 were assessed around 8:40 AM as a result of the allegations of abuse and no signs of trauma, bruising, swelling or injury were noted. Staff interviews conducted from 6/17/24 through 6/18/24: 6/17/24 11:32 AM - During an interview, E5 (RN, supervisor) stated that she had taken report from E4 on 6/10/24 who never mentioned the abuse allegation. It was sometime after 8:00 PM E1 (CNA) approached her and told her of the first allegation and now there was a second allegation made by R2. E5 confirmed that she immediately notified the NHA, DON, and the State police. E9 was removed from the facility. 6/17/24 4:10 PM - During an interview, E8 confirmed that she had reported the allegation of abuse to E4 immediately and around 8:00 PM that R2 alleged abuse. E8 stated I was wondering why [E9] was still on the floor, then [R2] was yelling and saying he raped me and that's when I went to [E5]. 6/18/24 10:00 AM - During an interview, E7 (LPN, UM) stated she was at home on 6/10/24 when she received a phone call from E2 (DON) notifying her of the abuse allegations made by R1 and R2. E7 reported both allegations to the State agency and confirmed this was reported later than the two hours required for an allegation of abuse. 6/18/24 11:16 AM - During a telephone interview, E4 (LPN) confirmed between 6:00-6:30 PM E8 had reported the abuse allegation. E4 stated R1 was assessed and found no redness or bleeding in the peri area. E4 further confirmed that it was not passed on in report to oncoming nurse. E4 stated, I own this, I know I should have reported it. 6/18/24 10:09 AM - 10:42 AM - The following residents were interviewed to determine any other possible allegations of abuse: R3, R4, R5, R6, R7, R8, R9, and R10 all expressed that they had never experienced any type of abuse and felt safe residing at the facility. R1 and R2 were not interviewable and unable to answer questions appropriately. 6/18/24 10:50 AM - Staff interviews were conducted and all reported they had completed the mandatory education in response to the two abuse allegations and aware of the need to immediately protect residents from an allegation of abuse. This surveyor reviewed the facility investigation package and confirmed the following corrective actions were taken: E4 was immediately suspended. After the conclusion of the facility investigation E4 was allowed to return to work and placed on a 90-day probation. E9's agency was notified that E9 will not be allowed to return to the facility. All facility staff and current agency staff completed mandatory in-service abuse training, all residents were interviewed and had a head to toe skin assessment performed. These corrective actions were completed on 6/14/24. In addition, the facility identified the root cause analysis as E4 failed to report an allegation of abuse to nursing management. 6/18/24 12:55 PM Findings were reviewed with E1 (NHA), E2 and E3 (Corporate nurse).

Based on record review, observation and interview it was determined that the facility failed to provide pain management care according to professional standard of practice for two (R105 and R42) out of 6 residents reviewed for pain management. R105 sustained harm when the facility continued to medicate R105 with an ineffective pain medication for approximately 15 hours before requesting a change in the medication order. Findings include: April 2002 - The pain management standards by the American Geriatrics Society included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management. 2012 - FDA recommendation of maximum [MEDICATION NAME] (Tylenol) dosage to prevent liver damage: a maximum daily dose for adults of 3 grams, with no more than 650 mg every 6 hours, as needed. Cross refer F580 1. Review of R105's clinical record and facility documents revealed: 4/5/18 Facility Event Report (closed 4/13/18): - E2 (DON) wrote: R105 was admitted to Renaissance on 4/15/15 for long-term care. On 1/22/18 she was transferred to our Dementia unit related to her marked increase in confusion related to her Dementia. She recently had Hospice services added after her decline. On 4/5/18 during the 11 PM -7 AM shift, she verbalized discomfort to her right hip. Interventions: She was assessed by the nurse and medicated. She was assessed by the Nurse Practitioner and an order for [REDACTED]. She is receiving [MEDICATION NAME] for her discomfort. Unknown etiology of fracture. ? Osteopenia (bone loss). ? Fall . - E32 (RN Supervisor) wrote: On 4/4/18 R105 was seen self-propelling in hallway. Last rounds approximately 9:30 PM resident showed no signs of pain. - E30 (CNA) wrote: I worked 3:00 PM to 7:00 AM on 4/4/18 into 4/5/18. I did not have R105 on the 3:00 PM to 11:00 PM portion of my shift. I did rounds on her at 11:30 PM, and noticed her laying facing the window. When I changed her she began to roll to her back and she began to yell out in pain. I asked her what hurt. She was holding her right hip. I went and told the nurse. Everytime I changed her she complained about pain. I have patient on 11:00 PM - 7:00 AM often; she always complains about some general discomfort, but last night was different. -E31 (LPN) wrote: On 4/5/18 approximately 4:00 AM called to (R105's) room due to resident continue to complain about pain to right hip. Upon assessment resident refused to move right leg and continue to state 'I can't, it hurt.' No discoloration noticed. Only resident favoring right leg and refused to lay anyway but on her left side with her knees bent almost in fetal position. E31 gave resident PRN [MEDICATION NAME], which was not effective. She received routine [MEDICATION NAME], which was not effective. Staff reported resident continued in pain to right side. Approximately 6:30 AM resident received PRN [MEDICATION NAME]. E31 documented and charted in the Doctor Book to have resident assessed and report it to next shift nursing staff. 4/5/18 at 4:23 AM - Review of eMAR: E31 (LPN) administered 1,000 mg of [MEDICATION NAME]. Pre (before) and post (after)pain scores were both 6, and documented not effective. 4/5/18 at 4:24 AM - Nursing Note: Resident received [MEDICATION NAME] 650 mg due to complaint of pain to right hip during care. Resident has very little range of motion, refuses to move right leg due to complaint of pain. When resident was asked to move her leg she stated I can't it hurt. Will continue to monitor. 4/5/18 at 6:00 AM - Review of eMAR: E31 (LPN) administered 650 mg of [MEDICATION NAME]. Pre and post pain scores were both 6 (out of 10), indicating not effective. 4/5/18 at 6:35 AM - Review of eMAR: E31 (LPN) administered 400 mg of [MEDICATION NAME]. Pre pain score was 6 and post pain score was 2, and documented only slightly effective. 4/5/18 at 6:58 AM - Nursing Note: Resident continued to complain of pain to right hip. Resident received [MEDICATION NAME] 400 mg; awaiting results at this time. Resident is laying on side. Will continue to monitor. 4/5/18 at 8:45 AM - Nursing Note: Resident lying in bed this morning complaining of pain all over, unable to straighten right leg. Resident has no redness swelling, discolorations, Notified Nurse Practitioner who came to assess and ordered a STAT right hip X-ray. Resident given [MEDICATION NAME] at 6:30 AM this morning. Hospice nurse in to see patient, will follow up with them with results. 4/5/18 at 2:00 PM - Review of eMAR: E37 (RN) administered 650 mg of [MEDICATION NAME]. Pre and post pain scores were both 7, indicating not effective. 4/5/18 at 2:44 PM - Nursing Note: Resident has remained on bed rest today. Incontinent of urine; skin care done. During skin care she complained of pain when repositioned. [MEDICATION NAME] given for pain with no positive results. Daughter remained at bedside. 4/5/18 at 3:00 PM - Nursing Note: Resident's x-ray results received and reviewed by Nurse Practitioner. Resident had acute [MEDICAL CONDITION] hip. Resident daughter met with Nurse Practitioner. She discussed with her the results and treatment options. Daughter does not wish for patient to be sent to hospital at this time for evaluation; she would like her kept here and made comfortable. [MEDICATION NAME] 5 mg every 4 hours ordered routinely, daughter agrees with new order at this time. 4/5/18 at 3:45 PM - Nursing Note: [MEDICATION NAME] given to patient; she is resting in bed at this time. 4/5/18 at 9:41 PM - Nursing Note: Resident on bed rest for fracture, [MEDICATION NAME] was given routinely. Resident complained of pain and discomfort when turned for care. Resident restless in bed. 4/6/18 at 1:25 AM - Nursing Note: Resident continues to be restless and have pain and discomfort, resident continued to favor right hip, resident received [MEDICATION NAME] 0.25 mL, resident received [MEDICATION NAME] 0.5 mg tab by mouth due to continued attempts to exit bed. 4/6/18 at 3:13 PM - Nursing Note: Resting in bed comfortably slight grimacing with care. [MEDICATION NAME] given as per MD order. Daughter at bedside this afternoon 4/6/18 at 11:11 PM - Nursing Note: Resident remained in bed on this shift, gave [MEDICATION NAME] routinely every 4 hours and monitored closely. Resident complained of pain and discomfort when doing care . 4/6/18 at 11:23 PM - Review of eMAR: E31 administered 1,000 mg of [MEDICATION NAME]. Pre pain score was 8 and post pain score was 4, and documented only slightly effected. 4/7/18 at 4:42 AM - Nursing Note: Resident continue to complain of, and show signs of, pain and discomfort related to right [MEDICAL CONDITION]. Will continue to monitor. 4/7/18 at 7:07 AM - Nursing Note: Resident received [MEDICATION NAME] 400 mg due to complaint of and signs of pain and discomfort, and [MEDICATION NAME] 0.5 mg due to increase anxiety; awaiting results at this time. 4/7/18 at 7:39 AM - Nursing Note: Some signs of discomfort Gave [MEDICATION NAME], effective; rested comfortably most of shift. 4/7/18 at 4:39 PM - Nursing Note: Assessed resident while giving routine medications. Resident grimacing, and visibly shaking. I sat resident up to give her the medications and resident cried out in pain and grabbed her hip. Reported excess pain and hospice recommendations to supervisor. 4/7/18 at 5:20 PM - Nursing Note: After medications given resident was resting comfortably, received scheduled [MEDICATION NAME] at 4:00 PM as well as PRN [MEDICATION NAME]. Resident is currently resting in bed, lowest position, appears comfortable. 9/5/18 at 10:45 AM - Interview with E2 (DON) reviewed that R105 was initially only medicated with [MEDICATION NAME] and [MEDICATION NAME] which was ineffective in managing her pain. The facility failed to analyze the information from the pain assessments and failed to notify the physician for a new medication order. 9/6/18 at 4:30 PM - Interview with R105's daughter and emergency contact confirmed that resident was in severe pain during the night shift and day shift on 4/5/18 and that R105 was not comfortable for several days after the [MEDICAL CONDITION] was discovered on 4/5/18. Additionally references listed above in nursing notes state that the resident stated her right hip hurt, refused to move her right leg due to pain and was unable to straighten her right leg. Despite the fact that R105 had increased pain first identified at 11:30 PM on 4/4/18 she only received [MEDICATION NAME] and [MEDICATION NAME], until 4/5/18 at 3:45 PM when the first dose of routine every 4 hour [MEDICATION NAME] was ordered and given. However, the [MEDICATION NAME] and [MEDICATION NAME] were ineffective in managing her pain for over 48 hours as evidenced by multiple episodes of severe pain documented in nursing notes. In addition, E31 documented R105 was given greater than recommended maximum [MEDICATION NAME] dosage of no more than 650 mg every 6 hours. On 4/5/18, E105 was given 1,000 mg at 4:23 AM and 650 mg at 6:00 AM (less than 90 minutes apart). The facility failed to effectively manage the resident's pain resulting in an extended period of severe pain. 2. Review of R42's clinical record revealed: 3/29/18 - Admission MDS assessment included that R42 had severe cognitive impairment from dementia with a BIMS of 3. 4/3/18 - Care plan for potential for pain related to surgery for [REDACTED]. March (YEAR) - August, (YEAR) - Review of eMARs and corresponding nursing progress notes found 6 out of 8 doses of PRN Tylenol without pain severity rating before and after the PRN medication to assess the effectiveness of the pain medication intervention. - (MONTH) 2 (3:21 AM). - (MONTH) 28 (6:04 AM). - Jun 29 (12:18 AM). - [DATE] (8:50 AM), 17 (6:44 PM) and 24 (12:13 AM). The entry on the eMAR did not include the space to write the pain severity before and after administration. 9/5/18 (4:20 PM) - Interview with E1 (NHA), E2 (DON) and E12 (Corporate Nurse) to verbally discuss findings and provide written documentation of issues discovered from medication reviews. 9/6/18 (10:40 AM) - Interview with E4 (UM) to review the missing pain assessments. E4 stated the order was not entered into the computer accurately since it was missing the boxes to enter the pain assessments. E4 confirmed the non-verbal pain scale assessing resident behaviors could be used for R42. This finding was reviewed with E1 and E2 during the exit conference on 9/6/18 at 2:00 PM.

Based on record review, observation and interview it was determined that, for one (R257) out of 45 sampled residents, the facility failed to identify signs of a UTI timely and failed to provide care and services according to standards of practice after discontinuation of an indwelling urinary catheter. - R257 was harmed when the facility failed to recognize early signs of a UTI , obtain a urine culture and administer antibiotics timely: R257 felt awful and was hospitalized after the resident's blood pressure became low and R257 developed confusion (usually oriented) and lethargy. Additionally for R257 the facility failed to monitor post void residuals after discontinuation of a urinary catheter that was inserted for retention. R257's bladder did not empty and an undetermined amount of urine accumulated leading to lower abdominal pain on two separate occasions when the bladder was overly full with 1,000 mls of cloudy dark urine. Findings include: National Institute of Diabetes and Digestive and Kidney Diseases, a division of National Institutes of Health, information on bladder infections in adults identified risk factors for developing a urinary tract infection [MEDICAL CONDITION]: female gender, inability to empty bladder completely and use of urinary catheter (R257 had all three risk factors). Untreated bladder infections can lead to kidney infection. Signs of a kidney infection included severe pain in the back near the ribs or in the lower abdomen, along with vomiting and nausea, fever may indicate a kidney infection. UTI prevention included drinking enough liquids (six to eight 8-ounce glasses of fluid), urinating often and when the feeling to urinate first happens since bacteria can grow when urine stays in the bladder too long. https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-infection-uti-in-adults - accessed 9/7/18. Review of R257's clinical record revealed: Hospital records documented the resident('s): - blood test on 8/16/18 showed kidney function was normal: BUN 14 (normal range 6-21), creatinine 0.8 (normal range 0.5 - 0.9). - received intravenous (IV) contrast on 8/17/18. - had a urinary catheter inserted at 4:00 AM on 8/20/18 for retention which was not assessed before discharge to the facility. - discharge summary by hospital physician did not include urine retention / catheter. 8/20/18 (1:00 PM) - admitted to the long term care facility after hospitalization for a stroke. 8/20/18 - Admission physicians' orders included: - urinary catheter (specific size ordered). - change catheter and drainage bag PRN. - record urinary and bowel output every shift. 8/20/18 - 8/25/18 - Review of R257's nursing progress notes and CNA documentation of temperatures indicated catheter drained clear dark yellow urine and R257 had elevated oral temperatures: (MONTH) 20 (99.4 F), (MONTH) 21 (100.3 F) and (MONTH) 22 (101.8 F). (Elevated temperature can be a sign of an infection. Dark urine can be a sign of poor fluid intake.) 8/21/18 - Physicians' orders included [DIAGNOSES REDACTED]. 8/21/18 - Physicians' orders included a urinalysis. (There was no evidence in the record that the urine test was ever obtained and completed.) 8/26/18 (8:54 PM) Nursing progress note - E17 (LPN) documented Draining dark urine. Foley deflate and partially rearrange and inflated again. (The nurse did not identify the rationale for the adjustment of the catheter.) 8/28/18 (between 9:00 AM - 10:00 AM) - Surveyor observed E19 (RN) holding a specimen cup containing dark red liquid at the nursing station. E19 stated the liquid was R257's urine. 8/28/18 (3:45 PM) Care Conference note - Patient was observed with blood in her urine. Her catheter was flushed today and her urine has been clear. (Review of progress notes and orders revealed no order to flush the catheter, that the physician was notified, nor was there documentation by E19 about the bloody urine. Bloody urine can be a sign of a UTI and no laboratory testing was done on the urine.) 8/29/18 Nursing Progress Notes and CNA documentation: - 9:44 AM: Resident catheter discontinued on prior shift. R257 had not urinated yet this morning and the resident stated s/he had not had much to drink that morning. Encouraging fluids. - 4:00 PM: resident urinated a large amount this afternoon. Fluids encouraged. - 10:22 PM: Passing yellow mucousy urine. Pushing oral fluids. (mucous in urine may be a sign of a UTI and no testing done on the urine) There was no evidence in the record as to: - the amount of urine in mLs R257 produced the first time after catheter removal (first void). - the number of mLs left in the bladder (post void residual) immediately after urination. - the amount of liquids R257 drank. - whether the physician was notified of the yellow mucousy urine. 8/29/18 (2:33 PM) - Interview with E11 (CNA) to review how R257 took oral fluids and about output since the catheter was discontinued. E11 stated R257 took fluids real well but needed reminders to drink. The CNA confirmed urine was not measured. When asked how the CNA determined the large amount, E11 stated s/he, along with E5 (UM), heard the resident urinate in the toilet and that it sounded like a large amount. 8/29/18 (approximately 2:50 PM) - Interview with E5 revealed monitoring intake and output was very rarely done unless the doctor specifically ordered it. 8/31/18 - Review of facility policy entitled Appropriate Indwelling Catheter Use (revised 3/16/17) which was presented to the surveyor in response to request for policy(ies) addressing monitoring after catheter removal, readjusting the catheter, and flushing the catheter. The policy addressed necessity for use, daily catheter care, changing of catheter/drainage bag and obtaining urine culture from a new catheter. (The policy did not address monitoring post void residuals, flushing the catheter or readjusting the catheter.) 8/31/18 - Review of physicians' orders and nursing progress notes found: - Blood test results (normal range): impaired kidney function: BUN 42 (7 - 17) , creatinine 2.2 (0.52 - 1.04), sodium 130 (137-145). infection: White Blood Count (WBC) 15.5 (3.7 - 8.9). - Physician ordered: IV fluids at 100 mL per hour for 3,000 mL total since R257 not eating / drinking (for kidney impairment / dehydration). IV antibiotic ordered for elevated WBC (for infection). urine culture (ordered three days after signs of a UTI of bloody and/or mucousy urine identified). 9/1/18 (9:30 AM) Nursing progress note - R257 reported s/he doesn't feel right. Temperature 100.6 F with lower abdomen tenderness. Bladderscan showed 875 mL. Encouraged to urinate on bedpan produced around 50 mL. (First evidence of measuring bladder residual.) 9/1/18 - Physicians' ordered straight catheterization (insert catheter to drain bladder, then immediately remove catheter) and stop IV fluids. Nursing Progress Notes / CNA documentation for temperatures/ urine output: - 9/1/18 (9:30 AM): Temperature 100.6 F. - 9/1/18 (9:45 AM): Bladder drained 1,000 mL (1 liter) of dark cloudy urine with reduction in abdominal discomfort. Tylenol given for fever. - 9/1/18 (11:30 AM - 11:45 AM): Temperature 98.4 F after Tylenol, blood pressure (BP) very low at 88/58. Physician on call notified, repeat vital signs in one hour. Daughter informed. - 9/1/18 (12:46 PM - 1:11 PM): BP remained low 94/55, temperature 97.4 F. Physician notified of BP and preliminary urine culture results with a large amount of a bacteria. - 9/1/18 (2:07 PM): Output - Small, incontinent. - 9/1/18 (7:30 PM): Temperature 99 F. - 9/1/18 (10:55 PM): Output - None. - 9/2/18 (9:59 AM): Resident stated feels awful. [MEDICAL CONDITION] 1-2 + generalized. ([MEDICAL CONDITION] can be a sign of impaired kidney function.) - 9/2/18 (11:29 AM - 12:34 PM): Resident complained abdominal pain and was confused (usually oriented x 3). Bladderscan showed over 600 mL. Temperature 98.2 F. - 9/2/18 (11:40 - 11:45 AM) Straight cathed for 1,000 mL dark cloudy urine. Report given to emergency department nurse. Sent 911 to hospital. 9/4/18 ( 1:15 PM) Interview with E17 to describe why the catheter was readjusted on (MONTH) 26. E17 stated the catheter was leaking a little. When asked how it was readjusted, the nurse said , s/he cleaned the tube down to the end, deflated balloon pushed catheter in a little, then reinflated balloon. E17 added there was no more leaking. 9/4/18 (8:30 AM) - Observation of a stack of approximately ten specimen hats in central supply. 9/4/18 (3:05 PM) Interview with E15 (Physician). When asked about measuring urinary output after catheter removal, the physician indicated that should get progressively more urine over the next 72 hours. Surveyor informed that R257's urine was recorded as small, medium and large by listening to the resident urinate in the toilet. The physician said that was subjective and should be in mLs. Surveyor informed the physician that the facility had specimen hats for colleting urine in toilets for measurement. Surveyor added that R257's intake went down and nursing documented they were pushing fluids, however no amount (outside the ordered amount on the MAR) was recorded. Surveyor described several instances when small or none urine output was recorded yet no evidence that the nurses were aware. E15 said after hearing what you had to say I think I may change how I do things (referring to measurements). 9/5/18 (8:38 AM) - Follow up interview with E11 (CNA), who was unable to describe how many mLs of urine equals small, medium and large voids. E11 said that when residents use the toilet it's hard to determine the amount and added mLs would be more accurate. E11 stated that output should be documented with every void. E11 added We write how much liquids are taken if they have to have fluids. 9/5/18 (11:00 AM) - Interview with F1 (resident's family member) revealed R257 was admitted to the hospital with [REDACTED]. F1 added that the doctor at the hospital said the facility needs to keep an eye out for early detection of UTI, make sure hygiene is done and a voiding trial. 9/5/18 (11:20 AM) Interview with E21 (Medical Director), in the presence of E2 (DON), who explained that R257 had dye (IV contrast) in the hospital. E21 admitted the resident had retention problems and added I wish the hospital would have included that in their discharge summary. The resident's catheter was removed here and s/he may not have been emptying her bladder which could have contributed to the renal function. (When bladder full, urine can back up to the kidneys and cause impairment / injury.) The (name of antibiotic) that was started was correct for the organism in the urine. E21 added after 3 liters of fluids her creatinine was still elevated (showing impaired kidney function) and wonder if there was kidney injury from the dye. There was no evidence that the facility reassessed kidney function during the first 10 days since admission. Kidney damage can be minimized with high intake of fluids to flush the contrast out of the body. 9/6/18 (8:50 AM) Interview with E22 (Director of Clinical Services) and E12 (Corporate Nurse). Surveyor explained s/he was interviewing staff to determine how intake and output was documented. E22 said we started IVs and did a bladderscan. The surveyor discussed concern over the lack of routine monitoring of post void residuals after the catheter was discontinued. When E22 stated bladderscans were completed, the surveyor pointed out that bladderscans were done only in response to resident having abdominal pain from retaining urine. 9/6/16 - Review of the hospital records after the resident returned to the facility on [DATE] discovered when a urinary catheter was inserted in the emergency room turbid, thick, purulent urine was collected for testing. WBC high at 16.3 (infection) and impaired kidney function: BUN 47 (high), creatinine 2.31 (high), sodium 130 (low), potasium 5.5 (high). Will be hydrated for acute kidney injury. Upon discharge R257's kidney function was nearly normal: BUN 19, sodium 140, potassium 4.1 (all normal), creatinine 0.92 (little high). The facility failed to identify early signs of a UTI and failed to routinely monitor R257's post (after) void residuals after discontinuation of the urinary catheter. R257 was harmed by these failures: - experienced abdominal pain and felt awlful on two separate occasions when bladder became overly full and 1,000 mLs of urine was drained each time. - experienced a decline in blood pressure and developed confusion and lethargy requiring hospitalization for treatment. It was unclear if hospitalization could have been avoided if the UTI was identified sooner, when the urinalysis was ordered 8/21/18, when bloody urine was discovered on 8/28/18 or when mucousy urine was observed on 8/29/18. Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference on 9/6/18 beginning at 2:00 PM.

Based on observation, record review and interview it was determined that the facility failed to prevent the development of a pressure ulcer for one (R228) out of 33 sampled residents. Prior to a fall on July 21, 2017, R228 was able to transfer from bed to chair with supervision, ambulate using a rolling walker and self-propel in a wheelchair. After the fall and discontinuation of a medication for dementia R228's ability to stand up, ambulate and self-propel in the wheelchair declined. The facility failed to reassess R228's risk for developing a pressure ulcer after this decline and did not evaluate for the implementation of additional preventative measures resulting in the resident developing a deep tissue pressure injury (DTI)to the right heel. Additionally the facility also failed to provide the necessary treatment and services to promote healing after the development of the right heel DTI. Findings include: 1. Review of R228's clinical record revealed: Cross Refer F279, Example 2, F312, Example 2, and F282. a. Pressure Injury Development 6/13/17 - Admission to facility with multiple [DIAGNOSES REDACTED]. 6/13/17 - Admission physical assessment documented heels pink and blancheable, no pressure injury wounds. Weight 181 pounds. 6/13/17 - Admission Braden Score (skin risk assessment) score was 21 indicating R228 was not at risk for developing pressure ulcer. 6/13/17 - Physicians' orders included: Encourage off load heels every shift; Encourage turn / reposition every 2 hours and PRN; and weekly skin checks on Tuesday evenings. 6/13/17 PT Evaluation and Plan of Treatment - For treatment period ending 6/27/17 R228 was at baseline level of supervision for transfers and ambulation with rolling walker. 6/16/17 (10:28 PM) Nursing Note - R228 had +1 [MEDICAL CONDITION] to both ankles, encourage to elevate both legs. 6/18/17 (10:11 PM) Nursing Note - Resident with +2 [MEDICAL CONDITION] to both ankles. 6/19/17 - Care plan problems included: - Potential for pressure ulcer related to decreased mobility had the goal to be free from open areas at pressure points. Approaches included pressure reducing mattress (usual mattress on the bed), skin checks every 2 hours and PRN; and turn and reposition every 2 hrs and PRN. - Fluid Maintenance included approaches to elevate legs above heart level as tolerated / allowed; and apply TEDS (compression stockings) as ordered and as resident tolerates. (TEDS were discontinued 7/11/17 since resident would roll them down and not wear properly.) 6/27/17 PT Encounter Note - Resident ambulated up to 125 feet x 2 with rolling walker. Transfer from wheelchair, standard chair and recliner chair all with supervision. 7/6/17 (9:15 AM) Nursing Note - Continued to be in wheelchair for mobility around the unit often stands unassisted, redirected often. 7/11/17 - Braden score was 19 and R228 remained not at risk for developing pressure ulcers. 7/21/17 (3:11 PM) Nursing Note - R228 was walking around the dining room unassisted, staff member attempted to help resident sit back in chair- resident sat buttocks on the edge of chair and slid down to the floor, did not hit head. 7/21/17 - Physicians' orders stopped [MEDICATION NAME]. 7/28/17 (12:06 PM) Nursing Note - Increase in difficulty standing and needing more staff assistance. Resident occasionally complaining of pain all over hips, knees, ankles. 7/30/17 PT Note - Poor weightbearing right ankle. Noted shoes tight on feet with current level of [MEDICAL CONDITION]. Spoke with nursing aides regarding limiting use of these shoes. 7/30/17 PT Evaluation and Plan of Treatment - R228 bilateral lower extremity [MEDICAL CONDITION] from knees to feet with right ankle pain reported during ROM and during weightbearing. Current mobility level is a significant decline from previous level of function at end of course of therapy. Decline appears to be consistent with leg [MEDICAL CONDITION], right ankle pain and strength deficits in legs. Recommended to nursing that R228 will need two person assistance for transfers on nursing unit. 7/31/17 PT Note - Resident avoiding weight bearing on right leg, requiring maximum assistance to pull to stand. Ultrasound to right ankle for [MEDICAL CONDITION] and pain control. Continues to grimace with passive ROM. There was no evidence in the clinical record that a skin risk assessment (i.e., Braden) was performed after R228's mobility declined. 8/1/17 Weekly Skin Check- Intact no comment noted. 8/2/17 (7:42 AM) Nursing Note - Informed by PT to assess right heel purple discoloration 4 cm by 4 cm partially fluid filled area. NP aware and new order to apply skin prep to both heels twice a day, daughter aware. 8/3/17 Wound Note - Seen for evaluation and treatment of [REDACTED]. Wound measuring 2.5 cm by 3.0 cm with 75% of wound base deep purple ecchymosis and 25% serous blister. Edges adherent to wound base. No drainage. No evidence of pain when area palpated. Assessment pressure ulcer of right heel, unstageable due to suspected Deep Tissue Injury (DTI). Deemed unavoidable due to patient overall decline, would self propel in wheelchair. PT initiated. Plan to cleanse affected area with NSS or wound cleanser, apply skin prep twice a day. Off load pressure to affected area. Continue repositioning according to facility policy. Interventions in place: redistribution mattress, wheelchair cushion. Recommend heel boots and no shoes except for therapy. (The term suspected DTI was changed in 2016 to DTI, dropping the word suspected. It was unclear why the reason for self-propelling was listed as contributing to the development of the wound, when the resident stopped the behavior weeks before the appearance of the wound.) 8/3/17 - Physicians' orders included no shoes except for therapy, right heel boot and skin prep to both heels twice a day. Review of most recent pertinent laboratory tests with (reference range): 4/10/17: [MEDICATION NAME] 3.5 (3.5-5.0), Total protein 6.0 (6.3-8.2) 7/5/17: Hemoglobin A1C 6.6 (4.0-6.0), Platelets 182 (165-429) July, 2017 - August, 2017 - Review of CNA documentation revealed: - Bedbath received: August 1 the evening before DTI discovered on right heel. There was no documentation in the record regarding any skin issues. - Offload heels: Every shift checked off except refusal on evenings July 19, 21, 25, 26, 28. - Skin check every 2 hours and PRN: Every shift except day shift August 3 when resident was combative - Encourage turn/reposition documented as every 2 hours and PRN: done on evenings and nights during time frame. Despite the fact that the resident was non-compliant with TED stockings and intermittently refused to offload heels on pillows (kicked out pillows), there was no evidence in the clinical record that heel boots were considered. During an interview with E11 (LPN) on 8/31/17 at 2:22 PM to discuss the use of shoes and the resident's [MEDICAL CONDITION] prior to the development of the DTI on 8/3/17, E11 said R228's daughter had brought in several pairs of mesh-type shoes of larger sizes when the resident's feet were more swollen. During an interview with E12 (day shift CNA who cared for R228 on July 30 and 31, [DATE] and 2) on 8/31/17 at 2:27 PM when asked to think back to when R228 was wearing shoes and how they fit when she had swelling, E12 stated When they (feet) got swollen we didn't put them back on. When asked what interventions were in place before the pressure injury wound developed, E12 said to offload the heels. The CNA explained that 3 pillows were needed since 1 didn't raise them (the heels) high enough. During an interview with E13 evening shift CNA who cared for R228 on July 28 and August 1 on 8/31/17 at 3:37 PM when asked how R228's heels were elevated before the pressure ulcer, E13 stated pillows, but the resident would push them out. When the resident did that I would document she refused. (E13 was the only CNA who documented refusal of offloading heels.) The surveyor said R228 had a bath on July 28 and [DATE] when E13 worked and asked the CNA to describe her heels at that time, E13 stated I do not remember. The facility failed to reassess R228 after a decline in function resulting in the development of a right heel DTI and failed to implement additional preventative measures resulting in harm to R228. Cross Refer F279, Example 2 and F282 b. treatment of [REDACTED]. 8/3/17 - Care plan problem for Actual pressure ulcer right heel included the goal that the area will show no signs of infection. Heel boot to right foot. Measure weekly on rounds. Skin check every 2 hours, pressure relieving device to bed/chair. Turn and reposition every 2 hours and PRN. 8/4/17 - Right heel boot initiated after product available. 8/8/17 Weekly Skin Check - Intact, no comment noted. 8/9/17 Nutrition Note - 4.8% (8 lbs) loss over past 30 days, now 172.4. Will add Med Pass 90 mL twice a day to promote wound healing of DTI. Liberalize meal plan. 8/10/17 PT Note - Multiple attempts with sit to stand transfers. She will initially make attempt but when PT tried to assist resident refused, unable to perform transfer independently. Did accomplish 1 sit to stand with maximum assistance. Attempted to take some steps but resident refused and sat down. Other therapy staff familiar with R228 noted significant confusion and worsening of the resident's cognitive status. 8/10/17 Wound Note - Unstageable right heel pressure ulceration measuring 3 cm by 4 cm with wound base 100% fading purple ecchymosis. 8/10/17 - Skin risk assessment score was 16 indicating R228 was at risk for developing pressure ulcers for the 8/10/17 Significant Change MDS assessment. 8/10/17 Significant Change MDS Assessment - R228 still had moderate cognitive impairment and required extensive assistance with two persons for both bed mobility and transfer. 8/16/17 - Care plan meeting summary documented R228 had decline in recent weeks - not standing as well as in past and DTI to right heel. [MEDICATION NAME] was discontinued at last [MEDICAL CONDITION] reduction meeting. Followed by (name of [MEDICAL CONDITION] center) for platelets which have been normal. Had recent fall. 8/17/17 - Wound Note missing in the clinical record. (It was unclear if R228's right heel wound was assessed this week.) 8/17/17 - Physicians' orders included an air mattress for the bed, 15 days after the development of the pressure injury ulcer. 8/21/17 PT Note - Pt resistant to all efforts for ROM, especially bending left knee. Continue ultrasound to left heel to facilitate circulation and healing to blistered area with goal to improve functional transfer without discomfort. Left heel blood blister present. (R228 had a DTI to the right heel, yet this note documented left heel or was it a new DTI?) 8/22/17 PT Progress Report - Spoke with nursing / CNA staff on unit who report bilateral leg [MEDICAL CONDITION] has decreased since starting therapy (7/30), but this has not improved R228's function. 8/24/17 Wound Note - exact same wording as 8/10/17 regarding right heel wound size and description. 8/28/17 (9:30 AM - 1:30 PM) - Observed R228 seated in wheelchair in dining / activity room without change of position. 8/29/17 PT Note - R228 very tearful during left knee flexion and not allowing passive ROM. But once resting resident was able to rest left leg in over 80% flexion (knee bent). Pulsed ultrasound to right heel for pain relief / circulation, heel blood blister (dry). After placing hands on rims of wheelchair resident able to propel self up to 15 feet at a time. Refused to use legs for propulsion, therefore leg rests in place. 8/29/17 Weekly Skin Check - Intact, no additional comments written. 8/31/17 (8:30 AM - 1:50 PM) - Observed resident seated in wheelchair without change of position in dining / activity room and own room during wound treatment. 8/31/17 (11:00 AM) - Observation of treatment to right heel by E10 (NP - wound care consultant) assessed and measured wound using mirror to visualize the DTI area on the outer side of the LEFT heel. After applying skin prep, NP replaced sock. (It was unclear why the NP assessed the left heel when it was the right heel that was the one being treated.) 8/31/17 (2:24 PM) - Observation of resident in bed with socks removed to look at both heels revealed DTI on left heel as seen when NP assessed earlier in day. Right heel with DTI on outer side heel that looks wider (larger) than left one. Skin intact on both heels, no open areas, purple / dark red discoloration. Review of August, 2017 CNA documentation revealed: - Right heel boot: signed off as done August 4 - 17. - Bilateral heel boots: signed off August 17 - 31 but wore one boot (due to unavailability) on August 22, 26 and 27 but did not indicate which foot it was used for. - Offload heels: Every shift checked off - Skin check every 2 hours and PRN: Every shift except day shift August 3 when resident was combative - Encourage turn/reposition every 2 hours and PRN: done on evenings and nights during time frame. It was also unclear why skin checks were signed off as being completed every 2 hours when there were observations on August 28 and 31 when the resident was continuously seated in the wheelchair for at least 4 hours. During a telephone interview with E10 on 9/1/17 beginning at 10:00 AM, when asked for the documentation of the August 17 weekly wound rounds, E10 said, I am almost positive I saw R228. E10 informed the surveyor that the file was not in the email sent to the facility, but did locate the document and would send it to E1 (NHA) to print to add to the clinical record. E10 confirmed that the right heel was the side being assessed weekly. When asked about the left heel DTI, E10 said, They never told me about the left one. Surveyor requested an explanation of how a left DTI was noted by PT on 8/21, yet the 8/24 wound assessment did not identify it. E10 said, It may have defaulted in from the week before when I assessed it. The NP clarified that the information from the previous assessment flows into the electronic document and must be changed to reflect the resident's current status. E10 offered no explanation when asked why, during wound rounds the day before, the left heel was assessed and treated with the findings documented as the right heel and that the right heel was not assessed or treated. When asked how E10 determined on 8/3/17 that R228's right heel DTI was unavoidable, E10 said the nurse informed him/her that the resident used heels to propel in the wheelchair and had a poor appetite. (The resident stopped self-propelling with feet in July.) During an interview with E14 (LPN, UM) on 9/1/17 at 10:43 AM when asked when s/he was aware of the blood blister on the left heel, E10 said Yesterday when it was discovered by the wound team. Surveyor informed the UM that E10 assessed the left heel DTI and the right one was never looked at the day before. During an interview with E17 (PT) on 9/1/17 at 11:02 AM E17 informed the surveyor that R228's right heel was the one that was being treated and the PT wrote the wrong side on the 8/21 note. I was working with her left knee and right heel. Last week it (DTI) was not there on the left heel. E17 stated s/he fixed the documentation. The facility failed to provide weekly assessment and treatment for [REDACTED]. These findings were reviewed with E1 (NHA) and E2 (DON) on 9/5/17 at 2:00 PM.

Based on staff and resident interviews, clinical record review as well as a review of other facility documents, it was determined that the facility failed to provide adequate supervision/assistance based on assessed safety needs and/or ensure that set-up and transfer techniques were utilized appropriately to maximize accident prevention. R1 fell on two separate occasions. On 12/5/16 R1 was transferred with assist of one staff instead of two staff. On 2/22/16 R1 fell again when the transfer board was positioned under R1 and the bed was elevated prior to the actual transfer, the wheelchair was not in position yet, and the second staff person needed for transfers was not in the room. R1 sustained a fracture of the right leg requiring hospitalization with surgical interventions. These deficient practices were evident for 1 (R1) out of 7 residents in the sample. Findings include: Clinical record review and a review of other facility documentation for R1 revealed the following: The quarterly MDSs dated 7/13/16 and 10/12/16 documented that R1 was cognitively intact required extensive assisstance for bed mobility and transfers with the support of two staff. R1's physician orders [REDACTED]. Non-ambulatory at this time. Special instructions: Patient to transfer towards right side at all times with one assist in front of patient and one behind to offer help if needed. In addition, the profile sheet indicated fall precautions included low bed and nonskid footwear. Progress note dated 12/5/17- reflected that at approximately 11:15 AM, CNA (E7) came into the hallway stating that resident (R1) was assisted to the floor during a transfer. R1 and E7 (CNA) both reported that R1 did not hit his/her head. No injuries were noted and R1 was monitored. Facility Event Report for R1 completed on 12/6/16 reflected that the event occurred on 12/5/16 at 11:15 AM during a transfer using the slide board. R1 was lowered to the floor. Fall Committee review documented that R1 was a slide board transfer of two staff but only one staff was assisting. Intervention was to re-educate E7 on the slide board transfer and the use of two persons based on R1's transfer status order. This re-education was completed on 12/5/16 according to a facility typed statement. The quarterly MDS dated [DATE] documented that R1 was cognitively intact and required extensive assistance with support of one staff for bed mobility and extensive assistance with the support of two staff for transfers. Progress note dated 2/22/17 at 12:04 PM- documentation reflected that CNA (name unknown) reported that resident (R1) was found on the floor and leg does not look good. Physician (E4) and Nurse Practitioner (E3) notified. Resident's right lower leg with an open fracture. Order given to send to the emergency room . Another progress note dated 2/22/17 at 12:15 PM reflected that R1 left the facility at approximately 12:15 PM by way of ambulance. Facility Event Report for R1 completed on 2/24/17 documented that the event occurred on 2/22/17 at 12:36 PM when R1 fell from his/her bed. Fall Committee review was done 2/23/17 and reflected the following- R1 was in the process of being set up for slide board transfer. While the bed was being raised the resident slid out of bed, down the slide board to the floor. R1 does have a history of attempting to begin transfer process before staff instruct resident to do so and it is unclear if he/she attempted to reposition the slide board and fell , if the bed raising moved the slide board, or if the blankets shifted during the bed raising. Intervention was to re-educate staff on slide board transfers, setup and safe transfers. R1 was sent to the emergency department for medical treatment. A typed statement from E5 Physical Therapist Assistant (PTA) reflected that on 2/24/17 he/she requested E6 (CNA) who was working with R1 when he/she fell on [DATE] simulate what took place. The statement indicated that E6 demonstrated how he/she put the sliding board under R1's right lower extremity and buttocks. Additionally, E6 stated to E5 that the slide board was horizontal on the bed and not angled as if she was setting up the actual transfer. E6 explained that he/she was waiting for the second person before the actual transfer would be done. E6 further explained that R1 was sitting up on the side of the bed with the slide board as stated above and R1 slipped and fell to the floor. Based on the details described to E5, E6 was re-educated that the resident's feet need to be properly positioned on the floor and only raise the bed to the proper height to provide the adequate decline for transfer from bed to chair. During an interview with the surveyor on 3/1/17 at 12:22 PM, E6 stated that during his/her orientation there was training on the slide board and E6 received training a couple days after the 2/22/17 incident involving R1. E6 stated that he/she was informed by E5 not to use the slide board until the actual transfer. E6 sequenced the events for the surveyor. The resident was on the edge of the bed and the slide board had been put under R1's right lower extremity and buttocks but not angled out, it was horizontal. E6 reached across in front of R1 with his/her arm grasping R1's left arm and E6 used the other hand to push the controls on the far side. E6 felt R1 sliding and could not prevent the fall at that point. E6 stated that the wheelchair was not in position because he/she was not going to transfer R1 until the second person came into the room. E6 had requested help from another CNA who stated he/she would be in just a few minutes. When asked about how E6 would know about specific care needs he/she stated that there are at least 6 books on R1's unit with specifics about resident care needs. E6 also stated that he/she floats and had helped R1's regular CNA on at least two occasions use the slide board to transfer R1 from the bed to the wheelchair. The surveyor interviewed E3 (NP) on 3/1/17 at 1:28 PM, E3 stated that he/she was called to R1's room on 2/22/17 in the afternoon and noted the resident on the floor with R1's right leg twisted and ankle inverted. The right leg was slowly moved in line and noted there was blood on pants. E3 requested gauze and for E4 (physician), who was in the building, to be paged to come and evaluate R1. Staff called 911 and R1's leg was splinted when emergency personnel arrived. During an interview with the surveyor on 3/1/17 at 3:35 PM, E4 stated it was his first day at the facility. E4 had visited with R1 earlier for the monthly visit. E4 did go to the room on 2/22/16 and R1 was being attended to by E3 and other nursing staff. When E4 arrived, R1's right leg was rotated inward and there was gauze over the shin area, E4 did see bone through the skin when the gauze was raised. Staff had everything under control and 911 had been called so E4 left. A History and Physical dated 3/1/17 documented that R1 slipped and fell out of bed a week ago and sustained an open fracture of the right lower leg. He was admitted to the hospital and underwent a surgical procedure. R1 had some problems with respiratory failure after a blood transfusion and required treatments for the condition in the intensive care unit. Returned to the facility today with a stapled wound to lower right leg which had a clean dry dressing. During an interview with the surveyor on 3/1/17 at approximately 3:05 PM. R1 did state that he/she did not get direction from the staff person on 2/22/17, the slide board was underneath him/her and another person was coming to help. R1 began sliding off the bed. R1 further stated that he/she doesn't remember much about the incident, its been a week. 3/1/17 4:00 PM- E5 was interviewed by the surveyor and confirmed that the statement above was accurate. E5 indicated that E6 was doing the setup not the actual transfer. New hires are trained during orientation how to use a slide board properly. E5 did indicate that R1 was a two person transfer using his/her strong side. E5 indicated that E6 demonstrated a safe transfer the week prior. During a brief interview on 3/2/17 at 8:15 AM, E5 stated that every resident's transfer status is posted in the room inside the closet. R1 returned to the facility late afternoon on 3/1/17. Readmissions are done using a mechanical lift transfer until the resident is evaluated by physical therapy unless the hospital sends specific transfer information. E5 gave the surveyor documents regarding sequencing a slide board transfer from bed to chair and diagrams. The document reflected that when the person was sitting on the edge of the bed, place sliding board under the extremity and buttocks (left or right side depends on specific assesment/evaluation instructions) and the other end on the wheelchair with its armrest removed. Then raise the bed slightly, to provide create a decline from the board (on the bed) to the chair. If the sliding board transfer is assist of two, one staff member would be in front of the resident and one staff member would be behind the resident. The transfer sequencing was not followed on 2/22/17 regarding the slide board and when to elevate the bed. There was no second staff member in the room. When interviewed again on 3/2/17 at 1:27 PM by the surveyor, E6 stated that in residents' closets there were care plans/profiles reflecting care needs. E6 further stated that the 6 books on the unit were related to resident assistive devices. The findings were discussed at the exit conference on 3/6/17 at approximately 2:45 PM with E1 (NHA) and E2(DON).

Based on record review and interview, it was determined that the facility failed to ensure the appropriate treatment and services to restore and /or maintain bladder function were implemented for one (R92) resident out of 39 sampled residents. The facility failed to assess and implement appropriate interventions when R92 had a decline in continence. R92 was admitted to the facility continent of urine and when her continence declined the facility failed to reassess and implement interventions such as a voiding diary and individualized toileting program to restore and/or maintain bladder function. Findings include: 1. The facility's policy and procedure for Bowel and Bladder Assessment documented it would be completed on admission, annually and with changes in bladder and bowel. Upon completion, a review of the assessment will be conducted and, if indicated, a three day voiding/ bowel movement diary will be completed by the CNA (Certified Nursing Assistant) and then the Director of Nursing or designee will complete the nursing evaluation and the care plan will be updated accordingly. The admission Minimum Data Set (MDS) assessment, dated 12/24/12, documented R92 needed limited assistance with one person for toileting, was always continent of urine, and that a toileting program was not in place. A voiding diary was completed upon admission and began on 12/18/12 and ended on 12/20/12. There were no instances of incontinence documented by the facility staff during this three day period and no toileting program was indicated during that time. A Care Plan that was initiated upon R92's admission to the facility was for a potential (not actual) of bowel and bladder incontinence related to Dementia and Impaired mobility. The goal documented was that R92 would be continent at all times for 90 days. Interventions included establishing voiding patterns and monitoring and documenting intake and output. Handwritten on the care plan were revision dates of 1/2/13 and 3/26/13 and a new target date of 6/26/13. No further interventions were added to the care plan. During an interview on 6/7/13 at approximately 1:15 PM, E2, Director of Nursing, confirmed the facility failed to revise the care plan to include actual urinary incontinence with interventions such as a voiding diary and an individualized toileting program. A Medicare payment MDS, dated [DATE], documented that R92 needed extensive assistance with one person for toileting, was occasionally incontinent of urine, and that a toileting program was not in place. Review of facility documentation revealed a Scheduled Toileting Flow Sheet that showed a toileting program that began on 1/18/13. The scheduled toileting was to occur after dinner, before bed and three additional times during the night shift (11PM - 7AM). The toileting program began after dinner on the evening shift (3PM-11PM) and did not include any toileting intervention on the dayshift (7AM-3PM). Review of the CNA flow sheet for 1/8/13 - 1/14/13 (the week prior to the MDS assessment) revealed that R92 was incontinent of urine during 4 out of 7 of the night shifts, 3 out of 7 of the evening shifts and 5 out of 7 of the day shifts. The facility implemented a toileting program on 1/18/13 that covered only part of the evening shift (beginning after dinner) and the night shift (11PM-7AM), omitting the day shift (7AM-3PM) completely. A significant change MDS, dated [DATE], documented R92 needed extensive assistance of one person for toileting, was frequently incontinent of urine (had been occasionally incontinent), and that a toileting program was in place. There was no evidence of reassessment (related to urinary incontinence) or individualization of the toileting program by the facility. On 6/12/13 at approximately 09:15 AM, a review of the facility record MDS Analyzer Report that was generated by the computer after completion of the MDS assessment and a documented submission date of 4/5/13 recommended that the facility ensure the resident' s care plan addressed toileting needs and that the facility's coding for incontinence and activities of daily living be rechecked for accuracy. In response to these suggestions, a hand written note in the column by these recommendations documented that R92 was on a toileting program. Review of the CNA Flow Sheet for 3/17/13 - 3/23/13 (the week prior to the MDS assessment) revealed that R92 was incontinent of urine 6 out of 7 night shifts, 1 out of 7 evening shifts and 5 out of 7 day shifts. There was no evidence that the facility reassessed R92 ' s urinary incontinence and the facility did not individualize the Scheduled Toileting program that was in effect at the time. The Scheduled Toileting Program remained the same from the time of implementation, 1/18/13 through 4/30/13, except when, on 4/1/13, the facility added a before dinner toileting time. The toileting program only covered part of the evening shift (beginning before dinner) and the night shift. The toileting program continued to omit the day shift completely even though the Certified Nursing Assistants had documented that 5 out of the 7 day shifts R92 had experienced episodes of incontinence. During an interview, on 6/10/13 at approximately 2:40 PM, with E5, Unit Manager, and E13, Assistant Director of Nursing, it was discovered that the facility did not have a toileting program in place for R92 during the time period of 5/1/13 to 6/10/13. E5 and E13 both confirmed that the toileting program was mistakenly not brought forward from April to May during the monthly transition period (replacing chart documents with new forms for the current month). E5 and E13 confirmed that R92 was not on a toileting program during this time. E13 confirmed that a 3-day voiding diary should have been completed in January when the decline in urinary continence was noticed and again in March when the urinary continence decline was noted. During an interview on 6/10/13 at approximately 2:30 PM, Lead Certified Nursing Assistant for day shift, E22, stated that she did not remember R92 being on a toileting program since she was moved to the unit in March. Review of the Certified Nursing Assistant ' s flow sheets from December 2012 through June 10, 2013 revealed the following episodes of urinary incontinence experienced by R92 during day shift: -0 day shifts with episodes of incontinence out of 13 day shifts for December or 0% of the time. -10 day shifts with episodes of incontinence out of 31 day shifts for January or 32% of the time. -4 day shifts with episodes of incontinence out of 28 day shifts for February or 14% of the time. -20 day shifts with episodes of incontinence out of 31 day shifts for March or 65% of the time. -30 day shifts with episodes of incontinence out of 30 day shifts for April or 100% of the time. -27 day shifts with episodes of incontinence out of 31 day shifts for May or 87 % of the time. -10 day shifts with episodes of incontinence out of 10 day shifts for June or 100% of the time (6/1/13 to 6/10/13). The facility failed to identify the decline in bladder continence on the day shift resulting in the failure to establish an individualized toileting program that included the day shift. During an interview on 6/11/13 at approximately 2:30 PM, E21, Corporate Nurse stated that the Medicare payment MDS, dated [DATE], was inaccurately coded related to urinary continence. E21 stated the MDS was coded as occasionally incontinent of urine and should have been coded as frequently incontinent. E21 noted the inaccuracy earlier in the day of 6/11/13, however, the facility was not aware of this inaccuracy until this time and failed to individualize R92's toileting program or reassess the resident's incontinence. These findings were reviewed on 6/12/13 at approximately 2:30 PM with E1, Administrator, and E2, Director of Nursing.

Based on clinical record review, staff interview and review of hospital records, it was determined that, for one (R46) of 39 residents sampled, the facility failed to provide the necessary treatment and services to promote healing of a pressure ulcer. Findings include: 1. R46 was admitted to the facility with [DIAGNOSES REDACTED]. The 01/17/13 nursing admission assessment note stated R46 was admitted with an open area on the left heel measuring "2 centimeters (cm) x (by) 1 cm width, right ankle reveals an 1 cm x 0.5 cm open area; hence no other open areas to any part of the body". The Resident Admission Assessment, dated 01/17/13, stated that R46 was admitted with two Stage II pressure ulcers (partial thickness loss of dermis). The facility developed a care plan, dated 1/27/13, for potential for Pressure ulcer with interventions that included off loading heels while in bed. On 1/27/13 a care plan was developed for actual pressure ulcers stage II pressure ulcers. Care plan interventions included measure on weekly wound rounds, notify of worsening wounds, pressure relieving device to bed/chair, skin checks every 2 hours and provide treatment per physician orders. Review of R46's Wound Evaluation Form, dated 1/25/13, revealed his left heel wound worsened to 50% necrosis (death of tissue due to insufficient blood supply) and 50% red that measured to 2 cm x 2 cm x 0.1 cm. R46 had an order dated 1/17/13 to off load heels while in bed. On 1/18/13 R46 had an order to cleanse the left heel with normal saline and apply [MEDICATION NAME] foam and change daily and as needed. Review of R46's Treatment record daily wound monitoring form revealed on January 28 there was no evidence that a dressing change was completed. On 2/8/13, R46 had an order to change the left heel dressing to santyl to necrotic area and cover with [MEDICATION NAME] daily. Review of R46's treatment record revealed on 2/12 and 2/13/13 there was no evidence a dressing change was completed for R46. A physician order [REDACTED]. Review of R46's nurses' notes, dated 2/23/13, documented that certified nursing assistant reported that R46's left heel was bleeding. Upon assessment, the necrotic area noted sloughing off. Beef red area noted along with necrotic area. Will request an order for [REDACTED]. The nurses were still documenting on 2/23/13 and 2/24/13 that they were using skin prep to R46's heels. On 2/25/13 (2 days later), an order was received to cleanse the left heel wound with normal saline, apply [MEDICATION NAME] silver, cover with [MEDICATION NAME] foam and change daily. On 6/12/13 at 11:15 AM, review of R46's record with E13, Assistant Director of Nursing, confirmed there was a lack of evidence that dressings were changed as ordered for R46's left heel wound. When R46's left heel wound changed, on 2/23/13, the nurse should have consulted the physician for a change in treatment to ensure R46 received the necessary treatment and services to promote healing.

Based on interviews, review of the clinical record, hospital records and other facility documentation it was determined that the facility failed to ensure that two (R1, R3) residents out of ten sampled were free of any significant medication errors. R1 was administered the incorrect dose of [MEDICATION NAME] (a narcotic) resulting in R1 being found unresponsive and requiring emergency intervention and treatment with an antidote. The facility failed to ensure that the new [MEDICATION NAME] order for R3 was implemented correctly. Findings include: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's admission nursing assessment documented that he had no pain or facial grimacing. Review of the facility's policy titled "Medication Orders, IB1: Prescriber of Medication Orders" documented for "Procedures c. Written Transfer Orders (sent with a resident by a hospital or other health care facility). 1. Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission. 2. If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medication is administered. The nurse documents verification on the admission order record by entering the time, date, signature. Example: "Order verified by phone with Dr. Smith/M. Jones, R.N." A review of R1's hospital "Discharge Instruction Sheet" dated 12/7/11 documented "[MEDICATION NAME] (a class of medications called opiate narcotic [MEDICATION NAME]) 5 mg. (milligram) PEG 2 X/day and TID (three times a day) PRN (as needed)." This documentation lacked evidence that the order was verified with R1's attending physician. Review of the "Admission Order Sheet" dated 12/7/11 revealed that a staff nurse (E12) documented "[MEDICATION NAME] 5 ML (millimeter) PEG BID (two times a day) and TID PRN pain." This documentation included in the section for "Physician Signature" "app. (Name of Nurse Practitioner/E13 and date of 12/7/11" implying that these orders were approved by E13. Although the [MEDICATION NAME] order was incomplete, the facility's reconciliation processes failed to identify and clarify the order. An interview with E15 (Pharmacy Director) on 2/24/12 at approximately 11 AM revealed that the pharmacy received via fax R1's hospital "Discharge Instruction Sheet" dated 12/7/11 which documented "[MEDICATION NAME] 5 mg. PEG 2X/ day and TID PRN." E15 verbalized that the [MEDICATION NAME] (HCL) 20 mg. per ml. was dispensed from pharmacy after obtaining a verbal order from the ordering provider since this was a narcotic. E15 related that the pharmacy did not receive via the fax the "Admission Order Sheet" dated 12/7/11 on 12/7/11 which documented "[MEDICATION NAME] 5 ML PEG BID (twice a day) and TID (three times a day ) PRN (as needed) pain." An interview with facility's Chief Operating Officer, E16 on 2/27/12 at approximately 2:30 PM revealed that the expectation would be that the pharmacy would dispense medications for new residents, such as R1 based on the verified medication orders on the facility's "Admission Order Sheet." Review of the electronic Medication Administration Record [REDACTED]" which was transcribed into the eMAR system by E12. Written statement by E12 dated 12/7/11 documented "On the discharge instructions it appeared to look like 5 ML or 5 mg., I called pharmacy. They stated "we are sending liquid [MEDICATION NAME]. I called for a reference number. I then look back to the chart and found the medication sheet with [MEDICATION NAME] HCL 5 mg.=5 ml., I assumed that was being sent." Although the transcribed order in the eMAR failed to include the dose of the [MEDICATION NAME], the facility's systems, including the eMAR system failed to identify the incomplete order. The eMAR documented that the 6 AM [MEDICATION NAME] HCL 5 ml. was administered by staff Registered Nurse (E5). Nurse's Note (N.N.) dated 12/8/11 timed 7:15 AM documented that R1 was found unresponsive by staff with pin point pupils with oxygen saturation of 84% on room air and 911 was called and R1 was transported to the hospital. Hospital's emergency room records dated 12/8/12 documented that R1 was administered [MEDICATION NAME] (medication which prevents or reverses the effects of narcotics, specifically used to counteract life-threatening depression of the central nervous system) 0.5 mg, en route to the hospital. R1 upon arrival in the ER was awake, non verbal and with a starring look and was administered second dose of 0.4 mg. of [MEDICATION NAME]. Two additional doses of [MEDICATION NAME] were administered prior to R1 being transported to the intensive care unit for close monitoring. On 12/10/11, R1 was discharged from the hospital and returned to the facility. Review of the "Discharge Summary" dated 12/10/11 documented a primary [DIAGNOSES REDACTED]. Review of facility's policy titled "Preparation and General Guidelines, IIA2: Medication Administration -General Guidelines, Procedures, A. Preparation, 3" documented: "Prior to administration, the medication and the dosage schedule on the resident's Medication Administration Record [REDACTED]. If the label and the MAR indicated [REDACTED]." A review of written statement dated 12/8/12 by E5 following the above incident revealed " ...Another medication was [MEDICATION NAME] 5 ml? or 5 mg. this was unclear but judgement told me it meant 5 mg. I was rushed and was thinking (without looking at bottle) doing in my head 5 mg. is 1/5 of 5 ml=1 ml which I gave. Only afterwards did I look at the box which said 20 mg./ml. " Further record review revealed that on 12/8/12 after the above incident, another Nurse Practitioner, E20 had written a clarification order "[MEDICATION NAME] 20 mg./ml. 5 mg. (.25 ml) via G tube q 12 hours and may have 5 mg. (.25 ml) via G tube q 6 hours PRN dispense 200 ml." An interview with the Director of Nursing (E2, DON) and Corporate Liaison (E4) on 2/21/11 at approximately 1 PM revealed that the current eMAR did not interface with the facility's pharmacy, thus, there was no reconciliation process by the pharmacy. However, it was their understanding that R1's admission orders [REDACTED]. An additional interview with the E2 on 2/22/12 at approximately 12:45 PM revealed that the eMAR currently continued to allow staff to enter ml. versus the actual amount of the dose, thus, allowing the potential for recurrence of the problem. Due to the following system failures, R1 was administered an incorrect dose of [MEDICATION NAME] which resulted in R1 becoming unresponsive and requiring hospitalization for two days. - Failure to ensure validation of transfer medication orders on the hospital's "Discharge Instruction Sheet" as evidenced by lack of signature and date by R1's attending physician prior to implementation of transfer orders. - Failure to identify and clarify the incomplete order for the [MEDICATION NAME] 5 ml. on the facility's "Admission Order Sheet." - Failure of the facility's eMAR system which allowed transcribing of an incomplete order for the [MEDICATION NAME] without the dosage. - Failure to clarify and confirm the order for the [MEDICATION NAME] prior to administration of the medication on 12/8/11 at 6 AM. Findings were reviewed with E16, E4, and E2 on 2/27/12 at approximately 2:30 PM. 2. R3 had a physician order [REDACTED]. alternate with 2 mg. and signed by the attending physician (E17) on 2/8/12. On 2/8/12, R3 was administered [MEDICATION NAME] 2 mg. The order was transcribed by staff nurse (E8) on 2/9/12 at 1:30 PM (approximately 24 hours after the order was written by E17). Review of the electronic Medication Administration Record [REDACTED]. was administered at 9 PM. On 2/10/12, the eMAR documented that two (2), [MEDICATION NAME] 2.5 mg. was administered for a total of 5 mg. of [MEDICATION NAME] and that R3 was not administered the ordered dose of 2.0 mg. An interview with the staff nurse (E11) who documented that she administered the two, [MEDICATION NAME] 2.5 mg. on 2/10/12 was conducted in the presence of the Unit Manager, E18 on 2/24/12 at approximately 3 PM. E11 related that she did not administer two dose of [MEDICATION NAME] 2.5 mg. but rather one, [MEDICATION NAME] 2.5 mg. In addition, E11 verbalized that she did not administer the 2.0 [MEDICATION NAME] as ordered. Findings were reviewed with E16, E4, and E2 on 2/27/12 at approximately 2:30 PM.

Based on interviews, review of the clinical record, and other facility documentation it was determined that the facility failed to ensure that two (R17 and R20) residents out of 22 sampled were free of any significant medication errors. Findings include: 1. R17 was admitted to the facility on [DATE] at 5 PM with [DIAGNOSES REDACTED]. The following medications were included on the hospital's discharge medication summary as ordered by the discharging physician for R17 and were due to be administered the evening of 5/14/12: Cipro 250 mg (antibiotic) due 8 PM [MEDICATION NAME] 4 mg (blood thinner) due PM [MEDICATION NAME] 0.4 mg (prostate medication) due PM [MEDICATION NAME] 25 mg (beta blocker/heart medication) due PM [MEDICATION NAME] 10 mg (Alzheimer ' s medication) due PM A nurse's note dated 5/16/12 as a late entry for 5/14/12 documented "resident was admitted on [DATE] at 5 PM. Resident medication was not verified by the doctor due to inability to reach. Doctor was called from 5 PM until midnight but unreachable. Shift supervisor was notified of the situation. Resident meds were not given until the following morning right after doctor was reached and medications were verified ." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the interim medication box list revealed that Cipro, [MEDICATION NAME] and [MEDICATION NAME] were available in the facility. An interview on 5/25/12 at 11:30 AM with E6, (RN) and E5 (LPN) revealed E8 (RN), the nurse involved did not have much experience with admitting residents and would be receiving additional training. E6 and E5 further revealed that the doctor, E7 involved was also the medical director at that time and was no longer employed by the facility. An interview on 5/25/12 at about 2:30 PM with the E2 (DON) and other administrative staff revealed that E8 (RN) was not the supervisor on duty that night and an LPN, E9 was responsible for the supervisory duties that evening. An interview on 5/29/12 at about 10:30 AM with E2 revealed that E9 was not actually the supervisor on 5/14/12 but an LPN, E11 was the supervisor. E11 was not included in the medication incident report or the plan for additional training. These findings were reviewed with E1 (Administrator) and E2 (DON) on 5/25/12. 2. R20 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED].F.), [MEDICAL CONDITION] stage III, and [DIAGNOSES REDACTED]. R20 had an order dated 4/17/12 for [MEDICATION NAME] 7.5 mg. by mouth daily for A.F. Review of R20's May 2012 MAR indicated [REDACTED]. administration scheduled for 9 PM contained a licensed nurse's initials (E10) with a circle around the initials. The MAR indicated [REDACTED]. A Nurse's Note dated 5/18/12 timed 9:24 PM by E10 documented " ...unable to get [MEDICATION NAME] 7.5 for pt. (patient) med. (medication) out of stock and was reorder ... " The 5/18/12 "24 Hour Report" for the 3 PM-11 PM shift section was blank and contained no documentation regarding R20 not being administered the [MEDICATION NAME] and/or that the medication was reordered from pharmacy. On 5/22/12, the Nurse Practitioner (E12) documented an assessment of R20, however, there was no evidence that E12 was notified of the omission of the [MEDICATION NAME]. An interview with the writer of the above N.N. (E10) on 5/29/12 at approximately 8:45 PM revealed that she worked primarily on the 11 PM-7 AM shift and may have worked once a month on the 3 PM-11 PM shift. E10 verbalized that she informed the 3-11 Supervisor, E11 that the [MEDICATION NAME] was unavailable. On 5/22/12, E10 related that she was educated on what medications were available in the interim box. On 5/29/12 at approximately 2:45 PM, E11 was interviewed. E11 confirmed that he was the 3-11 shift supervisor on 5/18/12 and E11 verbalized that he did not recall that E10 informed him that R20's [MEDICATION NAME] was not available on 5/18/12. E11 related that if he was informed, he would have obtained the [MEDICATION NAME] from the facility's Interim Box. Although the facility failed to administer the [MEDICATION NAME] 7.5 mg. on 5/18/12, record review lacked evidence that the attending physician was notified. On 5/25/12 at approximately 11 AM, the surveyor was provided a copy of a policy and procedure titled "Medication Not Available" by E3 (Registered Nurse Staff Educator). The "Procedure" included: " 1. When a medication is not available from the pharmacy, the nurse should than attempt to secure the med from the starter box or emergency box. 2. If the med still is not available from either of these sources, call the physician to determine if an alternate treatment plan is required." Although the facility had [MEDICATION NAME] 7.5 mg. available via the interim box, the facility's system failed to ensure that this medication was administered to R20. In addition, when the facility became aware of the omission of the [MEDICATION NAME] on 5/21/12, the facility failed to call the attending physician per the facility's policy. Lastly, when the medication error of omission was identified on May 22, 2012 (approximately four days after the incident), the facility failed to complete an incident report until inquiry by the surveyor on 5/24/12. Above findings were reviewed with E1 (Administrator) and E2 (DON) on 5/25/12.

Based on record review and staff interviews, it was determined that for one (1) of eleven (11) residents reviewed, the facility failed to evaluate and analyze hazard(s)/risk(s) and failed to modify interventions to ensure that Resident #1 received adequate supervision and assistive devices to prevent accidents. R1 experienced an unsupervised fall on 8/10/10 and required hospitalization . Findings include: R1 was admitted to the facility on [DATE] for rehabilitation after a short stay in the local hospital for shingles; her [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R1 had short and long term memory problems, required extensive staff assistance with transfers and required a one person assist while walking in her room. On a Fall Risk assessment dated [DATE], R1 scored an 11 indicating she was at high risk for falls. A care plan was initiated to address R1 ' s " Potential for falls related to the use of psychotropic drugs and an unsteady gait " and interventions included a call bell within reach and reinforcement to call for assistance, low bed, landing strips, nonskid socks, mat alarm and tag alarm. On 8/09/10 at approximately 10:00 PM R1 ' s alarm was going off and a Certified Nursing Assistant (CNA) E11, responded and found R1 walking in her room with her alarm in her hand. R1 thought it was time to get up and get ready for the day. E11 oriented R1 to the time and advised her not to remove her alarms and put her back to bed. This information was noted on a facility obtained employee statement written by E11. At approximately 1:30 am on 08/10/10 the Registered Nurse (RN) Supervisor, E13, heard someone cry out for help and found R1 lying on the floor and complaining of pain in her left hip. E13 noted that the alarms were in place but were not hooked up or alarming. Emergency 911 was called and R1 was transferred to the hospital. A nurse ' s note dated 08/10/10 (untimed) stated R1 said she was getting up to get ready for the day. R1 was confused and oriented to person only. When the nurse, E14, asked R1 if she unhooked her alarms she stated " I must have " . A nurse ' s note dated 07/26/10 10:00 PM stated " Continued confusion with alarms. " The facility report submitted by E13 to the Division of Long Term Care Residents Protection (DLTCRP) dated 08/10/10 notifying them of the incident stated " Alarms did not sound however was witnessed since admission self removing alarms. " This report was not signed by the author but was identified by the facility staff as the previous Assistant Director of Nursing (ADON), E15. A statement obtained by the facility dated 08/10/10 from E11 regarding R1 ' s fall stated " she have taking alarm off before "(sic) . During a phone interview with CNA, E11, on 11/8/11 she stated she recalled the incident involving R1. E11 stated she usually worked the day shift (7-3) but had worked over the night of 08/09/10. E11 stated R1 had taken her alarm off earlier on the night previous to the fall and that R1 and her roommate would take their alarms off all the time. E11 stated she had cared for R1 during the day shift on 08/09/10 and R1 had taken her alarm off 4-5 times during the day shift. E11 stated that R1 would take her alarm off several times during the day shift and this occurred over several weeks. E11 stated she would tell whatever nurse was working about R1 removing her alarms. On a second interview with E11 on 11/09/11 when she was shown her statement dated 08/10/10 where she wrote " she have taking alarm off before "(sic) , E11 stated " yea, I remember her; she would take her alarms off " . E11 repeated that she had told the nurses about R1 removing her alarms. During an interview with E15 on 11/10/11 she stated on the morning following R1 ' s fall, during discussion with the " Fall Committee " of why the alarm didn ' t sound, CNA E11 overheard the discussion and advised her (E15) that R1 had removed her alarm. E15 stated this was her first knowledge of R1 removing the alarms. The facility failed to ensure that R1 ' s environment remained free from an accident hazard by failing to address an identified hazard of R1 removing her alarm over a period of time as identified by a facility caregiver E11.

Based on record review and interviews, it was determined that the facility failed to provide necessary treatment and service for two (R105 &R266) out of 36 sampled residents who had pressure ulcers (PU). The facility failed to involve the interdisciplinary team to accurately assess R105's risk for development of a new PU when R105 experienced a change in condition following a [MEDICAL CONDITIONS]. This failure resulted in lack of interventions being implemented and R105 acquired a new, unstageable left heel PU. The facility also failed to provide the necessary services in measuring and documenting in order to accurately assess and monitor R266's stage IV pressure ulcer on her left heel. The facility also failed to notify the interdisciplinary team to accurately assess and monitor R266's stage IV pressure ulcer. Findings include: 1. R105 was readmitted to the facility on [DATE] following treatment in a hospital for [MEDICAL CONDITION] and generalized muscle weakness. R105's additional [DIAGNOSES REDACTED]. Review of R105's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's ability to perform activities of daily living (ADL) had deteriorated from the previous assessment and the resident no longer ambulated, required total assistance of staff for bed mobility, was totally incontinent of bowel and bladder and was severely impaired for daily decision making. In addition, there was no documentation indicating that R105 had any pressure ulcer (PU). R105's Nursing"Resident admission assessment" dated 7/7/10 noted the resident did not have any skin impairment and that the skin was intact. Review of R105's "Braden Scale for Predicting Pressure Sore Risk" dated 7/6/10 revealed that R105 was assessed "17" or not to be considered at risk for developing PU Review of "Occupational Therapy (OT) Evaluation and Plan of Treatment" dated 7/7/10 documented "Skin integrity-reddened areas (bilateral heels boggy with blotchyness. Nsg. (nursing) notified and are providing an air mattress with orders to elevate heels when in bed)." In the summary of this evaluation, it indicated that R105 presented with total dependency for ADL's transfers and mobility due to recent onset of [MEDICAL CONDITION]. The evaluation noted for "risk factors-due to the documented physical impairments and associated functional deficits, the patient is at risk for cardiac insufficiency, decrease in level of mobility, increased dependency upon caregivers, increased agitation and decreased skin integrity." Upon completion of the above OT evaluation, the "Rehab. Screening Form" was completed by the above OT(E8). Review of the "Rehab. Screening Form" dated 7/7/10 indicated for "positioning equipment/splinting devices" and for "Skin assessment/Braden Score", to implement an intervention to "elevate bilateral heels." Subsequently, the "Transfer Status and Rehab. Communication Form" was completed by the above OT on 7/7/10. Review of this communication form noted for "precautions: elevate bilateral heels." This form documented the process in which this intervention would be implemented which included "original form would be placed in the medical record under "Restorative Section". In addition, a copy to the RNAC (Registered Nurse Assessment Coordinator) and charge nurse/unit manager. Nurse to transcribe orders to CNA (Certified Nursing Assistant) flow record. A copy of the Transfer Status form may also be attached to the CNA flow record." An interview with the OT (E8) who completed the above evaluation, "Rehab. Screening Form", and "Transfer Status and Rehab. Communication Form" on 8/11/10 at approximately 11:20 AM revealed that the interventions to elevate the heels and for the use of the air mattress was to relieve pressure from the reddened area of the heels noted during the 7/7/10 evaluation. Although E8 recalls communicating the need for these interventions verbally with a nursing staff member in the unit, E8 did not recall the individual's name. An interview with E5 (charge nurse) on 8/11/10 at approximately 10 AM confirmed that the intervention to elevate bilateral heels, as noted on the "Transfer Status and Rehab. Communication Form" dated 7/7/10 was not implemented, as evidence of lack of documentation of this intervention on the CNA flowsheet for July 2010. An interview with E3 (Assistant Director of Nursing/ADON) on 8/11/10 at approximately 4:30 PM confirmed that interventions recommended by therapy to elevate heels bilaterally on 7/7/10 were not implemented. In addition, there was no evidence that the facility proceeded to obtain and implement the use of an air mattress on 7/7/10, as documented by the therapy department. An additional interview with E2 (Director of Nursing/(DON) on 8/11/10 at approximately 5 PM confirmed that the facility failed to implement the interventions recommended by therapy on 7/7/10 to elevate R105's bilateral heels and to use an air mattress. However, E2 reiterated that since R105 was assessed as not at risk for development of PU (score of 17) using the Braden scale, no interventions to relieve pressure of the heels were implemented when R105 was readmitted to the facility on [DATE]. Lastly, E2 related to the surveyor that she was not aware until during this survey that the therapy department documented reddened heels on 7/7/10 when R105 was readmitted . Review of the weekly nursing Skin Rounds" on 7/13/10 noted skin was intact. Nurse's note dated 7/16/10 timed 2:30 PM indicated that E5 (LPN) was called to the therapy department to assess a necrotic area of R105's left heel measuring 3 cm. in length and 3.5 cm in width without depth. Review of the "Weekly Wound Assessment" initiated by E5 on 7/16/10 noted R105 had a nosocomial (facility acquired) pressure ulcer of right heel. The wound was reassessed on 7/22/10, 7/28/10, 8/5/10 and 8/11/10. Interviews with both E5 (LPN) and the Staff Educator (E6) who documented the above reassessments on 8/11/10 at approximately 11 AM revealed that they incorrectly noted that the wound site was right but rather, it was the left heel. Review of the physician's orders [REDACTED]. to bilateral heels every shift, and to apply topical dimethicone to sacrum every shift and as necessary. Although R105 had acquired a PU of the left heel on 7/16/10, the facility failed to implement intervention to off load heels until 7/21/10. Review of the "Wound Evaluation Form" completed by E7 (nurse practitioner) dated 7/22/10 and 7/29/10 noted left heel "suspected deep tissue injury" measuring 3 cm. (L), 3 cm. (W) and no depth and 2.5 cm (L), 2.5 (W) and no depth respectively. In the "Additional comments" Pt. (patient) on air loss mattress. Suspend heels with foam booties. There is a possibility of worsening secondary to suspected deep tissue injury." An interview with E7 (nurse practitioner) on 8/12/10 at approximately 9:50 AM revealed that her first assessment of R105's left heel was on 7/22/10, approximately 15 days after readmission on 7/7/10. E7 related that completion of the Braden scale should be interdisciplinary including the therapy department. During the interview, E7 was questioned whether the left heel impairment was deep tissue injury (DTI). E7 reiterated that DTI is suspected and that confirmation of DTI would only be via ultrasound imaging during the initial assessment of the wound. Since E7 currently does not utilize ultrasound imaging in her practice, E7 related that she is unable to confirm that this is or is not a DTI. 2. The facility's policy and procedure for "Pressure Ulcer Prevention and Management" revealed " Purpose : To identify individuals at risk for skin breakdown and develop an ongoing plan of care for prevention, recognition and treatment of [REDACTED]. Involve Interdisciplinary Team as appropriate to ensure nutrition, hydration and all other interventions are implemented timely in order to prevent alterations in skin integrity as well as heal any problems that may occur. Implementation 1. Any resident with a total score of 16 or less on the Braden Scale are considered to be at risk for developing pressure ulcers.... 8. All residents scoring 16 or less on the Braden Scale will be reviewed in weekly high risk meeting to ensure appropriate nutrition and pressure relieving interventions/strategies are implemented. "Wound Identification Procedure: 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. " R266 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented R266 was cognitively intact for daily decision making. R266 required one person to assist with bed mobility, dressing, personal hygiene and bathing. She required two people to assist with transfers and toilet use. R266 was documented as having 2 stage II pressure ulcers and 1 stage 4 pressure ulcer. Review of R266's readmission "Resident Admission Assessment" form dated 7/22/10 documented for skin condition "bilateral scattered bruises arm, ... Left heel red with black forming... Right buttock 2 1/2 cm x 1/2 cm abrasion left buttock 2 cm x 2 cm." Review of the Braden Scale for Predicting pressure sore risk dated 7/22/10 documented R266 was scored as 17. ("Any resident scoring 16 or less is considered High Risk, A therapy Screen and Diet Alert must be initiated.") The Braden Scale did not rate R266 as a high risk for pressure sore even though the facility documented R266 had 3 pressure ulcers including a stage IV on re-admission to the facility. Review of R266's nurses notes revealed on 7/22/10 "The left heel is red with black areas..." 7/27/10 3;30 PM "...Allevyn heels in place." On 7/28/10 6:20 PM "... heel lift boot to left heel to prevent breakdown..." On 7/23/10 the physician ordered "air mattress, skin prep to heels bid (twice a day)." Review of the Skin Rounds Sheets for R266 revealed there was no documentation describing the condition of the skin and all bony prominences or measurements on the form for two weeks. Review of the wound sheets revealed on 8/5/10 R266 had her first wound documentation and measuring 14 days after it was identified. Review of the "Wound Evaluation Form" dated 8/6/10 from E7 (nurse practitioner) revealed "Stage unable to determine Highest Stage: unable to determine thickness (left blank)... Additional comments: Education provided to patient on off loading, pt. verbalizes understanding. Encourage nutrition and hydration. Pt states she does not like wearing foam booties in bed, but readily agrees to do so to heal blister. Blister appears to be reabsorbing, anticipate full healing with no complication with continued off loading." On 8/11/10 at 10:15 AM interview with E6 (facility wound nurse/educator) confirmed that she did not measure R266's left heel pressure ulcer until 8/5/10. She was not notified by the staff that R266 had a stage IV pressure ulcer to her left heel. E6 also stated that when the Braden Scale is 16 or below she is notified then she notifies the nurse practitioner/ wound nurse. However because the Braden Scale did not trigger the staff did not notify her of the wound. She continued to state that the RNAC notified her of the wound and she immediately assessed the wound. E6 continued to state that the wounds on R266's sacrum were healed. The facility failed to document weekly measurements and assess R266's left heel wound to ensure appropriate interventions were in place to enhance healing.