Every finding on record at Cadia Rehabilitation Silverside

Based on interview, observation, and review of clinical record, surveillance video and other records as indicated, it was determined that for one (R1) out of three residents reviewed for respiratory care, the facility failed to ensure that nursing staff provided appropriate care and services to R1, a resident with a diagnosis of congestive heart failure who had an acute respiratory change of condition that started after dinner on 8/2/26. While facility staff reported to the assigned nurse multiple times that R1 was coughing, had increased mucus but could not cough it up, and had trouble breathing, the nurse failed to recognize and act upon R1's acute respiratory change of condition by auscultating R1's lungs during her assessment, or to attempt to suction his airway for mucus/oral secretions. 911 was called by facility staff at 2:22 AM on 8/3/26. R1's airway was suctioned by EMS personnel before applying a CPAP to emergently transport resident to the hospital. Due to this failure, an Immediate Jeopardy (IJ) was called on 8/10/26 at 3:03 PM, with an abatement date of 8/11/26 at 5:08 PM. Findings include:Review of R1's record revealed: 7/20/26 - R1 was admitted to the facility with a diagnosis that included, but was not limited to, congestive heart failure. 7/21/26 - R1's care plan for congestive heart failure had the intervention to Monitor/report PRN [as needed] any s/sx [signs or symptoms] . SOB [shortness of breath] upon exertion . dry cough . crackles and wheezes upon auscultation of the lungs . increased heart rate . 7/28/26 - A cardiology note by C1 (PA) documented, . Physical Exam. Pulm [pulmonary] normal respiratory effort, CTA [clear to auscultation] bilateral. 7/30/26 - A follow-up note by E10 (NP) documented R1's . Respiratory: Symmetrical bilateral chest expansion, no accessary muscle use, Lungs CTA. The facility's surveillance video (without audio) in R1's hallway revealed the following:Sunday, 8/2/26-at 8:12 PM, R1's roommate exited the room and self-ambulated using his wheelchair down the hallway towards the nurse's station.-at 8:13 PM, E7 (CNA) exited R1's room, spoke to the other CNA sitting at the COW in the hallway, then walked down the hallway towards the nurse's station. Other CNA gets up from COW and entered R1's room.-at 8:14 PM, E6 (RN Supervisor) walked down hallway from the nurse's station and entered R1's room. The other CNA exited the room into the hallway. E5 (RN) was observed pulling the medication cart from the nurse's station into the hallway and then walked to R1's room and entered. E5 exited R1's room and returned to the medication cart.-at 8:17 PM, E6 (RN Supervisor) exited R1's room and stopped at the medication cart where E5 was standing to dispose of something in the medication cart trash. E6 continued to the nurse's station and E5 (RN) followed. E7 (CNA) was observed standing at the nurse's station and turned and walked down hallway and reentered R1's room.-at 8:19 PM, E7 (CNA) exited R1's room and walked down the hallway.-at 8:36 PM, R1's roommate entered the room.-at 9:18 PM, E5 (RN) entered R1's room after E7 (CNA) reentered.-at 9:21 PM, E5 (RN) exited from R1's room and returned to the medication cart. E7 (CNA) was observed pushing R1's wheelchair with him sitting upright out to the hallway to turn him around and pushed him back into his room.-at 9:37 PM, E5 (RN) entered R1's room.-at 9:38 PM, E5 (RN) exited R1's room.-at 11:33 PM, E8 (CNA) entered R1's room with cup of water, exited, then entered the storage room and returned to room with unidentified object in her hand and reentered R1's room.-at 11:37 PM, E8 (CNA) exited the hallway and continued to the nurse's station.-at 11:42 PM, E8 (CNA) reentered the hallway, walked past R1's room then returned and entered R1's room.-at 11:44 PM, E8 (CNA) exited R1's room.Monday, 8/3/26-at 1:32 AM, E8 (CNA) entered R1's room.-at 1:35 AM, E8 (CNA) exited R1's room.-at 1:49 AM, E8 (CNA) walked down the hallway, looked over toward R1's room and walked to the nurse's station.-at 1:54 AM, E8 (CNA) walked down hallway to the back hallway out of camera view. E5 (RN) was observed donning gloves while walking behind E8, stopped briefly to look in R1's room from the hallway, then continued to walk towards the back hallway out of camera view.-at 2:01 AM, E8 (CNA) walked down the hallway with linen and disposed it in soiled room then walked towards the back hallway out of camera view. Observed E5 (RN) walk from the back hallway and enter R1's room as E8 was passing her in the hallway.-at 2:03 AM, E5 (RN) exited R1's room and walked toward the back hallway out of camera view. E5 then was observed reentering R1's room holding a towel.-at 2:05 AM, E5 (RN) exited R1's room and walked to the nurse's station, retrieved vital sign equipment and returned to R1's room.-at 2:10 AM, E5 (RN) exited R1's room and entered the oxygen storage room at end of the hallway prior to the nurse's station.-at 2:11 AM, E5 (RN) exited oxygen storage room, nothing in hand, and walked to the nurse's station.-at 2:12 AM, E5 (RN) exited from the nurse's station (where the supplies closet is located) with oxygen tubing in hand, stopped at the oxygen storage closet and retrieved an oxygen concentrator and pushed it to R1's room. Observed E6 (RN) walking behind, entered R1's room briefly (approximately 8-9 seconds in the room) then exited and walked back to the nurse's station.-at 2:16 AM, E5 (RN) exited R1's room and logged on to the COW located in the hallway next to R1's door.-at 2:17 AM, E5 (RN) was using the COW then logged off and reentered R1's room.-at 2:20 AM, E5 (RN) exited R1's room and walked towards the back hallway then reentered R1's room briefly. E5 exited R1's room and walked to the nurse's station.-at 2:22 AM, E5 (RN) exited the nurse's station with NRB mask, entered the oxygen storage room then exited and returned to the nurse's station. E5 was observed carrying the oxygen tank and NRB down the hallway into R1's room.-at 2:25 AM, E5 (RN) exited R1's room, logged onto the COW, looked at something in the electronic health record, logged off and reentered R1's room.-at 2:28 AM, E6 (RN Supervisor) walked from the nurse's station into R1's room with paperwork.-at 2:30 AM, E6 (RN Supervisor) exited R1's room and walked back to the nurse's station.-at 2:31 AM, E5 (RN) exited R1's room, looked at something on the COW then reentered R1's room.-at 2:32 AM, BLS crew members walked past nurse's station, down hallway and into R1's room.-at 2:33 AM, E6 (RN Supervisor) walked down hall with paperwork and entered R1's room.-at 2:35 AM, E6 exited R1's room and returned to the nurse's station.-at 2:36 AM, ALS (Paramedics) walked past nurse's station, down hallway and into R1's room.-at 2:38 AM, BLS crew member exited R1's room and E5 (RN) walked to nurse's station to retrieve suction equipment.-at 2:40 AM, first BLS crew member at nurse's station and second BLS crew member walked down hallway to elevator. ALS paramedic walked out toward the back hallway and spoke to E8 (CNA). E8 walked toward the nurse's station. ALS paramedic reentered R1's room.-at 2:49 AM, BLS and ALS personnel exited room with R1 and walked to the elevator. 8/3/26 3:00 AM - A nurse's note by E5 (RN) documented, Resident observed in semi flowers (sic) position experiencing acute shortness of breath [SOB]. T-98.9 [temperature], BP-128/78 [blood pressure], P-108 [pulse], R-22 [respiratory rate], SPO2 [pulse ox] 84% RA [room air]. Oxygen 2L [liters] NC [nasal cannula] applied. After 10 minutes resident pulse ox was 90-93%. Heart rate -98, respiratory 18. After 15-30 minutes resident continues to experience SOB and observed with use of accessary muscle to breathe. Nonrebreather mask applied on 15L, pulse oximetry noted to be 88%. Small amount of white mucus noted on the mouth. NP [nurse practitioner] on call notified and n/o [new order] to send resident out to hospital for further evaluation. 911 initiated and resident sent out. Message left for [FM1, family member] and [FM2, family member] notified. 8/3/26 3:21 AM - The hospital emergency department record documented, . Noted to have gurgling respirations and hypoxia in the 70s. On arrival, patient with temperature of 33.5 [convert to 92.3 degrees Fahrenheit], tachycardic in the 110s, tachypneic in the 30s, saturating in the 80s on 100 % FiO2. Currently on Bipap. Suctioned extensively, respiratory therapy at bedside. Patient to be admitted to ICU [intensive care unit] for ongoing monitoring and care. 8/3/26 4:11 AM - The Prehospital Care Report completed by BLS personnel documented, . On scene, pt [patient] was found in his room lying in bed. Staff reported pt was complaining of SOB, had sputum coming out of his mouth, and his pulse ox was in the 80s on 15 LPM via NRB. Staff advised he had been like this for an hour, and the sputum was a white color. Staff reported pt to have a hx [history] of CHF. At this time, breath sounds were assessed, and a set of vitals obtained. Fluid could be heard in the lungs. CPAP was prepared. Shortly after, ALS arrived on scene. Verbal report was given to ALS. ALS requested to hold off on CPAP and for the pt to be suctioned first. Crew attempted to retrieve facility suction, but facility suction was missing components. Crew quickly retrieved suction from the truck and brought it to the pt. The pt was first moved to the stretcher via sheet lift and secured in. The pt was suctioned, and then CPAP was placed on the pt. 8/3/26 - The Prehospital Care Report completed by ALS personnel documented, . The patient's airway presented with pink, frothy sputum and gargled respirations that were emitting from his mouth, down his chin. He had a strong radial pulse. Staff reported the patient had been this way for about an hour, reported they had wiped his mouth but did not attempt to suction. The patient's mouth was suctioned, clearing his airway and CPAP was then placed. The patient was moved to the stretcher and secured in a fowler's position. During transport the patient was monitored by ALS. The patient's SpO2 improved with suction and CPAP, breathing became less labored. 8/5/26 11:50 AM - Observations of the facility's crash carts on the first and second floors revealed readily available suction equipment sitting on top. 8/7/26 7:34 AM - During an interview, E5 (RN) confirmed that she worked 7 PM to 7 AM on 8/2/26 into 8/3/26. E5 stated that when she was doing rounds at 2 AM, she realized that R1 was short of breath. E5 stated that she obtained vital signs and his pulse ox was 86-88% on room air and blood pressure was normal. E5 stated that she retrieved the oxygen concentrator and applied 2 Liters of oxygen via nasal cannula, which resulted in R1's pulse ox to increase 90-93%. E5 stated that she stayed with the resident monitoring his vital signs. E5 stated that R1 was still having shortness of breath and she increased the oxygen to 3-4 Liters. E5 stated that she observed that R1 was using his accessory muscles and struggling to breathe. E5 stated that she got the non-rebreather (NRB) mask and oxygen tank and administered 15 Liters of oxygen. E5 stated that she grabbed the portable oxygen tank from the crash cart in the nurse's station as there was none in the oxygen supply room closet. E5 stated that she notified her RN Supervisor [E6] and she assessed him and called 911. E5 stated that E6 was there in the room before the nasal cannula was placed. E5 stated that she checked R1's mouth and there was nothing. E5 stated that before I placed the NRB, there were no oral secretions. E5 stated that the paramedics arrived shortly after I placed R1 on the NRB. E5 stated that she saw a small amount of white secretions on the left side of the mouth with the NRB on R1. E5 stated that R1's breathing difficulty started 20-30 minutes before EMS arrived. E5 stated after the second group of EMS personnel arrived, they asked for suction equipment. E5 stated that she went to the supply room and nothing was there. Then I went to the crash cart, grabbed it and gave it to the EMS personnel. E5 stated that we didn't have a canister with it. E5 stated that E6 (RN Supervisor) went downstairs to get a canister. E5 stated that by the time [E6] brought the canister EMS were rolling [R1] out. E5 stated that she didn't suction him because he didn't have any secretions. In response to how often did E5 check on R1 during her shift, E5 stated that she saw him at 8 PM as he was sitting in his wheelchair; administered medications at 9-9:30 PM, and he was not able to verbalize his complaints; and then she tended to her other residents. When E5 was asked if a CNA said anything to you, she responded that the CNA told her [R1] was having trouble breathing around 2 - 2:15 AM. E5 said that the CNA told her when I was helping her change another resident, then I went in to see him. When asked if E5 auscultated R1's lungs during her assessment, she responded No. When asked who called 911, the on-call doctor and family, she responded E6 (RN Supervisor). E5 stated that she was focusing on the resident. E5 confirmed that this was her first time taking care of R1. 8/7/26 8:52 AM - During an interview, E6 (RN Supervisor) stated that she went to R1's room and R1 was sitting up in bed with NRB. E6 stated that R1 was in respiratory distress and she did not like how he looked. E6 stated R1's pulse ox was 70s and breathing heavy. E6 stated that she didn't see any need to suction. E6 stated that she called 911 and ambulance came immediately. E6 stated that at some point E5 (RN) was looking for suction canister. E6 said she immediately ran downstairs and got suction canister. When E6 was asked if she assessed R1, she responded that E5 was a competent RN. 8/7/26 10:00 AM - During an interview, P1 (ALS paramedic) stated that R1 had fluid in his lungs and in his mouth that was running down his chin and he needed to be suctioned. P1 confirmed that the facility's suction equipment was missing a component. 8/7/26 1:00 PM - During an interview, E7 (CNA) confirmed that she worked 3 PM to 11 PM on 8/2/26. E7 stated that R1 was fine prior to dinner. E7 stated that R1 started coughing a lot and had a lot of mucus after dinner from then on throughout the shift. E7 described R1's coughing as hardy with his mouth closed. E7 stated that she told E5 (RN) and E6 (RN Supervisor) that he had mucus and kept coughing with a closed mouth. E7 stated that they went to take a look at him. E7 stated that R1's coughing was new as she had worked with him before. 8/10/26 6:40 AM - During an interview, E8 (CNA) stated that she worked 11 PM to 7 AM on 8/2/26 into 8/3/26. As background, E8 stated that she recently completed school for LPN. E8 stated that when she was passing water, she heard R1's mucus and told R1 to cough it up but he couldn't cough it up. E8 stated that she gave R1 an emesis bin, sat R1 up and elevated the head of the bed. E8 stated that she kept telling R1 to cough it out. E8 stated that she told E5 (RN) about the R1's mucus, he was unable to cough and stated that he needed to be suctioned. E8 described R1's mucus as it sounded bad and he was struggling to breathe. E8 stated that E5 told her that R1 wasn't prescribed medication for mucus. E8 stated that she told E5 a second time and E5 went in R1's room, checked his pulse ox and told her that they were sending him out. E8 stated that when the EMS personnel arrived, they asked her for the suction canister, and she tried to look for one. E8 stated that she asked E9 (LPN) who was sitting in the nurse's station and E9 responded she didn't know. E8 stated that E5 was looking for a suction canister. E8 stated If you heard him [R1], the resident needed to be suctioned. 8/10/26 3:03 PM - An Immediate Jeopardy was called due to the facility failure to ensure that nursing staff provided appropriate care and services to R1, a resident with a diagnosis of congestive heart failure who had an acute respiratory change of condition that started after dinner on 8/2/26. While facility staff reported to the assigned nurse multiple times that R1 was coughing, had increased mucus but could not cough it up and had trouble breathing, the nurse failed to recognize and act upon R1's acute respiratory change of condition. 8/11/26 9:31 AM - During an interview, P2 (BLS crew member) confirmed that R1 was breathing fast and gurgling. 8/11/26 11:01 AM - During an interview, P3 (BLS crew member) confirmed that upon arrival that sputum was coming out of mouth, and you could see it through the NRB mask. P3 stated that there was no suction equipment in the room. 8/11/26 1:25 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (Corporate RN) and E4 (Corporate RN). 8/10/26 5:19 PM - The facility's abatement plan for the Immediate Jeopardy included: The Medical Director was made aware on 8/10/26.All current in-house residents were reviewed to identify if any were experiencing an acute change in respiratory condition that prompted further assessment. No residents were identified. This was completed on 8/10/26 at 4:15 PM.Facility initiated immediate education with licensed nurses on responding timely to acute changes in respiratory condition, performing respiratory assessments including auscultation of lungs, suctioning if needed, and documentation of the change in condition and their assessment. Competencies will be completed with licensed nurses. Education will be completed by end of day 8/11/26. Ongoing education will be completed with any remaining staff prior to the start of their next shift. 8/17/26 8:25 AM - A follow-up on-site visit occurred to verify the facility's IJ abatement plan. Surveyor reviewed education provided, competencies of licensed nurses, and interviewed ten (10) licensed nurses, including unit managers. The facility's IJ abatement date and time was 8/11/26 at 5:08 PM.

Based on interview and record review, it was determined that for one (R1) out of three residents reviewed for respiratory care, the facility failed to accurately document R1's edema on the daily skilled charting. Findings include: Cross refer F838 The facility's policy and procedure entitled Skilled Nursing Documentation, last reviewed 1/13/26, revealed:- POLICY: It is the policy of Cadia Healthcare to maintain clinical resident records in accordance with accepted professional standards and practices.- PROCEDURE: Resident care is documented in the electronic medical record. Documentation is completed at least daily to support skilled services. Documentation must reflect the clinical and medical necessity for the resident's stay. Documentation will illustrate resident's progress toward nursing and therapy goals. Review of R1's record revealed: 7/20/26 11:48 PM - R1's admission assessment by E11 (RN/UM) documented that he had bilateral lower extremity +3 pitting edema. 7/21/26 - R1's care plan for congestive heart failure had the intervention to Monitor/report PRN [as needed] any s/sx [signs or symptoms] . dependent edema of legs and feet. 7/26/26 - The admission MDS assessment documented that R1 had an active diagnosis of congestive heart failure. 7/28/26 - A cardiology consult note by C1 (PA) documented under Physical Exam that R1 had 3+ edema into bilateral thighs and Weight has been stable at 178 pounds at our facility which is consistent with hospital weight. Review of the daily skilled charting by the following six (6) nurses with respect to R1's edema revealed:-E12 (LPN) documented no edema on 7/22/26 12:03 PM and 2:23 PM;-E13 (LPN) documented no edema on 7/23/26 11:24 AM;-E14 (LPN) documented no edema on 7/24/26 3:15 PM, 7/25/26 2:49 PM, 7/26/26 3:10 PM, 7/28/26 3:04 PM, 7/29/26 3:30 PM, and 7/31/26 3:23 PM;-E15 (LPN) documented no edema on 7/27/26 10:41 AM;-E16 (LPN) documented no edema on 7/30/26 2:40 PM; and-E17 (LPN) documented no edema on 8/1/26 2:02 PM and 8/2/26 7:36 PM 8/7/26 1:00 PM - During an interview, E7 (CNA) stated that R1 had bilateral lower extremity edema. 8/10/26 3:25 PM - During an interview, the inaccurate daily skilled charting with respect to R1's lower extremity edema by six nurses for twelve consecutive days (12) were reviewed with E2 (DON). 8/11/26 1:20 PM - Finding was reviewed during the exit conference with E1 (NHA), E2, E3 (Corporate RN) and E4 (Corporate RN).

Based on interview and documentation review, the facility failed to ensure the facility assessment described the staff competencies and skill sets that were necessary to provide the level and types of care needed for the resident population, specifically for CHF residents. Findings included: Cross refer to F684 Review of the Facility Assessment Silverside 2025 - 2026 revealed the following:-under Section B. Acuity-Disease, Condition, & Treatments, Heart Failure (CHF) diagnosis accounted for 30.5% of Admissions/Stays and were at a Very High Frequency Relative to Benchmark; and-under II. Staffing, Training, Services & Personnel, B. Acuity-Diseases, Conditions, & Treatments. Pulmonary. Staff Training/Competencies/Skill Sets Evaluated. Suctioning. Staff Training/Competencies/Skill Sets Evaluated. 2. Staff training/competency/skills sets: Staff Training/Competencies and skills sets as required: All nursing staff that provide direct care are licensed or certified per their roles. The facility provides new hire orientation and annual mandatory training. All staff receive education related to the following: Customer Services, Workplace Harassment, Cultural Competence, Corporate Compliance, Fire Safety, Disaster Response, Oxygen Management, Tag out/Lockout, Hazardous Material Handling, Resident Rights, Trauma Informed Care, Communication of Resident Change in Condition, Abuse, Dementia, Infection Control, Body Mechanics, HIPAA, QAPI, and Risk Management. 8/11/26 11:35 AM - During a combined interview, E3 (Corporate RN) and E4 (Corporate RN) were asked to show in the facility assessment how the facility evaluates staff competencies and skills, upon hire and routinely thereafter, specifically for CHF residents. Finding was immediately confirmed. The facility assessment failed to describe how staff competencies and skills sets are evaluated by the facility of those who are providing care to CHF residents. 8/11/26 1:20 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 and E4.

Based on observation, interview, record review, and review of other documentation as indicated, it was determined that for three (R12, R63, and R76) out of three residents sampled for accidents, the facility failed to ensure that the residents received adequate assistance and supervision to prevent accidents to the extent possible. R12, a completely dependent resident, sustained a fall from the bed to the floor while a staff member was providing care and sustained a right ankle fracture. R63, a resident who required extensive assistance for transfers, sustained L2 and L3 fractures during a transfer from the shower bed to the bed and was sent emergently to the hospital. R76, a resident who was completely dependent on staff for transfers, sustained an injury to the top of his head during a transfer from a mechanical lift to his motorized wheelchair. R76 was sent emergently to the hospital and received three staples to his scalp. Findings include: Cross Refer F658 1. R12's clinical record revealed: 1/2/19 – R12 was admitted to the facility with the following diagnoses, including, but not limited to, anoxic brain injury, abnormal posture, multiple contractures of the upper and lower limbs and idiopathic progressive neuropathy. 10/1/25 – A review of R12's quarterly MDS documented R12 required substantial maximum assistance to roll left and right in the bed. 12/30/25 – A review of R12's quarterly MDS documented R12 required substantial maximum assistance to roll left and right in the bed. 12/3/25 1:00 AM – A facility reported incident to the division documented [R12] sustained fall 12/3/25 complaint of ankle pain later in day. Xray obtained, results unclear. Repeat film obtained on 12/5/25. 12/3/25 8:24 AM – A review of R12's post fall assessment documented by E29 (ADON) What was resident doing just prior to fall. Care being provided. Additional comments on R12's post fall assessment documented Proper positioning of resident. 12/3/25 8:33 AM – A progress note authored by E18 (LPN UM) documented Therapy reported to nursing R12 reported sliding out of bed when care was being provided. E18 also documented [R12] stated, Slid out of bed and was in a seated position on R12's bottom. 12/4/25 11:15 AM – A review of R12's initial right ankle Xray report addendum documented This is a limited study. There is a question of a fracture at the tip of medial malleolus seen on the AP view. Recommend follow up films including oblique views to see if a fracture is present or not. 12/5/25 12:48 PM – A review of R12's right ankle Xray findings documented Compared to study performed on 12/4/25 concluded stable fracture. 12/5/25 2:37 PM – A progress note documented Xray to right ankle completed and noted with stable fracture. Reviewed with E19 (NP) new order received to send [R12] to hospital for evaluation. FM2 made aware and in agreement. 12/5/25 11:07 PM – A progress not documented [R12] received back for the hospital at 10:48 PM as per hospital report, resident has a fracture to ankle, rest, ice, elevate ankle to help it heal. Ibuprofen or Tylenol to be taken as needed for pain. 12/12/25 – A facility five day follow up report to the division documented Through interviews with staff members it was determined that at approximately 1:00 AM, while resident was receiving care, R12 was sliding off the side of the bed and was lowered onto the floor in a seated position. 4/21/26 2:13 PM – A care plan for R12 initiated 4/1/20 documented [R12] is at high risk for falls related to cognitive impairment, contractures urinary and bowel incontinence, psychotropic and opioid medications and history of actual falls. 4/22/26 11:47 AM – During an interview E13 (LPN) reported [R12] required two person assistance total care and has always been a two person assist with care and transfers. 4/23/26 12:39 PM – During an interview with E25 (OT) reported [R12] reported rolling out of the bed to E25 during care. E25 stated, [R12] is dependent for bed mobility. E25 also stated, [R12] would not have been able to roll or slide off the bed and does not have the ability to do that [R12] is dependent for bed mobility. 4/23/26 12:45 PM – During an interview E19 (NP) reported [R12] was complaining of pain and when they did a further investigation it was founded [R12] had fallen out of bed during care. 4/23/26 3:11 PM – During a phone interview E24 (CNA) reported [R12's] call light was on I went in the room [R12] had thrown up, I was looking around to see if towels were in the room, I wasn't really paying attention, but I was standing on the right side of the bed and then [R12] started sliding off the bed to the left. I ran to try to catch [R12] but it was too late, so I lowered [R12] on the floor in a seated position. I ran to the door and called E14 (LPN). We put [R12] back in bed with the Hoyer lift. 4/23/26 3:30 PM – During an interview E29 (CNA) reported I have to physically assist [R12] to turn in bed [R12] is not able to move in the bed without help [R12's] legs don't move they just are there laying on top of the bed [R12] is total care. 4/24/26 9:40 AM – During an interview E15 (ADON) reported [E24] went into [R12's] room and [R12] had thrown up. [E24] was trying to clean up [R12] and had a towel under the resident's neck [R12] started sliding off the bed [E24] was on the other side of the bed and ran over to try to catch [R12] but ending up placing [R12] on the floor. E15 then stated, I'm thinking [R12] was too far over on the left side of the bed. 4/27/26 1:11 PM – During a phone interview E14 (LPN) reported I was called by E24 and told [R12] had fell I assessed [R12] and then assisted E24 with transferring the resident back to bed and with care. I wasn't there when the fall happened, I just wrote on the witness statement what E24 said happened. The facility failed to ensure R12 received adequate hands on assistance and supervision for a resident that required substantial maximum assistance with bed mobility when R12 slid out of the bed and had to be lowered to the floor and sent to the hospital for treatment and evaluation for a right ankle fracture. 2. R76's clinical records revealed: 6/2/22 – R76 was admitted to the facility with diagnoses, including but not limited to, brain bleed, seizure disorder and craniotomy which resulted in left sided paralysis. 6/13/22 – R76's transfer care plan documented, The resident requires Mechanical Lift (Hoyer) with 2 staff assistance for transfers. 9/3/24 – R76's care plan (revised 9/4/24) documented, [R76] is on anticoagulant therapy.monitor for bleeding. 9/28/24 – R76's medications included Xarelto 10 mg (anticoagulant) daily for deep vein thrombosis. 3/3/26 – R76's quarterly MDS assessment documented a BIMS score of 15, indicating a completely intact cognitive status, and a complete dependance on staff for all bathing and transfer needs. 3/31/26 5:00 PM – R76's clinical record included, Notified by the CNA that during two persons transfer with Hoyer lift in the shower room, the top of the lift made contact with his head. He has a small laceration to the top of his head, and c/o [complained of] neck pain 9/10. Resident stated, Hoyer lift came down on top of his head during transfer. 4/1/26 1:00 AM – R76's physician's record documentation included, . Sustained a head strike from a Hoyer lift. Patient states that he was being lifted out of the shower back into his wheelchair when the Hoyer lift collapsed onto his head. It struck him on the top of his head. He did not lose consciousness. He did not sustain any other injuries. Since the injury he has had pain on the top of his head . He endorses pain here along with neck pain.Given concern for intracranial hemorrhage [brain bleed] and particular because of his Xarelto use, CT head and C-spine was completed. R76's medication administration record from 4/1/26 to 4/19/26 revealed the use of pain medications for 17 out 39 opportunities for complaints of head and neck pain at a level between 7 and 9. 4/21/26 9:00 AM – During an interview, R76 stated, After my shower, the two aides used the lift to move me from the shower bed (in the shower room) to my chair. The hooks of the lift were not properly hooked to the bars, and this caused the front of the lift to become unbalanced and tilt backwards and I was dropped onto the chair. I was glad that the chair was there, or I would have fallen to the floor. This movement caused the bars of the lift to fall on top of my head. This is where I had the craniotomy. He indicated the top of his head and stated, My head and neck hurt now, and I have been taking pain medicine. The Surveyor asked the resident about other times when he was showered and how he got back into the chair. R76 stated, They usually bring me back into the room in the shower bed and transfer me to the bed and get me dressed in the bed. This has never happened to me before. I don't think the lift was operated correctly because the lift was not moving when they tried to put me in the chair and the bars fell on my head. 4/22/26 1:30 PM – During a telephone interview, E5 (CNA) stated, I helped [E6] (CNA) get [name of resident] from the wheelchair onto the shower bed. We used the purple lift. I left to do my work and then went back to check on the resident and [E6] a little later and saw that the resident had received his shower, was dressed and ready to get into the wheelchair. The sling was hooked up to the lift and [E6] was using the control to guide the lift. I was holding the sling to help guide him to the wheelchair. [E6] started to move the lift, it came above the wheelchair, and it looked like it was stuck because it wouldn't move. The way the lift was positioned, it looked like it was going sideways to the wheelchair. I told [6] that this does not look right and tried to pull him [R76] back to correct it, but the lift came upwards, and the bar hit him on his head. We got him into the chair and got the nurse. 4/22/26 3:30 PM – During an interview, E6 stated, I have worked at the facility for about 3 months now. I showered and dressed [R76] and hooked the sling up to the Hoyer lift. [E5] came in to help me get him into the chair. [E5] was guiding the resident in the sling, and I was using the control and moving the lift. I lifted him up and was putting him in the chair and his weight shifted causing the lift to tip back and the bar hit him on top of his head. I put him in the chair and told the nurse. 4/23/26 10:00 AM – The facility provided the Surveyor with a facility report dated, 4/1/26, and entitled Inspection Report – ARJO HOYER LIFT. A review of the document revealed that the lift was rated to use safely with patients up to 500 lbs. The lift was inspected and was found to be in proper working condition and met all operational and safety requirements, no repairs were required at that time. 4/23/26 11:00 AM – During an interview, the Surveyor asked E30 (PT) who makes the determination for the residents' transfer statuses. E30 stated, Therapy evaluates residents and writes the order for their transfer status based on what equipment and how much help they need to move from the bed to the wheelchair or the wheelchair to the bed and other surfaces. [R76] was not able to bear weight on his feet, and the Hoyer lift was determined to be safe to use for his transfers. The Surveyor asked E30 if it was likely that R76's head injury could have been caused during the transfer because his weight shifted. E30 stated, Not if the lift was used properly. R76's weight was 167.8 lbs. on 3/28/26. 4/24/26 2:00 PM – During an interview E3 (COO) stated, It is the facility's position that the incident occurred when the resident's weight shifted during the transfer. We reviewed the incident and the staff involved received education and training on safe transfers. It was an unavoidable accident. 4/27/26 2:15 PM: The facility provided the Surveyor with a document entitled, April 2026, entitled, Facility Position on Mr. [initial of R76's last name.] The document included, .The facility met all four key elements to minimize accident hazards, and the accident was UNAVOIDABLE. [Name of resident] weight shifted during at the last moment while transitioning from a supine to a sitting position in the sling of the mechanical lift. The facility utilized the proper equipment and personnel. A root cause analysis concluded, after gathering witness statements, return demonstrations by staff on proper Hoyer use, and satisfactory inspection of the equipment, that this last-minute weight shift caused him to bump his head, therefore was UNAVOIDABLE. The facility failed to ensure R76 received adequate assistance and supervision for a transfer from the Hoyer lift to the wheelchair resulting in an injury to the top of his head. 3. Review of R63's clinical record revealed: 9/23/24 – R63 was admitted to the facility with diagnoses including cerebral infarction and rheumatoid arthritis. 3/4/25 2:31 PM – An order entered in R63's clinical record documented, .Bed Mobility: extensive assist of one [staff person]. 4/24/25 – A quarterly MDS assessment documented R63 had a BIMS score of 11, indicating moderately impaired cognition. The assessment also documented that R63 required maximal assistance to roll from lying on her back to the left side or right side and for upper and lower body dressing. 4/29/25 12:10 PM – A facility incident report documented, .[R63] had been given a shower and was brought back to her room.[E7, CNA] lowered the side rail and pushed the shower bed against [R63]'s bed.[E7] prepped [R63] by turning her on her side and pulling the bath sheet out from under [R63] and started pushing the Hoyer pad underneath it.[R63] rolled over and fell between the 2 beds to the floor.[R63] was crying and very anxious. 4/29/25 12:47 PM – A Nurse's Note was entered in R63's clinical record documented, [R63] fell from shower bed to floor.[R63] transported to hospital. 4/29/25 – A facility document entitled, Education Note documented, .Employee Name: [E7] Education Provided: When using the shower bed, do not disengage the side railing until you are ready to transfer the resident and that all locks are engaged. 4/29/25 – A facility document entitled, Point of Inspection Review documented, .Equipment to be Inspected: Shower Beds.No repairs or maintenance issues were identified during the inspection.shower beds are in proper working order with secure locking and braking mechanisms. 4/29/25 9:25 PM – A hospital radiology report documented that R63 underwent a CT scan that revealed acute L2 and L3 vertebra compression fractures. 4/22/26 2:03 PM – During an interview, (E7) stated, I was getting [R63] ready to transfer back to her bed from the shower bed. I must have forgotten to lock the wheels on the shower bed. I rolled [R63] to put the Hoyer lift pad under her. The shower bed separated from [R63]'s bed and [R63] fell in between the two beds. [R63] won't take a shower anymore since the accident. [R63] will only take bed baths now. 4/23/26 9:39 AM – During an interview, (E2, DON) stated, Staff is trained on shower bed transfers during onboarding. The Surveyor asked if it was re-education for shower bed transfers that was provided to E7 on 4/29/25? E2 stated, Yes. 4/23/26 12:58 PM – Facility provided documentation of a QAPI meeting held on 4/29/25 to address R63's fall from shower bed, Nursing and CNA staff in-service shower bed transfer safety education completed on 4/29/25 and 5/6/25, and weekly audits of shower bed safety and CNA safe resident transfers conducted from 5/5/25 to 7/7/25. E2 confirmed that a Safe Patient Handling Competency training is completed by new staff upon hire and by existing staff during annual in-service training. 4/23/26 1:28 PM – Interviews were conducted with E8 (CNA), E9 (CNA), E10 (CNA), E11 (CNA) and E12 (CNA) to confirm that shower bed transfer safety education and Safe Patient Handling Competency training had been completed. 4/23/26 3:13 PM – Finding was reviewed with E1 (NHA) and E2. 4/27/26 1:35 PM - Finding was reviewed during the exit conference with E1, E2, E3 (COO), E16 (CN) and E17 (CN).

Based on interview and record review, it was determined that for one (R43) out of three residents reviewed for accident hazards, the facility failed to notify the provider when a new skin alteration was identified after an earlier incident where R43 spilled coffee. Findings include: R43's record revealed: 3/5/26 - R43 was admitted to the facility. 3/11/26 - The admission MDS documented that R43 required set-up assistance for eating. 3/30/26 8:30 AM - A nurse's note by E21 (RN/SD) documented, Resident placed his coffee on the bed railing after letting go of the cup it fell back onto his lap spilling onto his bilateral upper thighs. Resident was not wearing pants (sic) this nurse and CNA were about to assist resident with morning care. B/L [Bilateral] upper thighs nonblanchable redness all skin intact at this time. After morning care resident denied pain to the area . 3/30/26 1:47 PM - A nurse's note by E20 (Wound Care RN) documented, Evaluated skin to abdomen, thighs . No scalded skin present. PT [Patient] denies pain. 3/30/26 2:47 PM - A progress note by E19 (NP) documented under Physical Exam . Skin: refer to skin assessment . 3/31/26 12:00 AM - A late entry nurse's note by E22 (RN) was documented on 4/1/26 at 8:57 AM. The note stated, during incontinence care by assigned CNA a right upper thigh broken blister . was noticed . Right upper thigh broken blister cleaned with saline pat dry and applied kin (sic) prep. Review of the facility's incident documentation revealed that E23 (MD) was notified of R43's blister on 4/1/26 at 8:38 AM, over 24 hours after the blister was identified. 4/23/26 2:17 PM - During an interview, E19 (NP) stated that she was notified of R43's coffee spill on 3/30/26. However, E19 reviewed the physician binder and confirmed that there was no evidence of R43's change of skin condition was communicated to a Provider as noted on 3/31/26. The facility failed to notify the on-call Provider when R43 had a change in skin condition after an incident where R43 spilled coffee on his skin. 4/27/26 1:35 PM - Finding was reviewed with E1 (NHA), E2 (DON), E3 (COO), E16 (Corp. Nurse) and E17 (Corp. Nurse).

Based on observation, interview, record review, and other documentation as indicated, it was determined that one (R76) out of three residents sampled for choices, the facility failed to ensure that R76, a resident who was completely dependent on the staff for showers, received showers per his preference to maintain good grooming and hygiene. Findings include:R76's clinical records revealed:6/2/22 - R76 was admitted to the facility with diagnoses, including but not limited to, brain bleed, seizure disorder and craniotomy which resulted in left sided paralysis.6/13/22 - R76's activities of daily living care plan (revised 3/7/24) included, . [R76] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] CVA [cardiovascular accident] with left sided hemi [paralysis.] The interventions included, [R76] prefers to have afternoon or evening showers, he is scheduled for hair care/nail care and shower/bed bath weekly on Tuesday and Friday 3-11 shift, notify nurse if [R76] refuses.3/3/26 - R76's quarterly MDS assessment documented a BIMS score of 15, indicating a completely intact cognitive status, and a complete dependance on staff for all bathing and transfer needs.3/31/26 - An incident report submitted to Division reporting department included, [R76] stated that he has not taken a shower in 3 weeks and to beg for [one].4/21/26 11:30 AM - During an interview, the Surveyor asked R76 what his bathing preference was. R76 stated, I prefer to take showers. The Surveyor asked R76 when was the last time he received a shower. R76 stated, It's been a long time, and I begged for one and got it on the evening when the lift fell on my head.4/22/26 11:30 AM - During an interview, the Surveyor asked R76 if he received his shower that was scheduled for the previous evening. R76 stated, No, I was not offered a shower.R76's scheduled shower record revealed:2/26 - Five bed baths, one shower and three episodes of refusals.3/26 - Five bed baths, one shower and three episodes of refusals.4/3/26 to 4/19/26 - Four bed baths, 2 showers and 1 episode of refusal.4/24/26 12:00 PM - During an interview, the Surveyor asked E4 (UM) what process should be followed if a resident refused a shower. E4 stated, The aide will offer the shower again and try to arrange a time more suitable for the resident. The aide will then inform the nurse if the resident continued to refuse. The nurse will speak to the resident about the shower and if the resident still refuses, the unit manager will be informed. The unit will speak to the resident, and the refusal will be documented in the progress notes. The Surveyor asked E4 what would happen on the evening shift if the unit manager was not there. E4 stated, The evening supervisor will be informed, and a note will be written in the resident's record.R76's clinical record lacked evidence that he was offered a shower on 21 out of 27 opportunities.4/24/26 2:20 PM - Findings were confirmed with E1 and E3. 4/27/26 1:35 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (COO), E16 (CN) and E17 (CN).

Based on observations and interviews it was determined for one (R23) out of thirty four residents sampled for accommodations the facility failed to ensure R23's call light was within reach. Findings include:R23's clinical record revealed:6/13/22 - R23 was admitted to the facility. 4/22/26 10:39 AM - During an observation R23 was sitting up in the wheelchair near the left side of the foot of the bed. The call light cord was wrapped around the left side enabler at the head of the bed with the call light dangling near the floor.4/22/26 11:52 AM - A second observation revealed R23 sitting up in the wheelchair in the same position and the call light was not within reach.4/22/26 11:57 AM - During an observation E27 (CNA) and another staff CNA entered R23's room with a Hoyer lift to transfer R23 back to the bed.4/22/26 12:06 PM - R23 was observed in bed the call light remained wrapped around the enabler and not within the resident's reach.4/22/26 12:28 PM - E27 was observed in R23's room at this time and then exited the room. Call light remained not within R23's reach.4/22/26 12:43 PM - E27 observed leaving R23's room with the resident's lunch tray. R23's call light was not within reach.4/22/26 1:00 PM - During an interview E27 was asked by the surveyor If you have transferred a resident from the bed to the wheelchair and or from the wheelchair to the bed what would be the most important thing that you would do before leaving the resident. E27 stated, I would make sure the call light was within reach. Surveyor, then asked E27 is R23's call light within reach. E27 then stated, No, I'm sorry I apologize. E27 unwrapped the call light from the enabler and placed it within R23's reach.4/22/26 1:12 PM - Findings were confirmed with E28 (RN).

Based on observation and interview it was determined that for one (R23) out of thirty-four residents sampled for resident rights the facility failed to ensure R23 was provided with a dignified dining experience during lunch. Findings include:R23's clinical record revealed:6/13/22 - R23 was admitted to the facility.4/22/26 12:39 PM - During an observation R23 was in bed, E27 (CNA) entered the resident's room with R23's lunch tray. E27 placed the lunch tray on the overbed table and then began assisting R23 to eat while standing. E27 remained standing during the time frame that R23 was being assisted with the lunch meal.4/22/26 1:00 PM - During an interview E27 reported [R23] needs assistance with eating. The surveyor asked E27 If you were in the dining room and assisting a resident with their meal would you be sitting or standing E27 stated, I would be sitting E27 then stated and confirmed, I was standing I know that I should have been sitting down, I'm sorry.4/22/6 1:12 PM - Findings were confirmed with E28 (RN).

Based on interview, record review and other facility documentation it was determined for one (R12) out of four residents sampled for falls the facility failed to ensure that an RN performed the initial post fall assessment and documentation after R12 slid off of the bed and was lowered to the floor on the 11 PM-7 AM shift. An RN post fall assessment was not performed until the 7 AM - 3PM shift. Findings include: Cross Refer F689R12's clinical record revealed:1/2/19 - R12 was admitted to the facility with the following diagnoses including but not limited to anoxic brain injury, abnormal posture, multiple contractures of the upper and lower limbs and idiopathic progressive neuropathy.12/3/25 1:00 AM - A facility reported incident to the division documented [R12] sustained fall 12/3/25 complaint of ankle pain later in day. Xray obtained, results unclear. Repeat film obtained on 12/5/25.12/3/25 8:34 AM - A review of R12's initial post fall assessment was performed by E15 (ADON) on the 7 AM - 3 PM shift. [R12's] clinical record lacked evidence of an initial RN assessment until the next shift.04/22/2026 2:30 PM - A review of a facility form titled, Investigative Protocol Witness Summary Witness Written Summary by E14 (LPN) documented. [R12] was in a seated position s/p (sic) fall denied any pain. Assessed completed range of motion denied pain vss (sic) assisted CNA with care returned to bed.4/23/26 1:38 PM - During an interview E2 (DON) stated, the fall was not reported by the E24 (CNA) and E14 because they felt like it was not a fall because [R12] was assisted down to the floor.4/27/26 1:11 PM During a phone interview E14 stated and confirmed I was called by E24 saying [R14] fell we went in and provided care and assessed [R12]. I believe we called down to the RN, but I don't remember that was so long ago. I wrote what E24 said on the incident report. I wasn't there when [R12] fell.

Based on observation, interview and record review, it was determined that for one (R1) out of five residents reviewed for social services, the facility failed to provide medically-related social services to R1, a resident diagnosed with a paranoid personality disorder. Findings include:Cross refer F576, F657 example 1According to the CMS's RAI Version 3.0 Manual,Section C - Brief Interview for Mental Status (BIMS) revealed the following: . A resident's performance on cognitive tests can be compared over time.-An abrupt change in cognitive status may indicate delirium and may be the only indication of a potentially life-threatening illness.-If performance worsens, then an assessment for delirium and/or depression should be considered, as a decline in mental status may also be associated with a mood disorder.When cognitive impairment is incorrectly diagnosed or missed, appropriate communication, activities, and therapies may not be offered.Section E: Behavior.Hallucinations and delusions may-be distressing to residents and families,-cause disability,-interfere with delivery of medical, nursing, rehabilitative and personal care, and-lead to dangerous behavior or possible harm. Planning for Care.When the cause is not reversible, the focus of management strategies should be to minimize the amount of disability and distress.Review of R1's clinical record revealed:5/13/25 4:14 PM - A psychiatry consultation by C1 (NP) documented, . (checked) Other Dx (diagnoses). F22 [Delusional Disorder] F60.0 [Paranoid Personality Disorder] F44.2 [Other Hallucinations] Psych consult for evaluation and treatment. Psychotropic Medications none. Psychiatric History. 1. Cognitive Loss (checked) none. 5. Depression (checked) isolated. 6. Psychotic Features/Hallucinations/Delusions (checked) Paranoid. Compliant with Care (checked) No. Staff support/Directions (checked) Does not accept. Additional history. She has chronic paranoid delusions and hallucinations including smells from other rooms. She was calm and cooperative today she made eye contact. She is paranoid. She can make her needs known and accepts some care. she sleeps OK. Mood ok, affect in range. She denies suicide attempt. denies si hi [suicide ideation homicidal ideation]. Mental Status Examination. Speech. spontaneous, coherent. Thought process. (checked) Tangential and Disorganized. Mood (nothing checked). remains paranoid and refuses meds. Recommendation and Plan. cont (continue) supportive care. Not open to medications. Reviewed chart and discussed with staff.It should be noted that this was the last documented psych note in R1's clinical record.5/27/25 - A progress note by E3 (Physician) documented, . Patient seen and examined today. Patient endorses she is very upset because of her usual paranoid ideation issues, very hard to re-direct her and I could not do it today.5/30/25 at 12:03 AM - A nurse's note documented, Resident requested to make phone call. This nurse asked resident if she was aware of the time of night, and resident verbalized that she was aware of the time. Resident wrote down 2 phone numbers for this nurse to dial. This nurse dialed both calls this night. Resident could be heard speaking about things such as '.career criminals from Pennsylvania state prison.', '.prison gang here in the nursing home.' and '.the criminals are stalking and harassing the pastors from the local church.'. Resident also heard verbally attacking the other overnight cart nurse. Resident completed phone calls by 1215 [12:15 AM] and returned to room.6/17/25 - The quarterly MDS assessment for R1 was coded as:-BIMS was a 15/15 [cognitively intact] by E13 (RN).-Inattention and disorganized thinking were continuously present and did not fluctuate.-No hallucinations or delusions were checked as potential indicators of psychosis.-No verbal or physical behaviors directed towards others.-No rejection of care.6/17/25 2:44 PM - A social services note by E5 (SSA) documented, Resident remains on LTC with no plans to discharge at this time. Resident is alert and oriented x3. She allowed SSA to enter room to converse and provide support. Resident continues to have behaviors and delusions. Resident is not on any psychotropic medications at this time. SSA will continue to monitor resident.6/18/25 12:34 PM - A nurse's note documented, . Resident educated on importance of having follow up dental visit. Resident began shouting at both charge nurses swinging her back scratcher, stating 'I am a grown woman I do not need you to tell me what's important!' It's important for you to get the murderers and criminals out of here from Pennsylvania jail and turn off the industrial fans with chemicals.' Both nurses exited the room at request of resident.6/26/25 3:58 PM - A care conference note by E5 (SSA) documented, Residents care plan meeting was held today, resident refused to be apart of it. SS; [Social Services] Resident is not on any psychotropic medication at this time. SSA will continue to monitor resident for any LTC concerns.7/29/25 - A progress note by E3 (Physician) documented, . I went to patient's room, did not examined (sic), but she let out a [NAME] about her usual paranoid ideation, criminals from Pennsylvania jail are harming her in many ways, all illogical and inbelievable (sic). Unable to re-direct her today. Plan: Paranoid personality disorder. Staff endorses that patient increasingly agitated at times especially with new staff. Refuses formal therapy and medications. Often refuses meals/medications when given by new staff members. Declines labs/imaging in the ED.8/7/25 - A progress note by E6 (NP) documented, . Patient seen and examined today. continues with ongoing paranoia. Unable to redirect.8/11/25 5:14 PM - A nurse's note documented, Resident very agitated this evening. She told me the chemicals were coming into her room and three criminals from the state prison were in the hallway. Resident has a history of hallucinations and paranoid personality disorder.9/11/25 - The quarterly MDS assessment for R1 was coded as:-BIMS was a 00/15 (severe cognitive impairment) by E12 (ST).-Inattention and disorganized thinking were continuously present and did not fluctuate;-No hallucinations or delusions were checked as potential indicators of psychosis.-Yes, verbal behavioral symptoms directed towards others occurred 1 to 3 days during the look back period of seven days.-No rejection of care.9/15/25 1:38 PM - A social services note by E5 (SSA) documented, Resident remains in LTC [long term care] with no plans to discharge. Resident is alert and oriented x3. Resident is independent with activities of her choosing but primarily stays in her room watching television and enjoys watching spiritual/religious programming. Resident will occasionally sit near the nurses station to use the phone and to socialize with staff. SSA will continue to monitor resident.9/25/25 12:37 PM - A social services note by E5 (SSA) documented, A care plan meeting was held with IDT team this morning. resident. refused to participate. SS; (sic) No psychotropic medication at this time. SSA will continue to monitor resident.Despite a change in R1's BIMS and verbal aggression towards others on the 9/11/25 MDS assessment, there was no evidence of social services follow-up.10/1/25 - A progress note by E6 (NP) documented, . History of Present Illness. chronic paranoia (constantly thinks that the nursing home is abusing her, poisoning her, etc.), has been at her baseline. seen and examined today. continues with paranoid thoughts. Unable to redirect. Plan:. Paranoid personality disorder. Staff endorses that patient increasingly agitated at times especially with new staff. Refuses formal therapy and medications. Often refuses meals/medications when given by new staff members. Declines labs/imaging in the ED [emergency department].10/8/25 - A progress note by E3 (Physician) documented, . History of Present Illness. chronic paranoia (constantly thinks that the nursing home is abusing her, poisoning her,etc.), has been at her baseline. seen and examined today. continues with paranoid thoughts. Unable to redirect. Plan:. Paranoid personality disorder. Staff endorses that patient increasingly agitated at times especially with new staff. Refuses formal therapy and medications. Often refuses meals/medications when given by new staff members. Declines labs/imaging in the ED [emergency department].It should be noted that the progress notes by two different medical providers, dated 7/29/25, 10/1/25 and 10/8/25, are exactly the same with respect to the plan to manage R1's paranoid personality disorder. The medical provider notes documented no plan because R1 refused formal therapy and medications. There was no evidence in the provider notes that R1's chronic paranoia was discussed and/or referred to social services for follow-up. While the following nursing notes documented R1's paranoia episodes, there was no evidence that social services followed-up with R1.-10/30/25 6:17 AM - . resident was on the bathroom floor. When I asked what happened resident stated to many chemicals and criminals are too much (sic) me.-10/31/25 2:57 AM - . Resident yelling out about 'the chemicals are too much and the criminals are playing in the toilet.'-11/6/25 8:43 AM - . Resident still sitting on toilet since 0630. This nurse offered resident assistance and resident stated to leave her alone. Resident started mumbling about prisoners from PA jail playing on her phone and in her room.-11/24/25 11:35 AM - Observation of R1 on the phone at the open 1st floor nurse's station talking about FBI in front of multiple nursing staff and surveyors.11/24/25 11:44 AM - During an interview, R1 spoke in a rapid, distressed tone of voice about reporting to APS [Adult Protective Services], Governor, Trump, JD [NAME], [NAME], [NAME].[Name] ran from the police. they [unknown] lied to the police. hiding prisoners in the facility. stated that she has a [AGE] year old father-in-law in New York and she had to call [NAME], Attorney General and New York Governor [NAME] Hochul. [Name] is a prostitute. prisoners and prostitutes call and harass my [family member]. stated that she plans to call the new Virginia Governor and [NAME], the attorney . can't sleep at night because of next door. the sheriff New Castle County chief come in the middle. title theft, mortgage theft. steal our food, stole my stash. friend contacted [NAME], New Jersey Governor. friend from New Jersey called the Ombudsman. [two names] steal toiletries when they come into my room. smelling bleach right now. ministers helped her. [name] died. During this interview, surveyors observed multiple tissues placed around the room, vents were blocked and did not smell bleach.11/24/25 12:25 PM - During a combined interview with E4 (SSD) and E5 (SSA), E4 stated that she manages the residents on the 2nd floor (short term rehab) and E5 (SSA) manages the residents on the 1st floor (long term care).11/24/25 12:32 PM - During an interview, E5 stated that R1 was her own responsible party and F1 (family member) wants no responsibility or to be contacted.12/1/25 9:01 AM - During a follow up interview, E5 stated that if a new behavior comes up or is brought forward by the charge nurses, she will write it in the psych binder at the nurse's station so the resident can be seen and evaluated by the providers. E5 stated that the psych practitioners (psych NP and psychologist) come see me after to discuss the resident. E5 stated that C1 (Psych NP) often speaks to her about R1 informally. E5 stated that C1 hasn't made any recommendations for R1. E5 stated after she started working at the facility in April 2025, she reached out to families of all of the residents. When asked if she spoke to R1's family, E5 replied that yes, she spoke to F1 (family member #1) and he made it clear he wanted no information about R1. E5 stated that she left a voicemail for F2 (family member #2) and received no call back. E5 stated that no nursing staff or providers have notified her of a problem contacting either F1 or F2. E5 stated that she wasn't aware of the positive Trauma Screen that was completed on 3/20/25. E5 stated when we have a positive trauma screen, we inform the RNAC and it is care planned. E5 stated that she is responsible to do the care plan for LTC social services. E5 stated she was aware of R1's issues including, but not limited to, what kind of chemicals are being pumped into her room, everyone in LTC is being held hostage or as prisoners, can be verbally aggressive if some people enter her room, leaves her room to come to the nurse's station to use the phone, calls 911, and mentions the State Representative, President, Sheriff. E5 stated that staff redirect and reaffirm. E5 confirmed that R1 is her own responsible self and it was listed on her facesheet. E5 was asked has anyone approached you to discuss R1's documented chronic paranoia/delusions and her medical capacity (the ability to make medical decisions and understand the consequences of those decisions). E5 replied, Not that I would recall.12/1/25 9:54 AM - During an interview, E4 (SSD) stated she has worked in the facility for two years. E4 stated that she has not spoken to R1's family members. E4 stated that E5 (SSA) and the previous SSA tried to reach out and the family never called back. E4 stated there was no discussion about the 3/20/25 positive trauma screen for R1.12/1/25 10:44 AM - During an interview, E14 (ADON) stated that R1 still calls the police at the nurse's station, talks about chemicals, prostitutes and prisoners.12/1/25 11:05 AM - During an interview, E15 (LPN) stated that she was very familiar with R1. E15 stated that R1 changed and became worse after Covid. E15 stated that R1 had two friends in the facility that she used to attend activities with and they both died during Covid. E15 stated that R1 uses tissues in her room as air fresheners. E15 stated that R1 talks to friends and imaginary friends on the phone with her delusions. E15 stated that family sends flowers on Valentine's Day, Mother's Day and they brought her Christmas gifts. E15 stated that R1 doesn't come out of her room except to use the phone at the nurse's station.The facility failed to provide medically-related social services for R1 after multiple documented staff interactions where R1's paranoia was interfering with medical care in addition to the 9/11/25 quarterly MDS assessment where her BIMS score of 00 revealed a significant decline in the resident's mental status.12/1/25 3:30 PM - The findings were reviewed at the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for five (R1, R2, R3, R4, R5) out of five residents reviewed for care plans, the facility failed to have evidence that an attending physician participated in the IDT team care plan meeting. Findings include:1. Review of R1's clinical record revealed:3/26/18 - R1 was admitted to the facility.6/26/25 3:58 PM - R1's EMR documented in a Care Conference Note, . resident refused to be apart (sic) of it. Residents (sic) family was invited, but did not attend. IDT (Interdisciplinary team) members present include Nsg (nursing), UMs (unit managers), dietician, ST (speech therapy), OT (occupational therapy) and SSA (social services assistant). Activities director unable to attend but gave report to SSA. CNA (certified nursing assistant) also provided input for todays (sic) meeting.9/25/25 12:37 PM - R1's EMR documented in a Care Conference Note, . resident stated that she did not want to have a care plan meeting and she refused to participate. Residents family was invited but did not attend. IDT members present include Nsg, UMs, PT (physical therapy), dietician, SSA (social services assistant) and case manager. CNA (certified nursing assistant) also provided input for todays (sic) meeting.The facility failed to provide evidence of the attending physician's participation in both the 6/26/25 and 9/25/25 care plan meetings for R1.2. Review of R2's clinical record revealed:9/26/25 - R2 was admitted to the facility.9/30/25 - R2's EMR documented in a Care Conference Note, .IDT team; SSD (social services director), dietician, PT, OT, ST met with son over phone to review current goals. CNA also provided input to care plan.The facility failed to provide evidence of the attending physician's participation in the 9/30/25 care plan meeting for R2.3. Review of R3' Clinical record revealed:10/30/23 -R3 was admitted to the facility.7/31/25 4:08 PM - E5 (SSA) documented in R3's EMR in a Care Conference Note, .resident family was invited but did not attend. IDT team members present for this meeting include Nsg, UM, dietician, OT, Activities director and SSA. PT was unable to attend meeting but gave report to SSA. CNA also provided input for todays (sic) meeting.10/30/25 12:03 PM - E5 (SSA) documented in R3's EMR in a Care Conference Note, .resident family was invited but did not attend. IDT team members present for this meeting include PT, OT, SSA, Activities director and case manager. Nsg UM and dietician were unable to attend meeting but gave report to SSA. CNA also provided input for todays (sic) meeting.The facility failed to provide evidence of the attending physician's participation in the 7/31/25 and 10/30/25 care plan meetings for R3.4. Review of R4's clinical record revealed:3/8/22 - R4 was admitted to the facility.7/24/25 2:42 PM - E5 (SSA) documented in R4's EMR in a Care Conference Note, .resident's family was invited but did not attend. IDT team members present include Nsg UM, dietician, and SSA. CNA also provided input for today's care plan meeting.10/16/25 2:59 PM - E5 (SSA) documented in R4's EMR in a Care Conference Note, .resident's family was invited but did not attend. IDT team members present include Nsg UM, dietician, and SSA. PT was unable to attend meeting, but gave report to SSA. CAN also provided input for today's care plan meeting.The facility failed to provide evidence of the attending physician's participation in the 7/24/25 and 10/16/25 care plan meetings for R4.5. Review of R5's clinical record revealed:10/14/24 - R5 was admitted to the facility.6/26/25 12:56 PM - E5 documented in R5's EMR in a Care Conference Note, Care plan meeting was held today in resident's room, with resident's daughter, [name], present via speakerphone. IDT team members present include NSG UM, dietician and SSA. Activities director was unable to attend but gave report to SSA. CNA also provided input for todays (sic) care plan meeting. 9/25/25 12:30 PM - E5 documented in R5's EMR in a Care conference Note, .Resident informed SSA that she did not want her son-in-law to participate in this meeting. IDT team members present include Nsg UM, dietician and SSA. CAN also provided input for todays (sic) care plan meeting.The facility failed to provide evidence of the attending physician's participation in the 6/26/25 and 9/25/25 care plan meetings for R5.12/1/25 3:30 PM - The findings were reviewed at the exit conference with E1(NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R3) out of five residents reviewed resident records, the facility failed to accurately document in the EMR that R3 had a responsible party who makes medical decisions. Findings include:10/30/23 - R3 was admitted to the facility with diagnoses, including but not limited to, schizophrenia.7/28/25 - A quarterly MDS (Minimum Data Set) evaluation documented R3 as having a BIMS (Brief Interview for Mental Status) score of 9, which was reflective of a moderate cognitive impairment.10/7/25 - F3 (R3's niece/ emergency contact) signed consents for R3 to receive the COVID-19 and influenza vaccinations.11/25/25 1:15 PM - A review of R3's EMR revealed that R3 was listed as her own responsible party despite having a documented BIMS score of 9.12/1/25 11:45 AM - During an interview, E1 (NHA) stated that a BIMS score under 12 showed a questionable cognitive status and the facility then obtains a responsible person who is willing to be the decision maker who signs all consents. E1 stated that the resident continues to be included in the conversations about care and decisions but the responsible person is the one who sings the consents.12/1/25 3:30 PM - The findings were reviewed at the exit conference with E1(NHA) and E2 (DON).

Based on observation and interview, it was determined that for one (R1) out of five residents reviewed for communication, the facility failed to provide R1 with a fully functional phone in her room or a location outside her room where calls can be made without being overheard. Findings include:3/26/18 - R1 was admitted to the facility with diagnoses including but not limited to stroke.5/24/21 - A diagnosis of hallucinations was added to R1 diagnoses list in the EMR.8/30/22 - R1 was diagnosed with paranoid personality disorder.5/26/23 - A PASARR Level II documented R1, As of 1/24/23, you having ongoing false beliefs and routinely call government agencies sharing your false beliefs. You have paranoia, choose not to take your medication, and sometimes choose not to have your labs. You are hyper-verbal regarding your false beliefs and unable to be redirected. The PASARR Level II documented, At this time you meet PASARR inclusion criteria for Serious mental Illness with the diagnosis of Paranoid Delusional Disorder and Major Depressive disorder. You also have the diagnoses of Paranoid Personality disorder, Cognitive Disorder NOS (not otherwise specified) and Anxiety Disorder NOS. 6/17/25 - A quarterly MDS evaluation documented R1 as having a BIMS score of 15, which is reflective of normal cognition.11/24/25 10:20 AM - Surveyors observed [R1] sitting in her wheelchair at the open nurses' station on a telephone and R1 was discussing the FBI with whomever she was speaking with.11/24/25 10:40 AM - During an interview, R1stated, My phone. the number nine does not work. Surveyor asked permission to check the phone in her room with R1 present; the number 9 on that phone was non-functional.11/25/25 2:45 PM - A review of R1's Care Plan revealed documentation, .[R1] has a behavior problem: . 5. [R1] makes excessive phone calls to 911- May 2024 Police have stated this is an arrestable offense and resident will be arrested if the behavior continues. 6. [R1] excessively interrupts nursing staff to use the phone. Interventions- Ombudsman consulted and phone removed with continued behaviors. Resident given her phone back with #9 disabled, if resident needs to make a phone call requiring a 9, then resident may make two 15-minute phone calls a day at the nursing station, all phone calls to be dialed by staff due to repeated 911 calls- every shift. Date initiated 4/22/24It should be noted that R1's estranged husband's telephone number has the number 9 in it.12/1/25 9:16 AM - During an interview, E5 (SSA) stated when asked about R1's phone, I am not aware of that (that the #9 on R1's phone was non-functional). I can put a work order in for that. E5 also stated that R1 typically dials the phone numbers herself.12/1/25 10:25 AM - A review of R1's EMR September, October and November 2025 TAR (Treatment Administration Record) revealed an order, two 15-minute phone calls a day at the nursing staff (sic), all phone calls dial by staff due to repeated 911 calls every shift. This order was documented as being initiated on 4/22/24.12/1/25 11:45 AM - During an interview, E1 (NHA) stated that the Ombudsman was aware that the #9 on [R1]'s phone was disabled. E1 also stated that there was a private phone alcove on the first floor. E1 stated that typically [R1] makes her phone calls at the nurses' station and asked if the facility offered her [R1] access to the private phone alcove would that fulfill the regulation.The facility failed to provide R1 a place where calls can be made without being overheard since April of 2024.12/1/25 3:30 PM - The findings were reviewed at the exit conference with E1(NHA) and E2 (DON).

Based on interviews, record review, and policy review, the facility failed to ensure allegations of abuse were reported for one of three residents (Resident (R) 80) reviewed for abuse. The facility did not report to the State Agency alleged staff-to-resident abuse within the required time frame. Facility staff did not report R80's allegation of employee-to-resident abuse to the Administrator. This failure to report the allegation in a timely manner allowed the accused staff member to continue working in the facility with other residents. The Immediate Jeopardy began on 07/07/24, undetermined time between 12:00 PM and 3:00 PM. On 03/13/25 at 7:42 PM, the Administrator was notified of Immediate Jeopardy (IJ) Past Non-Compliance (PNC) in the area of Resident Abuse at F609. Prior to this survey, the facility identified the seriousness and immediacy of the deficient practice and implemented a Removal Plan on 07/11/24. A review of the facility ' s investigation revealed that the episode of failing to report abuse in a timely manner was brought to QAPI on 07/15/24, and a Performance Improvement Plan (PIP) was developed in response. The PIP was in place and reviewed from 07/15/24 through the end of September. Residents were selected randomly for review regarding abuse. All staff received re-education for abuse and the proper reporting of abuse. The survey team validated implementation of the Removal Plan on 03/13/25 at 7:56 PM. Based on the facility's implementation of corrective actions, the IJ and Substandard Quality of Care (SQC) were determined to be PNC and the IJ was removed, with substantial compliance achieved on 07/17/24 Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, dated 01/03/25, revealed, Policy-It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime. Cadia Healthcare adopts this policy to standardize procedures for employee screening, employee training, prevention, identification, investigation, protection, and reporting of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and reasonable suspicions of crime. Purpose: To ensure that all residents are protected from abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime . Guidelines . Protection: The facility will respond immediately to protect the alleged victim, the integrity of the investigation and provide protection from retaliation. Assessment of the alleged victim will be conducted for signs and symptoms of injury (physical and/ or psychosocial). Increased supervision, room changes, and staffing changes may be provided to the alleged victim and other residents. Psychological support will be offered during and after the investigation. The named person accused of the act will be immediately suspended pending outcome of the investigation. Reporting and Response: Witnessed or suspected incidents of abuse or reasonable suspicions of crime are to be reported immediately . The DON (Director of Nursing) or designee is responsible to conduct the abuse investigation. The NHA (Nursing Home Administrator) serves as the abuse coordinator. Allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours. Incidents involving reasonable suspicions of criminal conduct are reported to the applicable state agency and law enforcement within 8 hours or within 2 hours if the conduct causes serious bodily harm . Review of R80's undated Admission Record, located in R80's electronic medical record (EMR) under the Profile tab, revealed R80 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, unspecified dementia with agitation, major depressive disorder. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/24, located under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R80' was severely cognitively impaired. Review of the facility investigation revealed the incident occurred on 07/07/24 when Certified Nursing Assistant (CNA) 1 stuck her tongue out at R80 and threw three wipes toward R80's head while in the process of changing the resident. R80 then attempted to throw spit at CNA1. CNA2 witnessed the incident and she and CNA1 left the room. CNA2's undated witness statement revealed that after CNA1 threw the wipes at R80, R80 spit into her hand and threw it at CNA1. CNA2 reported the incident to Licensed Practical Nurse (LPN)1 on 07/07/24. The incident was not reported to the Abuse Coordinator until 07/11/24. Failing to report the allegation of abuse allowed CNA1 to remain on schedule and she worked 07/08/24, 07/10/24, 07/11/24. Further review of the Facility Reported Incident revealed a written statement from CNA1, dated 07/11/24, indicating I stuck my tongue out at R80 in response to a comment from her. R80 then called me a B**** and that's when I threw three wipes at her playing around. Phone interview on 03/13/25 at 12:26 PM CNA2 stated, R80 was aggressive like normal when we went to change her. Then CNA1 threw three individual wipes at R80's face, R80 then spit in her hand and threw it at CNA1. After that we both walked out of the room, and I went to tell the nurse (LPN1) what happened. I went back to check on R80 and she was fine, she didn't say anything about it. During an interview on 03/13/25 at 12:52 PM, Unit Clerk (UC) 1 revealed that she initially thought to report the incident but forgot after taking care of another resident. She learned about the incident on 07/08/24, did not report it at that time, and instead reported it on 07/11/24 after recalling it when the resident returned from the hospital. During an interview on 03/13/25 at 12:52 PM, Unit Clerk (UC) 1 revealed that she initially thought to report the incident but forgot after taking care of another resident. She learned about the incident on 07/08/24, did not report it at that time, and instead reported it on 07/11/24 after recalling it when the resident returned from the hospital. During a phone interview on 03/13/25 at 1:20 PM, the former Administrator stated, The CNA was suspended during the investigation and later terminated. By terminating her we would have confirmed the abuse. The DON performed the investigation. During an interview on 03/13/24 at 2:24 PM LPN1 revealed, I could not get a clear story as to what happened, I was not able to ask R80 due to cognitive status. I finished toileting R80 and made sure she was ok. Made sure that the aide did not return to the resident's room. I did not report anything. I thought at the time that keeping CNA1 away from R80 and keeping R80 safe was enough. Since then, I was retrained on the proper reporting of abuse allegations. I received training upon hire and in services after. The incident was at the end of the shift. I have no knowledge of any other concerns with CNA1.

25232 36190 Based on observation, interview and policy review, the facility failed to follow Transmission Based Precautions, use proper hand hygiene, and change gloves during incontinent care. These breaches in infection control could cause a spread in disease and affect all the residents. Findings include: Review of the facility policy titled Infection Prevention and Control Program Policy, revised 04/14/21, provided by the facility revealed individuals with suspected or diagnosed communicable disease are placed on the appropriate precaution for that disease, as recommended by the Centers for Disease Control and Prevention (CDC) . Employees will follow hand hygiene practices consistent with standards of care . Review of facility provided poster titled, Stop: Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities: .changing linen .changing briefs or assisting with toileting, device care or use: .feeding tube. Review of facility provided policy titled, Standard and Transmission Based Precautions, revised 01/02/25, indicated, .Policy: [name of the facility] institutes the following precautionary measures to help prevent the spread of Multi-Drug-Resistant Organisms (MDRO) and highly contagious infections/outbreaks. Our goal is to use these infection prevention principles to protect our residents and staff from spread of infections related to MDRO. The types of precautions and when to implement are defined below. Type of Precautions: 1. Standard Precautions-Applies to all residents. No room restrictions. Clean, non-sterile gloves when touching or coming into contact with blood, body fluids, secretions, or excretions. Remove gloves after use. Discard before touching non-contaminated items or environmental surfaces and before providing care to another resident. Hand Hygiene/alcohol-based hand gel/hand washing 2. Enhanced Barrier Precautions-Applies to all residents with wounds and/or indwelling medical devices (central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization as well as for residents with MDRO infection or colonization, when contact precautions do not otherwise apply. No room restrictions. Hand Hygiene/alcohol-based hand gel/hand washing Personal protective equipment (PPE)-gloves and gown and/or face protection during high- contact resident care activities: i.e.changing linens, changing briefs or assisting with toileting, device care or use. 3. Contact Precautions - Applies to all residents infected or colonized with a MDRO [multidrug-resistant bacteria] in the following situations: presence of acute diarrhea, draining wounds, or other sites of secretions or excretions that are unable to be covered or contained, . 1. Observation on 03/10/25 at 12:09 PM, Licensed Practical Nurse (LPN) 2 entered R68's enhanced barrier precaution (EBP) room with any person protective equipment (PPE) on and hung R68's tube feeding, removed the cap from the tube. LPN2 primed the line, dropped the tubbing on the floor, and picked the tubbing up off the floor. At the time of picking the tubbing off the floor, there was no observed cap at the end of the tubbing, and LPN2 flung it over the tube feed (TF) pole. LPN2 sat the two cups of liquid medications on the overbed table, then gave the medications. After incontinent care was completed, LPN2 went over to the TF pole, obtained the tubbing that was hung over the pole, and placed the tip of the tube into the g-tube without wiping it off. Observation on 03/10/25 at 12:24 PM, Certified Nursing Assistant (CNA) 12, entered R68's EBP room with PPE on. CNA12 had a gown, gloves, and mask. CNA12 brought another gown which she placed on R68's bed toward LPN2. LPN2 was on the right side of the bed that was closest to the window. CNA12 removed R68's wedges, and pillows. With the same gloves, CNA12 went to the bathroom got a gray basin, filled it with water, came back out and placed it onto the overbed table, and got R68's soap out of the top drawer of the nightstand. CNA12 removed R68's soiled brief tucking it under R68's bottom, then washing R68's perineal area. With the same gloves, CNA12 rinses and dries R68. CNA12 assists R68 in turning over to LPN2, and then CNA12 changed her. CNA12 removed fitted sheet, and bunched up brief which was soiled with bowel movement (BM) and washed, rinsed, and dried R68 all with the same gloves. CNA12 then placed a new brief on R68, and turned R68 towards her, while LPN2 removed linen, without LPN2 wearing PPE. After LPN2 removed the linen, LPN2 did not change gloves, but finished fixing R68's brief. CNA12 placed new linen on R68's bed with the same gloves. Review of Order Summary Report, dated 12/18/24, under the Orders tab, located in the Electronic Medical Record (EMR), indicated, EBP related to peg tube and history of extended-spectrum beta-lactamase (ESBL) in urine. Interview on 03/13/25 at 12:05 PM, LPN2 was unaware of EBP for tube feeding residents, stating that she has never worn a gown before giving tube feed. Indicated that the tube had a cap on it and that cap was present prior to her inserting the tip into the g-tube. Interview on 03/13/25 at 1:00 PM, CNA12 confirmed that she did not change her gloves when going from a dirty area to a clean area and indicated that she should have. 2. During observation on 03/11/25 at 10:06 AM, the Assistant Director of Nursing (ADON) went into R53's room without washing and/or sanitizing her hands prior to entering the room. R53 is on enhanced barrier precautions (EBP) and there was a sign on the door to let staff know what to do and a clear bin next to R53's door for personal protective equipment (PPE). Review of Order Summary Report, dated 12/02/24, under the Orders tab, located in the EMR, indicated, EBP related to gastrojejunostomy (GJ) tube. 3. During the medication observation pass on 03/11/25 at 10:39 AM, Registered Nurse (RN) 3 observed popping R74's seven medications into his left hand from the medication blister package followed by placing them into a clear medication cup on top of the medication cart. RN3 then gave R74 his medication. Interview on 03/13/25 at 10:53 AM, RN3 confirmed that he popped the medication into his hand; however, RN3 said that he sanitized his hands first and it was better than dropping the medication. Interview on 03/13/25 at 11:30 AM, the Director of Nursing (DON), she said that she expects nurses to pop medications directly into the medication cup, not into their hands. 4. Observation on 03/12/25 at 9:40 AM, the ADON entered R11's EBP room without washing her hands and/or sanitizing her hands; however, placed a gown on. Along with the ADON, Licensed Practical Nurse Supervisor (LPNS)2, entered the room at the same time, without putting on a gown, and did not wash hands and/or sanitize hands before entering the room but put on gloves. LPNS2 picked up linen off the floor near bed B and ADON left the room at 9:43 AM, removing her gown without sanitizing her hands or washing her hands, going down the hallway to get a hamper, and returned to the room. At 9:46 AM, ADON went back inside the room without washing hands and/or sanitizing hands and delivered hamper to LPNS2. LPNS2 finished gathering linen up off the floor and gathered linen off bed B, placing all linen in the hamper. Interview on 03/12/25 at 9:52 AM, the LPNS2 confirmed that she did not wear any PPE and should have. Confirmed that linen should not have been on the floor. 5. Observation on 03/13/25 at 3:25 PM, the ADON entered and exited R82's EBP room without washing and/or sanitizing her hands. Review of R82's Order Summary Report, dated 12/11/24, located under Orders tab in the EMR, documented, Enhanced Barrier Precautions related to history of Methicillin-resistant Staphylococcus aureus (MRSA). Interview on 03/14/25 at 2:00 PM, the ADON confirmed that she did not sanitize hands and/or wash her hands prior to and/or exiting EBP rooms as she should. Interview on 03/13/25 at 10:01 AM, the Infection Preventionist (IP) confirmed that medications should be popped directly into a medication cup, not into a nurse's hand. Said that when providing peri-care, gloves are to be changed when going from a dirty area to a clean area. She said that when giving medications through a gastrotomy tube (g-tube), if the tubing falls on the floor, that tubing is not to be used. If a resident is on EBP donning (putting on) is to occur prior to entering the room along with washing and/or sanitizing hands, and doffing (taking off) PPE prior to exiting the room, placing PPE in the bins provided in the room. After staff exit an EBP room, staff are to wash their hands and/or sanitize their hands. 6. Review of R15's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/05/25 and located in the electronic medical record (EMR) under the MDS tab, revealed R15 had an admitted [DATE] and a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R15's cognition was intact. The MDS assessment indicated R15 had diagnoses of aftercare following joint replacement surgery, cancer, and disorder involving the immune mechanism, unspecified. Review of R15's nurses notes, dated 03/08/25, located in the EMR under the Progress Note tab revealed Received Urinalysis culture report. Urine positive for ESBL [extended-spectrum beta-lactamase (a bacteria resistant to many antibiotics)]. Notified on call nurse [name] and obtained order for 1gm [gram] of Ertapenem [antibiotic] daily x 7 days. Notified Infection Control Nurse. Awit [sic] further recommendations. Called Mr. [name] and informed of UA [urine analysis] Culture report and the start of the antibiotics. Review of R15's orders, dated 03/08/25, located in the EMR under the Order tab revealed Contact Precautions r/t [related to] ESBL in urine with ABT [antibiotic] tx [treatment] every shift for ESBL UTI [urinary tract infection] for 10 Days. On 03/10/25 at 2:12 PM, R15's room was noted to have a sign that read Stop, Contact Precautions everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. A supply of protective personnel equipment (PPE) that included gowns and gloves were hanging on the outside of the door. On 03/10/25 at 2:13 PM, Heavy Housekeeping (HH)1 was observed to knock on R15's closed door, enter the room without donning a gown and gloves and started sweeping the floor. R15 was sitting in the room dressed and groomed and talking on her phone as HH1 swept the floor around her. On 03/10/25 at 2:15 PM, HH1 came out of R15's room and briefly went across the hall to another room to sweep with the same broom and then back to his cart. HH1 was asked if he was supposed to wear a gown and gloves when cleaning R15's room. The contact precaution sign and the supply of PPE supplies were pointed to on the door. HH1 stated he wouldn't have known if he should use the gowns as no one told him. HH1 confirmed he didn't wear a gown and gloves into R15's room. On 03/12/25 at 12:22 PM, Licensed Practical Nurse (LPN)2 was observed entering R15's room without donning a gown to give R15's medications and stayed in the room for a few minutes talking with R15. LPN2 came out of R15's room and back to the medication cart. LPN2 was asked if R15 was still under contact precautions and LPN2 stated, No. LPN was asked if she should have used PPE to give medications and the supply of PPE and the contact precaution sign were pointed to on the door. LPN2 stated, No, only if she came in contact with R15's urine. During an interview on 03/13/25 at 10:30 AM, the Infection Preventionist (IP) was asked about R15. The IP stated R15 was currently taking an antibiotic for a urinary tract infection with ESBL. The IP stated R15 was complaining of burning upon urination and that's when a urinary analysis was conducted. The laboratory results came back with ESBL. The IP went on to say R15 was receiving treatment and contact precautions were started. The IP was asked if housekeeping should use PPE when cleaning R15's room since she has ESBL. The IP stated, Yes, housekeeping should use PPE. The IP was informed that HH1 didn't use PPE on 03/10/25. The DON was present and stated housekeeping were contract and they are responsible for their own training. The IP stated she will assist with additional training with housekeeping if she identifies a need. During an interview on 03/13/25 at 10:35 AM, the IP asked if LPN2 should wear PPE while passing medications to R15 while in her room. The IP stated, Yes. The IP was informed that LPN2 entered R15's room without donning PPE to give medications on 03/12/25. The IP was informed that LPN2 stated R15 wasn't under contact precautions and that she should only wear PPE if she encountered R15's urine. 7. Review of the COVID-19 policy dated 01/03/25 and provided by the facility revealed it was the policy of the facility, to prevent the spread of COVID-19 (Coronavirus) . When a resident meets the criteria to be a Person Under investigation (PUl) for symptoms identified or confirmed COVID, staff must contact the Provider and the Director of Nursing (DON). The resident will immediately be placed in isolation with contact/droplet precautions using Personal Protective Equipment (PPE) as described below . Personnel entering the room should use PPE, including gown, gloves, N95 respirator (or equivalent or higher level respirator), and eye protection. Facemasks can be used if N95 respirator (or equivalent or higher level respirator) is not available. For residents with suspected or confirmed COVID-19, an N95 (or equivalent or higher level respirator) mask, eye protection, gloves, and gown must be worn while performing any of the above procedures. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R158 was admitted to the facility on [DATE] and was discharged on [DATE]. R158's closed record was reviewed. Review of a Physician's Order dated 10/13/24 and provided by the facility revealed the Physician ordered droplet and contact precautions for R158 from 10/13/24 through 10/21/24. During an interview on 03/11/25 at 3:47 PM, Family Member (FM)1 stated R158 was quarantined during her stay due to being exposed to someone in the facility with COVID in October 2024. During an interview on 03/13/25 at 10:12 AM with the IP and the DON, they stated if a resident was exposed to COVID, they were placed on quarantine with both contact and droplet precautions in place for eight days. All staff were required to don a gown, wear gloves, an N95 mask, eye protection, and a face shield to go into a COVID quarantine room. The IP and DON stated that the door to the room should remain closed. During an interview on 03/13/25 at 10:49 AM, LPN4 stated she remembered R158 being quarantined due to exposure to staff that tested positive for COVID. LPN4 stated R158 was under quarantine for seven days and there should have been a sign regarding isolation and PPE requirements posted outside the door. LPN4 stated contact isolation would have been in effect and nursing staff would have been required to wear full PPE if providing resident care: however, she did not think other staff such as housekeepers would have been required to wear PPE. LPN4 did not indicate that droplet precautions should also be in effect.

36190 Based on observation, interview, record review, and policy review, the facility failed to inform seven of seven residents in the resident council about the facility's grievance policy, the grievance official responsible for overseeing the grievance process was with their contact information and resolve grievances for three (Residents (R)158, R34, and R59) of three residents reviewed for grievances. This failure could prevent residents from addressing concerns and seeking resolution, leading to frustration and potentially impacting their well-being. Findings include: Review of the facility policy titled, Grievances, review date 01/03/25, provided by the facility revealed All grievances reported by a resident, responsible party, resident representative or family member will be promptly investigated and resolved. Follow up will be reported to the resident and/or reporting party. The facility will post guidance on how to file a grievance or complaint in prominent locations throughout the facility. a. All grievance decisions shall be documented on the Resident Concern Form. 1. Review of the resident council minutes for March 2024 through February 2025 did not include any discussion of the facility's grievance process. On 03/12/25 at 01:48 PM, the grievance policy was observed posted in the glass case in the front hallway at the second-floor main entrance. The posting was high above the standard height, making it difficult to read. On 03/11/25 at 2:29 PM, seven of seven residents in the resident council stated they were unaware of any formal complaint process the facility had. They were also unaware of any posting that would inform them. None of them knew of anyone designated to report complaints to, except the social worker. During an interview on 03/11/25 at 5:03 PM, the Social Service Director (SSD) was asked who the facility's grievance officer was. SSD stated it was the Administrator. SSD stated most complaints come through her department. SSD stated she writes out the concern and gives it to that department to be investigated and resolved. The Administrator then reviews it and signs off on them. SSD was asked how residents learned how to make a complaint. SSD stated they asked during resident council if anyone has a concern, and the policy was also posted. SSD was asked how residents that don't attend resident council find out about the grievance process. SSD stated she wasn't sure but going forward they will find a way to better educate. During an interview on 03/14/25 at 2:11 PM, the Administrator was informed during the resident council interview, seven of seven residents stated they were unaware of the facility's grievance process, how to make an anonymous complaint or who the grievance officer was. The Administrator stated there was a complaint box in front of the building residents could use and she has received complaints from residents from the box. 2. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R158 was admitted to the facility on [DATE] and was discharged on [DATE]. R158's closed record was reviewed. During an interview on 03/11/25 at 3:47 PM, Family Member (FM)1, the responsible party for R158, stated there were multiple concerns occurring during R158's stay at the facility. FM1 stated she had filed grievances and talked with numerous staff including the SSD, Director of Nursing (DON), and the Administrator. FM1 stated one of her concerns was poor housekeeping services. FM1 stated the housekeeper assigned to R158's room did not clean the room and bathroom adequately. FM1 stated R158's toilet went five days one time without getting cleaned. FM1 stated public areas were also not cleaned and there were dirty floors, furniture etc. R158 stated staff did not address her concerns adequately and filed housekeeping grievance more than once. Review of a Resident Concern Form dated 09/03/24 and provided by the facility revealed FM1's grievance was taken by the SSD and included two concerns. One concern related to nursing and call bells and the other concern was about housekeeping. The housekeeping concern indicated there was a lack of housekeeping over the weekend, the garbage was full, and there were flies. The Resident Concern Form investigation was completed by the DON and addressed the nursing concern; however, did not address the housekeeping concerns. There was no response to the Resident Concern Form addressing the housekeeping issues. Review of a Resident Concern Form dated 10/11/24 revealed FM1 filed a grievance on this date with the SSD due to R158's room and bathroom not being cleaned for days at a time, feces on the bathroom floor and the dining room not getting cleaned from the previous day. The Resident Concern Form investigation was completed by the Housekeeping Director (HD) and FM1 was contacted on 10/18/24 with the results. Resolutions included inservicing housekeeping staff about the importance of cleaning rooms. During an interview on 03/12/25 at 3:10 PM, the SSD stated she did not remember FM1 expressing any concerns to her. The SSD stated when residents or family brought her concerns, she initiated the Resident Concern Form and then forwarded the form to the relevant department to do the investigation, document their response and contact the complainant once the investigation was completed. The SSD stated once the investigation was completed, the department head brought her the completed form, and she took it to the Administrator for signature. During an interview on 03/12/25 at 3:27 PM, the Housekeeping Director (HD) stated she remembered speaking to FM1 about housekeeping concerns and had responded to a Resident Concern Form. The HD stated when she received a Resident Concern Form she investigated the concern, documented the information on the form, and then contacted the complainant to discuss the results. The HD reviewed two Resident Concern Forms one dated 09/03/24 and one dated 10/11/24. The HD stated she completed the investigation and responded to the Resident Concern Form dated 10/11/24. The HD stated she personally checked R158's room for cleanliness after the grievance filed on 10/11/24. The HD reviewed the Resident Concern Form dated 09/1024 and verified she had not responded to that grievance and there was no response on the form related to the housekeeping concerns. The HD stated she did not remember responding to more than one Resident Concern Form from FM1. During an interview on 03/14/25 at 11:30 AM, the DON stated she met with FM1 several times about her concerns. The DON verified she responded to the nursing concerns on the Resident Concern Form dated 09/03/24. The DON stated when a grievance had concerns that addressed two departments such as nursing and housekeeping, two copies of the form were made with each copy going to the appropriate department head. The DON stated she did not investigate or respond to the housekeeping concerns on the Resident Concern Form dated 09/03/24. During an interview on 03/14/25 at 1:46 PM, the Administrator stated she was not employed when the grievance in September 2024 was filed by FM1. The Administrator stated the Administrator oversaw the grievance process and signed off on the grievance once completed. The Administrator stated if there were allegations for two different departments, each department should get a copy of the grievance and each department should respond. The Administrator stated the two responses should get combined for the total response. During an interview on 03/14/25 at 4:05 PM, the Administrator stated she could not find where the housekeeping part of the grievance dated 09/03/25 had been addressed. 3. Review of R34's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/10/24 and located in the EMR under the MDS tab, revealed R34 had an admitted [DATE] and a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R34's cognition was intact. The MDS assessment indicated R34 had diagnoses that included depression, anxiety, and cerebrovascular disease. Review of R34's care plan, dated 03/20/20, located in the EMR under the Care Plan tab revealed an intervention R34 states that it is important to her to take care of her personal belongings and things. R34 prefers to use personal products she has purchased (dollar store/trips) but will also use facility issued personal products. She performs her own oral care and for hygiene requests that the staff keep her well groomed and nice. She prefers to have her personal items kept in order in her room. Review of R34's orders, dated 07/01/20, located in the EMR under the Order tab revealed Palliative Care . Review of the facility's grievances, dated 03/2024 to 03/2025, revealed no grievance addressing R34's personal property. During the resident council interview on 03/11/25 at 2:29 PM, R34 stated she had a small refrigerator for two or three years in her room and staff recently took it out of her room with no explanation. R34 stated the small refrigerator was currently at the nurse's station for her family to pick up. R34 went on to say it was only big enough to hold two or three cans of soda. During an interview on 03/11/25 at 3:48 PM, Licensed Practical Nurse Supervisor (LPNS)2 confirmed R34's small refrigerator was removed from her room and stored in a drawer at the nurses' station. LPNS2 opened the drawer, and the refrigerator was observed to be a mini box cooler only big enough to hold a few canned drinks. LPNS2 was asked why R34's refrigerator was removed from her room. LPNS2 stated because it's the facility's policy no personal refrigerators in resident rooms as they have a designated refrigerator for residents behind the nurses' station. On 03/12/25 at 9:24 AM, R34 was awake in bed watching television. R34 was asked in what manner was her refrigerator removed and how long ago. R34 stated two nurses came into her room sometime after Christmas saying they were conducting room checks. R34 stated the nurses walked around her bed and spotted her small refrigerator. They told her You can't have this and took it. They gave her no explanation. R34 stated she was so upset over the manner she called her granddaughter. Her granddaughter came in and the staff told her It's unsafe without further explanation. During an interview on 03/12/25 at 9:34 AM, the Social Service Director (SSD), was asked if she was aware R34's small refrigerator was removed earlier this year. SSD stated, Yes, it was an administrative decision. SSD stated the reason was because the refrigerator was a fire safety risk, she but she wasn't sure how it was a safety risk. SSD was asked if it was a new policy and SSD stated, No. SSD was asked why R34 wasn't given an explanation. SSD stated she didn't know. During an interview on 03/12/25 at 9:41 AM, the Administrator was asked if she was aware of R34's mini box cooler was removed sometime after Christmas. The Administrator stated, Yes for safety, as R34 was unable to maintain its cleanliness, ensured it was at the correct temperature and food was dated. The Administrator stated, the company doesn't allow it, and the reason was explained to R34's niece. The Administrator was asked for a personal property policy. The Administrator stated they didn't have a policy addressing personal property, just the grievance policy. The Administrator was asked if the admission packet included no small refrigerators allowed. The Administrator stated she wasn't sure. The Administrator was asked why the facility's outside food policy didn't mention the designated resident refrigerator at the nurses' station and only addressed perishable foods (time/temperature controlled foods). The Administrator was informed that R34's small refrigerator was a box cooler that only held soda cans which aren't perishable foods. The Administrator stated she would look at the policy and update it as indicated. The Administrator was asked if there was documentation of the staff's right to take R34's property. The Administrator stated, No after reviewing the EMR and finding no documentation. 4. Review of R59's quarterly MDS, with an ARD of 12/04/24 and located in the EMR under the MDS tab, revealed R34 had an admitted [DATE] and a BIMS score of 15 out of 15, which indicated R59s cognition was intact. The MDS assessment indicated R59 had impairment on one side of this upper extremity, was dependent with transfers and had diagnoses that included other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left non-dominant side, epilepsy, and muscle weakness. Review of R59's care plan, dated 06/13/22, located in the EMR under the Care Plan tab revealed an intervention R59 states that it is important to him to: take care of his personal belongings and things . Review of R59's social service note, dated 01/07/25, located in the EMR under the Progress Note tab revealed Met with resident about several issues today and called his [family member] to keep her in the loop. His electric razor is missing, but his [family member] doesn't want to buy another one and is just encouraging him to get used to disposable razors, which he used today. Also - per [family member], resident will need reminders about phone scams and to be more cautious. Nsg [nursing] already aware and SS [social services] discussed this with him today . On 03/14/25 at 11:10 AM, R59 was awake in bed holding his cell phone. R59 stated the facility does a good job with care, except his electric razor had been missing recently. R59 stated he ordered it off Amazon and it cost $60. R59 stated he asked Certified Nursing Aide (CNA)11 to plug it in to charge and that's when it was discovered gone. He reported it to the Unit Managers and maintenance looked around his bed for it and it was not found. R59 stated the electric razor kept him more independent as it's easier to do a good job shaving. R59 stated that other razors have been broken when the CNAs pushed his overbed table away during care very fast and his razor flies off, breaking it. During an interview on 03/14/25 on 11:15 AM, CNA11 was asked about R59's missing electric razor. CNA11 confirmed R59 had an electric razor, and he asked her a while ago to plug the razor in to charge and it wasn't there. CNA11 stated the razor was there the shift before her's. During an interview on 03/14/25 at 12:22 PM, the Director of Nurses (DON) asked about R59's missing razor on or around January 2025. The DON stated she thought she remembered something about this, and the social worker made a note. The DON asked if the missing razor should have been written as a grievance. The DON stated she thought so. During an interview on 03/14/25 at 1:41 PM, Licensed Practical Nurse Supervisor (LPNS)2 was asked if she was aware R59's electric razor was missing. LPNS2 stated, Yes, she was aware, but it was already reported to social services. LPNS2 stated his [family member] said she wasn't going to buy him any more razors as he keeps breaking them. LPNS2 was asked if R59 was his own representative and LPNS2 stated, Yes but it was the [family member's] Amazon account that he ordered the razors from. LPNS2 informed R59 stated the CNAs push his overbed table away during care very fast and his razor flies off it and they break. LPNS2 stated she was unaware of that. During a telephone interview on 03/14/25 at 6:38 PM, the Activity Assistant (AA) stated she assisted SSD and was asked if she was aware R59's electric razor was missing. AA stated, Yes she knew about it in January 2025 and R59's [family member] wanted R59 to use disposable razors because he's broken too many electric razors. AA was asked if R59 was his own representative and AA stated, Yes but R59 wants his [family member] in on his financial business. AA was asked if a written report was made about the missing razor. AA stated, No because R59's [family member] was not overly concerned about it. AA was asked could R59 had lost his electric razor since he was confined to the bed and required total assistance to get out of bed. AA stated, No. AA was asked if anyone looked for his razor beyond his room such as laundry in case it got caught in his bedding or if it fell in the trash or if it was stolen. AA stated she wasn't sure and would have to check with SSD. During an interview on 03/14/25 at 7:16 PM, the Administrator was asked why R59's missing electric razor wasn't written as a grievance per their policy. The Administrator stated R59 broke it and his [family member] said she wasn't going to get him anymore. The Administrator was informed the R59 reported it as missing and not broken. However, R59 reported the other electric razors had been broken when the CNAs pushed his overbed table aside quickly to give care. The Administrator stated she visits R59 regularly and he has never told her that.

Based on observations, record review, and interviews, the facility failed to ensure a medication error rate of less than five percent. During observation of medication pass, there were three errors observed out of 30 opportunities, resulting in a 10% error rate. This had the potential to place two residents (Residents (R) 36 and R93) at risk of not receiving the full benefit of their medication therapy. Findings include: 1.Review of R93's facility provided Order Summary Report revealed ritalin oral tablet 20 milligrams (mg) (Methylphenidate HCL), give one tablet by mouth (PO) two times (BID) a day for attention deficit disorder (ADD), starting 01/15/25. Review of R93's facility provided Order Summary Report revealed omeprazole oral capsule delayed release 40 mg, give one capsule PO one time a day for gastroesophageal reflux disease (GERD), starting 02/04/25. Review of facility provided Blister Package indicated omeprazole 40 mg capsule, one time a day for GERD .Take on empty stomach, before eating. Review of facility provided Blister Package indicated Methylphenidate 20 mg tablet twice daily for ADD. Preferably take 30-45 minutes before meals. Observation on 03/12/25 at 9:00 AM, Registered Nurse (RN) 1 prepared medications for R93, which included ritalin (hyperactivity medication) 20 mg one tablet, and omeprazole 40 mg one capsule, which she popped into a clear cup. After RN1 obtained all the medications needed for R93, she administered the medications. Interview on 03/12/25 at 9:05 AM, R93 said that she already had eaten breakfast. R93 said that she ate cereal this morning. Interview on 03/13/25 at 10:41 AM, RN1 confirmed that she was aware that these medications were to be given before meals; however, RN1 stated that she does her best to give them to the resident before breakfast but has other things to do prior to giving these medications. 2. Review of R36's facility provided Order Summary Report revealed glipizide 2.5 mg, give one tablet PO one time a day every Monday, Wednesday, Friday for diabetes. Give 30 minutes before meals, starting 12/03/24. Review of the facility provided Blister Package indicated, glipizide 2.5 mg one tablet PO one time a day every Monday, Wednesday, Friday for diabetes. Give 30 minutes before meals. Observation on 03/10/25 at 10:00 AM, Licensed Practical Nurse (LPN) 2 prepared medications for R36, which included glipizide (diabetes medication) 2.5 mg one tablet, which she popped into a clear cup. After LPN2 obtained all the medications needed for R36, she administered the medications. Interview on 03/10/25 at 10:15 AM, LPN2 confirmed that R36 already had her breakfast tray. Follow up interview on 03/13/25 at 12:05 PM, LPN2 said that R36's medication was held due to her blood sugar being low (blood sugar documented at 112) and said that she gave R36's medication around 9:00 AM; however, when the correct time for administration was discussed, LPN2 had nothing to say. Interview on 03/13/25 at 11:30 AM, the Director of Nursing (DON) said that she expects medications to be given as ordered, and according to blister package instructions.

Based on observation and interview, the facility failed to ensure the outdoor garbage/dumpster area was maintained in a manner to prevent pests from accessing garbage. A large dumpster contained garbage; there was no lid, and the bags were observed with holes and food. Findings include: During an observation on 03/10/25 at 9:45 AM with the Dietary Manager (DM), there was garbage on the ground around the garbage compactor including cigarette buts, paper, and pieces of cardboard. The DM verified the presence of the garbage on the ground and stated maintenance was responsible for keeping the area cleaned up. In addition, there was an extra-large dumpster that did not have a lid, and it could not be closed. This dumpster contained a lot of garbage, including large plastic bags of waste from the kitchen. There were five bags visible that had rips or torn areas with garbage such as food scraps/containers visible. The DM stated the compactor was gone for a while due to being repaired and that was why the large dumpster was present. The compactor had been repaired and returned to the premises; however, the large dumpster had not been removed. During an observation on 03/11/25 at 10:13 AM, the large dumpster was observed with the same garbage from 03/10/25 including the ripped garbage bags with food scraps/containers visible. During an observation on 03/11/25 at 7:05 PM, a large dumpster was observed with the same garbage noted at 10:13 AM with holes in the bags and food scraps/containers visible. During an observation on 03/12/25 at 10:01 AM, the DM and surveyor checked the dumpster area. The large dumpster continued to have ripped bags of garbage visible which was verified by the DM. The DM stated it was important to have a lid to cover the garbage so animals could not get into it. The DM stated the dumpster would be removed today. The garbage on the ground around the garbage compactor observed on 03/10/25 continued to be present (cigarette buts, paper, cardboard). During an interview on 02/12/25 at 10:18 AM, the Maintenance Director (MD) stated the large dumpster had been present for a couple of weeks while the compactor was repaired. The MD stated he had reached out to waste management to come and remove the dumpster. The MD stated waste management did not provide dumpsters that had lids. The MD stated the maintenance staff typically cleaned the garbage area twice a week on Mondays and Fridays. The MD stated the large dumpster was scheduled to be picked up on 02/13/25. During an interview on 03/13/25 at 10:29 AM, the Administrator stated there was no facility policy related to maintenance of the dumpster area. During an interview on 03/13/25 at 5:35 PM, the Registered Dietitian (RD) stated she completed sanitation inspections of the kitchen which included checking the dumpster area. The RD stated she looked to ensure the dumpster was not overfilled, that the lid was closed, and that there was no food/garbage on the ground. The RD stated the lid should be closed to ensure animals did not get into the garbage. During an interview on 03/13/25 at 6:59 PM, the Administrator stated the large dumpster was picked up today. She stated she was not sure how long the dumpster had been present at the facility. The Administrator stated the dumpster should have had a lid so the garbage would be enclosed.

30347 36190 Based on review of facility documentation, staff interview, and resident interview, the facility failed to protect the resident's right to be free from abuse for three of three (Resident (R) 80, 359, 78) reviewed for abuse of 41 sampled residents. This failure to protect the residents increased the risk of further exposure to abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, dated 01/03/25, revealed, Policy It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime. Cadia Healthcare adopts this policy to standardize procedures for employee screening, employee training, prevention, identification, investigation, protection, and reporting of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and reasonable suspicions of crime. Purpose: To ensure that all residents are protected from abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime . Guidelines . Prevention: The facility will; Provide residents and staff information on how to report concerns and incidents without fear of retribution. Provide training to ensure resident rights and safety are met. Monitor staffing patterns in relation to reported allegations or suspicions of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime . Protection: The facility will respond immediately to protect the alleged victim, the integrity of the investigation and provide protection from retaliation. Assessment of the alleged victim will be conducted for signs and symptoms of injury (physical and/ or psychosocial). Increased supervision, room changes, and staffing changes may be provided to the alleged victim and other residents. Psychological support will be offered during and after the investigation. The named person accused of the act will be immediately suspended pending outcome of the investigation. Reporting and Response: Witnessed or suspected incidents of abuse or reasonable suspicions of crime are to be reported immediately . The DON (Director of Nursing) or designee is responsible to conduct the abuse investigation. The NHA (Nursing Home Administrator) serves as the abuse coordinator. Allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours. Incidents involving reasonable suspicions of criminal conduct are reported to the applicable state agency and law enforcement within 8 hours or within 2 hours if the conduct causes serious bodily harm . 1. Review of R80's undated Admission Record, located in R80's electronic medical record (EMR) under the Profile tab, revealed R80 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, unspecified dementia with agitation, major depressive disorder. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/24, located under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R80' was cognitively severely impaired. Review of the facility investigation, started 07/11/24, revealed the incident occurred on 07/07/24 when Certified Nursing Assistant (CNA) 1 stuck her tongue out and threw three wipes toward R80's head while in the process of changing the resident. R80 then attempted to throw spit at CNA1. CNA2 witnessed the incident and she and CNA1 left the room. CNA2 reported the incident to Licensed Practical Nurse (LPN)1 on 07/07/24. The incident was not reported to the Abuse Coordinator until 07/11/24. Failing to report the allegation of abuse allowed CNA1 to remain on schedule and she worked 07/08/24, 07/10/24, 07/11/24. Phone interview on 03/13/25 at 12:26 PM CNA2 stated, R80 was aggressive like normal when we went to change her. Then CNA1 threw three individual wipes at R80's face, R80 then spit in her hand and threw it at CNA1. After that we both walked out of the room, and I went to tell the nurse (LPN1) what happened. I went back to check on R80 and she was fine, she didn't say anything about it. During a phone interview on 03/13/25 at 1:20 PM, the former Administrator stated, The CNA was suspended during the investigation and later terminated. By terminating her we would have confirmed the abuse. The DON performed the investigation. 2. Record review of facility provided documentation and resident record review revealed one incident of resident-to-resident aggression with R17 as the assailant. On 06/12/24, R78 was revealed to have informed the facility that they had been struck by R17 on 06/11/24, the previous day. Review of R17's electronic medical record (EMR) Profile tab, revealed admission to the facility on [DATE] with diagnoses of syncope and collapse, undifferentiated schizophrenia, epilepsy, and major depressive disorder recurrent/moderate. Review of R17's quarterly MDS under the MDS tab of the EMR, with an ARD of 05/01/24, revealed a BIMS score of nine out of 15 which indicated moderate cognitive impairment. Further review revealed that R17 had no behaviors including physical and/or behavioral symptoms directed toward others. The incident of resident-to-resident behavior occurred 06/11/24. Review of R17's annual MDS under the MDS tab of the EMR, with an ARD of 01/29/25, revealed a BIMS score of twelve out of 15 which indicated moderate cognitive impairment. Further review revealed that R17 had no behaviors including physical and/or behavioral symptoms directed toward others. No recording of any physical and/or behavioral symptoms directed towards others since the 06/11/24 incident. Review of R17's Care Plan in the EMR under the Care Plan tab, initiated 02/17/23 and last revised 08/02/23, revealed R17 had the potential to have socially inappropriate behavior with the potential for physical resistiveness towards others as evidenced by scratching, swinging, kicking, pushing, and/or slapping. Interventions identified prior to the incidents below, to allow ten to 15 minutes for the resident to calm down then reapproach, approach calmly and unhurriedly, to avoid overstimulation, and to explain all care tasks prior to providing care. Review of R78's EMR Profile tab, revealed admission to the facility on [DATE] with diagnoses of Parkinson's disease, dementia, neurocognitive disorder with Lewy bodies, and anxiety disorder. Review of R78's annual MDS under the MDS tab of the EMR, with an ARD of 05/03/24, revealed a BIMS score of twelve out of 15 which indicated moderate cognitive impairment. Further review revealed R78 had no behaviors nor rejected care. The incident of resident-to-resident behavior occurred 06/11/24. Review of R78's quarterly MDS under the MDS tab of the EMR, with an ARD of 01/31/25, revealed a BIMS score of ten out of 15 which indicated moderate cognitive impairment. Further review revealed that R78 had no behaviors nor rejection of care. No recording of any physical and/or behavioral symptoms directed towards others since the 06/11/24 incident. Review of R78's Care Plan in the EMR under the Care Plan tab, initiated 09/29/23 and last revised 11/08/23, revealed R78 had the potential to be verbally aggressive (yelling and cursing) to staff and make false accusations of staff not providing care when all needs were met. Interventions identified prior to the incident below were to provide paired care for the resident, assess the resident's understanding of the situation and allow time for the resident to express self and feelings towards the situation, to assess and anticipate the resident's needs, and when the resident becomes agitated, to intervene before agitation escalates and guide away from source of distress. Review of the facility provided the Incident Report that documented on 06/12/24 at 1:30 PM, that there was a resident-to-resident abuse situation between R17 and R78. The incident was unwitnessed, and the resident representatives and the physician were notified timely. R78 stated that on 06/11/24, the day prior, R17 had stood over her and hit her in the face. She reported that the incident occurred during the night of 06/11/24 and that R17 had used her open hand and struck her in the forehead. She also stated that this was the first physical altercation with R17. The investigation of the 06/11/24 incident revealed no injuries to R17. R78 was sent to the hospital for a psychological evaluation on 06/12/24 and was readmitted on [DATE] with no new physician orders. R17 was readmitted to a different room. R78 was followed by psych services, with no deviation from baseline. Other facility residents were interviewed to determine if they had experienced any abuse, and there were no identified concerns. Staff were also interviewed with no identified concerns. The investigation revealed the interventions after the resident-to-resident included sending R17 to the hospital for psychiatric evaluation upon notification of the incident, a room change, and in-house psychiatric follow-up. No additional observations or reported incidents of resident-to-resident abuse have been documented between R17 and R78 since the event on 06/11/24. During an interview on 03/10/25 at 4:13 PM, R17 stated that she was not fearful of any residents or staff in the facility, including R78. She stated she was satisfied with her private room. She was unable to recall the resident-to-resident incident. During an interview on 03/11/25 at 11:18 AM, R78 stated she had a previous concern with a former roommate. She was unable to recall the resident's name, but stated she was not afraid of the other resident or anyone else. R78 said she was not bothered by the incident from 06/11/24 and had no concerns that she wished to discuss. During an interview on 03/14/25 at 11:25 AM, the Assistant Director of Nursing (ADON) said that she had completed the initial report for the resident-to-resident incident, but the former Director of Nursing had completed the investigation. She stated that staff would have told her what happened, reported the incident, and she would have informed the former Director of Nursing. She said she had two hours to report it and the investigation would have had to be done in five days. She stated that she would expect to see interviews with the residents involved, any witnesses, and staff. She said the facility would have gotten statements with other residents to see if they had any problems with the residents in the incident. She stated that there were no problems at all. She said the residents lived on separate hallways. The ADON said that R17 had her own room since the incident, and there had been no further issues. She said that R17 was able to be moved into a new room right away because there was open and available at the time of the incident. During an interview on 03/14/25 at 2:23 PM, the Director of Nursing (DON) stated she had not been in her current position during the time of the incident. She stated R17 did have behaviors, but the facility staff had been able to redirect her. The facility provides emotional support. Whenever they see the resident cycling or ramping up with behaviors, they have psych services see her again, to which she is usually agreeable. The resident was provided with her own room because she has had some roommate problems in the past, due to personality conflicts. She said R17 liked and did best in her own room. She does come out of her room, is social, circles around the nurse station, and sometimes goes to activities. The DON stated that staff have been trained to redirect her and provide her support because they want staff to deescalate the situation and makes sure all residents are safe. She stated dementia training was provided upon new hire and annually so they can handle difficult behaviors. She said that R78 has no ongoing behavioral issues and has done well with her new roommate. She said that if staff see abuse, she wants them to report it immediately so she can report it immediately and do the investigative process. The DON said she wants residents to be safe, and to separate them if there is a resident-to-resident behavior. She stated that if there is any incident they will begin behavior monitoring until psych services can see them. She said an investigation includes interviewing staff to complete the whole investigation process. She said psych services typically get involved with resident-to-resident incidents, and that they come in regularly so the residents can be assessed. During an interview on 03/14/25 at 3:44 PM, the Social Service Director (SSD) stated that R17 did have some paranoid behaviors and could get agitated. She said R17 had some history of agitation with other residents and staff, just yelling out. SSD said R17 was redirectable. SSD stated R17 was given her own room because she had believed that her former roommate had talked about her. SSD confirmed the resident did best in her own room. She stated that abuse training was completed by all staff upon hire and annually. During an interview on 03/14/25 at 6:45 PM, CNA13 stated that abuse training was completely on an ongoing basis. CNA13 said R17 moved rooms, to a different unit, and had not seen any behaviors since the original incident. She stated R78 had not been observed interacting with R17 since the room change. During an interview on 03/14/25 at 6:55 PM, Licensed Practical Nurse (LPN) 5 stated that the facility did abuse training a few times each year. He stated that he started last summer and had multiple abuse training since he had been at the facility, because the facility did not tolerate any types of abuse. LPN5 stated that if anyone saw anything that could be considered as potential abuse, anything on the body or that you notice is new, you had to report it immediately so it could be investigated. LPN5 said that there had been no identified concerns with R17 or R78 since working at the facility. 3. Review of R359's annual MDS, with an ARD of 10/08/24 and located in the EMR under the MDS tab, revealed R359 had an admitted [DATE] and a BIMS score of 15 out of 15, which indicated R359's cognition was intact. The MDS assessment indicated R359 had diagnoses that included glaucoma, acquired absence of right leg above knee, and cerebrovascular disease. Review of R359's care plan, revised 10/29/24 located in the EMR under the Care Plan tab revealed The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] Activity Intolerance, RAKA [right above the knee amputation], Impaired balance, Limited Mobility, Musculoskeletal impairment/Acquired absence of right leg below the knee. An intervention included Assist with hygiene, grooming, toileting, dressing, oral care, and eating as needed. Review of the facility investigation dated 10/28/24, provided by the facility, revealed on October 28, 2024, at approximately 2pm, the resident and [family member] reported to his assigned nurse that they were upset about events that occurred over the weekend. The nurse then reported immediately to the social worker [name] and [name] ADON The social worker then met with the resident to perform a psychosocial visit. The resident stated that his 11-7 CNA (identified as CNA10) on Friday, October 25, 2024 treated him rudely and told him he needed to clean up his room because it was a mess. He also stated later on this past weekend (resident unsure of date/time) another CNA who he could not identify yanked up his brief causing him pain. Resident stated to the social worker to talk to his [family member] [name] as she knows everything that happened now it's not fresh in his mind. [name] ADON spoke to resident's [family member] [name] who stated that the resident called her on October 26, 2024, around 12:37pm and stated his new CNA on 11-7 told him Rudely to clean up his room, but he cannot see well so he couldn't do it. [Family member] also stated that she received a call from her husband on Sunday October 27, 2024, around 21:16 pm that he had put his call light on and an aide who he did not know came in and he asked for a diaper and the aide told him to put it on himself'. When he said he couldn't, she was very rough with him and pulled the tabs tight causing him pain to his penis and scrotum. A skin assessment was completed by nursing and no injury or skin abnormality was found on the resident. DON [Director of Nurses] and ADON were able to identify the 11-7 CNA who was involved in the October 25, 2024, incident as [CNA10] who was suspended immediately pending further investigation. Further investigation revealed [name] CNA10 did tell the resident to clean up his room because it was a mess. [CNA] was subsequently terminated on October 30, 2024, related to poor customer service. DON and ADON were unable to identify who the suspected CNA was involved in the alleged October 27, 2024, incident. All cognitively appropriate residents along the hallway where R359 resides were interviewed to determine if they experienced any care concerns. Full body skin checks were also completed on other residents who could not be interviewed, and no new skin abnormalities were identified. Staff members were also interviewed and denied having any knowledge of the- in question or any other incident involving the resident or any other residents, nor did they recall any concerns, issues, or complaints from R359 when providing care. Review of the facility's all staff training, conducted on 10/28/24, provided by the facility, revealed an abuse in-service was conducted by the staff developer in response to the abuse investigation that was substantiated for R359. The in-service included all types of abuse, reporting all suspected and alleged abuse immediately following the chain of command, writing statements, and monitoring residents involved in abuse. Review of CNA10's statement, dated 10/28/24, provided by the facility revealed I did a double 10/25 into 10/26 11-7 . On west [hall] I enter room [number] spoke with [bed number] R359 [resident's name]. Approx. [approximately] 12:25 when doing rounds I noticed his room had been cleaned w/ [with] things in it proper place. I mentioned that his room looked cleaned and that would be nice because he might receive a visitor. That comment came from a conversation [room and bed number] bed had with [room and bed number] bed to which they included me in saying that they were roommates at one point and that [room and bed number] would be visiting him [R359 room and bed number]. Later that morning [room and bed number] became bothered by the comment and reported some what of the truth to the RN [registered nurse] at the desk. I was informed not to enter that room. Review of the ADON's statement, dated 10/28/24, provided by the facility revealed I sat down with CNA10 to discuss the complaints from R359 and his [family member] [name]. I explained to her that they were very upset about way she talked to him, on October 26 at 12:37 in the morning. She [CNA10] stated to me that his room was a mess. that there were papers and trash on the floor and she did tell him that the room was disgusting and he needed to clean this mess up in case he had visitors. Review of CNA10's personnel file provided by the facility, revealed CNA10 was suspended pending the investigation on 10/28/24 and terminated on 10/30/24 due to poor customer service. During an interview on 03/12/25 at 2:13 PM, the ADON stated she became aware of the allegation by another staff member. The DON asked her to conduct skin assessments and interviews. The ADON stated she didn't remember specifics as it's been too long ago but she obtained a statement from CNA10. The ADON stated CNA10 admitted to her she told R359 his room was a mess; his room was disgusting and he needed to clean this mess up in case he had visitors. The ADON stated after further investigation they determined there was only one perpetrator. During an interview on 03/12/25 at 6:11 PM, the Administrator and DON stated safe surveys were completed on residents that had contact with CNA10 with questions about abuse and safety. The DON stated staff were also interviewed and statements were obtained from those who had worked with CNA10. During an interview on 03/13/25 at 6:26 PM, the SSD was asked about R359's investigation. SSD stated staff alerted her to R359's room as he had a complaint and was upset. SSD stated R359 told her his CNA pulled on his brief, and it was hurting him. SSD stated R359 didn't remember the details, but he had told his [family member] earlier. SSD stated she reported it immediately and the ADON called the [family member]. SSD stated she understood there was only one perpetrator identified and that it was CNA10. SSD stated R359 had no lasting pain from the brief. During a follow up interview on 03/13/25 at 6:30 PM, the ADON stated the timeframes helped substantiate that there was only one perpetrator, CNA10. ADON stated they compared the nursing schedule using a 72-hour timeframe and statements were taken from all nursing staff. R359 had no roommate, and there was not a second staff member present to witness care. During an interview on 03/13/25 at 7:00 PM, DON stated the ADON told her about R359's complaint and they started putting the pieces together by comparing schedules and assignment sheets. DON stated, just one person was identified, and a second person could not be substantiated. DON stated R359 wasn't certain CNAs by name and by process of elimination they figured it out. DON stated she didn't get the impression CNA10 meant any harm in her interactions with R359, and they couldn't prove his brief was pulled off abruptly as R359 had no injury or redness.

Based on observation, interview, record review, and policy review, the facility failed to ensure an injury of unknown origin was investigated for one out of 11 residents reviewed for abuse (Resident (R)2). R2's thumb was noted with a 1.5 centimeter (cm) by 1.5 cm purple area with swelling; once staff to resident abuse was ruled out as a potential cause, the facility failed to investigate further to determine how R2 sustained the injury. Findings include: Review of the facility's Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime policy dated 01/03/25 revealed, It is the policy of [facility name] to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime . Injuries of unknown source are injuries where the source of the injury was not observed by any person; the source of the injury could not be explained by the resident; the injury is suspicious because of the extent of the injury or the location of the injury . All alleged incidents . including injuries of unknown source, shall be reported to the NHA [Nursing Home Administrator] or designee immediately. The NHA or designee shall investigate allegations . Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/19/25 in the EMR under the MDS tab revealed R2 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Incident Report for Web Intake #84519 (Initial Report) dated 03/18/24 and provided by the facility revealed R2 reported on 03/18/24 that on 03/17/24 at 1:30 PM Certified Nursing Assistant (CNA)2 pinched his thumb after he threw a soda can at her, causing an injury to his thumb. Review of the facility's Incident Report for Web Intake #84519 - Follow Up (Five Day Follow up Investigation file) provided by the facility dated 03/21/24 indicated on 03/17/24 at 2:00 PM, CNA2 was sitting at the computer on wheels in the long hallway and R2 approached and requested that she make his bed. CNA2 asked him to give her a minute as she was charting. R2 responded by pushing the computer on wheels into her knees and moving the computer screen side to side. CNA2 stated she was logging off the computer to leave when R2 threw a soda can at her. CNA7 came out of another resident's room and observed CNA2 charting and R2 sitting next to her. CNA7 witnessed R2 throw a can of soda at CNA2. CNA2 alerted 911 to file a police report against R2. R2 was transported to the emergency room [ER] for a psych evaluation on 3/17/24 at 3:00 PM and returned at 9:30 PM. The report indicated that review of the ER records revealed R2 stated he felt like staff was not cleaning him up after an accident or providing him with food so became frustrated and threw food. The investigation revealed on 03/18/24 R2 showed the Speech Therapist his right thumb and stated CNA2 hurt him on 03/17/24. R2's thumb was assessed and a 1.5 cm x 1.5 cm area of purple tone was noted. An X-ray was obtained on 03/18/24 and showed no acute fracture or dislocation but showed soft tissue swelling to the R2's thumb. CNA2 was suspended related to the allegation of abuse made on 03/18/24. CNA2 stated she did not touch R2. CNA7, who was a witness stated she did not see CNA2 touch R2. Video footage showed R2 pushed the computer into CNA2, shook the computer screen, and threw a soda at the CNA which hit her. The video footage in the hallway did not show CNA2 making contact with R2. The investigation revealed there was no documentation about the thumb injury in the emergency room documentation on 03/17/24. The allegation of CNA2 abusing R2 was unsubstantiated. There was no additional documentation showing further investigation into the injury of R2's thumb, which became an injury of unknown origin after the allegation of abuse by CNA2 towards R2 was ruled out as the cause. During an interview on 03/10/25 at 12:03 PM, R2 stated he remembered the incident with a CNA a year ago in which he was pinched. R2 stated a CNA wanted a soda from him and he stated no and threw the soda at her. During an interview on 03/13/25 at 02:37 PM, the Assistant Director of Nursing (ADON) stated the abuse incident dated 03/17/24 included an allegation of CNA2 grabbing R2 which was not substantiated. The ADON stated she did not remember an injury to R2's hand when the original investigation was completed; however, the next day he had a scratch on his hand and it would be considered an injury of unknown origin. The ADON stated any bruising or injury that was new and the staff did not know how it happened, was considered an injury of unknown origin. During an interview on 03/13/25 at 7:03 PM, the Administrator confirmed the investigation occurred prior to her employment at the facility; however, she would look to see if there was any further information about the injury to R2's hand. During an interview on 03/14/25 at 12:03 PM, the Director of Nursing (DON) stated the investigation into R2's injury to his hand should be part of the original investigation. The DON stated she would review the file to determine if there was any additional information to show how R2's hand was injured. During an interview on 03/14/25 at 2:19 PM, the DON stated the facility did not investigate the injury to R2's thumb after it had been ruled out that CNA2 did not abuse R2.

Based on interviews and reviews of clinical records, facility policy, CDC (Centers for Disease Control) COVID-19 guidelines and other documentation as indicated, it was determined that the facility failed to identify and inform R1's family and continuing care providers of the discharge needs for R1 prior to his discharge on 9/21/2020. Specifically, the facility failed to disclose the following: R1 was having signs and symptoms (s/s) related to COVID-19 (fevers and cough) from 9/20/2020 through 9/21/2020; R1 was exposed to COVID-19 as he shared a room with another resident who was symptomatic and tested positive to COVID-19 on 9/21/2020; R1 was on droplet precautions from 9/19/2020 through 9/21/2020; and R1 had a pending COVID-19 PCR test performed on 9/21/2020. The facility's discharge system failed to re-evaluate the established discharge plan after R1's change in status; failed to ensure that all current and critical medical information was communicated among all interdisciplinary team members; and failed to identify and disclose critical medical information to R1's family member and continuing care providers prior to his discharge, which placed R1 in a serious adverse situation where his discharge plan did not meet his current care needs. An immediate jeopardy (IJ) was called on 10/15/2020 at 10:45 AM and was abated on 10/15/2020 at 4:51 PM. Findings include: 1/2/2020 (last revision) - The facility's Discharge Planning policy stated, It is the policy of Cadia Healthcare that the resident discharge process is safe and promotes resident well being in the next care setting . 5/13/2020 - The CDC website published Symptoms of Coronavirus. On the website, CDC stated, .People with these symptoms may have COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea . Review of documentation, including R1 and R2's clinical records revealed: 9/15/2020 at 11:33 AM - A social worker's (SW) note stated that R1's home health services start of care was scheduled on 9/17/2020. 9/15/2020 at 1:30 PM - A physician progress notes [REDACTED]. E4 stated that R1 had no fever or cough. 9/15/2020 at 4:30 PM - A SW note stated, (R1's) Family requested an extra day extension of dc (discharge) in order to assist with personal/private duty care schedule prior to his dc home . IDT (interdisciplinary team) notified. 9/15/2020 at 4:52 PM - R1's Cadia Discharge Summary stated, 1. Therapy .physical status (checked) dependent . Education and training completed with resident/family/caregivers: (checked) yes . In person training with (F1, family member) for ADL training, bed mobility, and W/C mgmt. Video call with private caregiving company . 2. Social Services .Recommended . (checked) PT/OT/RN/Home Health Aide . 6. Discharge . Other: (blank) . Unit Manager/Supervisor signature and date (E9) 9/17/2020 . 9/15/2020 - R1's Discharge Summary, completed by E4 (NP) stated, .Date of Admission: 6/08/2020 . Reason for Discharge: family initiated discharge. Released to: (F1, family member) . Nurses Signature: (E9, RN) Date: 9/16/2020 . Discharge Condition: (checked) improved . Summary: admitted s/p (status [REDACTED]. readmitted to hospital for nonhealing cervical fractures. Continued c PT (physical therapy). Family initiated dc (discharge) to home. While the Discharge Summary was completed on 9/15/2020, the document was never updated to reflect R1's current medical status as of 9/21/2020. 9/18/2020 at 8:15 AM - A SW note stated, (R1) is planned to dc home on Monday 9/21 with private duty support split between two agencies. (CCP #2) will provide coverage 8-12p, 4-8p mon-sun with the exception of Friday. (CCP #1) will staff Friday 8-12p, 4-8p. (F1, family member) will assist any time in-between . 9/18/2020 at 4:07 PM - R1's SW note stated, Transport established for patient discharge home Monday 9/21 - (CCP #2) CNA confirmed with SOC (start of care) for Monday at 9a (9 AM). Transport set for 10a (10 AM) from Silverside to patients (sic) home . (Family member) and home care notified of same. From 9/19/2020 (Friday) through 9/21/2020 (Monday), R1 shared a room with R2. Review of R1 and R2's clinical records revealed that both residents were exhibiting signs and symptoms of COVID-19 over the weekend. Below are the details for each resident: Review of R2's clinical record revealed: -9/19/2020 during evening shift - R2 had elevated temperatures of 102.4 and 100.9 degrees F. A physician's orders [REDACTED]. -9/20/2020 during day shift - R2 complained of nausea, vomited and exhibited a low-grade fever (99.1 degrees F) that was not effective by administration of Tylenol. -9/20/2020 during evening shift - R2 had symptoms of cough, sore throat, nausea and low-grade fever (99.0 degrees F). R2 complained of chills and his pulse ox was fluctuating between 92 - 95%. Oxygen was ordered by E8 (on call NP). -9/21/2020 during night shift - R2 had an elevated temperature (101.7 degrees F). -9/21/2020 during day shift - R2 had a low-grade fever (99.8 degrees F). -9/21/2020 at 9:30 AM - R2 tested positive using the POC device at the bedside for COVID-19. Review of R1's clinical record revealed: -9/19/2020 - The following two physician's orders [REDACTED]. -9/19/2020 at 11:45 PM - R1 had an elevated temperature of 100 degrees F. -9/20/2020 at 11:28 AM - R1 was noted with an intermitten (sic) cough. -9/20/2020 at 4:02 PM - R1 was noted with an occasional cough. -9/20/2020 at 7:10 PM - R1 was given Tylenol for a low-grade fever (99.7 degrees F). -9/20/2020 at 8:08 PM - E8 (on-call NP) was told about R1's temperature of 99.7. E8 ordered to give Tylenol and [MEDICATION NAME] for cough as needed. -9/21/2020 at 2:50 AM - R1 was given Tylenol for an elevated temperature (101.0 degrees F). -9/21/2020 at 5:53 AM - A nurse's note stated, Spoke with on call NP (E8) regarding temp of 101.0 Tylenol given with no effect but staying the same. Temp is not increasing. On call has no new orders at this time but to continue Tylenol and will follow up in am. Despite R1's change in condition and a nurse's note indicating the on call NP (E8) was to follow-up in (the) AM, R1 was not seen or evaluated by a medical doctor/NP prior to discharge from the facility. -9/21/2020 at 6:48 AM - A nurse's note stated, Temp of 101.0 with Tylenol down to 98.6. -9/21/2020 at 9:29 AM - R1 tested negative for the coronavirus using the POC [MEDICATION NAME] test at the bedside. -9/21/2020 untimed - R1 was tested for the coronavirus using the PCR test as part of universal testing due to a facility outbreak. Despite R1 being symptomatic and exposed over the weekend to his roommate (R2) who tested COVID positive on the morning of 9/21/2020, the facility failed to have R1 re-evaluated by one of their practitioners and they failed to re-evaluate his discharge needs prior to his discharge at 10 AM on 9/21/2020. 9/21/2020 untimed - Cadia's Discharge Summary for R1, completed on 9/15/2020 at 4:52 PM, was signed by E4 (NP) and by E5 (Unit Manager/RN) and by telephone with F1 (family member) on 9/21/2020. R1's discharge summary was not updated and failed to disclose critical medical information to meet his continuing care needs post discharge that included: - R1's change of condition over the weekend, that included exhibiting s/s of COVID-19; - R1 had a physician's orders [REDACTED]. - R1's exposure to roommate (R2) who also was exhibiting s/s of COVID-19 from 9/19/2020 through 9/21/2020 and tested positive for COVID-19 on 9/21/2020 at 9:30 AM; and - A COVID-19 PCR swab test was performed on R1 prior to his discharge on 9/21/2020 at 10 AM in response to the outbreak of COVID-19 that occurred on the same hallway where R1 resided. 9/21/2020 at 1000 - A nurse's note stated, Patient discharged home from the facility via wheelchair with GEM transportation at 1000 (10 AM). Personal belongings, medications, discharge instructions and prescriptions departed from facility in the patient's possession. Discharge instructions, prescriptions and follow-up appointments reviewed with (F1, family member), no questions at this time. 9/21/2020 at 10:36 AM - A physician's orders [REDACTED]. 9/21/2020 at 12:30 PM Late Entry - A SW note that was created on 9/28/2020 at 12:36 PM, stated, Call placed to (F1, family member) with notification that patient has been exposed to Covid-19 secondary to roommates positive test results. This writer further inquired, based on recent findings, if (F1) wanted to continue with dc as planned. (F1) indicated she will dc patient home this morning as scheduled despite about notification. F1 will call (CCP #2) to ensure care giver was to arrive at 9 AM and noted to this writer by the scheduler. Additional calls placed to (name of CCP #3) home care liaison with notification of Covid exposure. Message left with (C4) at (CCP #2) with request from return call regarding above findings and F1's request to continue to dc home. Despite the facility's social service note which stated that information was relayed to R1's family and the continuing care providers prior to R1's discharge, interviews with F1 (family member) and the continuing care providers and review of additional supportive documentation provided by them contradicted the facility's documentation. 9/23/2020 at 9:17 PM - R1's nurse's note stated, COVID-19 PCR results received - resident is POSITIVE for the coronavirus. Testing was completed as part of universal testing due to facility outbreak. Social Services to inform Home Health Agency. 9/29/2020 at 10:20 AM - During an interview, C2 (staff person from CCP #3) stated that she was informed on 9/21/2020 at 2:58 PM that R1 was exposed to COVID-19 on that day. C2 stated that she called F1 (R1's family member) on 9/21/2020 at approximately 4:45 PM to discuss their care that was to start on 9/22/2020. During the telephone conversation, C2 stated that F1 was not aware of R1's exposure to the roommate (R2) who tested positive for COVID-19 on 9/21/2020. C2 stated that she felt bad that she was the one who told F1 about R1's exposure to COVID-19. 9/29/2020 at 11:01 AM - During an interview, C3 (staff person from CCP #3) stated that she communicated with E6 (Cadia SW) several times on 9/21/2020 about R1 and was told the following: R1 tested negative to COVID-19 on 9/21/2020; and R1 was cleared for discharge. C3 stated that she was aware of a COVID-19 outbreak in the facility and asked E6 where the outbreak occurred and if R1 was directly exposed to COVID-19. C3 stated that she was told by E6 that R1 had medium exposure with his roommate who tested positive for COVID-19 on 9/21/2020. (R1's exposure information was not provided until after R1 was discharged at 10 AM on 9/21/2020 and stated he was only exposed to the roommate, R2, that day.) C3 stated that she did not receive any updated discharge documentation for R1 prior to or on the day of the 9/21/2020 discharge. C3 stated that she did not know about R1's COVID-19 PCR test performed on 9/21/2020 prior to his discharge until she was notified by E6 (Cadia SW) on 9/23/2020 at 9:06 PM that R1's PCR test from 9/21/2020 came back positive for COVID-19. 9/29/2020 at 11:50 AM - During an interview, F1 (family member) stated that she was told by the facility that R1 tested negative for COVID-19 on 9/21/2020. F1 stated that C1 (aide from CCP #2) came to their home on 9/21/2020, worked from 9 AM to 1 PM and provided care to R1. F1 stated that she received a phone call on 9/21/2020 at 4:40 PM from C2 (staff person with CCP #3), who told her that R1 was exposed to COVID-19 because his roommate (R2) tested positive on 9/21/2020. F1 stated that C1 (aide from CCP #2) returned to her home to work from 5 PM to 9 PM on 9/21/2020. F1 stated that when C1 arrived for the 5 PM shift, she immediately told C1 about R1's exposure in the facility where his roommate tested positive for COVID-19 on 9/21/2020. F1 stated that C1 left their home without working the evening shift on 9/21/2020 and never returned. 9/29/2020 at 3:25 PM - During an interview, C4 (representative from CCP #2) stated that F1 (R1's family member) called her directly on 9/21/2020 after 5 PM after informing C1 (aide from CCP #2) of R1's exposure at Cadia to his roommate, who tested positive for COVID-19 on 9/21/2020. 10/12/2020 at 2:13 PM - During an interview, E6 (SW) stated that she was told R1 was medically cleared for discharge. E6 stated that she was not aware of the COVID-19 PCR swab test performed on 9/21/2020. E6 stated that she called F1 (family member) and the CCP #3, and left a message for C4 (representative at CCP #2) about R1's exposure to his COVID-19 positive roommate, R2. E6 stated that she was never notified about the aide from CCP #2 being pulled out of the home. 10/12/2020 at 3:40 PM - During an interview, E5 (RN/UM) stated that he reviewed the discharge paperwork with F1 (family member) on 9/21/2020. E5 stated he was not aware of R1 having signs and symptoms related to COVID-19 over the weekend. E5 acknowledged that fever and cough are signs and symptoms of COVID-19. 10/12/2020 at 4:02 PM - During an interview, E4 (NP) stated that nursing will tell me if there are any issues with a resident before they are discharged . E4 requested to look at R1's clinical record. In a return call at 7 PM, E4 stated that she saw R1 on 9/15/2020 at 1:30 PM for the discharge. E4 stated that she was not told there were any issues with R1 and she did not see him again before discharge on 9/21/2020. 10/15/2020 at 11:45 AM - A follow-up interview was conducted to confirm with F1 (family member) in response to repeated verbal statements made by E1 (NHA) and E2 (DON) to the surveyor that F1 insisted on R1 being discharged from the facility on the morning of 9/21/2020. F1 stated that she never insisted on R1 being discharged to home on 9/21/2020. 10/15/2020 at 4:51 PM - The Immediate Jeopardy was abated. 10/15/2020 at 5 PM - Findings were reviewed during an exit conference with E1 (NHA), E2 (DON) and E3 (CNO).

Based on clinical record reviews, interviews and review of facility documentation, it was determined that the facility failed to ensure that 2 (R9, R91) residents out of 31 stage 2 sampled residents, who were incontinent of bladder, received the appropriate treatment and services to restore as much bladder function as possible. The facility failed to assess R91's urinary status twice upon readmission, failed to develop a care plan and failed to identify potential causes for a UTI after R91's hospitalization , failed to implement a 3 day voiding diary when there was a decline in R91's urinary status, failed to comprehensively assess R91's bladder incontinence after the FCS dated10/3/14 to 11/3/14 and the 11/11/14 quarterly MDS revealed a decline in bladder function, and failed to identify that R91's bladder function was not recorded by the CNA's from 12/13/14 to 12/17/14. For R9, the facility failed to comprehensively assess upon admission on 8/6/14 and after the 11/13/14 quarterly MDS, which indicated an increase in R9's urinary incontinence. In addition, the facility failed to identify, reassess and respond to R9's increase in urinary incontinence for approximately five (5) months (September 2014 through January 26, 2015). Findings include: The facility's policy entitled "Incontinence (Treatment)", dated 7/12/13, stated, "Purpose: A resident who is incontinent of bladder will receive appropriate treatment and services to prevent urinary tract infection and to restore/improve normal bladder function as possible. Appropriate treatment begins with assessment ... Following the assessment, individualized goals will be developed and implemented ... The first step is to identify residents already experiencing some level of incontinence ... Every resident will be assessed for incontinence on admission, or re-admission, quarterly and with significant change ... 1... Identify those residents who are incontinent, or have experienced a decline in continence ... 2. On admission, all residents who code as 1, 2, or 3 should have a voiding diary completed. The diary need only be completed with new incontinence or changes in incontinence patterns (decline) ... 3. Complete the diary for three days (72 hours), evaluation (sic.) the resident every 2 hours ... 4. After 72 hours, review the Voiding Diary to determine if there is a voiding pattern. When evaluating the Voiding Diary, assess cognitive status and toilet use to determine appropriate plan of care (i.e. toileting plan). Complete the Incontinence Assessment. 5. If a toileting plan is developed, monitor the planned toileting times and its results. Modify the schedule as needed ... 9. On a quarterly basis utilize the Quarterly Continence Assessment to determine the appropriate plan of care. Update the care plan and the Toileting Program flow sheets as needed. Review with CNAs and follow through as needed." The facility's policy entitled "Bowel and Bladder Assessment", last revised 6/26/13, stated, "On admission, after the three (3) day voiding diary, quarterly and with changes in bladder ..., the Bowel and Bladder Assessment will be completed. A review of the assessment will be conducted and if indicated a three day voiding ... diary will be completed or a toileting program will be put into place. Procedure: 1. The CNA/designee is to complete the voiding ... diary. 2. At the end of this three day period the DON/designee will complete the nursing evaluation. 3. The care plan/toileting plan will be updated accordingly." Cross refer to F327. 1.R91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Document review revealed the following: - Interagency Nursing Communication Record completed by the hospital and dated 8/4/14 - continent of bladder. - Bowel and Bladder assessment dated [DATE] - always continent of urine. - FCS dated 8/4/14 to 9/4/14 - actively participates in toileting and did not identify incontinence as an issue. - Admission MDS assessment dated [DATE] - always continent. Review of the clinical record for August and September 2014 revealed the following nurse's notes, laboratory findings and other documents: - 8/16/14 at 11:09 AM "Resident c/o (complaint of ) painful urination. New order (n/o) to collect urine for UA CS. No temp (temperature) noted...." - 8/17/14 UA and C&S which resulted in no growth and no new orders. - 9/3/14 at 7:45 AM " ...complained of having frequent and painful urination..." - 9/3/14 UA and C&S which resulted in no growth and no new orders. - 9/7/14 at 5:24 PM "This nurse was made aware that resident has change in MS (mental status) as known to her regular CNA. Resident's urine had a strong odor, c/o dysuria (difficult or painful urination) ...Urine noted to be dark brown in color and thick, noted with Hematuria (blood in the urine)..." -9/8/14 at 6:21 AM "resident awake all night, very lethargic and tearful, resident urinating frank red blood, change mental status..." The same day urine C&S revealed a positive UTI and R91 was sent to the hospital. - 9/8/14 the report from the emergency room (ER) noted that the chief complaint was urinating blood for 16 hours prior to admission and the patient stated that she felt as though she had less control over her bladder and felt as though she had to "pee" more often. The hospital diagnosed her with a hemorrhagic urinary tract infection and prescribed an antibiotic, [MEDICATION NAME] twice a day for (7) seven days. - 9/8/14 at 1:43 PM "Resident back from ER, @ (at) 1200 PM via a w/c (wheelchair) with 1 person assist ..." - 9/10/14 at 2:41 PM "Urine culture and sensitivity results called to Dr (doctor).... and orders received and processed to change abx." - 9/11/14, R91 was prescribed a different antibiotic, Bactrim, for (7) days for [DIAGNOSES REDACTED]. There was lack of evidence in the clinical record that upon readmission a bowel/bladder assessment was done and care plan was implemented for R91's UTI. Review of the clinical record for October 2014 revealed the following nurse's notes, laboratory findings and other documents: - FCS dated 10/3/14 to 11/3/14 - now incontinent daily yet the record lacked evidence that interventions were put into place to restore R91's bladder function. - 10/4/14 at 3:47 PM "Resident with c/o urinary discomfort and frequency, but does not wish to be straight cath (a flexible tube inserted to allow the passage of drainage of urine from the bladder)...NP (Nurse Practitioner) ...made aware, new order to obtain u/a c&s, may straight cath if resident allow or clean catch ..." - 10/6/14 UA and C&S which resulted in no growth and no new orders. - 10/18/14 at 5:15 AM "Resident c/o needing to urinate but unable to..." - 10/20/14 at 9:41 AM "Resident has been c/o having to urinate, however she is unable. n/o UA C/S may straight cath." - 10/21/14 at 6:27 AM "Resident refused to be straight cath, ..." - 10/21/14 at 1:36 PM "Resident refused to be straight cath to collect urine specimen for UA C&S. Unable to collect a clean catch specimen because urine was contaminated with stool." - 10/22/14 at 2:11 PM "Resident has been refusing to be straight cathed for urine specimen and cognitively cannot do a clean catch. Resident is voiding without problems, physician aware. N/O to d/c (discontinue) UA C/S". - 10/22/14 UA and C&S which resulted in no growth and no new orders. - 10/24/14 UA and C&S which resulted in no growth and no new orders. Review of the clinical record for November 2014 revealed the following nurse's notes, laboratory findings and other documents: - R91 had increased behaviors where she refused care and had lodged false allegations toward staff. - 11/11/14 UA and C&S resulted in a new order for an antibiotic, [MEDICATION NAME], twice a day for (7) days for [DIAGNOSES REDACTED]. - 11/11/14 quarterly MDS assessment stated R91's cognition was moderately impaired. The same MDS stated R91 was now coded as a (2) frequently incontinent and was not on a toileting program, during the seven (7) day review time period (11/5/14 through 11/11/14). - 11/11/14 Bowel and Bladder Assessment noted that the resident was confused, able to make self understood, occasionally incontinent and listed dribbles as a voiding symptom/problem. -11/13/14 at 1:53 PM, "Quarterly MDS ... done, indicates possible Significant (SIG) Change/decline. However, resident has had increased accusatory behaviors over the past week which has resulted in the need for two staff members to be present for all conversation and care. Resident also with a positive UTI. Present decline in ADL's is considered to be self limiting as part of behavioral management and also related to UTI. No Sig Change will be done at this time. Behavioral care plans adjusted as needed." - 11/13/14 care plan for "Urinary incontinence r/t (related to) impaired mood/behaviors and impaired mobility" was developed. The goal target date of this care plan was 2/13/2015 and it stated, "resident will be clean, dry ...r/t incontinence X 90days. Approaches included: "bowel and bladder on admission, quarterly, and PRN (as needed); toileting schedule as per diary results. Adjust as needed and monitor effectiveness. Voiding diary on admission to assess bladder/bowel patterns." The clinical record lacked evidence that a 3 day voiding diary was completed and analyzed in order to establish a toileting schedule. There was no evidence that the facility developed an individualized toileting schedule since R91 lacked a voiding diary or assessed toileting needs for managing incontinence. -11/26/24 at 6:37 PM "Notified by nurse that resident appeared weak ... T (temperature) 101.8. Gave PRN (as needed) Tylenol (medication for fevers) ..." -11/26/14 at 10:07 PM "Resident still appears weak. Cannot maintain upright position in wheelchair ...Upon start of shift patient had 101.1 fever and was given ... Tylenol ... fever resolved ..." - 11/28/14 at 6:31 AM "Hydration encouraged ..." - 11/29/14 UA and C&S which resulted in a new order for an antibiotic, Bactrim, twice a day for (7) days for [DIAGNOSES REDACTED]. Review of the clinical record for December 2014 and January 2015 revealed the following nurse's notes, laboratory findings and other documents: - 12/10/14 R91 was transferred to the hospital with a hospital documented [DIAGNOSES REDACTED]. On 12/13/14, R91 was readmitted back into the facility. There was lack of evidence in the clinical record that upon readmission a bowel/bladder assessment was done as per facility protocol for R91. - 12/16/14 physician's progress note stated, [MEDICAL CONDITION] was resolved on 12/12 and that the facility did not agree with the [DIAGNOSES REDACTED]. - 12/18/14 UA and C&S which resulted in no growth and no new orders. - 12/31/14 at 2:55 PM "Resident has requested to urinate multiple times this shift without any urine..." - 1/5/15 UA and C&S which resulted in a new order for an antibiotic, [MEDICATION NAME], twice a day for (7) days for [DIAGNOSES REDACTED]. Review of the "CNA Flowsheet ", completed by CNAs that capture if the resident is continent or incontinent of bladder, for August 2014 through January 2015 revealed the following: - 8/4/14 through 8/31/14 consisted of a total of 84 shifts (3 shifts per day) during which R91 had no episodes of incontinence (0%). - 9/1/14 through 9/30/14 consisted of a total of 90 shifts during which R91 was incontinent on 5 out of the 90 shifts (6%). - 10/1/14 through 10/31/14 consisted of a total of 93 shifts during which R91 was incontinent on 25 out of the 93 shifts (27%). - 11/1/14 through 11/30/14 consisted of a total of 90 shifts during which R91 was incontinent on 29 out of the 90 shifts (32%). - 12/1/14 through 12/31/14 consisted of a total of 84 shifts during which R91 was incontinent on 23 out of the 84 shifts (27%). In the month of December, R91 was hospitalized from [DATE] to 12/13/14. In addition, there was no record of R91's bladder function from 12/13/14 through 12/17/14. - 1/1/15 through 1/27/15 consisted of a total of 78 shifts during which R91 was incontinent on 26 out of the 78 shifts (33%). Inclusive on January 1st, during the day shift (7 AM - 3 PM), R91 had 10 episodes of incontinence. The following information was gathered during interviews with employees of the facility: - 1/28/15 at 9:18 AM E20 (CNA) stated that it was facility practice for the CNA to write the number of times that the person was continent or incontinent during the shift. E20 stated that if any resident was on a voiding diary, the medication RN would tell you in the morning because her paper would have it. E20 also stated that they would not document this in their monthly CNA flowsheet, voiding diaries are kept on a separate clipboard at the nurse's station. There was no clipboard at the nurses station because no residents are on a voiding diary. - 1/28/15 at 10:05 AM E21 (CNA) stated that, as R91's usual aide since September of 2014, R91 likes to be very independent. E21 stated that she could not recall R91 ever being on a voiding diary. When asked if R91 was more continent or incontinent since her admission, E21 stated that she was more incontinent. - 1/28/15 at approximately 10:45 AM, E5 (UM) stated the RNAC is the person responsible for implementing and revising the care plan if they see a decline in the MDS. E5, stated that the UM is responsible to implement a care plan if the UM gets the "MDS Decline Notification Form", which is usually sent via e-mail. E5 would then sign the form and send it back to the RNAC. With regards to the Urinary Incontinence care plan, dated 11/13/14 by the RNAC, E5 stated she could not recall getting an e-mail about this new care plan. When asked if she recalled R91 having a voiding diary, E5 stated she thought R91 had them because they are supposed to be done upon admission and re-admission. E5 was unable to provide the surveyor documentation of any voiding diaries for R91 since admission. - 1/28/15 at 10:54 AM E4 (RNAC) stated in order to determine the coding for the Bladder and Bowel section of the MDS, she would use tools such as the voiding diaries and the toileting schedules. When asked what she would use if these tools were not present, E4 stated she would use the CNA documentation flowsheets. E4 stated that she would not implement a care plan for urinary continence, she would use the MDS Decline Notification sheet to communicate to the UM to do a care plan. E4 stated she did not keep copies of those sheets, the DON would have a copy of them. E4 was shown the Urinary Incontinence care plan, dated 11/13/14 that had her signature as implementing it. E4 then stated she could not say either way whether she did or did not communicate to the UM this particular care plan. With regards to the FCS, E4 stated, "it is just a paper we fill out for Medicaid. It is a form that we have to fill out for Medicaid." R91 went from just being toileted for the period 9/4/14 to 10/3/14 to toileting and incontinence in the 10/3/14 to 11/3/14 time frame. When asked if the information between two months are compared to see a resident's status, E4 stated, "No." When asked if the information gathered on this paper is shared, E4 stated, "No." - 1/28/15 at 3:51 PM E3 (Corporate RN) stated that during the seven (7) day review time period (11/5/14 through 11/11/4) for the 11/11/14 quarterly MDS, they identified a miscoding and R91 should have actually been coded as a (1) occasionally incontinent and not a (2) frequently incontinent. - 1/29/15 at 9:38 AM E23 (SSD) stated that NP1, the psych NP that assessed R91 on 11/11/14 would not do anything because the results of the UA were pending. Once the results indicated that the UA was positive, the NP would not treat the patient since the behaviors were attributed to her infection and therefore did not admit her to the Psych Unit. E23 stated this was verbally communicated to her via E24, the clinical liaison. - 1/29/15 at 11:20 AM E8 (LPN) who has worked at the facility since their opening, stated that the Bowel/Bladder assessments are done on new admissions and readmissions. E8 stated that in order to do an assessment she would listen to the resident ' s bowel sounds; look at the fluid intake captured in the MAR and meal intake book; look at the resident's meds to see if they are ordered any diuretics and pain meds; talk to the CNAs that have the resident; talk to the resident; encourage fluids and monitor fluids for 24 hours; and check the voiding diary that is initiated by the UM. With regards to R91 who was positive for a UTI and was on antibiotic therapy, E8, stated she would have started a voiding diary. Findings were reviewed with E1 (NHA) and E3 (Corporate RN) on 1/28/15 at approximately 1:00 PM. Review of supplemental information provided by the facility on 2/4/15, indicated that R91 was admitted on [MEDICATION NAME] (medication used to treat a mental disorder) and [MEDICATION NAME] (medication used to treat high cholesterol) which can cause urinary incontinence. Although there was a care plan for her [MEDICAL CONDITION] disorder to report any adverse side effects to the primary doctor and psychiatry, there was lack of evidence in the clinical record that the incontinence was communicated since her [MEDICATION NAME] was increased in the month of November. There was also a lack of evidence in the clinical record that R91's high cholesterol care plan listed urinary incontinence as a potential side effect or to report any side effects with regards to the medication. Also, despite a decrease in both [MEDICATION NAME] and [MEDICATION NAME] in the month of December, her episodes of urinary incontinence increased in January. The facility twice failed to assess R91's urinary status upon readmission; failed to develop a care plan and failed to identify potential causes for a UTI after R91 was hospitalized ; failed to implement a 3 day voiding diary when there was a decline in R91's urinary status; failed to comprehensively assess R91's bladder incontinence after several documents revealed a decline in bladder function and failed to identify that R91's bladder function was not recorded by CNAs for four days in the month of December. 2. R9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Bowel and Bladder Assessment, dated 8/6/14, stated that R9 was alert and oriented; required assistance for mobility; and was always incontinent of urine. The facility identified the type of R9's incontinence as a functional type, that is, the inability to toilet in time. Additionally, another identified contributing factor to her incontinence was the use of narcotic [MEDICATION NAME] (pain medication). On 8/7/14, the facility initiated a three-day (72 hours) voiding diary to determine R9's voiding pattern. However, review of the 3-day voiding diary revealed that the facility failed to complete it as there were 19 missing hours from 8/7/14 through 8/9/14. On 8/11/14, E5 (RN) initiated a toileting program for R9 based on an incomplete and/or inaccurate voiding pattern assessment. R9's toileting program was scheduled as follows: toilet upon rising, after breakfast, after lunch, before dinner, after dinner and before bed. The admission MDS assessment, dated 8/13/14, stated R9 was cognitively intact (able to make daily decisions), however, she required extensive assist of one staff for transfers and toilet use. The same MDS identified R9 as occasionally incontinent of bladder, which did not reflect the admission bladder assessment, dated 8/6/14, as "always incontinent". Review of R9's 3-day voiding diary, the CNA Flow Sheet and the Scheduled Toileting Flowsheet during the 7-day assessment review period revealed that R9 was incontinent of urine ten (10) times, thereby, the 8/13/14 admission MDS was incorrectly coded as occasionally incontinent when it actually should have been coded as frequently incontinent. On 8/20/14, the facility initiated R9's care plan as "Resident on a scheduled toileting plan R/T (related to) hx (history) of urinary incontinence, present occ (occasional) urinary incontinence ...". The care plan approaches included: ... Complete a bladder record for 3 days upon admission and prn (as needed) any changes in bladder continency, evaluate and develop or revise toileting program as needed ... Toilet as scheduled per toileting program". There was no record of a repeat voiding diary done to re-assess R9's voiding pattern in accordance with this care plan. Review of R9's Scheduled Toileting Flowsheets and the CNA Flowsheets revealed the following: 8/11/14 - 8/31/14 (7 AM - 11 PM) - incontinent of urine 30 times out of 123 opportunities or 24%; (11 PM - 7 AM) - continent 100%. 9/14 (7 AM - 11 PM) - incontinent of urine 58 times out of 180 opportunities or 32%; (11 PM - 7 AM) - incontinent 23 times out of 30 opportunities or 77%. 10/14 (7 AM - 11 PM) - incontinent of urine 42 times out of 186 opportunities or 23%; (11 PM - 7 AM) - incontinent 29 times out of 31 opportunities or 94%. 11/14 (7 AM - 11 PM) - incontinent of urine 57 times out of 180 opportunities (32%); (11 PM - 7 AM) - incontinent 100%. Additionally, on 11/1/14 R9 was diagnosed with [REDACTED]. On 11/3/14 and 11/4/14, R9 was prescribed 2 doses of [MEDICATION NAME] (water pill) which may contribute to frequent urination, for the treatment of [REDACTED]. A quarterly Bowel and Bladder Assessment, dated 11/13/14, stated that R9 was aware of bladder urges and requested toileting; required assistance for mobility; and was occasionally incontinent of urine. The assessment was incomplete as it failed to identify predisposing diagnoses, voiding symptoms/problems and contributing factors and medications. The quarterly MDS assessment, dated 11/13/14, stated R9 was cognitively intact and required extensive assist of one staff for transfers and toilet use. The same MDS stated that R9 was frequently incontinent. The two assessments, both dated 11/13/14, contradicted each other as the Bowel and Bladder Assessment stated R9 was occasionally incontinent while the MDS assessment stated she was frequently incontinent. 12/14 (7 AM - 11 PM) - incontinent of urine 59 out of 186 opportunities or 32%; (11 PM - 7 AM) - incontinent 29 out of 31 opportunities or 94%. 1/1/15 - 1/26/15 (7 AM - 11 PM) - incontinent of urine 51 out of 156 opportunities or 33%; (11 PM - 7 AM) - incontinent 100%. In an interview on 1/28/15 at 9:19 AM, E9 (CNA) stated that R9 was on a toileting program and she was usually incontinent of urine upon rising in the morning. E9 stated that R9 does not recognize "the urgency" to urinate. In an interview on 1/28/15 at 10:45 AM, E5 (RN) stated she was not aware of R9's increase in urinary incontinence. E5 could not provide additional information as to the facility's response to the increase in R9's urinary incontinence. The facility failed to recognize, accurately assess, re-assess, monitor, review R9's incontinence episodes and revise approaches to managing R9's urinary incontinence and to restore as much normal bladder function as possible. Findings were reviewed with E1 and E3 on 1/28/15 at approximately 1:00 PM.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that two (R7 and R3) of 13 reviewed residents received the necessary care and services to attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure that R7 was sent out to the hospital as per the residents request and physician's orders [REDACTED]. Findings include: 1. R7 was admitted to the facility on [DATE]. The five day Minimum Data Set (MDS) assessment, dated 4/8/13, documented that R7 was independent for daily decision making and had no problems with short and long term memory. A nurse's note, dated 4/7/13 and timed 5:44 PM, revealed R7 complained of having a cough. an order for [REDACTED]. A physician's progress note, dated 4/9/13, timed 1:10 PM and completed by E5 (R7's physician), stated R7 desired to be sent to the hospital, but first wanted to speak to the social worker (E8), regarding insurance coverage. E5 subsequently wrote an order, dated 4/9/13, stating "Pt (patient) desires to go to hospital-social worker eval (evaluation), nurse informed." Interview with E7 (Registered Nurse/RN) on 7/25/13 at 12:00 PM confirms her signature as the nurse noting the 4/9/13 physician's orders [REDACTED]. E7 initially stated she was unable to remember why R7 was not sent to the hospital on [DATE]. In a second interview on 7/25/13 at 2:10 PM with E7 (after she reviewed the 4/9/13 physician's orders [REDACTED]." During an interview with E8 on 7/25/13 at 2:35 PM, she stated that she did not receive any notification on 4/9/13 to speak with R7. During an interview with E5 on 7/25/13 at 3:15 PM, she stated "that she did not feel that R7 needed to be sent to the hospital but since the resident desired to go, she wrote the order." E5 stated she informed the nurse directly because she didn't want it to go unattended to and that she expected that R7 would have been sent out by that evening, unless she would have changed her mind after speaking with the social worker. Review of the clinical record revealed that R7 was not sent out to the hospital until the following morning (4/10/13), when E16 (Medical Director), wrote an order "please send to (name of hospital) hosp (hospital) for persistent cough/poss (possible) [MEDICAL CONDITION] (inflammation in the lungs causing breathing problems and severe coughing) pt request." The facility failed to ensure that R7 was sent to the hospital as per the resident's request and the physician's orders [REDACTED]. These findings were acknowledged by E3 (corporate nurse) on 7/25/13 at approximately 2:00 PM. 2. R3 was admitted to the facility on [DATE]. The Admission Order Sheet, dated 12/5/12, revealed that R3 was allergic to sulfa (a group of medications used to treat infections). Sulfa medications include the antibiotic, Bactrim DS. A physician's orders [REDACTED]. Review of the facility's Emergency Drug Kit Utilization Record, dated 4/8/13 and timed 8:30 PM, revealed that E12 (licensed practical nurse) signed out one (1) tablet of Bactrim 800 mg (milligrams) for R3. The facility's April 2013 Medication Administration Record [REDACTED]. However, R3 received a total of two (2) doses of Bactrim DS, one on 4/8/13 at 9:00 PM and one on 4/9/13 at 9:00 AM. R3's record revealed that she did not experience any adverse reactions from the administrations of Bactrim DS. The facility failed to ensure that R3 did not receive a medication that was listed on her allergy history.

Based on observation, record review and interview, it was determined that the facility failed to provide care and services necessary to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care for one resident (R2) out of 8 sampled. The facility failed to follow the plan of care for R2 and an incorrect diet was served to R2 on more than one occasion. On 10/11/13 after receiving and consuming the incorrect diet, R2 presented with signs and symptoms of an impending aspiration (food or drink from the throat goes into the lungs or respiratory tract) such as increased mouth secretions, coughing and spitting out mucous. R2 was sent to the hospital Emergency Department (ED) per physician's orders [REDACTED]. Surgical intervention was required to remove the impacted food bolus for R2. The food bolus was identified in hospital records as full-thickness meat products/pork. Findings include: The facility's "Dining Room Procedure" stated, "The Restorative Aides, Activities Aides, CNAs (Certified Nurse's Aide) and Dietary Staff report to the dining room...The CNA will place the diet ticket (diet slip that identifies the food and the resident's diet consistency) at each resident's place setting...After completing the meal ticket with the resident's preference, the tickets are brought to the dietary staff member at the steam table. The dietary staff member then reads the ticket and places the food based on each resident's request and diet...The CNA will also monitor resident for signs of choking and aspiration..." Review of R2's admission Minimum Data Set (MDS) assessment dated [DATE] and quarterly assessment dated [DATE], this resident had active [DIAGNOSES REDACTED]. According to R2's most recent quarterly MDS assessment dated [DATE], this resident's cognitive skills for daily decision-making were moderately impaired; decisions poor; cues/supervision required. R2 was dependent on staff for his activities of daily living but he was independent with a food tray. On 7/18/2013 the facility initiated a care plan entitled "Potential for aspiration related [MEDICAL CONDITION], s/p (status [REDACTED]. Provide verbal cues for resident to swallow as needed. Assist resident as needed to complete meals. Provide/encourage to eat small bites and alternate liquids and solids Refer to OT (occupational therapist) for feeding difficulties Refer to ST (speech therapy) as needed for changes in status-choking, coughing, or any other s/s (signs/symptoms) of aspiration Report s/s of aspiration to MD (Medical Doctor). On 9/24/13 R2's attending physician wrote an order to have speech therapy evaluate and treat this resident 5 times for 2 weeks for therapeutic feed of mechanical soft diet (soft, easy to eat and do not need a lot of chewing to swallow safely). Review of the Speech Therapy Evaluation and Plan of Treatment dated 9/25/13 revealed the following: Reason for referral indicated that R2 had an [MEDICAL CONDITION] stricture (narrowing or tightening of the esophagus that causes swallowing difficulty and food becomes stuck in the throat when swallowing) and a Schatski ring (a muscular tissue that narrows the lower part of the esophagus and could develop intermittent difficulty swallowing or, more seriously, a completely blocked esophagus which would stop the passage of food). Also, R2 was taken to the ER (emergency room ) in August, 2013 and had a procedure for dilatation (food was removed from R2's lower esophagus). R2 was tolerating pureed /thins (food ground and blended to a soft creamy paste/thin liquids) since then and MD suggested "trialing solids (food) and monitor". On 9/27/13 as per E8's (Speech Therapist) evaluation and recommendation, R2's diet was changed from pureed diet to mechanical soft diet and to monitor R2's tolerance. The Speech Therapist's assessment summary dated 9/27/13 indicated that R2 had a risk factor for aspiration. The Speech Therapist recommended "Supervision for Oral Intake= Close supervision." A physician's orders [REDACTED]. Advance to Mechanical Soft + NAS (no added salt); 2. All meals out of bed - in chair; 3. Supervision." On 10/11/13, R2 received and consumed the incorrect diet. A nurse's note dated 10/11/2013 (2:09 PM) stated, "Resident was in the dining room for lunch when he was eating the incorrect diet. Resident became (sic) coughing and spitting out mucous...noted with increased secretions...Speech Therapist aware and assessed Resident. (Name of Physician) aware. Ordered to send resident to (Name of Hospital)...". Review of the facility's Incident/Accident Report Investigation dated 10/11/13 and timed 1:00 PM stated that R2 was "served the wrong diet in the dining room" and the Employee Warning Notice dated 10/11/13 indicated that E6 (CNA) "was taking orders and serving the dining room without following proper procedure. R2, as a result was served the wrong consistency of foods". On 10/11/13 R2 was sent to (Name of Hospital) for evaluation and treatment per physician's orders [REDACTED].#1 (Attending Physician) on 10/28/13 at 11:35 AM, he stated that the [MEDICATION NAME] maneuver (emergency technique for preventing suffocation when a person's airway (windpipe) becomes blocked by a piece of food or other foreign object) was not performed because R2 was not showing signs and symptoms of shortness of breath, stridor (high pitched wheezing sound), choking and wheezing and did not demonstrate acute stress. According to AP#1, he had the patient sent to the hospital ER "as a precautionary measure" and that the "facility did not have the instrumentation and ability to dislodge the foreign body". According to a "Pre-hospital Care Report" by ambulance transport/Paramedic dated 10/11/2013, the patient (R2) "was coughing and vomiting small amounts of vomitus" when they arrived. "Pt (patient) was given the wrong meal for lunch and portion of pork may have lodged in throat. (Review of the facility menu indicated that the facility's lunch menu on 10/11/13 included encrusted pork loin). Pt was being tended by the nursing staff at the facility upon arrival." Review of the Hospital Consultation report dated 10/11/13 stated, that R2 had "history of [MEDICAL CONDITION] ...multiple food bolus impaction episodes in the past. He previously has been seen by (name of Physician) in 08/13 with food bolus impaction and dilation was performed... with resolution of his moderate Schatzki's ring. He is here in the emergency room from his nursing home after being fed apparently an incorrect meal of full-thickness meat products...". The hospital's Operative/Procedure Report dated 10/11/13 stated that the procedure performed was an "Upper Gastrointestinal Endoscopy/EGD..."The GIFH180J (a small flexible lighted instrument/endoscope) was introduced through the mouth, and advanced under direct visualization to the second part of duodenum (hollow jointed tube that connects the stomach to the small intestine)...Food was found in the lower third of the esophagus. Removal of food was accomplished... [MEDICAL CONDITION] (swelling) and [DIAGNOSES REDACTED] (reddening) was found in the stomach. Mildly severe esophagitis (inflammation of the esophagus) was found in the lower third of the esophagus". The hospital's Post Anesthesia Care Record dated 10/11/13, identified the food as "pork". On 10/28/13 a lunch time observation was made at 12:30 PM. Lunches had already been passed out and R2 was observed taking bites of cut up meat placed aside on the left side of his place mat while E7(CNA) was busy cutting the portion of the solid baked chicken on his plate. R2 was intermittently coughing and his face was turning red as he coughed. E5 (Food Director) arrived and told E7 to stop cutting because R2 was on a pureed diet. The diet slip read "Regular/ NAS (no added salt)/PUREE" and each food's name on the diet slip was individually identified as "Pureed". E5 (Food Director) left and returned with a plate of pureed food consistency to replace the regular food served to R2. E5 then removed the pile of cut up pieces of chicken with his hands from the table with permission from R2. E4 (Corporate Registered Dietitian/RD) was present during this lunch observation. There were approximately 5 unidentified staff members present. During an interview with E7 on 10/28/13 at 2:10 PM, she stated that she did not serve the meal on 10/28/13, that she arrived at 12:30 PM. She came from another floor and the plate was already on the table when she arrived and she saw R2 taking bites of chicken and coughing. E7 stated she tried to help and she proceeded to cut the chicken. She asked R2 if somebody was there to help him and R2 said "nobody" (this conversation was overheard by surveyor). E7 continued to cut up the chicken. She admitted that she saw the ticket and the word Regular on the ticket and continued to cut the chicken until E5 stopped her. E7 stated she did not know who served the regular food, because nobody (staff) wanted to admit to the mistake. During the discussion of this finding with E1 (Administrator), E2 (Director of Nursing) and E9 (Corporate Registered Nurse Consultant) on 10/29/13 at approximately 11:00 AM, it was learned that the facility was aware of R2's recurrent food bolus impaction episodes. The facility had the following approaches identified in the 7/18/13 care plan: "Provide verbal cues for resident to swallow as needed. Assist resident as needed to complete meals"; "Provide/encourage to eat small bites and alternate liquids and solids." The facility failed to ensure R2's plan of care was followed and that R2 was served the correct diet. R2 who was assessed as a high risk for aspiration, was served the wrong diet on 10/11/13 and 10/28/13. In addition, on 10/28/13, no one was closely supervising/monitoring this resident during mealtime to ensure his safety.

Based on record review, interviews, and review of other facility and non-facility documentation, it was determined that the facility failed to ensure that one resident (R3) out of 13 sampled residents with pressure ulcers (PUs - sore area of skin that develops when the blood supply to it is cut off due to pressure) was consistently monitored, failed to provide treatments as ordered to promote healing and failed to ensure that new pressure ulcers did not develop. The facility failed to have a thorough system to measure, assess and treat pressure ulcers, and communicate to the Wound Care Center and other care providers. Findings include: Stages of pressure ulcers (categorization system used to describe the severity of PUs): Stage I (1) - a reddened area of intact skin usually over a boney prominence, that when pressed does not turn white. This is a sign that a PU is starting to develop. Stage II (2) - skin blisters or skin forms an open sore. The area around the sore may be red and irritated. Stage III (3) - skin develops an open, sunken hole called a crater. There is damage to the tissue below the skin. Stage IV (4) - ulcer has become so deep that there is damage to the muscle and bone and sometimes to tendons and joints. Unstageable - Tissue loss in which actual depth of the ulcer is unable to be determined due to the presence of slough (yellow, tan, gray, green or brown dead tissue) and/or eschar (dead tissue that is tan, brown or black and tissue damage more severe than slough in the wound bed). Deep Tissue Injury (DTI) - Purple or maroon localized area of discolored intact skin. May be preceded by tissue that is painful, mushy, firm, boggy (wet, spongy feeling), warmer or cooler than adjacent tissue. The facility's Pressure Ulcer Prevention and Management policy, dated 4/2010, stated "PURPOSE: ...develop an ongoing plan of care for prevention, recognition and treatment of [REDACTED]. Upon admission to the facility and weekly afterwards, the nurse will complete a skin assessment on the Skin Rounds form ... 3. Residents will have a plan of care developed ...will be updated on an ongoing basis ... 7. Involve Interdisciplinary Team ...to ensure ... interventions are implemented timely in order to prevent alterations in skin integrity ...Education ... 2. ...Plan of care will reflect consistent episodes of non-compliance with pressure relieving measures ...Wound Identification Procedure ... 1. Residents will have a total body skin check upon admission ... 2. When a stageable wound is identified (Stage 1, 2, 3, or 4), Nursing will: a. Contact the Physician/NP (nurse practitioner) for Tx (treatment) order. b. Treatment order to be transcribed to 'Daily Wound Monitoring' TAR (treatment administration record). c. Document Physician/NP response ...in the Nurses Notes ... d. Complete wound assessment weekly, document wound appearance; include location, size, type, odor and drainage using the Weekly Wound Assessment sheet ... f. Update Care Plan ...". R3 was admitted to the facility on [DATE] post hospitalization with a left [MEDICAL CONDITION]. [DIAGNOSES REDACTED].), Diabetes Mellitus (disease where sugar levels are too high) and a history of pressure ulcers prior to admission to the facility. The 12/5/12 Resident Admission Assessment identified that R3 had an open area on the sacrum (tailbone) that measured 2.3 centimeters (cm) length by 2.3 cm (width) by 0.1 cm (depth) and had 4.5 cm of redness around the open area. The facility failed to ensure that the 12/5/12 assessment was complete and included staging (type), odor, description of the wound edges, presence of pain and/or drainage. admission orders [REDACTED]. On 12/10/12, C1 (wound care nurse practitioner consultant) noted the sacral PU measured 2.5 cm by 5 cm by UTD (unable to determine). The depth of the PU was unable to be determined due to the presence of slough. The area surrounding the PU was noted to be red and boggy, measuring 8 cm by 8 cm with an area of sDTI (suspected Deep Tissue Injury) at the 5 o'clock position. On 12/10/12, the treatment was changed to cleanse with normal saline solution (NSS), apply Santyl (ointment containing enzyme that helps remove dead tissue), cover with [MEDICATION NAME] and ABD (abdominal dressing pad) daily and PRN (as needed). Review of the December 2012 Daily Wound Monitoring Form (DWMF - A facility form documenting PU treatments, frequency, presence of pain, dressing status, PU deterioration, and the status of the area surrounding the PU) from 12/7/12 to 12/14/12 revealed that dressing changes were signed off as completed, however, the record lacked evidence that monitoring the PU for deterioration was completed on 6 out of 8 days. R3's care plan initiated on 12/6/12 (last revised on 1/15/13) for "Actual pressure ulcer: Stage 2 to saccrum (sic) ... and non-compliance with turning & repositioning." Stage 2 was crossed out and sDTI was written in with unknown date. Interventions included: "measure on weekly wound rounds; notify of worsening wounds; monitor site for s/s (signs/symptoms) of complications; pressure relieving device to bed/chair; skin checks q (every) 2 hours; skin treatments as ordered; turn & (and) reposition q 2 hours & prn (as needed)." According to the admission Minimum Data Set (MDS) assessment, dated 1/3/13, R3 was cognitively intact (able to make own decisions) and required extensive assistance of two (2) staff members for bed mobility. The 1/3/13 MDS revealed that R3 had a total of three PUs. R3 was also occasionally incontinent of bowel and bladder. A physician's order, dated 12/6/12, stated R3 was using her "own non-medical grade seat cushion" in her wheelchair (w/c) and that R3 declined a facility cushion. On 12/10/12, C1 recommended a physical therapy (PT) evaluation for a w/c cushion and noted that R3 had previously refused, was educated and verbalized understanding. On 12/10/12, an order was written for use of a Roho (pressure reducing cushion) at all times when in her w/c. The order was not transcribed onto the Treatment Administration Record (TAR) until 1/9/13. There was no evidence in the record if the Roho was in use from 12/10/12 until 1/9/13. Review of a maintenance request/order slip, dated 12/6/12, revealed a request for a facility air mattress for R3. The slip stated "Done", but did not specify a date/time completed. On 12/10/12, an order was written and transcribed onto the TAR for a pressure reducing air mattress to the bed and to check proper inflation every shift. On 12/10/12, C1 (wound care nurse practitioner consultant) recommended a PT evaluation for low level laser therapy (Diathermy - aides to promote healing of PU). Although recommended by C1, the order for diathermy was not written until 12/26/12 (16 days later). R3 was admitted to the hospital for pneumonia from 12/14/12 through 12/21/12. Upon readmission to the facility on [DATE], R3 was noted to have a total of three (3) PUs. Review of R3's PUs from 12/21/13 to 12/31/13 revealed the following: Sacrum - The 12/21/12 Resident Admission Assessment noted that the sacrum had a deep area measuring 5 cm by 2.5 cm by 1 cm with a yellow and red center. The 12/21/12 admission assessment was not signed as completed by the nurse until 12/24/12 (3 days later). Readmission orders [REDACTED]. On 12/24/12, E10 (registered nurse) noted the sacral PU had worsened and had undermining (skin edges have lost supporting tissue under intact skin). On 12/24/12, E10 recommended to continue with the same treatment with the exception of the ABD. The treatment was not changed until an order was written on 12/30/12 (6 days later). Review of the DWMF revealed that treatments were signed off as completed, however the record lacked evidence of monitoring the PU for deterioration on 5 out of 10 days. Ischium #1 and #2 (bony areas on each buttock) were identified as 2 new PUs on the 12/21/12 readmission. The 12/21/12 Resident Admission Assessment noted two (2) open areas with slough in the center with both having the same measurements of 1.5 cm by 0.5 cm by 0.2 cm. The facility failed to perform a thorough and complete assessment for R3's three PUs on the 12/21/12 re-admission. The record lacked evidence that treatment orders were obtained upon the 12/21/12 readmission. On 12/23/12, an order was written to cleanse the right inner thigh, apply Santyl and cover with [MEDICATION NAME] and ABD pad without specifying the frequency of the dressing change. When this order was transcribed onto the TAR, it was written to be changed daily and as needed. It is unclear whether this was one of the two areas noted on the ischium or a new PU. The 12/24/12 Weekly Wound Assessment noted no change to the PUs and the recommendation was to continue with the same treatment with the exception of the ABD. The record revealed that the change in treatment on 12/24/12 was ordered and transcribed onto the DWMF on 12/30/12 (6 days later). Review of the DWMF from 12/23/12 to 12/31/12 revealed that treatments were signed off as completed, however, the record lacked evidence of monitoring for PU deterioration on 7 out of 9 days. The Right Hip was identified as a new PU on 12/28/12. According to a nurse's note, dated 12/28/12 at 4:00 AM, R3 was found to have a "reddened area to (R) (right) lateral thigh ...". An order, dated 12/28/12 was written to apply Replicare (wound dressing), cover with a 4 by 4 (dry dressing) and paper tape every other day until healed. On 12/30/12, this order was discontinued and a new order was written to cleanse the open area to the right hip with NSS, apply Santyl, cover with [MEDICATION NAME] foam daily and PRN. The record lacked evidence that a thorough assessment was completed on 12/30/12 of the right hip PU, which was now an open area. Documentation of the right hip PU, originally identified on 12/28/12, lacked evidence of a thorough assessment until 1/3/13. Review of the DWMF revealed treatment was completed as ordered, however the record lacked evidence of monitoring for deterioration on 3 out of 5 days. R3's Food Intake Records for December 2013 averaged 25% to 50%. E17 (dietitian) frequently monitored R3's food intake and pre-[MEDICATION NAME] level (measures nutritional status) and recommended adjustments to R3's supplements to aide in wound healing. Review of the MAR from 12/23/12 through 12/31/12 revealed Nepro and ProSource (supplements) were not given on 3 out of 18 scheduled times as R3 was at [MEDICAL TREATMENT]. It was unclear in the record why supplements were not administered to R3 prior to leaving for [MEDICAL TREATMENT]. According to E17's nutrition note on 1/2/13, R3's pre-[MEDICATION NAME] level was 3.2 (normal limits 18.0 - 38.0). Review of December 2013 CNA Flow Sheets revealed one documented refusal of turning and repositioning. However on 12/28/12, 12/30/12 and 12/31/12, nurse's notes stated R3 refused to turn and reposition and education regarding the importance to turn and reposition was provided. Review of R3's PUs during the month of January 2013 revealed the following: On 1/3/13, the sacrum treatment was changed to cleanse with NSS, apply Santyl, pack with [MEDICATION NAME] and cover with [MEDICATION NAME] foam and an ABD pad for protection. Review of physician order sheets revealed that an order was not written and transcribed onto the DWMF for the 1/3/13 treatment change until 1/10/13 (seven days later). On 1/14/13, the treatment was changed to a wound vac (negative pressure therapy that applies mechanical forces to the wound to create an environment that promotes wound healing) at 125 mmHg (millimeters of Mercury). an order for [REDACTED]. The wound vac treatment started on 1/16/13. According to the DWMF, the dressing changes to the sacrum were signed off as completed, however, the record lacked evidence of monitoring of the PU for deterioration on 18 out of 21 scheduled treatment days. Right Ischium #1 worsened. The treatment remained the same. According to the DWMF, the dressing changes were not done on 1/8/13 and 1/19/13 as R3 was at [MEDICAL TREATMENT]. There was no indication in the record that treatment was done when R3 returned from [MEDICAL TREATMENT]. The record lacked evidence of monitoring of the PU for deterioration on 10 out of 31 days. Right Ischium #2 merged into the right ischium #1 as of 1/21/13. The treatment remained the same. Treatment was not done on 1/8/13 as R3 was at [MEDICAL TREATMENT], and there was no indication in the record that treatment was done when R3 returned from [MEDICAL TREATMENT]. The record lacked evidence of monitoring of the PU for deterioration on 7 out of 20 days. Right Hip #1 did not change. The treatment remained the same. The DWMF lacked evidence that treatment was done on 1/8/13, 1/12/13 and 1/19/13 as R3 was at [MEDICAL TREATMENT] and there was no indication in the record that treatment was done upon R3's return from [MEDICAL TREATMENT]. The record lacked evidence of monitoring of the PU for deterioration on 16 out of 31 days. The facility also failed to develop a plan of care for wound treatments to incorporate R3's absence from the building for [MEDICAL TREATMENT]. Right Hip #2 was identified as a new PU on 1/28/13. The treatment recommended by C1 on 1/28/13 for this newly identified PU was not ordered by the physician nor was it transcribed onto the DWMF for documentation of treatment and monitoring. Review of the January 2013 TAR revealed documentation that R3 was non-compliant with turning and repositioning on 6 out of 66 shifts. Review of the CNA (Certified Nurse Aide) Flow Sheets revealed documented refusals of turning and repositioning on 5 out of 63 shifts. Review of R3's PUs during the month of February 2013 revealed the following: Sacrum worsened. Treatment remained the same. On 2/8/13, a nursing progress note stated "wound vac off tonight. Will address in AM." The record lacked evidence of physician notification and follow-up documentation regarding the reason for the treatment being held. It was unclear what treatment was put in place in lieu of the wound vac. The record lacked evidence of monitoring of the PU for deterioration on 7 out of 13 scheduled treatment days. Right Ischium #1 improved. Treatment remained the same. Review of the DWMF revealed that despite the right ischium #2 PU merging into #1 on 1/21/13, the record stated "cleanse 2 areas on right ischium ...". The DWMF lacked evidence that the dressing changes were completed on 7 out of 28 days and that monitoring for deterioration was completed on 22 out of 28 days. Right Hip #1 improved. Treatment remained the same. The DWMF lacked evidence that the dressing changes were completed on 9 out of 28 days and that monitoring for deterioration was completed on 20 out of 28 days. Right Hip #2 healed as of the 2/25/13 weekly wound assessment. It was unclear in the record what treatment was provided for this PU as there was no physician order when it was identified on 1/28/13 and a DWMF was not initiated to treat and monitor the PU. On 2/18/13, E10 (registered nurse) noted on the Weekly Wound Assessment that R3 "refuses to turn to left side and does not use her ROHO cushion when she goes to [MEDICAL TREATMENT], despite education that she is to take it with her." It is unclear in the record if the facility communicated R3's need of offloading (removal of pressure from an area) to the [MEDICAL TREATMENT] center. Review of the February 2013 TAR revealed only two (2) documented refusals of turning and repositioning. Review of R3's PUs during the month of March 2013 revealed the following: Sacrum worsened. On 3/4/13, C1 (wound care nurse practitioner consultant) recommended to increase the wound vac pressure to 150 mmHg, however no physician order was written for it. The DWMF revealed the wound vac pressure remained at 125 mmHg through 3/6/13. On 3/7/13, the DWMF noted that the wound vac pressure was increased to 150 mmHg, despite there still being no written order. On 3/11/13, treatment was changed to cleanse with NSS, apply Santyl and [MEDICATION NAME] (antimicrobial wound gel) mix to the wound bed then apply wound vac at 150 mmHg and secure with Hy-Tape (pink tape used for delicate skin). The Wound Evaluation Form, dated 3/18/13 and completed by C1, stated there was no odor present. On 3/19/13 at 4:10 AM, a nurse's note revealed "...wound vac changed upon start of shift ...Wound has (decreased) in size however remain (sic) odorous c (with) little drainage noted." The record lacked evidence that the physician was notified of the "odorous" wound and that a thorough assessment was completed of the wound. The DWMF revealed that a new treatment order, dated 3/25/13, was included on the TAR; the prior treatment order, however, was not discontinued on 3/25/13 as per the physician order. This resulted in both treatments being signed off as completed on the DWMF for 2 out of 3 scheduled treatment times. On 3/26/13 at 3:00 PM, a progress note stated "wound vac removed prior to [MEDICAL TREATMENT] center." The record failed to identify physician notification and what type of dressing was applied in lieu of the wound vac when R3 was sent to [MEDICAL TREATMENT]. Right Ischium improved. On 3/11/13, an order was written to change the treatment to cleanse with NSS, apply Santyl and [MEDICATION NAME] mix, cover with [MEDICATION NAME] foam daily and PRN. Review of the DWMF revealed that despite the right ischium #2 PU merging into #1 on 1/21/13, the monitoring form continued to state "cleanse 2 areas on right ischium ...". The record lacked evidence that treatments were completed on 8 out of 31 days and monitoring for deterioration was completed on 17 out of 31 days. Right Hip improved. On 3/11/13, an order was written to change the treatment to cleanse with NSS, apply Santyl and [MEDICATION NAME] mix, cover with [MEDICATION NAME] foam daily and PRN. The DWMF lacked evidence that daily dressings were completed on 8 out of 25 days and monitoring for deterioration was completed on 15 out of 25 days. On 3/25/13, R3 was evaluated at the hospital wound care center for the sacral and right ischium PUs. The 3/25/13 Wound Care Physician's (C2) progress note stated that the sacral PU was debrided (surgical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) due to a large amount of necrotic (dead) tissue, that R3 needs a high level air mattress/Clinitron/Level 3, high concern for [DIAGNOSES REDACTED] (infection and inflammation of the bone) check x-ray and labs (blood work), culture taken will f/u (follow-up), Juven/Ensure or Pro-Source (supplements) three (3) to five (5) times per day. C2's wound care instruction sheet, dated 3/25/13, stated "...Sacrum/right buttock...apply Santyl, wound vac at 125 mmHg to sacral and right buttock...bridge vac foam to hip, (M/W/F), patient not to sit directly on wound vac tubing! *Pt (patient) cannot be in WC (wheelchair) for longer than 30 min (minutes). Right ischial/right buttock - Santyl + (plus) Allevyn (wound dressing)...". On 3/25/13, the facility wrote orders for C2's treatments listed above, however they failed to order a high level air mattress, supplement three to five times a day, and not sitting longer than 30 minutes in the wheelchair. On 4/1/13, R3 was seen by C2. (C2's hospital wound care center progress notes were obtained during the Delaware Long Term Care Resident's Protection's investigation and were not part of R3's facility record.) The hospital wound care center progress note revealed "...R3 has actually developed a new wound since her last visit last week...The daughter was told that they cannot order an air mattress because 'the one she has is adequate,' and the VAC was never placed to the sacral wound because they could not figure out how to bridge it ...R3 is getting worse ...On physical exam today ...her sacrum does not appear actually that it has had a VAC on it for very long, it is sloppy, really does not appear that it had the VAC on. It is a stage III measuring 4.7 cm in length x 2.1 in width x 2.2 in depth, 60% slough ... debrided today ...The right ischial ulcer is a stage II, it is new today. This is wound #3, ... debrided ...Wound #2 to the right buttock, stage III ...measures 2.6 x 2.2 x 0.5 and ...also has a stage II wound #4 on the right buttock and spine ...The culture grew up Pseudomonas (bacteria) and Proteus (bacteria) suggestive of growing bowel contamination, which is also suggestive that the VAC has not been intact for long periods of time...She needs a Clinitron (air flotation mattress that minimizes pressure) mattress ...Understandably, R3 has [MEDICAL CONDITION] and complains when she is lying flat, but her wounds are starting to break down. She is going to get worsening infection and [MEDICAL CONDITION] (potentially deadly medical condition characterized by a whole-body [MEDICAL CONDITION] state) should these continue to get worse...". Treatments ordered on [DATE] by C2 were as follows: 1. Sacrum/Right Ischial - Santyl to base of wounds. Black granule foam (specialized non-absorbent wound dressing used with a wound vac) to sacrum and right ischial. VAC setting at 125 mmHg. Change M/W/F. 2. Duoderm (absorbent wound dressing) around Stage III right ischial. 3. Right/Left Buttock - Duoderm to stage II/I new wounds surrounding sacral. 4. Right Buttock - stage III, Santyl & Allevyn (absorbent wound dressing). On C2's Wound Care Instruction Sheet, dated 4/1/13, it was written "no sitting for more than 20 minutes at a time. Developed a new ulcer. Needs Clinitron Level 3 mattress." The new treatment orders listed above were never transcribed onto the facility's physician order sheet or the Daily Wound Monitoring Form. Review of the DWMF revealed that the prior treatments were being continued. There was no evidence that the facility provided a Level 3 air mattress. Review of the TAR (completed by licensed nurses) and the CNA Flow Sheets from 3/25/13 through 4/9/13 lacked evidence that the facility attempted to limit R3's time seated in the wheelchair to 20 - 30 minutes. R3's care plan failed to be revised to reflect the need for limited seating time in the wheelchair. It was also unclear in the record whether the facility communicated with the [MEDICAL TREATMENT] center regarding R3's need of offloading to promote wound healing. Record review revealed that a physician's order was written on 4/7/13 (originally ordered on [DATE] by C2) to discontinue previous right ischial orders and to now cleanse with NSS, apply Santyl to the base of wound, cover with black granule foam and apply wound vac at 125 mmHg. On 4/8/13, R3 was seen by C2. C2's hospital wound care center progress note stated "...orders for no sitting > (greater than) 20 minutes/Clinitron/& (and) vac placement not followed - family reports told 'her mattress fine' and has been up sitting in chair most of day. Pt has developed two new pressure wounds consistent with sitting on (L) (left) ischium - stage IV & (R) (right) ischium - stage II. Sacral wound originally developed in acute care has progressed to stage IV." Treatment orders by C2 on 4/8/13 were as follows: 1. Sacrum/Right Ischial - Santyl, wound vac set at 125 mmHg, continuous with black granule foam. Change M/W/F. Santyl nickel thick to base of wound. 2. Right Buttock and Left Ischial - Santyl, [MEDICATION NAME], Allevyn or some sort of foam dressing daily. 3. Protein supplementation/Juven or Ensure 3-4 times per day. (check) pre-[MEDICATION NAME] now and monthly. 4. (Check) x-ray sacrum ... osteo (osteo[DIAGNOSES REDACTED]). 5. Clinitron / Level 3 mattress. 6. Pt (patient) not to be out of bed at all. 7. Bactrim DS (antibiotic) 1 tablet by mouth twice a day for 3 weeks for a [DIAGNOSES REDACTED]. Review of the R3's record revealed that blood work and x-ray results were obtained on 3/26/13, however the results were not reported to the wound care center until 4/8/13 (13 days later). It is unclear why there was a delay in communicating the results to the Wound Care Center. R3's pre-[MEDICATION NAME] level was 7.0 on 3/26/13, an increase from 6.7 on 3/12/12. A progress note, dated 4/8/13 and completed by C3 (wound care center nurse practitioner), stated "Called facility and spoke with DON (Director of Nursing)...Explained to her that pt has two (2) new wounds - clearly from sitting. Pt came in...sitting on the vac tubing even tho (though) we has (sic) called, explained and sent her back w/ (with) the correct technique. Also explained that we asked for a Clinitron bed & (and) was told 'her bed is fine.' DON agreed: 1) Clinitron bed 2) cannot sit in chair ... 3) vac dressing needs to be bridged to the side...". Review of the clinical record revealed that on 4/8/13 the facility developed a behavior monitoring sheet on which CNA's began to document the occurrence of refusal of care and being turned. Additionally, on 4/10/13 the facility noted on the TAR and CNA Flow Sheets that R3's time in the wheelchair was limited to 20 - 30 minutes, although the 4/8/13 order from C2 stated the resident was not to be out of bed. Record review of the physician's progress notes from 12/6/12 through 4/9/13 revealed the absence of documentation regarding R3's pressure ulcers. It was not until 4/10/13 that a physician progress notes [REDACTED]. Largely in part as pt declines to lay in bed & desires to sit in wheelchair for prolonged periods. In any event I discussed case via phone c WCC 4/9/13 explaining situation to understand pt has been non-compliant c rest, and also c repositioning to off-load areas. Call has been placed to family as well & decline hospitalization at this time, understanding wounds most likely will not heal if not off-loaded & not persistently sitting in chair...I discussed c (with) DON & administration & agree that if (sic) pt has right to refuse care as she is alert & oriented. Case was discussed c family per DON & relayed to me that family does not want her hospitalized . Family will speak to pt as well to hopefully agree c better compliancy of care...Air mattress replacement ordered. No Clinitron at this time as...pt not cooperative c care. I don't believe will assist c healing...". On 4/10/13, a Level 3 alternating air mattress was obtained for R3. According to a nutrition note, dated 4/10/13 at 11:17 AM, R3's pre-[MEDICATION NAME] level was 3.8, a decrease from 7.0 on 3/26/13. E17 increased R3's ProSource supplement. On 4/17/13, R3 was seen by C2. Debridement was performed on the stage III right ischial wound and stage IV sacral wounds. Treatments ordered on [DATE] by C2 were as follows: 1. Sacrum - wound vac at 125 mmHg continuous, black granule foam to sacrum only. Change M/W/F. 2. Right Ischial & Right Buttock - Santyl, [MEDICATION NAME] foam, tape daily. 3. Right Thigh / Left Thigh - Continue to pad areas well. Change M/W/F. Review of physician's orders, dated 4/17/13, only addressed the change in orders for the right ischium PU. The DWMF lacked evidence that treatment was provided to the right ischium on 4/25/13. The facility failed to transcribe the new order for the sacral PU. As a result, the facility continued to apply Santyl to the wound bed on four (4) occasions from 4/17/13 through 4/26/13. The facility failed to provide any treatment to the sacrum, as evidenced by a lack of signatures on 4/22/13 and 4/29/13. The DWMF revealed that the sacral dressing was changed on 4/18/13 and not changed again until 4/24/13 (five days later). Review of nurse's notes, TAR and CNA Flow Sheets, from 4/10/13 to 4/30/13 revealed that at times R3 refused turning and repositioning and requested to be out of bed for meals and activities. Review of chest x-ray results from 4/24/13 revealed R3 had right and left lower lobe pneumonia with bilateral effusion (excess fluid between the layers of the lungs). R3 continued to receive an antibiotic through the end of April 2013 for the PUs and pneumonia. On 4/29/13, R3 was seen by C2 and treatments ordered were as follows: 1. Sacrum and Right Ischial - wound vac with black granule foam to wounds at 125 mmHg continuous. Change M/W/F. May irrigate with saline prior. 2. Right Buttock - Santyl/Duoderm/Foam daily. 3. Juven (supplement) 3x/day. Review of the record revealed that C2's wound care orders were not transcribed until 4/30/13 onto a physician's order and not transcribed onto the Daily Wound Monitoring Form until 5/1/13. The record lacked evidence that treatments were provided as ordered to the sacrum, right ischium and right buttock on 4/29/13 and 4/30/13. Review of the record revealed that R3 was sent out to the hospital on [DATE]. Review of the hospital's nursing care flow sheet, dated 5/1/13 and timed 6:30 PM, revealed that the right buttock and right hip PUs had an odor and that the sacral PU had an odor and purulent (containing pus) drainage. The hospital's Physician Assistant Comprehensive Progress Note, dated 5/1/13 and timed 7:52 PM, stated "[MEDICAL CONDITION]ly (secondary to) [MEDICAL CONDITIONS] exacerbation [MEDICAL CONDITION] with likely sources including pna (pneumonia) and extensive skin (pressure) ulcers...". R3 passed away on 5/3/13. The death certificate, dated 5/3/13, listed the primary cause of death [MEDICAL CONDITION] and multi organ failure. During an interview on 7/26/13 at 6:20 PM, E2 (Director of Nursing) was asked what her expectations are when daily treatments are not done on the 7:00 - 3:00 PM shift when the resident is out of the facility. E2 stated "I would expect 3:00 - 11:00 PM shift to do the daily treatment." During an interview on 7/26/13 at 1:25 PM, E4 (R3's facility physician) stated there was no wound care nurse in the beginning of R3's stay at the facility. E4 stated R3 was non-compliant and he counseled R3 on positioning to which she replied to him "I don't care I am going to do what I want to do." E4 stated that in his opinion a Clinitron bed would not have made any difference in R3's wounds healing as she kept sitting in her chair all day and was in poor overall condition. The facility failed to consistently monitor R3's pressure ulcers when treatments were provided. The facility failed to ensure that treatments were provided as ordered to promote healing, prevent infection and prevent new ulcers from developing. Additionally, the facility failed to have a system in place to ensure the timely transcription and implementation of wound care orders as well as wound care monitoring.