Every finding on record at Complete Care at Hillside LLC

Based on observation, interview, and record review, it was determined that for three (second floor, third floor and fourth floor) of three shower rooms, the facility failed to ensure that adequate housekeeping and maintenance services were provided to maintain a clean, sanitary, and home-like environment. Additionally, the hallway carpet on all the units, and the floors of multiple residents' rooms were visibly soiled. Lastly, the facility also failed to ensure that resident care equipment was maintained in good repair and sanitary condition. Findings included: 1. 1/21/26 11:11 AM – During a tour of the second floor, the shower room was observed with cracked tiles, standing water on the floor, discolored walls and water dripping from the shower head. The handwashing sink was inaccessible due to multiple equipment including wheelchairs and mechanical lifts in the room. An area between the wall and the window was observed with a large amount black debris. During an interview, E13 (CNA) stated, A heater used to be there. But it was removed a while ago. The Surveyor asked E13 about access to the handwashing sink. E13 stated, We are not able to get to the sink because there is too much stuff in the way. 1/21/26 11:30 AM – During a tour of the third and fourth floor shower rooms, the floors were also observed with broken tiles, dripping shower heads and discolored walls. The handwashing sinks were also inaccessible because of the wheelchairs, and other equipment present. During an interview, the Surveyor asked E6 (CNA) about access to the handwashing sink. E6 stated, It's not easy to wash hands in there because of all of the stuff in the way. 1/21/26 12:00 PM - During a tour of all three units, hallway carpet and multiple residents' rooms were observed with visibly soiled areas. During an interview, C4 (ESD) stated, There was no schedule for carpet cleaning. We are getting schedules to deep clean the rooms and carpeted areas. 1/22/26 1:30 PM - During a tour of the three units, the hallway carpet and resident rooms continued to be visibly soiled. 1/22/26 1:45 PM - During a tour of the shower rooms on all three units, the rooms continued to be observed with clutter. 1/23/26 3:00 PM - During a tour of the three units, the hallway carpet and resident rooms continued to be visibly soiled. 1/23/26 3:15 PM - During a tour of the shower rooms on all three units, the rooms continued to be observed with clutter. 1/23/26 3:15 PM - Findings were confirmed with E1, E2, and E13. 1/30/26 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E13 (Nurse Educator/IP), E20 (ADON) and E21 (Corporate Educator) at the exit conference. 2. 1/27/26 10:42 AM - A plastic cushion, with five to six surface openings exposing the underlying permeable foam, was observed laying on a shower bed located in the fourth floor shower room. 1/28/26 1:33 PM - During an interview, E27 stated, That cushion has been like that for a while. 1/29/26 9:15 AM - During an interview, E13 (Nurse Educator/IP) confirmed the openings on the shower bed cushion. The surveyor asked E13 how the shower bed cushion can be disinfected if the plastic is torn and has openings. E13 stated, I will have it removed. 1/30/26 9:00 AM - Finding was reviewed with E1 (NHA).

Based on record review and interview, it was determined that for one (R103) out of three residents reviewed for dignity, the facility failed to ensure that R103 was treated with dignity when staff did not wake the resident or obtain resident's permission before attempting to provide incontinence care. Findings include: Review of R103's clinical record revealed:8/19/25 - R103 was admitted to the facility with diagnoses including orthostatic hypotension and heart failure.8/25/25 - R103's admission MDS documented a BIMS score of 15, indicating an intact cognition. 8/26/25 - A facility incident report documented, [R103] reported that four days ago [8/22/25] a male aide came into his room and assaulted him by pulling down his underwear. [R103] then said it wasn't his underwear but it was his pants. [R103] unclear [sic] with this allegation and stated that he has been foggy since admitted from [hospital], medications have taken over his mind. [sic] The CNA who cared for [R103] that day was [E16, CNA] .8/26/25 - A follow up facility incident report documented, .[R103] said he was woken up by [E16] was [sic] trying to pull my underwear down to get them off .[R103] denied being touched inappropriately. [R103] said he didn't want [E16] to take care of him again. [R103] did not want the police called and wasn't fearful .8/29/25 - A facility incident report documented, Statement from [E16] .[E16] adamantly denied this allegation, stating that he did take care of [R103] but did not pull down his underwear or assault him .9/15/25 1:47 PM - Correspondence submitted by E2 (DON) to the State Agency documented, .[E16] was educated as to [sic] customer service explaining why you have entered the room and if you want check the patients for incontinence to let them know that .1/29/26 1:45 PM - During an interview, R103 stated, .I was asleep and felt tugging at my hip. [E16] said that I had to take my underwear off. [E16] did not touch me sexually or anything but he didn't announce himself and he didn't knock on the door .1/29/26 2:11 PM - During an interview, E2 stated, No follow up training was given to [E16] after the incident. [E16] only works every other weekend. When [E16] returned the resident was already discharged from the facility.1/30/26 2:30 PM - Findings were reviewed with E1, E2, E13 (Nurse Educator/IP), E20 (ADON) and E21 (Corporate Educator) at the exit conference.

Based on record review and interview, it was determined that for three (R55, R98 and R105) reviewed for care plans, the facility failed to provide care that meets the professional standards of care. For R55 and R105, an LPN completed R55's and R105's admission assessments in violation of the State Board of Nursing Scope of Practice. For R98, there was no evidence of an RN providing discharge education. Additionally, for R105, there was no evidence that an RN completed post fall assessments and documentation. Delaware State Board of Nursing – RN, LPN and NA/UAP Duties 2024. admission Assessments * - RN. * = Once a care plan is established, the LPN may do assessments. Post Fall Assessment & Documentation ^ - RN .^ = RN must do initial fall assessment; LPN can do subsequent assessments. Discharge Process (RN must do initial teaching) **. ** = LPN can reinforce discharge teaching/plan. RN must do all initial assessments. Review of R55's clinical record revealed: 11/22/25 – R55 was admitted to the facility. 11/22/25 – E15 (LPN) completed the Nursing Admission/ Readmission/Annual/Sig Change Assessment in R55's EMR (electronic medical record). 11/22/25 – E15 completed R55's Lift/Transfer/Reposition evaluation, AIMS assessment, PHQ9 evaluation and bedrail evaluation in R55's EMR. An LPN, not an RN as required by the Delaware State regulation for Board of Nursing Scope of Practice, completed the admission process for R55. 2. Review of R98's clinical record revealed: 11/11/25 – R98 was admitted to the facility. 11/19/25 – R98 was discharged from the facility. 1/26/26 10:32 AM – A review of R98's Discharge Plan Documentation revealed E17 (Social Work Assistant) and E18 (nursing clerical assistant) documented all aspects of R98's discharge to home plan. The facility lacked evidence of any licensed personnel reviewing R98's Discharge Plan documentation. 1/27/26 9:57 AM – A review of R98's EMR progress notes revealed no evidence that an RN provided discharge education prior to R98's discharge. E19 (Social worker) documented in R98's EMR progress notes, Pt (patient) is discharging per choice. He was informed that he can and should stay and he declined. He was educated on the risks of not completing rehab. 1/28/26 2:10 PM – During an interview, E18 stated, I sign at the bottom of the discharge plan because I am the one printing it out. The nurses should write a note about the discharge and the education given. The resident/family gets a copy, we (the facility) keep a signed copy that goes in the paper chart and I mail a copy to the PCP (primary care provider). The facility lacked evidence that an RN provided R98 any discharge education. 1/30/26 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON, E13 (Nurse Educator/IP), E20 (ADON) and E21 (Corporate Educator) at the exit conference. 3. Review of R105's clinical record revealed: 6/27/25 - R105 was admitted to the facility with diagnoses including breast cancer and dementia. 6/27/25 7:15 PM - E24 (LPN) completed a Nursing Admission/Readmission/Annual/Significant Change Assessment form in R105's EMR. 6/27/25 7:15 PM - E24 entered a System Note in R105's clinical record documenting that an admission nursing assessment was completed. 7/8/25 10:45 AM - A facility fall incident report documented, .[R105] found lying on her side in front of her wheelchair .Immediate Action Taken: Neurocheck in effect. Assessment done. Lump noted on left side of [R105's] head .Person Preparing Report: [E23, LPN] . 7/8/25 - A facility document titled, Neurological Evaluation Flow Sheet noted that E23 completed an initial neurological assessment for R105 at 10:45 AM. 1/29/26 11:32 AM - During an interview, E21 (Corporate Educator) stated, The nurse who is assigned to the resident will do the post fall assessment and any other assessment prompted by entering a change in condition note [in the EMR]. 1/29/26 12:00 PM - Review of a facility staffing document dated 7/8/25 noted that E23 was assigned to R105 at the time the fall occurred. 1/29/26 12:15 PM - During an interview, E23 stated, I don't remember the resident but if I was assigned to a resident that fell and hit their head, I would do a full body assessment and the neuro checks for the shift. 1/29/26 1:00 PM - Review of R105's EMR lacked evidence that an RN completed R105's admission assessment or post fall assessment. 1/30/26 9:00 AM - Finding was reviewed with E1 (NHA). 1/30/26 2:30 PM - Findings were reviewed with E1, E2 (DON), E13 (Nurse Educator/IP) and E21.

Based on record review and interview, it was determined that for one (R99) out of two residents reviewed for activities of daily living, the facility failed to ensure the dependent resident received his scheduled bathing/showers. Findings include: Review of R99's clinical record revealed: 8/19/25 - R99 was admitted to the facility. 8/19/25 - R99 was care planned for ADL self-care performance deficit related to a stroke. An intervention was that R99 was totally dependent on staff to provide bath/shower. 8/21/25 - R99 was care planned that it was . important that he has the opportunity to engage in daily routines that are meaningful and relative to his preferences. An intervention for R99 was .very important for [R99's name] to choose how he [was] bathed. He prefers a shower or bed bath. Review of R99's Documentation Survey Reports from 8/19/25 through 9/4/25 revealed that he was scheduled to be showered or bathed every Wednesday and Saturday evening shift and as needed. Out of five scheduled shower/bathing opportunities documented, R99 received bathing two times and refused bathing one time. Review of R99's progress notes lacked evidence of the reason for no bathing provided on 8/30/25 and 9/3/25. 1/30/26 11:50 AM - E13 (NE/IP) confirmed the finding. 1/30/26 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E13 (NE/IP), E20 (ADON) and E21 (CE).

Based on review of facility policy, record review, observations and interviews, the facility failed to ensure facility infection control procedures were followed related to Transmission Based Precautions (TBP)/Isolation for four Residents (R) R48, R93 and R199 of a total of 47 residents reviewed in the sample. This failure created the potential for residents to become ill related to facility outbreak of infection. The findings include: The facility's Transmission-Based (Isolation) Precautions Policy most recently revised 03/14/23 read, in pertinent part, It is our policy to take appropriate precautions to prevent transmission of pathogens' modes of transmission; and Facility staff will apply Transmission Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 1. Review of R48's Admission Record, dated 02/06/25 and found in the EMR under the Admissions tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included End Stage Renal Disease (ESRD) and history of stroke. Review of R48's annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/16/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated the resident was severely cognitively impaired. Review of R48's Physicians Orders, found in the EMR under the Orders tab, revealed an order, with an original order date of 02/01/25, for Guaifenesin (a cough syrup medication) give ten milliliters (MLs) every four hours as needed for cough and an order, with an original order date of 02/03/25, for the resident to be placed on isolation for her diagnosis of influenza. There was no order for isolation (Transmission Based Precautions) entered for the resident related to her respiratory symptoms prior to that date. Review or R48's progress note, dated 01/31/25 and found in the EMR under the Notes tab, revealed, Constant coarse cough. COVID-19 test done and is negative. Review or R48's Physician Encounter Progress Note, dated 02/03/25 and found in the EMR under the Notes tab, revealed, Patient seen today per nurse request secondary to positive influenza swab with wheezing and cough. The note indicated the resident was to remain on isolation for flu and was to receive her as needed Guaifenesin as well as Tamiflu related to her symptoms. During an interview with Licensed Practical Nurse (LPN7) on 02/03/25 at 9:00 AM, he stated R48 had not been feeling well and had been experiencing upper respiratory symptoms (cough, congestion, and runny nose) for the last couple of days. LPN7 stated, She really doesn't feel well. There was no signage on the resident's door to indicate the resident had been placed on isolation/TBP of any kind related to her symptoms as of that time. LPN7 stated he thought R48 should be on isolation related to her symptoms and advised the surveyor to wear a mask when entering the resident's room. During an interview with R48 in her room on 02/03/25 at 9:10 AM, she confirmed she had a cough and congestion and stated she had not been feeling well for two days. During an interview with the Infection Preventionist (IP) on 02/03/25 at 1:20 PM, she stated R48 had been tested for influenza and the test results were positive. The IP stated R48 had been placed on isolation (Droplet TBP) as of that date related to the flu diagnosis. 2. Review of R93's Admission Record, dated 02/06/25 and found in the EMR under the Admissions tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included fracture of the right lower leg. Review of R93's admission MDS assessment, with an ARD of 01/06/25 and found in the EMR under the MDS tab, indicated a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Review of R93's Physicians Orders, found in the EMR under the Orders tab, revealed an order, with an original order date of 01/31/25, for resident to receive Guaifenesin Liquid (cough suppressing syrup) 100 milligrams per 5 milliliters (MG/5ML) give 10 milliliter by mouth every 4 hours as needed for Cough for 10 Days and an order, with an original order date of 02/04/25, for the resident to be placed on isolation related to her respiratory symptoms as of that date. Review of R93's Physician Encounter Note, dated 01/31/25 and found in the EMR under the Notes tab, revealed, Chief Complaint / Nature of Presenting Problem: Cough; and History Of Present Illness: Resident with cough and runny nose x 1 day. Resident reports she does have seasonal allergies and she takes an allergy pill . states the cough has been here for 1 day. Her COVID test was negative. She denies a sore throat, fever, aches or chills. During an interview with R93 on 02/04/25 at 9:17 AM, she stated, I'm congested, and I don't feel good. They did a COVID test last Friday so I guess I have been congested since then. She stated she thought the results of the COVID test had been negative. R93 had a wet cough and appeared flushed and was weepy during the interview. There was no TBP signage on the resident's door and there was no PPE at or near the resident's door. During an observation of R93 on 02/04/25 at 12:01 PM, the resident was sleeping in her bed. She continued to have a wet cough. There was still no TBP signage on door or PPE available next to or near the resident's room. During an interview with the Director of Nursing (DON) and the IP on 02/04/25 at 1:07 PM, the IP stated R93 was being placed on isolation related to her respiratory symptoms. She stated the resident had not yet tested positive for any infection; however, the facility's process was to place symptomatic residents on isolation if there was suspected infection (such as influenza or COVID). The DON confirmed R93 should have been placed on isolation earlier based on her symptoms and the confirmation of influenza and COVID residents in the facility. 3. Review of R199's Admission Record, dated 02/06/25 and found in the EMR under the Admissions tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included chronic kidney disease and colon cancer. Review of R199's admission MDS assessment, with an ARD of 02/04/25 and found in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R199's Physicians Orders, found in the EMR under the Orders tab, revealed an order, with an original order date of 02/04/25, for resident to receive Guaifenesin Liquid give 10 ML by mouth every 4 hours as needed for Cough for 10 Days and an order, with an original order date of 02/04/25, for the resident to be placed on isolation related to his respiratory symptoms as of that date. Review of R199's Nursing Progress Note, dated 02/03/25 and found in the EMR under the Notes Tab, revealed the resident had anew order for Guaifenesin due to his complaint of having a cough. During an interview with R199 in his room on 02/04/25 at 9:06 AM he was observed to have a frequent wet cough. R199 stated he had been coughing and had not felt well for two days. He stated, Last night they gave me a COVID test because of my cough. R199 stated he thought the COVID test results had been negative. There was no TBP signage on R199's door or PPE located in or near the resident's room. R199 was observed in his room on 02/04/25 at 12:01 PM. The resident still had a productive wet cough. There was no TBP signage on the resident's door. R199 was observed in his room as above on 02/04/25 at 2:00 PM. The resident continued to cough and stated he did not feel well. Signage to indicate the resident was on isolation (Droplet TBP) had been placed on the resident's door and PPE was placed at the entrance to the resident's room. During an interview with the IP on 02/06/25 at 9:35 AM, she confirmed R199 had not been placed on TBP related to his respiratory symptoms until the afternoon of 02/04/24. She stated R199 had been tested for COVID again that morning and the result of the COVID test was positive. She confirmed R199 remained on isolation as of the time of the interview. During an interview with the DON and IP on 02/04/25 at 1:07 PM, the DON stated they were testing everyone in the facility with respiratory symptoms for COVID and influenza as of that time. She stated respiratory screening had been initiated for all residents as of the night of 02/03/25 after the survey team began inquiring about residents with respiratory symptoms. The DON confirmed testing was expected to be done for any resident with respiratory symptoms and confirmed her expectation was the facility policy indicating any resident with known or suspected infection was to be placed on isolation precautions. The DON confirmed R48, R93 and R199 had not been placed on isolation precautions timely related to their symptoms and this had created the potential for the spread of infection including flu and COVID. During an interview with the Administrator on 02/06/25 at 12:57 PM, she confirmed her expectation was symptomatic residents with suspected or confirmed infection were to be placed on isolation precautions immediately.

Based on observation, record review, interview, and policy review, the facility failed to ensure medications were not left at bedside for a resident that was not assessed to self-administer medications for two resident (Resident (R) 24 and R298) out of 47 residents in the sample. This had the potential to affect all residents who received medications. Findings include: Review of the facility's policy titled, Resident Self-Administration of Medication, undated, indicated, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medication may be self-administered safely .Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication .All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage . 1. During an observation and interview on 02/03/25 at 3:26 PM of R24's room revealed two inhalation aerosols lying on the bedside table. The resident stated that they had been left there since the night before when the nurse brought in the treatment. Review of the Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed R24 was admitted to the facility on [DATE] with diagnosis of stroke affecting the right dominant side and unspecified asthma. Review of R24's annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date of 12/15/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. Review of R24's Orders located in the Orders tab of the EMR revealed the inhaler Beclomethasone Diprop HFA Inhalation Aerosol Breath Activated 80 MCG/ACT, to be given two times a day (one puff) for asthma. The other inhaler was Olodaterol HCI Inhalation Aerosol Solution 2.5 MCG/ACT, to be given (two puff) one time a day for asthma. There were not orders for self-administration. On 02/03/25 at 4:02 PM, the Director of Nursing (DON) observed the two inhalers on R24's bedside table. The resident again told the DON that they had been left since the night before by the nurse. The DON stated, R24 does not have orders to have these at bedside. I am removing these and putting them back on the medication cart. 2. Review of R298's Face Sheet, located in the electronic medical record (EMR) under the Profile tab revealed the resident was readmitted to the facility on [DATE] with diagnoses which included muscle weakness, and polyneuropathy. Review of R298's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/25 and located in the resident's EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was not impaired. Review of R298's Care Plan, dated 01/23/25 and located in the resident's EMR under the Care Plan tab, revealed the resident was not care planned for self-administration of medications. Review of R298's Physician Order Summary, dated 01/23/25 and located in the resident's EMR under the Orders tab revealed, resident MAY NOT administer own medications. During an observation on 02/04/25 at 9:35 AM and again on 02/05/25 at 9:50 AM, R298 had an inhaler lying on the bedside table that was in plain sight. R298 stated he has had the inhaler since he was admitted , and that staff were aware. During an interview on 02/05/25 at 9:55 AM, Registered Nurse (RN)1 stated R298 was assessed to self-administer medications, but she was unaware he had an inhaler. She asked R298 if he had an inhaler, and he lifted the inhaler up that was lying on the bedside table. She said he should not have the inhaler and corrected herself and stated he was not assessed to self-administer medications. RN1 stated again that he should not have the inhaler at all. During an interview on 02/05/25 at 10:27 AM, the Infection Preventionist (IP) said she was made aware of the inhaler on Monday by a nurse. The IP said she spoke with R298, and he agreed to put the inhaler away, but she did not document anything about the conversation. During an interview on 02/06/25 at 12:33 PM, the Director of Education stated any medications a resident is admitted with would have had to be checked in by the nurses and that staff should be observing anything in the room and removing any medications they find in the resident's room.

Based on observations, interviews, and facility policy review, the facility failed to ensure call lights were within reach for one(Residents (R)85) out of a sample of 47 residents reviewed for accommodation of needs and preferences. Specifically, the facility failed to ensure residents had access to their call lights to best assist the residents in maintaining and/or achieving their independent functioning, dignity, and well-being to the extent possible. Findings include: 1. Review of R85's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was originally admitted on [DATE], with diagnoses including diabetes mellitus type two, polyneuropathy, epilepsy, and acquired absence of left leg below the knee. Review of R85's quarterly Minimum Data Set (MDS) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 12/04/24, revealed a Brief Interview for Mental Status (BIMS) assessment with no recorded score due to the resident refused to participate in the BIMS portion of the MDS. R85's quarterly MDS with an ARD of 09/04/24 revealed a BIMS score of 15 out of 15 indicating that R85 was cognitively intact. R85 was dependent for toileting hygiene, shower/bathing, dressing, and personal hygiene. R85 was observed on 02/04/25 at 9:01 AM in bed with the call light button clipped to the call system on the wall behind the resident, out of reach. He stated he could not reach it from his bed and was able to use the call light. Additional observations on 02/04/25 at 4:50 PM and 02/05/25 at 8:59 AM, revealed R85 in bed with his call light button again clipped to the call system on the wall behind him out of reach. During an interview on 02/05/25 at 9:00 AM, Licensed Practical Nurse (LPN 4 stated that call lights should be kept in close reach of residents when they were in their bed. LPN4 observed R85's call light attached to the call system on the wall and stated it should be attached and within his reach. LPN4 moved the call light to within reach of R85. She said that she was not sure why his call light had not been placed appropriately. She confirmed the resident was alert and oriented and able to use the call light. During an interview on 02/06/25 at 10:20 AM, the Administrator stated that call lights should be answered as promptly as possible. If the residents were in their room, the call light should be reachable. The Administrator stated R85 was an interviewable resident. She stated she would want the resident to have access to his call light. During an interview on 02/06/25 at 10:40 AM, Infection Preventionist/Educator Nurse Practice (IP/ENP) stated that the call lights should always be in reach of the resident when they were in their room.

Based on record review, interview, and facility policy review, the facility failed to investigate misappropriation of property for two of four residents (Resident (R)84 and R108), This failure has the potential to affect all residents who choose to keep money and/or personal property in their rooms. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation, dated 09/12/24 indicated Investigation. the facility will investigate all allegations and types of incidents as listed above in accordance with facility procedure for reporting/response as described below.the facility will perform an investigation that focuses on whether abuse or neglect occurred and to what extent, clinical evaluation for any signs of injury, causative factors, and interventions to prevent further injury. 1. Review of R84's Admission Record located in the electronic medical records (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE]. 2. Review of R108's Admission Record located in the EMR under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of the Facility Reported Incident (FRI) dated 05/01/24 which revealed R84 had informed the Administrator that Certified Nurse Aide (CNA)1 took cigarettes from him and in addition, took money from R108. The FRI failed to contain evidence of interviews with other residents or potential staff as witnesses. During an interview on 02/06/25 at 12:32 PM, the Administrator stated she did not remember how CNA1 accessed R108's secured drawer. The Administrator stated she typically does interview other residents and staff during the investigation. The Administrator was provided with an opportunity to identify additional information on the investigations of theft that involved R84 and R108, and no further information was provided by the end of the survey.

Based on interview, record review, and facility policy review, the facility failed to develop comprehensive care plans related to nebulizer treatment for one resident (Resident (R) 12) out of a total sample of 47 residents. This failure had the potential to negatively impact the resident's quality of life, as well as the quality of care and services received. Findings include: Review of the facility-provided policy titled Care Plans, Comprehensive Person-Centered, dated 10/2019, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and residents condition change . Review of the Face Sheet located in the Profile tab of the Electronic Medical Record (EMR) revealed R12 was admitted to the facility on [DATE] with diagnosis of heart failure, diabetes, and cancer of the left breast. Review of the Orders located in the Orders tab of the EMR revealed R12 had an order for Ipratropium-Albuterol Solution 0.5-2.5 MG/3ML orally via nebulizer two times a day for wheeze/cough. Review of the Care Plan located in the Care Plan tab of the EMR revealed R12 did not have a Comprehensive Care Plan for nebulizer treatment and care. Interview with the Assistant Director of Nursing (ADON) on 02/05/25 at 2:40 PM revealed Myself and nursing document care plans. I do not know why this was not care planned. It should have been.

Based on observations, record reviews and interviews, the facility failed to ensure two residents of five residents (Resident (R) 31 and R200) who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene (showers per personal preference) out of a total sample of 47 residents. Findings include: Review of a facility policy Resident Showers dated 03/14/23 indicated .It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. 1. Review of R31's Admission Record located in the electronic medical records (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE] a stroke which affected the right side. Review of R31's Care Plan located in the EMR under the Care Plan tab dated 06/13/24 indicated that the resident identified it was important for her to take showers. Review of R31's annual Minimum Data Set (MDS) located in the EMR with an Assessment Reference Date (ARD) of 12/12/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident identified it was extremely important for her to decide whether she received a bath, shower, or a bed bath. The assessment indicated that the resident was dependent on staff for baths/showers. Review of a document provided by the facility titled Shower/Bathing/Personal Care Shower Monday and Thursday 7-3 and as needed for the month of 12/24. The document failed to show that the resident received a shower on 12/09/24, 12/16/24, 12/23/24, 12/26/24, and on 12/30/24. Review of a document provided by the facility titled Shower/Bathing/Personal Care Shower Monday and Thursday 7-3 and as needed for the month of 01/25. The document failed to show that the resident received a shower on 01/06/25 and on 01/27/25. During an interview on 02/03/25 at 10:55 AM, R31 stated she has not had a shower in one week. The resident also stated she receives bed baths but prefers to have a shower instead. During an interview on 02/04/25 at 12:47 PM, Certified Nurse Aide (CNA)5 stated that R31 preferred showers instead of bed baths and verified on the shower/bath document that the resident did not receive showers on her assigned days. CNA5 stated R31 rarely refuses showers. During an interview on 02/04/25 at 12:50 PM, the Resource Nurse confirmed the shower/bath document had gaps in the documentation. During an interview on 02/05/25 at 10:14 AM, the Resource Nurse stated that she has been addressing the documentation aspect with CNAs to reflect cares. During an interview on 02/05/25 at 10:55 AM, the Director of Nursing (DON) stated residents should be offered a shower twice a week. 2. Review of R200's Admission Record, dated 02/06/25 and found in the EMR under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included spinal stenosis and type 2 diabetes. Review of R200's admission MDS assessment, with an ARD of 01/16/25 and found in the EMR under the MDS tab, indicated a BIMS score of 12 out of 15, which indicated the resident was mildly cognitively impaired. The assessment indicated R200 required partial/moderate assistance from staff to complete her bathing. Review of R200's ADL Care Plan, dated 01/16/25 and found in the EMR under the Care Plan tab, indicated the resident was at risk for a decline in her ADLs related to activity intolerance, fatigue and impaired balance. The care plan indicated R200 was to receive baths/showers twice weekly on Wednesdays and Saturdays on the evening shift. Interventions included, The resident requires assistance by (1) staff with bathing/showering as necessary. Review of R200's bathing records, dated 01/10/25 through 02/05/25 and found in the EMR under the Tasks tab revealed the resident received a bath/shower only once during that time, on 01/18/25. There was nothing in the resident's record to indicate the resident refused to bathe during that period of time. During an interview with R200 on 02/05/25 at 9:10 AM, she stated she had only been bathed once since her admission to the facility on [DATE]. She stated she would like to be bathed. During an interview with CNA6 on 02/06/25 at 11:43 AM, she confirmed she was familiar with R200 and stated the resident was supposed to be bathed twice weekly on the evening shift. CNA6 stated she usually worked on the day shift and staff tried to keep up with showers on that shift, but it was not uncommon for residents to report they had not been showered on the evening shift. During an interview with the Administrator on 02/06/25 at 12:51 PM, she stated her expectation was residents would be bathed according to their plan of care and bathing was to be documented in the EMR. The Administrator stated refusals to bathe were also expected to be documented in the EMR.

Based on observation, record review, interview, and review of the facility policy, the facility failed to ensure one of three residents (R)85 reviewed for prevention of skin breakdown, received treatment and interventions according to physician orders out of a total sample of 47 residents. This failure placed the resident at an increased risk for a worsening pressure ulcer, pain, and a decrease in quality of life. Findings include: Review of the facility's policy titled, Pressure Injury Prevention and Management, revised 05/26/23, revealed, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate . Evidence-based interventions for prevention will be implemented for all residents who care assessed at risk or who have a pressure injury present. Basic or routine care interventions could include .redistribute pressure (such as repositioning, protecting, and/or offloading heels .provide appropriate, pressure-redistributing, support surfaces .Compliance with interventions will be documented in the weekly summary charting. Review of R85's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was originally admitted on [DATE], with diagnoses including diabetes mellitus type two, polyneuropathy, epilepsy, and acquired absence of left leg below the knee. Review of R85's quarterly Minimum Data Set (MDS) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 12/04/24, revealed a Brief Interview for Mental Status (BIMS) assessment with no recorded score due to the resident refused to participate in the BIMS portion of the MDS. R85's quarterly MDS with an ARD of 09/04/24 revealed a BIMS score of 15 out of 15 indicating that R85 was cognitively intact. R85 received pressure reducing devices to his chair and bed. R85 was dependent for toileting hygiene, shower/bathing, dressing, and personal hygiene. A review of a Progress Note by the Wound Care Nurse Practitioner on 01/08/25 documented that R85 has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. The patient is incontinent of urine and stool and is at an increased risk of skin breakdown. Recommend continuing ongoing interventions and protocol for incontinence management . New Recommendations: Recommend an alternating air/low air loss mattress for pressure redistribution. Ensure settings are maintained at an appropriate level based on the patient's needs and body habitus. Review of R85''s Care Plan, located in the EMR under the Care Plan tab and initiated 11/18/23, revealed R85 had impaired tissue or potential for impaired skin tissue lower abdomen redness. It was revised 01/03/25 for a scrotum unstageable pressure injury and converted to stage three on 01/14/25. Interventions included air mattress to bed check function and placement every shift, initiated on 11/20/23; offload heels while in bed, initiated on 11/20/23; treatment as ordered, initiated 11/18/23; and turn and reposition every 2 hours and as needed with skin checks, last revised 01/26/24. During an observation and interview on 02/04/25 at 9:04 AM, R85 said he had a sore on his bottom and now had a catheter because of it. He was observed lying in bed on a regular mattress, which he confirmed was the only mattress he used. Review of R85's Physician Order, dated 11/20/23, located in the EMR under the Orders tab revealed R85 had an order for an air mattress to bed, check function and placement every shift. This was discontinued 02/13/24. During an observation on 02/04/25 at 1:51 PM, it was again confirmed the mattress for R85 was a regular mattress. During additional observations on 02/04/25 at 4:50 PM and 02/05/25 at 8:59 AM, R85 was again observed lying on a regular mattress in his room. During an interview on 02/05/25 at 3:20 PM, Licensed Practical Nurse (LPN)4 said that the wound nurse went around with the wound doctor. LPN4 stated the doctor would document notes and orders, and the wound care nurse would put those recommendations in the system directly. LPN4 stated the other floor nurses would not place the orders. During an interview on 02/06/25 at 9:20 AM, LPN5 stated that R85 did not use an air mattress, but that the facility had a lot of them available. LPN5 said that an air mattress would be a good idea, but she had not heard of R85 being offered one. During an additional interview with 02/06/25 at 9:25 AM, R85 stated no one had offered him an air mattress for his wound healing. During an interview on 02/06/25 at 9:41 AM, the Resource Nurse said that the wound care nurse would write in her progress notes when she did rounds with the wound doctor. She stated the wound doctor would put in their notes and recommendations and should put in their own orders. She said the wound nurse should also note the concern. The Resource Nurse said if the resident had a history or risk of pressure ulcers, an air mattress would have been appropriate. During an observation on 02/06/25 at 10:01 AM with LPN5 and IP/ENP, R85 was observed resting on a regular mattress. During an interview on 02/06/25 at 10:40 AM, Infection Preventionist/Educator Nurse Practice (IP/ENP) stated that the wound care team went around the facility and a nurse that went with them would write in the notes and the orders into the EMR. She stated R85 had been using the same Broda chair since admission, and he was not currently using an air mattress. IP/ENP said the facility had plenty of air mattresses, and one was going to be taken to him. IP/ENP confirmed the wound care team made a request for an air mattress on 01/08/25, but the nurse had forgotten to write the order to get the new mattress placed for him. Review of R85's Physician Order, dated 01/14/25, located in the EMR under the Orders tab revealed a treatment order for Santyl External Ointment 250 Unit/GM (gram), apply to posterior scrotum topically everyday shift for stage three wound. Cleanse open area posterior scrotum with soap and water, dry and apply Santyl ointment and cover with dry dressing daily and as needed. During a treatment observation on 02/06/25 at 12:01 PM, LPN5 was observed applying Santyl to the scrotum of R85. Per LPN5, she put the Santyl on the whole scrotum, which was observed. During an interview on 02/06/25 at 12:42 PM, the Director of Education stated that the wound care team came to the facility on ce a week to review residents. She said the team looked at all wounds, and that a nurse went with them who would do the dressings as they went along, as well as take measurements. She stated that at the end of the day the administration received a wound tracker to indicate if there were any changes or if there were any order changes that needed to go into the EMR before they left. The Director of Education stated that the nurse providing the treatment should not put Santyl all over the scrotum. She confirmed that the wound tracker would go to the Director of Nursing, and she would get it at the regional level, which would be how the facility would ensure they catch the order if it was missed initially.

Based on observations, interviews, record review, and policy review, the facility failed to ensure that a resident with a urinary catheter bag was properly positioned in a manner to prevent potential urinary tract infections due to contamination for one of two residents (R)85 reviewed for urinary catheters and urinary tract infections out of a total sample of 47 residents. Findings include: Review of the facility's policy titled, Indwelling Catheter Care, revised 08/11/24, revealed It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Catheter care will be performed every shift and as needed by nursing personnel .Privacy bags will be available and catheter drainage bags will be covered at all times while in use .Ensure drainage bag is located below the level of the bladder to discourage backflow of urine .Assist resident to a comfortable, appropriate position .Document care and report any concerns noted to the nurse on duty. Review of R85's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was originally admitted on [DATE], with diagnoses including diabetes mellitus type two, polyneuropathy, epilepsy, and acquired absence of left leg below the knee. Review of R85's quarterly Minimum Data Set (MDS) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 12/04/24, revealed a Brief Interview for Mental Status (BIMS) assessment with no recorded score due to the resident refused to participate in the BIMS portion of the MDS. R85's quarterly MDS with an ARD of 09/04/24 revealed a BIMS score of 15 out of 15 indicating that R85 was cognitively intact. R85 was dependent on toileting hygiene. He was documented always incontinent of urine and bowel. Review of the Physician Orders located in the EMR under the Orders tab revealed a 01/13/25 order for Foley catheter 16 French .for diagnosis: Wound healing. The resident's goal was to be free from catheter-related trauma. Interventions included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door, and providing catheter care every shift. During an observation 02/04/25 at 8:58 AM, the catheter bag was observed lying directly on the floor on the left side of the resident's bed. During an observation on 02/04/25 at 11:30 AM, the resident was observed in the common area of the unit, resting in his Broda chair. The catheter tubing was observed lying across his lap and over the left arm rest of his chair. The catheter bag was observed hanging freely with gravity approximately 18 inches off the floor, visibly weighted down with urine. The catheter bag was not supported. During a concurrent interview on 02/04/25 at 11:35 AM, Licensed Practical Nurses (LPN) 6 and LPN5 stated that the catheter bag should be attached to R85's Broda chair when the resident was up in his chair and should be off the ground. LPN5 stated she was going to find something to lift the catheter bag off the left arm rest and give it support. LPN5 returned with a clip to attach the catheter bag to the side of the Broda chair. Both LPN5 and LPN6 said that the catheter bag should not be left unsupported when R85 was in his chair. During an interview on 02/06/25 at 10:23 AM, the Administrator stated that catheter bags should not be placed onto the facility floors for proper catheter care. During an interview on 02/06/25 at 10:40 AM, Infection Preventionist/Educator Nurse Practice (IP/ENP) said that catheter bags should always be hanging off of the floor and with a hook to the side of the resident bed or the chair they are using. During an additional observation on 02/06/25 at 12:01 PM, R85's catheter bag was observed in contact with the floor upon entrance to his room during wound care. During an interview on 02/06/25 at 12:42 PM, the Director of Education stated that she would not want to see catheters placed onto the floor.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that one resident (Resident (R) 12) out of 47 sampled residents was provided with the necessary respiratory care and services in accordance with professional standards. This failure had the potential to impact the residents treatment and interventions. Findings include: Review of the facility-provided policy titled Nebulizer Therapy, dated 03/13/23, revealed, It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .Correctly assemble the tubing, nebulizer cup, and mouthpiece and ensure connections are secured tightly .Observe the resident during the procedure for any change in condition .When medication delivery is complete, turn the machine off .Disassemble and rinse the nebulizer with sterile or distilled water and allow to air dry .Air dry on an absorbent towel .Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag .Change the nebulizer tubing every seven days or per facility policy .Periodically disinfect unit per manufacturer's recommendations . Review of the Face Sheet located in the Profile tab of the Electronic Medical Record (EMR) revealed R12 was admitted to the facility on [DATE] with diagnosis of heart failure, diabetes, and cancer of the left breast. Review of R12's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/10/25 located in the EMR under the MDS tab revealed R12 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. Observation on 02/03/25 at 2:30 PM of R12's room revealed the residents nebulizer sitting on the nightstand beside the bed. The mouthpiece was wrapped in paper towels. The nebulizer unit was dirty with white, crusty debris. The inside of the tubing was wet. The tubing and mouthpiece were not in a plastic bag. Interview with observation with R12 revealed This nebulizer is old. I wrap the mouthpiece in paper towels when I am done with it. Nursing does not turn it off when finished, I do. I have no idea the last time the tubing or mouthpiece was changed. Observation and interview with the Director of Nursing (DON) on 02/04/25 at 11:54 AM revealed This nebulizer is filthy, and the mouthpiece is wrapped in paper towels. I am going to get the resident a new system. The DON confirmed the nebulizer should have been cleaned after each use. Interview with Licensed Practical Nurse (LPN)3 on 02/04/25 at 11:57 AM revealed I gave R12 her treatment this morning. When asked if she saw anything wrong with the nebulizer, LPN 3 stated The mouthpiece and tubing is not in a bag and the machine is dirty. When asked if she saw the machine was dirty when she gave the treatment, LPN 3 stated I didn't look. I did not stay in the room while the machine was on. When asked if she turned the machine off and cleaned it, LPN 3 stated I wiped the mouthpiece off. During an interview with the Administrator on 02/06/25 at 10:44 AM revealed, We need to take a look at nebulizers and see what is going on. This should not have happened.

Based on observation, interview, and record review, the facility failed to ensure residents received alternative measures prior to installation of side rails for two residents reviewed for side rails (Resident (R) 83 and R298) of 31 sampled residents. The lack of alternate side rail measures could lead to potential safety concerns related to bed rail use for residents with bed rails. Findings include: 1. Review of R83's Face Sheet, located in the electronic medical record (EMR) under the Profile tab revealed the resident was readmitted to the facility on [DATE] with diagnoses which included paraplegia, and complete traumatic amputation of right shoulder and upper arm. Review of R83's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/05/24 and located in the resident's EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was not impaired. Review of R83's Care Plan, dated 10/09/23 and located in the resident's EMR under the Care Plan tab revealed, The resident required assistance and was dependent with ADL care related to bed mobility. Interventions in place were bed rails as an enabler. Observation on 02/03/25 at 11:15 AM R83 sitting in bed with head of bed upright and side rail were in the up position on both sides of bed. Review of R83's Bed Rail Evaluation dated 10/09/23 and located in the EMR under the Assessments tab revealed no alternates were attempted prior to the placement of the siderails. Further review revealed the determination was no bed rails should be used. 2. Review of R298's Face Sheet, located in the electronic medical record (EMR) under the Profile tab revealed the resident was readmitted to the facility on [DATE] with diagnoses which included muscle weakness, and polyneuropathy. Review of R298's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/25 and located in the resident's EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was not impaired. Review of R298's Care Plan, dated 01/23/25 and located in the resident's EMR under the Care Plan tab revealed, The resident required assistance and was dependent with ADL care related to impaired balance. Interventions in place were 1/4 side rails to assist with bed mobility. Observation on 02/04/25 at 9:35 AM R298 sitting up in bed with head of bed upright and side rails were in the up position on both sides of bed. Review of R298's Bed Rail Evaluation dated 01/23/25 and located in the EMR under the Assessments tab revealed no alternates were attempted prior to the placement of the siderails. Further review revealed the determination was no bed rails should be used. During an interview on 02/05/25 at 1:10 PM Licensed Practical Nurse (LPN)6 said during admission on all residents are provided with a bed rail use consent form to sign and all residents have bedrails unless they sign refusing. Staff do not discuss alternatives and alternatives are not explored prior to bedrail use but the form they sign discusses risk versus benefits. Staff only complete the bedrail assessment on admission and not again after that. He stated they do complete ongoing reassessment for continued bedrail use. He was not aware that the residents' bed rail assessment indicated not to use bed rails. He stated when he completes the assessment that it is not what he sees. But he stated he was unsure what the assessment was supposed to say. During an interview on 02/06/25 at 12:33 PM the Director of Education stated that bed rail assessments should be completed on admission and yearly after that. She also stated that staff should always be looking at bed rail alternates prior to bed rail use. She was unaware that both residents bed rail assessments indicated bed rails should not bed used. A review of the facility's policy titled Use of Bed Rails revised 01/14/23 revealed, it is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails.

Based on record review and staff interviews, the facility failed to ensure the medical necessity of psychotropic medication administration for one Resident (R)48 of five residents reviewed for Psychotropic Medication Administration and a total of 47 residents reviewed in the sample. Informed consent was not obtained from the resident and/or resident's representative related to administration of psychotropic medication. This failure created the potential for the resident to receive unwanted medications. The findings include: Review of the facility's policy titled Use of Psychotropic Medications, revised in 07/11/24 read, in pertinent part, Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. Review of R48's Admission Record, dated 02/06/25 and found in the EMR under the Admissions tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included End Stage Renal Disease (ESRD), depression and anxiety. Review of R48's annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/16/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated the resident was severely cognitively impaired. The assessment indicated R48 did not exhibit any behaviors during the assessment reference period, however the document revealed R48 did exhibit signs and symptoms of depression nearly every day of the assessment reference period. Review of R48's physicians orders, dated 02/06/24 and found in the EMR under the Orders tab, revealed an order, with an original order date of 11/02/24, for Trazadone (an antidepressant medication) 50 MG (milligrams) by mouth twice daily for sedation and an order, with an original order date of 10/30/24, for hydroxyzine (an antianxiety medication) 50 MG by mouth one time daily on Monday, Wednesday and Friday before dialysis for anxiety. Review of R48's undated Psychotropic Medication Care Plan, found in the EMR under the Care Plan tab, revealed the resident was receiving psychotropic medications for anxiety and depression. Interventions included giving medications as ordered and Discuss with MD (Medical Doctor), family regarding ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Review of R48's Medication Administration Record (MAR) dated 01/01/25 through 02/05/25 and found in the EMR under the Orders tab, revealed the resident was receiving her psychotropic medication as ordered. Review of R48's comprehensive record revealed nothing to show risks and benefits of the resident's Trazadone or hydralazine were discussed with the resident and/or her representative or that informed consent had been obtained for the administration of the medication. During an interview with the Director of Nursing (DON) on 02/05/25 at 03:04 PM, she confirmed she was not able to locate R48's informed consent for her psychotropic medications in the resident's record. During an interview with the Administrator on 02/06/25 at 12:55 PM, she stated her expectation was informed consent was to be obtained for any psychotropic medication administered to a resident.

Based on interview, observations, record review, and review of facility policy, the facility failed to ensure one Resident (R)201 of seven residents reviewed during medication pass observations was free from a significant medication error. The resident's insulin (a medication used to control blood sugar) was not properly administered, creating the potential for the resident to receive an inaccurate dose. A total of 47 residents were reviewed in the sample. Findings include: Review of the facility's policy titled Insulin Pen Procedure, dated 03/13/23 read, in pertinent part, j. Injecting the insulin: v. While still pressing the plunger, keep the needle in the skin for up to 6 to 10 seconds and then remove the needle from the skin. Review of R201's Admission Record, dated 02/05/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes. Review of R201's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/03/25 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was mildly cognitively impaired. Review of R201's Order Summary Report, dated 02/05/25 and found in the EMR under the Orders tab, indicated an order for Humulin Insulin inject five units subcutaneously twice daily. Review of R201's Medication Administration Record (MAR), dated 02/01/25 through 02/06/25 and found in the EMR under the Orders tab, indicated the insulin was being administered routinely per physician's orders. Licensed Practical Nurse (LPN)7 was observed administering R201's insulin on 02/05/25 at 12:27 PM. LPN7 dialed up five units of insulin and then injected the insulin into the resident's left arm, holding the needle into the resident's subcutaneous tissue for approximately two seconds before removing the needle. During an interview with LPN7 on 02/05/25 at 12:31 PM, he stated he had never been told the insulin pen needle should remain in the resident's skin for six to 10 seconds after injecting the medication. During an interview with the Administrator and the Infection Preventionist and Educator (IP/ENP) on 02/06/25 at 1:00 PM, the IP/ENP stated the insulin pen needle was expected to be left in the resident's skin for 10 seconds after administration of the insulin.

Based on interview, observations, record review, and review of facility policy, the facility failed to ensure resident medication stored in facility medication carts was appropriately labeled to indicate the open date of the medication for three Residents (R)47, R110, and R298 out of a total resident sample of 47. This failure created the potential for residents to experience negative effects related to the administration of expired and/or out-of-date medication. Findings include: Review of the facility's procedure titled Insulin Pen Procedure, dated [DATE] read, in pertinent part, Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date; and Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation. The medication cart on the facility's third floor was observed with Licensed Practical Nurse (LPN)8 on [DATE] at 9:20 AM. Open insulin glargine pens were found in the cart for R110 and R298. Neither of the insulin pens had an open date or a discard by date indicated on the pen to alert staff about when the insulin needed to be discarded. During an interview with LPN8 on [DATE] at 9:25 AM, she confirmed the insulin pens did not have open/discard dates indicated on them and stated the pens should have been dated to indicate when the pens needed to be discarded. The medication cart on the facility's fourth floor was observed with LPN9 on [DATE] at 09:45 AM. An open Lantus insulin pen was found in the cart for R47. The insulin pen did not have an open date or a discard by date indicated on the pen to alert staff about when the insulin needed to be discarded. During an interview with LPN9 on [DATE] at 9:50 AM, she confirmed the insulin pen did not have open/discard date indicated on it and stated the pen should have been dated to indicate when the pen needed to be discarded. During an interview with the Administrator and the Infection Preventionist and Educator (IP/ENP) on [DATE] at 1:00 PM, the IP/ENP stated insulin pens were expected to be labeled to indicate the date the insulin was opened so staff was able to determine when the insulin needed to be discarded.

Based on interview, record review, facility policy review, the facility failed to ensure that one (Resident (R) 9) of five residents, reviewed for influenza and pneumococcal vaccinations were provided risks verses benefits prior to the administration of the pneumococcal vaccine. Findings include: Review of a facility policy titled Pneumococcal Vaccine, dated 08/02/24, indicated .It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations.Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education documented in the clinical record. Review of R9's Admission Record, located in the electronic medical records (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE]. The resident was over the age of [AGE] years old. Review of the Medication Administration Record (MAR) for the month of 10/23, provided by the facility, indicated R9 was administered the pneumococcal 20-valent (Prevnar 20) vaccine. Review of R9's EMR failed to contain evidence the risks verses benefits were explained to the resident and/or her representative and documented in the clinical record. During an interview on 02/04/25 at 1:06 PM, the Infection Preventionist confirmed that R9 had no risks verses benefits or consent to receive the Prevnar 20 vaccine.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that the room for one resident (Resident (R) 54) of 47 sampled residents was equipped with a functioning call light. This failure had the potential to result in a delayed response to the needs of the resident. Findings include: Review of the facility-provided policy titled Call Lights: Accessibility and Timely Response, dated [DATE], revealed The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance .Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied . Review of the Face Sheet located in the Profile tab of the Electronic Medical Record (EMR) revealed R54 was admitted to the facility on [DATE] with diagnosis of heart failure, chronic bronchitis, and chronic kidney disease. Review of R54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] located in the EMR under the MDS tab revealed R54 had a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], which indicated the resident was moderately cognitively impaired. Observation on [DATE] at 2:12 PM in R54's room revealed the call light was not working. R54 asked the surveyor to get him help due to wheezing and coughing. The call light was pressed twice and did not work. The light outside the room did not work and the call light did not register at the nurse's desk. The Director of Nursing (DON) was notified immediately and came to R54's room. The DON pressed the call light several times and it came on but would not shut off. Interview with the DON on [DATE] at 2:20 PM in R54's room revealed I am calling maintenance now and getting this fixed. R54 is wheezing and coughing and needs to be able to use his call light. Observation on [DATE] at 1:43 PM in R54's room revealed the call light working when pressed. Review of the logbook for the call system testing was provided by the facility. The call lights are randomly checked on each of the three floors. Interview with the Administrator on [DATE] at 10:38 AM revealed Our call lights are checked monthly. If a call light is reported as non-functioning, a work order is placed and fixed immediately. I am not sure why this was not reported.

Based on interviews and record review, the facility failed to ensure that a qualified activity professional was hired. This has the potential to affect the 96 residents' quality of life who currently reside in the facility. Findings include: Review of an undated facility document titled Activities Director Job Description indicated . The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who .Is licensed or registered, if applicable, by the state in which practicing.Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October l, 1990; or o Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or o Is a qualified occupational therapist or occupational therapy assistant; or o Has completed a training course approved by the State. Review of a facility document titled Employee Action Form, dated 11/24/24, indicated the Activity Assistant had a change in pay status to the Activity Director. During an interview on 02/03/25 at 12:20 PM, the Activity Director (who was the previous Activity Assistant) stated she was currently working on her certification, and the certification would be completed in March 2025. The Activity Director stated she would be sitting for the federal exam after completion of her courses. During an interview on 02/05/25 at 8:49 AM, the Administrator said her expectation was to have a qualified activity professional, but the previous Activity Director had unexpectedly passed away. The Administrator stated after recruiting for the past two months she decided to give the current acting Activity Director the opportunity to complete her training to become a qualified Activity Director.

Based on record review, interview, and review of other facility documentation as indicated, the facility failed to ensure that residents' code status' listed in their electronic medical record (EMR) matched their signed advanced directive document and code status sticker on the front of the paper chart. For two (R4 and R53) out of 97 sampled residents, the code status documented in their EMR were inconsistent with the code status documented in their paper charts. For R53, her EMR profile and physician orders [REDACTED]. For R4, his EMR profile, physician orders, and code status sticker on the front of his paper chart documented that he was a DNR, however, his signed advanced directive had conflicting information and stated on the same document that he wanted to be a full code and wanted to be a DNR. Staff were interviewed regarding how they check a resident's code status, and they stated they would check the EMR, and if that were not available, they would refer to the chart. The facility failed to have a system in place for staff to obtain residents' accurate code status, which placed these residents in an immediate jeopardy situation. The IJ was identified on 1/9/19 at 11:58 AM and was abated on 1/9/19 at 4:20 PM. Findings include: The facility's Health Care Decision Making policy (effective 6/1/96, revised 1/1/13) stated, It is the right of all patients to participate in their own health care decision making, including the right to decide whether they wish to accept or refuse life prolonging measures or other treatments. 1. Review of R53's clinical record revealed: 7/22/15- R53 signed an advanced directive indicating that she wanted to be a DNR. 1/9/19- During the initial pool record review it was revealed that R53's EMR profile and physician orders [REDACTED]. R53's EMR had a scanned copy of her 7/22/15 advanced directive indicating she wanted to be a DNR. R53's paper chart was observed to have a red DNR sticker on the front and had a copy of her 7/22/15 advanced directive indicating she wanted to be a DNR. 1/9/19 10:38 AM- During an interview, E18 (LPN), a nurse who was working on R53's floor, stated that to find a code status in an emergency, she would check the EMR. If the EMR was down, she would check the paper chart. 2. Review of R4's clinical record revealed: 7/26/18- R4 signed an advanced directive indicating that he wanted to be a full code and wanted to be DNR on the same document. R4 and two witnesses signed R4's advanced directive document, which contained the conflicting information. The facility failed to seek clarification of the document to indicate R4's wishes regarding his code status. A new document was never created indicating what R4 wanted regarding his code status. 1/9/19- During the initial pool record review it was revealed that R4's same advanced directive, which contained conflicting code status information, was located in his paper chart and a scanned copy was in his EMR. Despite R4 not having a confirmed code status, his EMR profile and physician orders [REDACTED]. In addition, on the front of R4's paper chart there was a red DNR sticker. 1/9/19 10:29 AM- During an interview, E10 (LPN), a nurse who was working on R4's floor, stated that to find a code status in an emergency, she would check the EMR and if the EMR was unavailable she would go to the paper chart. Immediate Jeopardy was identified per review of R4 and R53's records. The following information relates to both residents: 1/9/19 11:58 AM- Findings were reviewed with E1 (NHA), E2 (DON), and E17 (Social Worker) and they were advised that an IJ was identified when two current residents were found to have inconsistent code status information on their electronic and paper charts. 1/9/19 1:12 PM- E1 (NHA), E2 (DON), and E17 (Social worker) confirmed findings. E1 (NHA) stated that it was confirmed that R53 wanted to be a DNR and that her EMR indicated she was a full code. E1 (NHA) stated that a correction would be made to her EMR code status. E1 (NHA) stated that R4's advanced directive had conflicting information. Staff subsequently communicated with R4 and it was confirmed that he wanted to be a DNR. E17 (Social Worker) stated the ombudsman would update R4's advanced directive to correct his code status on 1/10/19. 1/9/19 4:20 PM - At this time, the survey team received an approved plan of correction that included: correction of code status' on identified residents after a whole facility audit was done to verify that the physician order, the code status noted on the EMR, and the advanced directive (if one existed) all matched, staff were educated on obtaining code status and verifying advanced directives, DNR and full code stickers were to be removed from resident paper charts, code status was added to all resident paper charts in the first position on a form entitled Order Details and staff were educated that this was how to check code status' when the EMR was inoperable, and audits and monitoring would be completed on the above measures. The IJ was abated at this time. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 1/16/19 at 6:15 PM. The facility failed to maintain consistent documentation of R4 and R53's code status leading to the possibility that the incorrect code status could be implemented during an emergency event resulting in immediate jeopardy.

Based on interview and review of the clinical record, facility documentation and professional clinical resources as indicated, it was determined that for one (R19) out of 2 sampled residents, the facility failed to ensure that a resident received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. R19 had a history of [REDACTED]. On 3/14/18, the facility identified a skin alteration on R19's sacrum, however, they failed to do a thorough baseline assessment, including staging of R19's sacral PU. From 3/14/18- 4/18/18, facility documentation lacked evidence of thorough assessments and effectiveness of the wound treatment in place. This resulted in harm when R19 was diagnosed with [REDACTED]. On 4/23/18, R19 was sent to the hospital at the request of R19's POA with a [DIAGNOSES REDACTED]. R19 continued treatment with IV antibiotics and underwent a debridement of the sacral pressure ulcer in the hospital. Findings include: According to the National Pressure Ulcer Advisory Panel (April (YEAR)), the stages of pressure injuries/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. This stage should not be used to describe MASD. Stage III (3) - skin develops an open, sunken hole called a crater. There is damage to the tissue below the skin. Undermining may occur. 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 is more severe than slough in the wound bed). The facility's policy entitled Skin Integrity Management, last revised on 11/28/16, stated, .Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed .Practice Standards: .3.2 Perform skin inspection .weekly. Document on Treatment Administration Record (TAR) or in PointClickCare (PCC). 3.3 Perform wound observations and measurements and complete Skin Integrity Report .upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. 3.4 Perform daily monitoring of wounds or dressings for presence of complications or declines and document . Review of R19's clinical record revealed: 8/27/11 - R19 was admitted to the facility with [DIAGNOSES REDACTED]. 3/15/13 (last revised 9/30/14) - R19 was care planned for exhibiting or at risk for alterations in functional mobility related to [MEDICAL CONDITION]. Interventions included, but were not limited to: - observe for signs of breakdown, redness, [MEDICAL CONDITION] and notify rehab/physician of any changes in skin integrity or complications; - perform skin check when placed back in bed; and - turn and reposition every 2 hours and as needed, check skin for redness. 11/9/11 (last revised 11/2/18) - R19 was care planned for prevention and treatment of [REDACTED]. Interventions included, but were not limited to: - assist resident in turning and repositioning every 2 hours with skin checks; - Braden assessments; and - weekly skin assessment by a licensed nurse. 1/18 through 2/9/18 - Review of the weekly skin assessments revealed that R19 was identified with the following skin injury/wound(s) on: - 1/12/18 at 12:12 PM - MASD on buttocks; - 1/19/18 at 11:46 AM - MASD on buttocks; - 1/26/18 at 1:05 PM - MASD on buttocks; - 2/2/18 at 1:07 PM - MASD on buttocks; and - 2/9/18 at 10:24 AM - MASD (unidentified location). 2/9/18 at 7:20 PM - A physician's orders [REDACTED]. 2/16/18 through 2/28/18 - Review of the weekly skin assessments revealed that R19 was identified with the following skin injury/wound(s) on: - 2/16/18 at 8:54 AM - MASD (unidentified location); and - 2/23/18 at 11:17 AM - MASD on buttocks. 2/28/18 at 12:45 PM - A nurse's note stated, weight warning .5.6% change over 30 days .Eating 100% for meals. Receiving HS snack. BMI=Normal. No concerns. Not on a diuretic. Will continue to monitor. RD, MD, Resident aware. 3/18 - Review of the (MONTH) (YEAR) CNA documentation report revealed that a mixture of Z-guard ointment and A&D ointment was being applied to R19's buttocks after each incontinent episode and as needed and R19 was being turned and repositioned every 2 hours. 3/2/18 at 7:32 AM - A weekly skin assessment revealed that R19 was identified with MASD on the buttocks. 3/8/18 at 5:03 PM - A nurse's note stated that R19's skin was intact and R19 was incontinent of bowel. Despite R19 receiving ongoing treatment for [REDACTED]. 3/9/18 at 9:05 AM - A weekly skin assessment revealed that R19 was identified with MASD on his buttocks. 3/9/18 at 12:04 PM - A nurse's note stated, weight warning .6.1% change over 30 days .Eating 100% for meals. Receiving HS snack. BMI=normal. No concerns. RD, MD, Resident aware. 3/14/18 at 10:22 AM - A physician's orders [REDACTED]. Cleanse MASD with NSS, pat dry, apply hydrogel and cover with ABD pad daily and PRN until healed . Despite the facility treating R19's buttocks for MASD with a mixture of Z-guard and A&D ointment, the facility failed to identify and assess R19's sacrum as a new skin alteration in a pressure area. When the physician ordered a new treatment to the sacrum on 3/14/18, the facility failed to initiate and complete a Skin Integrity Report for R19's sacrum, that included identifying the type of wound, location, staging, presence of pain, appearance, measurements, undermining, tunneling, drainage, surrounding tissue, wound edges and odor. The facility also lacked evidence that R19's POA was notified of the new skin alteration on his sacral area and the treatment ordered. 3/15/18 through 3/31/18 - Review of R19's eTAR revealed that Hydrogel treatment was applied to his sacrum daily. However, R19's clinical record during this timeframe lacked evidence of any pressure ulcer monitoring and assessments of his sacral area and whether the Hydrogel treatment was effective. 3/16/18 through 3/23/18 - Review of the weekly skin assessments revealed that R19 was identified with the following skin injury/wound(s) on: - 3/16/18 at 8:15 AM - MASD on buttocks. - 3/23/18 at 10:36 AM - Sacrum. The facility failed to identify an issue with the sacral area on the 3/16/18 weekly skin assessment and failed to identify the type of issue with the sacrum on the 3/23/18 skin assessment. 3/26/18 at 12:47 PM - A progress note, written by E22 (NP), stated that R19 was seen and examined. E22 stated that R19 had a recent weight loss, but remained stable with dietary interventions. E22 stated that R19 preferred to stay in his room despite encouragement. R19's skin abnormality was assessed and stated that his skin was warm, dry and intact. The facility failed to identify and follow-up on R19's skin integrity issues on his buttocks that had been ongoing since (MONTH) (YEAR) and a new area identified on his sacrum with a treatment ordered on [DATE]. 3/30/18 at 1:01 PM - A weekly skin assessment revealed that R19 was identified with MASD. The assessment lacked evidence of the MASD's location. 4/1/18 through 4/13/18 - Review of R19's eTAR revealed that the Hydrogel treatment, ordered on [DATE], was applied to his sacrum daily. Despite the daily treatments to R19's sacrum, the clinical record lacked evidence of any assessments or monitoring to determine if the treatment was effective. 4/1/18 through 4/22/18 - Review of the (MONTH) (YEAR) CNA documentation report revealed that a mixture of Z-guard ointment and A&D ointment was applied to R19's buttocks after each incontinent episode and as needed and R19 was being turned and repositioned every 2 hours. 4/1/18 at 1:11 PM - A nutritional assessment stated that R19 had no pressure ulcers and .MASD to buttocks noted .treatment in place. Per nursing, MASD is not healing, resident is resistive to turning or repositioning . Despite documentation by the CNAs that R19 was turned and repositioned every 2 hours, the clinical record lacked evidence when R19 resisted turning and repositioning. 4/2/18 - A quarterly MDS assessment stated that R19 had moderate cognitive impairment, required extensive assistance of one staff person for bed mobility, required total assistance of one person for toilet use, had bilateral lower extremity impairment, was always incontinent of bowel, had active [DIAGNOSES REDACTED]. The facility failed to identify that there was a skin integrity issue of the sacral area, a pressure point. 4/2/18 at 12:18 AM - A comprehensive nursing assessment, which included a Braden assessment, was completed. The Braden assessment stated that R19 was completely immobile - does not make even slight changes in body position by self .Bedfast - confined to bed .Problem - frequently slides down in chair or bed .Very moist - incontinent once a shift .Skin impairment(s) .(checked) not present . The facility failed to capture R19's current skin integrity issues on his buttocks and sacrum in the Braden assessment. 4/6/18 and untimed - A progress note stated, .For weight support and healing of wounds, he gets supplemental shakes .Hydrogel Gel .Vitamins A & D Ointment Apply to b/l buttocks topically as needed for MASD .Physical Exam General: .alert and oriented to self .Bedbound .3/12/18 [MEDICATION NAME] 3.1 Protein, Total 6.4 .2/5/18 .[MEDICATION NAME] 3.2, total protein 6.1 .General weakness and debility present .patient is doing reasonably well . 4/6/18 through 4/13/18 - Review of the weekly skin assessments revealed that R19 was identified with the following skin injury/wound(s) on: - 4/6/18 at 8:25 AM - MASD; - 4/13/18 at 2:07 PM - MASD. The facility failed to document the location of the MASD on both assessments. 4/13/18 (untimed) - A verbal physician's orders [REDACTED]. Despite the change in treatment to R19's sacrum on 4/13/18, the clinical record lacked evidence of any assessment of the sacrum performed by either the physician/NP and/or nursing staff. 4/14/18 through 4/17/18 - Review of R19's eTAR revealed that puracol treatment was applied to his sacrum daily. Despite daily treatments to R19's sacrum, the clinical record lacked evidence of any assessments or monitoring to determine if the treatment was effective. 4/18/18 and untimed - A Skin Integrity Report (completed by a nurse) stated: - Location: marked with an X on sacral area; - Type of Wound: Unstageable; - Presence of Pain: not applicable; - Appearance: necrotic (eschar) 100%; - Length: 13.7 cm; - Width: 16 cm; - Depth: 1.5 cm; - Undermining: at 12 o'clock and 2 o'clock; - Drainage: Purulent moderate; - Surrounding Tissue: macerated, inflamed/indurated; - Wound Edges: macerated; - Odor: yes. 4/18/18 at 10:30 AM - A physician order, written by E22 (NP), stated to clean sacral wound with Vashe, apply [MEDICATION NAME] powder, then apply a thin layer of Santyl. Pack .with ABD pad BID and PRN. Low air pressure mattress. 4/18/18 at 1:02 PM - A progress note, written by E22 (NP), stated, XXX[AGE] year old .with MS .seen and examined d/[MEDICAL CONDITION] .Today morning (sic) during medpass, Rt was noted with lethargia (sic), confusion .fever of 101.7, HR 120 .Discussed with PCP [MEDICAL CONDITION] work up ordered with STAT labs, chest Xray, UA .Urine appears cloudy and segmented. Infection could be a(sic) related to UTI .Rt is oriented x1, very lethargic and falls to sleep while conversing .Non-verbal .Integumentary: Rash yes, Abrasions yes .difficulty speaking yes .Skin Abnormality: assessed, warm: yes, dry: yes .Fiscussed (sic) P[NAME] with E4 (Physician) and is agreeable . There was no evidence that E22 evaluated R19's sacral wound and considered that it could be the source of R19'[MEDICAL CONDITION]. 4/18/18 at 2:23 PM - A physician's orders [REDACTED]. 4/18/18 at 3:11 PM - A nurse's note stated, CNA notified me this morning at (7:30 AM) that this resident did not seem like himself. This nurse assessed him and called NP who came down to assess him . 4/19/18 at 9:30 AM - A physician order [REDACTED]. D/C [MEDICATION NAME] powder order to sacral wound. 4/21/18 (untimed) - A progress note, written by E22 (NP), stated that R19 was seen and examined. However, the progress note failed to address the current status of R19's unstageable sacral pressure ulcer and treatment effectiveness. 4/21/18 at 10:30 AM - A physician order [REDACTED]. 4/21/18 at 1:51 PM - A physician order [REDACTED]. Despite this physician's orders [REDACTED]. The facility continued wound treatment with the 4/19/18 physician's orders [REDACTED]. 4/22/18 at 3:22 AM - The X-ray report of the sacrum stated there was no [DIAGNOSES REDACTED]. 4/22/18 - Review of the eTAR revealed that R19's sacral wound treatment was not signed off as done at 9 AM. The scheduled 9 PM wound treatment had NN signed off by nursing staff, which indicated to See Nurse Notes. The 4/22/18 nurse's notes lacked evidence of any documentation with respect to R19's sacral wound. The facility failed to provide R19 with sacral wound treatment on 4/22/18 and they failed to document a note for the 9 PM wound treatment. 4/23/18 at 1 PM - A physician order, written by E22 (NP), stated, Send to ER for Evaluation. 4/23/18 at 4:20 PM - R19 arrived at the hospital by non-emergency ambulance transport and was admitted . 4/23/18 at 5:23 PM - The hospital record stated, .Physical Exam .Skin: 14 cm x 14 cm unstageable sacral decubitus ulcer (same as PU) with exposed bone soiled with stool (sic) patient is incontinent of stool .Per the family, they have been told that he had a relatively small ulcer that was being treated with IV antibiotics at the long-term care facility. However, today he was not speaking to them which was worsening compared to his declining interactions over the last week. Family asked to see the ulcer and it was significantly worse (sic) they would like to believe, at which point they requested that he come here for further evaluation .He did have an x-ray done of his pelvis which they were told did not show any signs of osteo[DIAGNOSES REDACTED] .Patient has extensive ulceration over his lower back with obvious sacral exposure, stool has tracked from his diaper into his wound . 4/24/18 at 8:04 AM - A hospital consult by C1 (Plastic Surgeon) stated, .Wound assessment: .sacrum; size: 9cm x 5cm x 1.2cm; description: Stage IV (4) ulcer of the sacrum with extensive necrotic tissue and sloughing. No tenderness to palpation, mild [DIAGNOSES REDACTED] along borders, no [MEDICAL CONDITION] or warmth. Kerlix and [MEDICATION NAME] dressing is soaked with exudate and purulence. Edges macerated and undermined. Malodorous .Plan: Continue antibiotic treatment .Will likely need debridement . 4/25/18 - The hospital records stated that R19's Stage IV (4) sacral wound was debrided. 1/16/19 at 10:43 AM - During an interview, E4 (Physician) stated that she was told about R19's sacral wound on Friday night, 4/20/18. E4 stated that E22 (NP) did not look at the wound. When asked if she saw R19 during the time he was being treated for [REDACTED]. E4 stated that R19's medical care was driven by the (managed care partner), not me. 1/16/19 at 6:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the Exit Conference. 1/23/19 - Review of additional documentation provided by the facility revealed a text message sent 4/18/18 (untimed) from E22 (NP) to E4 (physician), which stated, .Meanwhile we noticed his sacral wound looks worse and unstageable but no indication of infection or purulent discharge. This description contradicts the facility's wound assessment by a nurse on 4/18/18 which stated 100% necrotic, moderate purulent drainage and odor. The facility failed to provide pressure ulcer treatment and services to R19 by the failure to: - identify the sacrum as a pressure ulcer and perform a baseline pressure ulcer assessment on 3/14/18; - monitor and assess R19's sacral pressure ulcer from 3/14/18 through 4/23/18 for signs and symptoms of a decline, infection and to determine if the treatments ordered on [DATE], 4/1/18, 4/14/18, 4/18/18 and 4/19/18 were effective; and - seek clarification of which wound treatment to use when 2 wound treatment orders (4/19/18 and 4/21/18) were in place and the facility continued with the 4/19/18 wound treatment until R19 was hosptalized on [DATE]. R19 was identified with an unstageable sacral PU on 4/18/18 and admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED].

Based on closed record review and interview, it was determined that the facility failed to ensure that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two (R4 and R6) out of nine sampled residents. For R4, the facility failed to identify a deterioration of a right foot wound on two (2) occasions and failed to obtain timely changes in treatment. On 2/14/13 when the wound deteriorated and was 80% necrotic and on 2/18/13 when the wound presented with a large amount of foul smelling drainage the facility failed to reassess and failed to implement new interventions. The facility failed to ensure an x ray was performed in a timely manner when on 5/21/13 R6 had increased pain, a bony prominence protruding from the right hip and unequal leg lengths. Findings include: 1. The facility's policy entitled, "Skin Integrity Management," revision date 10/01/10 stated, "...Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed...Procedure...3.3 Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with any deterioration of wound. 3.4 Perform daily monitoring of wounds or dressings for any presence of complications or declines. Document on TAR (Treatment Administration Record) and/or on Nurses' Note...6. Notify Rehabilitation Services as indicated. Examples include: 6.3 Seating and positioning...12.1 Daily monitoring of any ulcer site, with or without dressing, on the TAR, and/or in the Nurses' Note...12.1.2 For wounds requiring daily dressing change, monitor for any signs of decline in wound status. If any decline in wound, surrounding tissue, or wound pain, complete the Skin Integrity Report and notify physician..." R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Although closed record review revealed documentation in nursing progress notes that checks for circulation were being completed of the right foot from 12/6/12 through 1/24/13, the facility failed to develop a plan of care for the casted leg. A nurse's progress note, dated 1/25/13 and timed 1:08 PM, stated "...Went to see Ortho (Orthopedist/bone doctor)...and had cast removed...When cast removed MD (Medical Doctor) noted an open area on top of right foot. Noted to be 50% slough (yellow, tan, gray, green or brown dead tissue) and 50% necrotic (dead tissue). Dr. (name of R4's physician) aware and wound treatment ordered..." The facility completed a Skin Integrity Report, dated 1/25/13, which identified the wound at the top of the right foot as being a pressure ulcer/wound (skin breakdown due to prolonged pressure). The wound was measured as being 3.0 cm (centimeter) length x 1.5 cm width x < (less than) 0.1 cm depth. The appearance of the wound was described as 50% slough and 50% necrotic, no drainage and the surrounding tissue was healthy. Review of the treatment administration record (TAR) from 1/25/13 through 2/14/13 revealed the facility was cleansing the wound with normal saline solution and applying Santyl (ointment containing enzyme that helps remove dead tissue) and a clean dry dressing as ordered daily, excluding 2/4/13 and 2/8/13, when there was no documentation that the wound dressing was completed. Weekly Skin Integrity Reports were completed on 1/31/13 and 2/7/13. The 2/7/13 report stated that the wound measured 2.9 cm length x 1.1 cm width x < 0.1 depth and that there was 5% granulation tissue (new tissue and tiny blood vessels formed on the surface of a healing ulcer or wound), 95% slough, no drainage and the surrounding tissue was healthy. On 2/14/13, the weekly Skin Integrity Report stated that the wound was now 20% slough and 80% necrotic, measured 7.0 cm length x 4.3 cm width x 0.2 cm depth and the surrounding tissue was inflamed (classical signs of inflammation are pain, heat, redness, swelling, and loss of function; a protective attempt by the body to remove injurious stimuli and initiate the healing process) and the wound edges were macerated (softening of tissue). The clinical record lacked evidence that the physician was notified regarding the deterioration of the wound. A nurse's progress note, dated 2/18/13 and timed 4:41 PM, stated "...treatment done to top of right foot. Large amount of foul smelling drainage..." Review of the record lacked evidence that the physician was notified regarding the foul smelling drainage. Review of the TAR from 2/14/13 through 2/21/13 revealed that treatment continued with Santyl daily. On 2/21/13, the weekly Skin Integrity Report stated the wound remained with 20% slough and 80% necrotic, measured 6.0 cm length x 5.1 cm width x 0.3 cm depth, surrounding tissue remained inflamed, wound edges macerated and there was heavy drainage. A nurse's progress note, dated 2/21/13 and timed 10:26 AM, stated "New order for wound care for the wound on top of right foot. Resident has a large amount of serosanguinous (blood and clear fluid) drainage...Appt. (appointment) made with (name of hospital) WCC (Wound Care Center) for 2/28/13. Spoke with dgt. (daughter)...and she will accompany to appt..." On 2/21/13, a physician's orders [REDACTED]. Review of the TAR from 2/22/13 through 3/5/13 revealed dressing changes were completed as ordered. Review of nurse's progress notes for 2/28/13 lacked any documentation regarding the scheduled visit to the WCC for evaluation of the right foot wound. The Skin Integrity Report, dated 2/28/13, stated that the wound was 100% necrotic, measured 11.5 cm length x 8.8 cm width x 0.2 cm depth, had heavy drainage, inflamed surrounding tissue and macerated wound edges and had no odor. There was no change to the treatment plan at this time. A nurse's progress note, dated 3/4/13 and timed 1:34 PM, stated treatment to the top right foot was completed and noted a large amount serosanguinous drainage with strong odor present. On 3/5/13 new physician's orders [REDACTED]. - to receive an antibiotic every 12 hours for 10 days for wound infection; - to cleanse the top of the right foot with normal saline solution, apply [MEDICATION NAME] (wound gel) to wound and cover with clean dry dressing daily; - PT (physical therapy) to evaluate for leg positioning. Record review revealed that although the new order for the [MEDICATION NAME] dressing change was transcribed onto the TAR on 3/5/13, staff continued to apply the Maxsorb on 3/5/13 and 3/6/13. Review of the TAR revealed that the antibiotic was administered as ordered, however, there was no evidence that the PT consult was completed as ordered. The weekly Skin Integrity Report, dated 3/7/13, stated the wound was 100% necrotic, measured 15.0 cm length x 8.7 cm width x 0.2 cm depth, had no drainage, surrounding tissue was inflamed and wound edges were macerated and there was no odor. On 3/7/13, R4 was evaluated at the WCC and returned to the facility with orders to cleanse the wound with soap and water, apply Santyl and a 4 x 4 gauze and wrap with Kerlix (dressing). Additionally, vascular ( related to blood vessels to determine blood supply and potential for healing to occur) studies of the right foot were ordered, an x-ray of the right foot to rule out broken bones and a consult with a vascular physician were also ordered and to return to the WCC on 3/14/13. The WCC Nursing Wound Assessment, dated 3/7/13, stated the wound of the top right foot measured 8.3 cm length x 5.3 cm width x 0.1 cm depth, had a small amount of drainage, foul odor, a small amount (1-33%) of granulation tissue and a large amount (67-100%) of necrotic tissue. The x-ray of the right foot was completed in the facility on 3/8/13 and revealed no fracture (broken bone). A nurse's progress note, dated 3/8/13 and timed 1:13 PM, stated "Update/summary r/t (related to) top of rt (right) foot wound...Weekly wound rounds with measurements and assessment done along with MD ordered daily care/tx (treatment) in progress. Wound appearance was variable each week however no drainage noted until 2/21/13 when heavy drainage was identified as well as increase in size of wound. MD consulted to obtain order to send pt (patient) to wound care center...Appt (appointment) made for WCC for 2/28/13. Pt sent to said appt but WCC has misscheduled pt. Pt returned to center unseen, new appt made...evaluated by Genesis wound care specialist on 2/28/13. At that time it was identified that measurement should include the entire borders of wound hence showing a significant increase in size. MD made aware of change in wound appearance - drainage and odor..." Although this note states the physician was made aware of changes to the wound's appearance on 2/28/13, the facility failed to identify the deterioration of the wound as noted on the 2/14/13 Skin Integrity Report and failed to act upon it at that time. Physician's progress notes were reviewed from 12/6/12 through 3/1/13. The 3/1/13 progress note was the only note that made mention of any wounds. It stated, "...wounds...R (right) foot/ankle...lower extremity wounds - refer to wound care..." Review of the March, 2013 TAR revealed documentation that the facility completed wound treatments as ordered by the WCC from 3/8/13 through 3/14/13. Record review revealed that R4 was seen at the WCC on 3/14/13 and returned to the facility with orders to continue to apply Santyl as previously ordered to the wound on the top right foot and to return for a follow up on 3/21/13. An infectious disease consult, dated 3/15/13, stated "...limb threatening wds (wounds) R foot w(with)/multiple co-morbid (presence of two or more ailments in the body in addition to the original) conditions c (with) VRE (type of bacteria called [MEDICATION NAME] that have developed resistance to many antibiotics, especially [MEDICATION NAME]) + anaerobic (organism that does not require oxygen for growth). Admit expedite vascular..." The hospital History and Physical, dictated on 3/16/13, stated "...diabetes [MEDICAL CONDITION] cardiovascular disease (hardening of the arteries) with [MEDICAL CONDITION] (narrowing or occlusion of arteries outside of the heart and brain) as well as [MEDICAL CONDITION] (plaque in artery walls of the inner lining of the blood vessels that supply blood to the heart)...Extremities: Show a 9 x 7 cm large necrotic ulceration...The wound has a foul odor...there is a trace...pulses on the left, no...pulse on the right...This infection appears to be far advanced and likely involves osteo[DIAGNOSES REDACTED] (infection in the bone) as well. Restoring vascular integrity of the foot may be the critical issue check for any limb salvage in this far advanced situation...the patient's problem is a circulatory problem and an infected ulcer." Review of the hospital record revealed that R4 required surgical removal of the necrotic tissue on the right foot wound, as well as a split thickness skin graft (both layers of skin) and procedures to increase the blood flow to the right leg to improve healing. [DIAGNOSES REDACTED] was confirmed as present in the right first metatarsal (bone in the foot just behind the big toe). The hospital Discharge Summary, dated 4/26/13, stated "...palliative care was consulted based on the patient's poor quality of life and poor prognosis..." On 10/8/13 at approximately 3:30 PM, findings were reviewed with E1 (Administrator) and E2 (Director of Nursing). On 10/9/13 at approximately 4:15 PM, E1 stated that the physician had signed off on all the wound care orders and thus was aware of what was happening. E1 also stated that on 3/5/13, E19 (Registered Nurse) had called the WCC and obtained orders based on her (E19's) nurse's note, dated 3/5/13 and timed 10:28 AM, which stated, "...wound care center consulted per orders..." During an interview with E19 on 10/9/13 at 5:10 PM, E19 stated that she has called the WCC for orders in the past but was not able to recall having called them on 3/5/13. In an interview with E18 (Assistant Director of Nursing) on 10/10/13 at 11:00 AM, she stated that she recalls speaking with the physician regarding R4's wound and the need for the resident to be seen by the WCC and then speaking to the physician again regarding the possible need for an antibiotic. E18 stated that was when the antibiotic was ordered on [DATE]. E18 stated that she had not called the WCC for any recommendations on 3/5/13. During the exit conference on 10/10/13 at approximately 4:30 PM, E1 stated she did not feel the outcome would have been different given R4's co-morbidities. 2. R6, an alert and oriented resident, was admitted to the facility on [DATE] due to a fall at home which resulted in broken ribs. Additionally, R6 had intractable (severe, constant) low back pain without any fractures (broken bones). Upon admission, the doctor ordered [MEDICATION NAME], a narcotic pain medication, that R6 could have every four hours as needed for pain. The doctor ordered both physical and occupational therapy services for R6 on 5/14/13. On 5/16/13, R6's doctor ordered a Bengay patch (A pain relieving patch with deep, penetrating heat, [MEDICATION NAME] up to eight hours.) to be applied to her right hip every morning and removed every evening for pain. The physical therapy note by E8 (Physical Therapy Assistant/ PTA), dated 5/21/13 at 3:28 PM, noted that R6 had a "...More prominent bony (referring the bone sticking out more) area at R (right) hip, noted leg length discrepancy (difference in length of the resident's two legs) as well, increased pain when palpating (To examine or explore by touching an area of the body). Informed PT (Physical Therapist, Manager referring to E7) per discussion hold wt (weight) bearing to R (referring to right leg), nursing informed, requested xray". Review of the 5/2013 Medication Administration Record [REDACTED]. The result of the pain medication was positive and reduced the pain score to 3/10. The nurse's note, dated 5/21/13 at 7:36 PM included the following observations, "Resident alert, verbal and oriented x (times) 3 (referring to the person being oriented to person, place and time). Returned from thearpy (sic) and helped back to bed and c/o (complained of) discomfort. 9/10 to right hip....Resident 2 person assist for transfers... Resident's response: My pain is a 12, no I'm exaggerating it is a 9...." Also, the pain medication was given " ...with good effects, pain 3/10... within the hour." Review of the 5/2013 MAR indicated [REDACTED]. The result of the pain medication was positive and reduced the pain score to 2/10. However, review of the nurses' notes, dated 5/21/13, lacked any evidence that R6's doctor was notified on 5/21/13 to order an x-ray and act upon the results as indicated. There was no evidence that R6's doctor had examined the resident nor had written progress notes on 5/21/13 or 5/22/13 regarding the right hip concerns which the physical therapy services had identified. Review of the 5/2013 Medication Administration Record [REDACTED]. The result of the pain medication was positive and reduced the pain score to 2/10. On 5/22/13 at 10:20 AM, R6's doctor gave an order by telephone for an x-ray of the right hip, approximately 19 hours after the hip issue was first identified by therapy. The nurse's note, dated 5/22/13 at 12:45 PM, noted the new order by R6's doctor for a right hip x-ray due to the right leg being shorter than the left leg and there being increased pain in the right leg. The nurse's note, dated 5/22/13 at 2:59 PM, noted that the right hip x-ray results were pending. On 5/22/13 at 5:04 PM, the x-ray report of the right hip noted that R6 had a broken or fractured right hip. The nurse's note, dated 5/22/13 at 6:23 PM, was a transfer note that stated that R6 was transferred to the hospital via ambulance due to a right [MEDICAL CONDITION]. On 10/10/13 at 12 PM, E7 and E8 were both interviewed. E8 reviewed her physical therapy note of 5/21/13 confirming her concerns regarding R6's right hip. E7 stated that she was asked to assess R6 by E8 on 5/21/13 during the afternoon physical therapy session. E7 stated that she advised E8 that R6 should not bear any weight on the right leg. Additionally, E8 stated that she definitely spoke with a nurse (but was unsure of which nurse) to tell about R6's concerns and the nurse said to E8 that she would get an order/request an x-ray. R6's right hip was not x-rayed until 5/22/13 and she was not transferred to the hospital for more than twenty four hours from the time that the physical therapy department initially observed the "...More prominent bony area at R (right) hip, noted leg length discrepancy as well, increased pain when palpating...". The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being when R6 presented with right hip pain and leg length discrepancy resulting in a delay in further assessment and treatment for [REDACTED]. On 10/10/13 at 1:15 PM, E2 (Director of Nursing/DON) confirmed the findings.

Based on closed record review, interview and review of other facility documents as indicated, it was determined that the facility failed to ensure that for one (R4) out of nine (9) residents sampled, who entered the facility without pressure sores (ulcer/sore area of skin that develops when the blood supply to it is cut off due to pressure) did not develop a pressure sore unless the individual's clinical condition demonstrates that it was unavoidable. According to R4's admission Minimum Data Set (MDS) assessment, dated 12/13/12, R4 was at risk for developing pressure ulcers, but had no unhealed pressure ulcer (s) on admission to the facility. On 1/19/13, R4's left (L) heel wound was not discovered until it was a 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). Findings include: The facility's policy entitled, "Skin Integrity Management," revision date 10/01/10 stated, "...Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed...Procedure...3.3 Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with any deterioration of wound. 3.4 Perform daily monitoring of wounds or dressings for any presence of complications or declines. Document on TAR (Treatment Administration Record) and/or on Nurses' Note...6. Notify Rehabilitation Services as indicated. Examples include: 6.3 Seating and positioning...12.1 Daily monitoring of any ulcer site, with or without dressing, on the TAR, and/or in the Nurses' Note...12.1.2 For wounds requiring daily dressing change, monitor for any signs of decline in wound status. If any decline in wound, surrounding tissue, or wound pain, complete the Skin Integrity Report and notify physician..." R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Nursing Assessment, dated 12/6/12, stated R4 was unable to make significant changes in position independently and required extensive assistance, and that she had current weakness of the left leg. This same assessment noted that R4 had bruises on various parts of the body and had healed pressure areas to her sacrum (tail bone area). There was no documented evidence of any current pressure sores upon admission. A Braden Scale (for predicting pressure sore risk) was completed on 12/13/12 and identified R4 as being at high risk for developing pressure sores. On 12/14/12 a care plan for the problem "at risk for skin breakdown as evidenced by immobility" was developed and included the intervention "monitor skin for signs/symptoms of skin breakdown i.e. (for example) redness, cracking, blistering, decreased sensation, and skin that does not blanche easily." Review of Certified Nurse's Aide (CNA) "Intervention/Task" computerized data from 12/6/12 through 1/19/13 revealed that the CNAs were documenting that they were applying a left foot heel medic (sic) boot (soft boot to lift heel off bed and relieve pressure) on all three (3) shifts, except on the evening shifts (3 PM - 11 PM) of 1/4/13 through 1/7/13 and on 1/11/13, when it was documented as not having been applied. A physician's orders [REDACTED]. Additionally, review of CNA "Intervention/Task" computerized data from 12/6/12 through 1/19/13 revealed that the CNAs were documenting that they were turning and/or repositioning, and checking R4's skin every two (2) hours. The admission MDS assessment, dated 12/13/12, stated R4's cognitive skills for daily decision making were severely impaired (never/rarely made decisions) and that there were no behavior problems and no issues with rejection of care. This same MDS stated R4 required extensive assistance of two (2) staff for bed mobility and had a functional limitation in range of motion of the lower extremity on one side. The 12/13/12 MDS stated R4 was at risk for developing pressure ulcers and had no unhealed pressure ulcer (s). Review of the bi-weekly skin assessments, completed by the licensed nursing staff, documented that the assessments were completed on Mondays and Thursdays. A skin assessment completed on 1/17/13 noted that there was "no skin injury wound." A "Skin Integrity Report," dated 1/19/13 noted that R4 had a deep tissue injury (DTI) to the left heel measuring 1.5 cm (centimeter) x 1.2 cm and that it's appearance was "intact/deep purple." A physician's orders [REDACTED]. Despite CNAs documenting that skin checks were being completed every two hours, the left heel wound was not identified until it was a deep tissue injury. Additionally, the facility failed to revise R4's comprehensive care plan to reflect the presence of the left heel DTI. Review of weekly Skin Integrity reports revealed that on 2/7/13 the heel wound measured 1.6 cm x 1.7 cm and it's appearance was 100% necrotic/eschar (dead tissue that is tan, brown or black in the wound bed). The facility continued to complete weekly Skin Integrity Reports and on 3/7/13 the left heel measured 5.1 cm x 4.0 cm and was 100% necrotic with inflamed surrounding skin. A "Change in Condition" progress note, dated 3/11/13 and timed 3:38 PM, stated the DTI scab on the left heel had fallen off and exposed a small open area with 60% slough (yellow, tan, gray, green or brown dead tissue) and 40% granulation tissue (new tissue and tiny blood vessels formed on the surface of a healing ulcer or wound). The physician was notified and a new treatment was ordered. There were no measurements found of the left heel wound for 3/11/13. The last measurement completed in the facility was on 3/7/13, as R4 was admitted to the hospital on [DATE]. Although the facility documented use of the left heel medix boot, turning and repositioning every two hours, and that CNAs were checking R4's skin for changes every two hours, the facility failed to identify changes to R4's skin until the heel had a DTI. During an interview on 10/10/13 at approximately 1:30 PM, findings were acknowledged by E2 (Director of Nursing).

Based on closed record review and interview, it was determined that the facility failed to ensure that one (R2) out of four (4) sampled residents received adequate supervision and assistance devices to prevent accident and injuries. A CNA (Certified Nursing Assistant) removed R2's bolster and fall mat from the bedside to transfer her to a wheelchair. The CNA left the room twice to obtain supplies while R2 was unattended while in bed. Upon the CNAs return to the room the second time, R2 was found on the floor with injuries. R2 sustained a bump on the right side of her forehead with a hematoma and a 1 cm laceration, swelling of the right orbital area and a bump on the right side of the forearm. R2 expressed pain via facial grimacing. A CT scan of the head dated 11/8/11 indicated a right subdural hematoma. Six (6) days later R2 complained of right hip pain and an x-ray showed an acute right hip fracture. Findings include: The facility's policy and procedures entitled , "Falls Care Delivery Process" and "Falls Management" was reviewed. R2 was admitted in the facility with [DIAGNOSES REDACTED]. R3 was assessed as a high risk for falls. According to R2's quarterly Minimum Data Set (MDS) assessment, dated 9/4/11, this resident scored 03 out of 15 in her brief interview for mental status/BIMS. R2's cognitive skills for daily decision-making were severely impaired. R2 needed staff's extensive assistance in all Activities of Daily Living (ADLs). R2 had lower extremity impairment on both sides. R2's mobility device was the wheelchair.R2 had 0 Pain Management, no scheduled pain medication regimen, no PRN medication and no non-medication pain intervention. The facility initiated a care plan dated 11/6/2007 on the problem of: Resident demonstrates a potential for falls due to decline in strength and endurance and parkinson last revised 12/29/10. Goal : Resident will have no falls with injury x 90 days The Interventions included the following: Encourage resident to participate in activities outside of room Seat resident in Lounge area, if possible revision; 6/4/2009 assess resident for pain and administer pain medication as needed. Resident displays anxiety and restlessness with symptoms of pain revision: 6/4/09 Bed bolsters to bed for proper alignment revision: 6/4/09 *** 1 person assist for all transfers revision 1/21/2010 *** Place call light within reach at all times. Encourage and remind resident to use call bell revision: 6/4/09 11/1/2011 -Maintain a clutter free environment in resident's room 11/3/11 -When resident is in bed-monitor that the fall mat and bumper pads are in place q shift Fall risk assessment per protocol 11/1/11 A nurse's note dated 10/28/11 stated. " Resident was in bed. CNA was getting ready to get her up she removed the floor mat and bumper then she stepped out to get a brief when she returned she needed gloves, had to run across the hall, upon return to room, resident was on the floor, on right side; bump noted on forehead (hematoma), ice pack applied...experiencing pain head facial expression - grimacing- swelling of the right orbital area and bump on right side of forearm". The facility's Incident report dated 10/28/11 identified a 1 cm laceration (forehead). Facility's investigation of the incident included E8's (CNA) written statement dated (unknown) which stated that she had removed the bolster and fall mat (safety equipment) from resident's bedding area to transfer her to wheelchair...stepped out to get brief came back, resident was ready to pass bowels, skipped across hall to get gloves from 208 (dropped a couple) came back, resident was on the floor with bump on right side of forehead. Bed was not elevated but mat was removed from floor, nurse was informed. 10/28/11 Skull -4Vx-ray result indicated the "orbital structure normal; no evidence of fracture or dislocation". According to the facility's summary/conclusion following the post fall evaluation, "Resident safety equipment was removed by the CNA (E8) prior to getting the resident out of bed-then momentarily left the resident unattended where the resident slid out of bed". The care plan established by the facility (revised 1/21/10) stated R2 was a one person assist for all transfers. Neurological assessments were done as per facility policy. There were no identified signs and symptoms of neurological abnormalities/findings documented. A nurse's note dated 10/30/11 stated "Resident complained of pain on her left leg, medicated with 2 tylenol 650 mg with relief" A Hospice Clinical Note dated 11/1/11 documented other ongoing problems: agitated, calling out, tearing bed clothes, confused and forgetful. A nurse's noted dated 11/3/11 stated that at 8:00 PM and during care resident complained of grimacing of pain to the right hip area, but unable to rate her pain but was unable to flex the right leg secondary to pain. STAT X-ray to the right hip was done per physician's orders [REDACTED]. A nurse's note dated 11/3/11 stated that resident complained of right hip pain, found resident's leg in flexed position, cried out when leg was touched and could not tolerate being turned. X-ray result of the right hip showed that R2 had a "right subcapital fracture with modest displacement...Osteoporosis present. Conclusion: Acute right hip fracture". R2 was sent to the hospital per physician's orders [REDACTED]. Hospital record revealed that a CT scan of the head was done on 11/8/11 and the result indicated subdural hematoma on the right measuring approximately 9 mm in maximum thickness with 5 mm of midline shift. There was edema of the right cerebral hemisphere and posttraumatic subarachnoid hemorrhage and intraventricular hemorrhage. No skull fracture. No surgery was done on the hip fracture due to R2's high risk from the cardiovascular standpoint/high risk for cardiac event. This finding was discussed with E1 (Administrator) and E2 (DON) on 4/9/12.

Based on closed record review, review of hospital records and interviews, it was determined that the facility failed to ensure that one (R3) of 6 sampled residents received and was provided with the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility failed to report R3's abnormal PT/INR (measure blood coagulation) result to the physician prior to administering two anticoagulant medications, [MEDICATION NAME] and [MEDICATION NAME]. R3 had a physician order for [REDACTED]. The facility failed to monitor the INR and continued to administer the [MEDICATION NAME] for a total of 4 doses. The facility failed to adequately monitor and immediately report adverse side effects (bleeding) to the physician so that the dose of anticoagulants could be reduced or discontinued. R3 was hospitalized following a fall and mental status change. R3's was admitted with a [MEDICAL CONDITION](stroke) with [MEDICATION NAME]-induced coagulapathy with an INR 2.3. R3's clinical status worsened progressing to brain death and R3 expired. Findings include: The facility policy dated [DATE] and entitled, "15.12 [MEDICATION NAME] ([MEDICATION NAME]) Monitoring" was reviewed. R3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Upon admission, R3's medications included a daily aspirin (platelet inhibitor) 325mg, [MEDICATION NAME] 150 mg/ml (milligram/milliliter) q (every) 12 hrs until INR > 2 then D/C ([MEDICAL CONDITIONS] [MEDICATION NAME]) and [MEDICATION NAME] 6 mg po (by mouth) daily ([MEDICAL CONDITION]). R3's physician's order, dated [DATE] and timed 2100 stated, "Give [MEDICATION NAME] 6 mg (milligrams) po tonight. PT/INR Q (every) AM (morning) via lab til INR >/= (greater than or equal to) 2." On [DATE]at 6 PM, E6 (nurse) called R3's physician and reported the PT/INR abnormal (high) lab result (18XXX,[DATE].8). The physician ordered, "Continue on same dose of [MEDICATION NAME]. Recheck PT/INR on [DATE]." Review of R3's clinical record revealed that on [DATE], lab results (collected on [DATE] at 11:25 am) were faxed to the facility at 1:14 PM that stated, PT=37.4 (high), INR=3.3. Review of R3's ,[DATE] MAR (Medication Administration Record) revealed that on [DATE], R3 incorrectly received [MEDICATION NAME] at 9 PM. Additionally, R3 received [MEDICATION NAME] at 5 PM on [DATE] and [DATE] as ordered. R3 ' s ,[DATE] MAR revealed documentation that R3 incorrectly received [MEDICATION NAME] on [DATE] at 9 AM and 9 PM and again on [DATE] at 9 AM. Additionally, R3 continued to receive [MEDICATION NAME] at 5 PM on [DATE] and [DATE] as ordered. During an interview on [DATE] at 11:30 AM, E5 (physician) stated that he was unaware of the [DATE] PT/INR lab result until [DATE], the day R3 expired. He stated that the [MEDICATION NAME] should not have been administered on [DATE] (9 PM) through [DATE] as per the ordered parameters and that had the facility informed him of this result, he probably would have held or decreased the dose of [MEDICATION NAME] and ordered another PT/INR lab to be sure of the result. He stated that the normal process would be for the nurse to call lab results and indicate on the lab result sheet that the physician was notified and if there were any orders given, then document it on the lab result sheet and in the chart... if no orders given, staff would document that too. E5 confirmed that he changed the order for daily INR on [DATE] to be rechecked on [DATE]. E5 stated that it was his clinical judgement that the INR was close to therapeutic range but did not expect that it would change that much before [DATE]. During an interview on [DATE] at 12:30 PM, E3 (Assistant Director of Nursing/ADON) acknowledged that on [DATE] through [DATE], R3 received 4 additional doses of [MEDICATION NAME] despite the physician's order to discontinue it when the INR was >/= 2. E3 stated that someone (nurse) should have reported the [DATE] INR lab result to E5 with a request for further orders regarding additional lab testing or dose adjustment for [MEDICATION NAME]; the [MEDICATION NAME] should have been discontinued and not administered. She stated that the reason the nurses did not know to look for the lab result was that the lab order had been changed on [DATE] to "recheck on [DATE]" and it was documented as such on the [MEDICATION NAME] MAR (Medication Administration Record). E3 did not know who ordered the [DATE] INR. E3 stated that initially when R3 was admitted the order was for a daily INR to be done. Approximately, four lab slips should have been done to go through the weekend. E3 stated that INR needs to be done daily... once stable... might have parameters. E3 acknowledged that whoever removed the lab result from the fax machine and placed it in the doctor's book should have notified the physician of an abnormal (high) INR 3.3 result. During an interview on [DATE] at 3:25 PM, E8 (nurse) stated that she was the ,[DATE] nurse assigned to R3 on [DATE]. E8 stated that she was unaware that a lab had been drawn on [DATE] and denied knowledge of any INR results when she had called E5 (physician) at 2 PM to obtain an order for [REDACTED]. E8 stated that E7 was the ,[DATE] nurse and also was assigned to R3 on that shift. (E7 was not interviewed as she no longer works for the facility.) R3's care plan dated [DATE] and entitled, "Resident is at risk for injury or complications related to the use of anticoagulation therapy" was reviewed. Interventions included "Anticoagulant to be given as ordered; Labs as ordered; and Monitor for active bleeding..." R3's clinical record lacked any evidence of nurse's notes from [DATE] at 2:42 PM to [DATE] at 12:31 AM. On [DATE] at 12:30 AM, a nurse's note was written for a "Change in condition-Skin" that stated, "...Boil on Lt (left) inner buttock 0.6 x 0.6 indurated 0.2, experiencing pain. Mild when sitting or laying on it... Physician notified... new orders obtained, continued observation, see skin assessments." A skin assessment sheet was completed. A physician's order was obtained on [DATE] at 1 AM that stated, "1. Warm soaks to boil Lt inner buttock Q shift PRN (as needed) 2. Cleanse boil ... c (with) Skin integrity... dry drsg (dressing) Q shift until healed." Review of R3's Progress note, dated [DATE] and timed 08:31 stated, " ....Treetment (sic) continues to left buttocks, denies any pain some amount of bloody drainage observed but no odor." During an interview on [DATE] at 3:40 PM, E6 (nurse) denied informing E5 of R3's change in condition. E6 stated that R3 "had a wound/boil ... it was expected bleeding... normal bleeding ... did not need to be reported." E6 stated that he just cleaned it up and applied a new dressing to the wound/boil area. Another progress note, dated [DATE] and timed 2:08 PM stated, " Resident bleeding from his penis this morning, MD notified new order for Vitamin K (counteracts the anticoagulant medication) 2.5 mg x (times) 1 dose now, ... also PT/INR to be drawn today ... lab drawn already ... Resident given incontinent brief to help contain bleeding ... " During this same interview on [DATE], E6 reported this progress note as a "summary note" and stated that sometime around 9:,[DATE] AM on [DATE] (after med pass), he observed R3 with some blood noted to his pants and a small amount of blood on the bed linen. E6 denied notifying the physician regarding this change in condition because he "wasn't sure where the bleeding was coming from...need to know what to tell the doctor". E6 stated that he cleaned the resident up, offered R3 a disposable brief which R3 declined and changed the bed linen. E6 stated that he applied gauze around R3's penis to see if blood was coming from there. He then continued orienting a new nurse. Approximately 30 minutes later, E6 and the orientee rechecked R3. This time E6 observed R3 with "blood through his pants, blood on the bed ... much more than 30 minutes earlier." E6 stated that he thought R3 might be bleeding from his penis and requested that E3 check it with him. E6 (nurse) stated that E3 (ADON) applied pressure around the boil area and they observed bleeding from R3's penis. E3 left the room to call the physician while E6 cleaned R3 up, gave incontinent brief and again had R3's linens changed. E6 stated that he was informed of a physician's order that was obtained for "Vitamin K 2.5 mg po x 1 dose and to get a STAT PT/INR.". E6 stated that he spoke with the charge nurse (E9) and asked if R3 was going to be sent to the hospital. E6 stated that E9 repeated the doctor's orders and stated that they were just going to monitor the resident. E6 administered Vitamin K as ordered at 11 AM. E6 denied any knowledge of R3's INR 3.3 on [DATE] or that another lab had been done since [DATE] so, therefore had not reported that either. E6 stated that he was concerned with the resident's condition and spoke with a fell ow nurse (E10) regarding his observations. He stated that E10 agreed with his concern and told him that the doctor should be called again and that the resident should probably go to the hospital. E6 denied informing E5 of his concerns and instead just monitored the resident. R3's progress note, dated [DATE] and timed as a "Late Entry" 16:13 stated, " ...@ (at) 1520 (3:20 PM) found resident on the floor, bleeding from his penis (not new was bleeding during day shift). Abrasion noted to right chest and golf ball size bump just behind and slightly above right ear. Pupils equal @ 4 sluggish. alert but not answering questions. this is a change in his status from the past 3 days. not following all commands. when asked his name he just stared at me. + (positive) plantar/dorsi flexion on the left none on right. + grips Left greater than right. VS ,[DATE]-[DATE].1 PO (Pulse Ox (indicates oxygen saturation in the blood) 98% on room air...Ambulance arrived @ 1545 (3:45 PM) to transport..." During a telephone interview on [DATE] at 12:35 PM, E5 stated that the first time that he was aware of any bleeding was at 11 AM when he ordered the Vitamin K 2.5 mg po and a STAT PT/INR lab to be obtained. He stated that he had been informed of "some bleeding but not enough to send the resident to the hospital." E5 stated that he had been told by E3 that the bleeding was under control... "It kind of stopped". E5 denied being informed of any more active bleeding and that R3's vital signs were stable. He ordered the Vitamin K to be administered. Stated that it was only later that he found out that staff were "reinforcing with the diaper..." . E5 stated that he should have been told that R3 was actively bleeding and he would have immediately sent him out to the hospital. Review of the facility policy entitled, "2.16 Physician Notification" stated, "Upon identification of a patient who has a change in condition or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician. If unable to contact attending physician, the Medical Director will be contacted." During an interview on [DATE], E4 (Medical Director) reviewed R3's clinical record with the surveyor. E4 stated that he would want to get INR results at least a couple of times a week... would do daily INRs until INR greater than or equal to 2. Then would order PT/INR at least ,[DATE] times a week. E4 acknowledged that being on [MEDICATION NAME], aspirin and [MEDICATION NAME] does increase the risk of bleeding. E4 stated that when the [DATE] INR = 3.3, the [MEDICATION NAME] should have been stopped and E5 should have been informed. E4 stated that he did not know of a specific protocol for administering anticoagulants and how often labs should be drawn, but if he had been informed of the INR 3.3, he would order to hold the [MEDICATION NAME] or at least decrease the dose on [DATE] and ordered another PT/INR that night to see how much it was fluctuating. E4 stated that a STAT PT/INR could have been ordered from the lab and even the nurse's could have done one with the machine in the building. E4 stated nursing should be monitoring for signs and symptoms of bleeding, blood pressure changes, etc. and informing the physician of any unusual symptoms. When asked, E4 stated that on [DATE], he would have ordered R3 to be sent out to the hospital to be evaluated. E4 stated that any staff could have called him if there was any concern but, "I wasn't called." E4 stated that there have been other times when staff have called him and he has had no problem with that. Review of R3's hospital records revealed a consult dated [DATE] that stated, "Final Diagnoses: [REDACTED]. 2. Cerebral infarction. 3. Coagulapathy (clotting/bleeding disorder). 4. Change in mental status... discussed with the emergency room and the treatment staff, the patient's condition. He does have evidence of an iatrogenically induced (as a consequence of taking a drug prescribed by the physician) coagulapathy with an INR noted to be significantly elevated... recommended that this be corrected and reversed. Upon arrival, the patient rapidly deteriorated and became unresponsive... examination was consistent with brain death..." The hospital "Discharge Summary," dictated on [DATE], stated, "[MEDICAL CONDITION] admission to (name of hospital) with [MEDICATION NAME]-induced coagulopathy with an INR 2.3. The patient had reversal of his coagulopathy... neurologic exam was significantly depressed upon admission with very poor overall prognosis... worsened progressing to brain death... patient ... expired..." During an interview on [DATE] at 11:25 AM, E2 (Director of Nursing/DON) confirmed that the facility failed to report the [DATE] lab result INR 3.3 to E5. E2 stated the same reason that E3 stated, the nurses aren't looking for a lab result because they are following the [MEDICATION NAME] MAR and it stated that the next PT/INR was due on [DATE]. E2 denied knowing who ordered the lab work on [DATE], denied knowing who picked up the lab after it was faxed, stated the facility has been unable to determine that. She confirmed that the INR 3.3 was clearly abnormal and should have been called to the doctor. Instead it was found in the doctor's book on [DATE]. E2 confirmed that the facility failed to discontinue the [MEDICATION NAME] as per ordered parameters and instead incorrectly continued to administer it to R3. E2 acknowledged that the facility failed to immediately report signs and symptoms of bleeding on [DATE] when there was bloody drainage to R3's boil referred to in the [DATE] 8:30 AM progress note, and when R3 was observed to have bleeding by E6 shortly after he completed his med pass (9:,[DATE] AM). E2 confirmed that the facility failed to have evidence of adequately monitoring R3 from [DATE] at 2:42 PM to [DATE] at 12:31 AM due to the lack of any progress notes during this time. The facility failed to follow their policy and R3's plan of care. Findings were confirmed with E1 (Administrator) and E2 on [DATE]. E1 stated that R3's chart was being reviewed by their corporate Medical Director. The facility failed to ensure that R3 received the necessary care and services in accordance with the plan of care.