Every finding on record at Coral Springs Rehab & Healthcare

Number of residents sampled: Number of residents cited: Based on observation, interview, facility document and policy review, and the United States Food and Drug Administration (FDA) guidelines the facility failed to store, distribute, and serve food in accordance with food safety standards. Specifically, the facility failed to ensure staff dated prepared food items held for storage, stored potentially hazardous food below ready-to-eat food and failed to ensure freezer items were dated and labelled and in closed containers. Additionally, the facility failed to ensure that the dish machine was dispensing appropriate sanitizer per manufacturer guidelines and food was at the appropriate temperature while being held on a hot steam table for service.Findings included:1. An undated facility policy titled, Food Storage, indicated, Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Foods will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. The policy indicated, Cooked foods must be stored above raw foods to prevent contamination. Raw animal foods will be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. The policy further indicated, All foods should be covered, labeled and dated.Observations on 12/01/2025 beginning at 9:32 AM revealed prepared sandwiches undated in the reach-in cooler. During a concurrent interview, the Regional Dietary Services Consultant (RDSC) stated that the person who made the sandwiches was responsible for dating the sandwiches. The RDSC discarded the sandwiches. Observations of the walk-in cooler revealed lunch meat with no date and cut cantaloupe with no date. Raw pork breakfast meat was stored on a shelf above eggs and lettuce. During a concurrent interview, the RDSC stated the raw meat should not be stored above the lettuce because of the risk of cross contamination. An observation of the walk-in freezer revealed frozen waffles open to air and frozen chicken in a bag with no label. During a concurrent interview, the RDSC stated she had not seen the kitchen look that bad in a long time. 2. An undated facility policy titled, Cleaning Dishes/Dish Machine, indicated, The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing.Observations on 12/02/2025 at 10:39 AM revealed Dietary Aide (DA) #17 and Dietary Aide (DA) #18 washing dishes in the dish room. During a concurrent interview, DA #17 stated she thought the manager checked the temperature and sanitizer for the dish machine. DA #17 stated she had never been trained in how to check the temperature or sanitizer. DA #18 stated that the dietary aides did not check the dish machine temperature or sanitizer.During an interview on 12/02/2025 at 10:41 AM, Dietary Director (DD) #19, who was assisting from a sister facility, stated anyone should be able to check the dish machine temperature and sanitizer levels.During an observation on 12/02/2025 at10:55 AM, DD #19 checked the sanitizer level for the dish machine, which showed that there was no sanitizer dispensing onto the dishes.On 12/02/2025 at 10:59 AM, DD #19 instructed the dietary aides to use the three-compartment sink to soak the dishes for 15 seconds to sanitize the dishes since the dish machine was not working properly.A review of the dish machine log indicated no temperature or sanitizer levels had been recorded on the morning of 12/02/2025.The manufacturer's guidelines for the dish machine sanitizer indicated that the sanitizer should be a minimum of 50 parts per million (ppm).During a concurrent observation and interview on 12/02/2025 at 11:23 AM, DD #20, who was assisting from a sister facility, checked the sanitizer level on the three-compartment sink. The sanitizer level was at the appropriate concentration. DD #20 stated they had to soak the dishes for 15 seconds in the solution to sanitize them. A review of the manufacturer's guidelines posted on the wall indicated items should soak for 1 to 2 minutes. DD #20 stated, Oh shoot, and then began resoaking the dishes in the sanitizer solution.The manufacturer's guidelines for the three-compartment sink sanitizer indicated that articles should be immersed for a minimum of 60 seconds.3. A review of the United States Food and Drug Administration (FDA) 2022 Food Code revealed Chapter 3 Section 3-501.19 indicated, (1) Except as specified in (B)(2), the food shall have an internal temperature of 57 C [degrees Celsus] (135 F [Fahrenheit]) or greater when removed from hot holding temperature control.An observation on 12/03/2025 at 11:31 AM revealed [NAME] #6 taking the temperatures of the hot food being held for service on the steam table. [NAME] #6 took the temperature of the beef stew, pureed beef stew, and pureed carrots. [NAME] #6 put the temperature logbook down and prepared to serve the lunch meal. During a concurrent interview, [NAME] #6 stated he did not check the temperature of the carrots or mechanical soft beef stew because It's not on the temperature log. [NAME] #6 stated he only checked the temperature of items listed on the log sheet.On 12/03/2025 at 11:42 AM, DD #20 checked the temperatures of the remaining food items prior to serving. DD #20 checked the temperature of the carrots and stated that they were not hot enough and placed the carrots back on the stove to reheat them.During an interview on 12/04/2025 at 9:56 AM, the Regional Dietary Services Consultant (RDSC) stated that the training of the dietary staff was the responsibility of the Dietary Director. The RDSC stated that staff who were working with the dish machine should be checking the temperature and sanitizer level. The RDSC stated [NAME] #6 had been a Dietary Aide who had just recently started cooking. The RDSC stated staff should follow the recipes and menus.During an interview on 12/05/2025 at 1:18 PM, the Administrator stated staff should follow the guidelines for dating and labelling foods. The Administrator stated that dietary staff should be able to check the temperature and sanitizer of the dish machine.

Number of residents sampled: Number of residents cited: Based on observation, interview, and facility document and policy review, the facility failed to follow the planned menu. Specifically, the facility did not follow the recipe and served the incorrect portion size for the regular and pureed diets for the lunch meal on 12/03/2025. This failure had the potential to affect 151 residents who received meals from the kitchen.Findings included:A facility policy titled, Standardized Menus, revised 02/2025, indicated, The facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents based on the Recommended Daily Allowances (RDA) of the Food and Nutrition Board of the National Research Council, of the National Academy of Sciences, standardized cycle menus are planned in advance and utilized.A facility policy titled, Food Preparation Guidelines, revised 02/2025, indicated, The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes.Facility recipes for the lunch meal indicated the beef stew should be made with beef, Spanish onions, red potatoes, carrots, and celery. The recipes revealed that the instructions for pureed beef stew were to count the number of servings of prepared beef stew needed and process in a food processor until smooth.Observations on 12/03/2025 beginning at 11:10 AM revealed [NAME] #6 making the pureed beef stew. No potatoes or carrots were noted in the stew being pureed. [NAME] #6 was then observed adding carrots to the regular beef stew.A [Facility name] Menu Extension for 12/03/2025 indicated the lunch meal was to include beef stew served with an 8 ounce (oz) serving spoon or two #8 (4oz) disher scoops for the regular diets and two #8 (4oz) disher scoops for the pureed diets.Observations on 12/03/2025 at 11:42 AM revealed [NAME] #6 serving the lunch meal. [NAME] #6 was using a 6 oz ladle to serve the regular beef stew and one #8 (4oz) disher scoop to serve the pureed beef stew.During an interview on 12/04/2025 at 9:50 AM, [NAME] #6 stated he did not follow any recipes on 12/03/2025 for the lunch meal because the facility did not have any recipes. [NAME] #6 stated that the portion sizes were on the spreadsheet. [NAME] #6 stated he thought that he had used an 8 oz ladle for the beef stew and a #10 (3.2 oz) disher scoop for the pureed beef stew. [NAME] #6 stated he had been told to always use the #10 disher scoop.During an interview on 12/04/2025 at 9:56 AM, the Regional Dietary Services Consultant (RDSC) stated [NAME] #6 had been a Dietary Aide who had just recently started cooking. The RDSC stated staff should follow the recipes and menus. The RDSC stated that the portion sizes should be accurate according to the extension sheet. The RDSC stated it was important to serve the correct portions to prevent weight loss.During an interview on 12/05/2025 at 10:06 AM, Registered Dietitian (RD) #27 stated she expected staff to follow the menus, recipes, and portion sizes so they would meet the residents' nutrition requirements and maintain the residents' weight.During an interview on 12/05/2025 at 1:18 PM, the Administrator stated she expected staff to follow the menus and recipes.

Number of residents sampled: Number of residents cited: Based on observation, interview, and facility policy review, the facility failed to ensure medication and treatment carts were locked when not within line of sight for 5 (one treatment cart on the F and G Halls, one medication cart on the B Hall, one medication cart on the D Hall, one medication cart on the G Hall, and one medication cart on the F Hall) of 9 medication and treatment carts observed in the facility. Findings included:A facility policy titled, Medication Storage, revised 03/2025, revealed, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the medication cart/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Guidelines: 1. General Guidelines: a. All drugs and biologicals will be store in locked compartments (i.e. [id est, that is], medication carts cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. and c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.During an observation on 12/03/2025 at 5:53 AM, there was a medication cart on D Hall unlocked and unattended. During an observation and interview on 12/03/2025 at 5:55 AM, Licensed Practical Nurse (LPN) #21 approached the cart on the D Hall from the E Hall and stated the medication cart should be locked, stocked, and secured if not attended. She stated she was down the E Hall and had left the medication cart unlocked and unattended.The distance from the D Hall medication cart to the entrance of E Hall was approximately 64 feet and 8 inches. (Measured by the Maintenance Director)During an observation on 12/03/2025 at 6:00 AM, there were two medication carts and a treatment cart unlocked and unattended in front of the F Hall and G Hall nurses' station. The G Hall medication cart had the door open to the narcotic box, but the narcotic box was locked. The F Hall medication cart's top drawer contained over the counter (OTC) including aspirin, vitamin supplements, eye and ear drops, handheld inhalers and updraft nebulizer medications, insulin pens and vials. The carts second and third drawer contained resident bubble packs consisting of Plavix (anticoagulant), Seroquel (antipsychotic), metoprolol tartrate, (antihypertensive) gabapentin (analgesic) Lasix (diuretic), and potassium chloride. The distance from the beginning of the G Hall to the medication cart in front of the nurses' station was approximately 98 feet. The distance from the middle of F Hall to the nurses' station was approximately 50 feet. During an observation and interview on 12/03/2025 at 6:04 AM, Certified Nursing Assistant (CNA) #22 locked the two medication carts in front of the F Hall and G Hall nurses' station and said the nurses were on break. During an observation and interview on 12/03/2025 at 6:07 AM, LPN #23 approached the G Hall medication cart and said the cart was assigned to her and it should be locked when she was away and out of sight of the cart. She said she was off the floor for about 10 minutes, leaving the carts unattended. She said she had been trained on the importance of keeping the medication and treatment carts locked when they were not in her line of sight. During a concurrent observation, the G Hall medication cart top drawer contained OTC meds as well as a plastic container with a glucometer, lancets, and alcohol prep pads. The next two drawers had resident bubble packs including medications such as antihypertensive, anti-coagulants, and anti-diabetics. The bottom drawer had a container of Super Sani-Colth Wipes (bacterial wipes), and other supplies.During an observation on 12/03/2025 at 6:08 AM, the medication cart was observed unlocked and unattended on the B-Hall.During an observation and interview on 12/03/2025 at 6:15 AM, LPN #24 was observed entering and exiting the medication room at the G Hall and F Hall nurses' station. She said she was assigned the F Hall medication cart, and she and another nurse were both assigned the treatment cart. She said the carts should not have been left unlocked. She said she was off the floor and out of sight of the carts for around 10 - 15 minutes. She said that she was an agency nurse but had been trained on the importance of keeping the carts locked by the agency and the facility. During an observation and interview on 12/03/2025 at 9:05 AM, a medication cart was unlocked on the F Hall. At 9:08 AM, LPN #25 was observed coming out of a resident's room (approximately 35 feet from the medication cart). Immediately after LPN #25 got to the medication cart, she said the medication cart should be locked, but she had to run to see what the resident needed since the resident was yelling. She then said it should be locked when not in her line of sight, but the resident was yelling, and she had to see what they wanted. During an interview on 12/06/2025 at 12:24 PM, the Director of Nursing (DON) said she expected the medication and treatment carts to be locked when they were out of sight of the nurses assigned to them. During an interview on 12/06/2025 at 12:26 PM, the Administrator said she expected medication carts to be locked when the nurses were away and out of the line of sight from them.

Number of residents sampled: Number of residents cited: Based on interview, record review, and facility policy review, the facility failed to respect a resident's right to refuse a medication for 1 (Resident #181) of 7 sampled residents reviewed for choices.Findings included:A facility policy titled, Promoting/Maintaining Resident Dignity, revised 02/2025, indicated, 2. During interactions with residents, staff must report, document and act upon information regarding resident preferences.Resident #181's admission Record revealed the facility admitted the resident on 03/25/2025. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder, conversion disorder, rheumatoid arthritis, and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/2025, revealed Resident #181 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.Resident #181's Care Plan Report, revealed a focus area initiated on 03/02/2025, that indicated the resident had the potential for constipation. Interventions directed staff to administer bowel medications and provide interventions as ordered. Further review revealed staff were to monitor and document bowel sounds and abdominal distention if Resident #181 refused bowel interventions.Resident #181's Order Summary Report, with active orders as of 04/07/2025, revealed an order dated 03/02/2025 for Dulcolax suppository 10 milligrams (mg) with instructions to inserted rectally as needed if the resident did not have a bowel movement after milk of magnesia was administered. Resident #181's 04/2025 Medication Administration Record revealed that Registered Nurse (RN) #13 documented that they administered Dulcolax suppository 10 mg on 04/07/2025.A Council Concern/Recommendation Form, dated 04/10/2025, indicated Resident #181's family had expressed concern about a bowel suppository being administered to Resident #181. A typed Interview with [Resident #181] document dated 04/09/2025 indicated that Resident #181 stated that they had told the nurse (RN #13) that they did not want a suppository medication because they had already had a bowel movement earlier in the day. The document revealed Resident #181 stated that the nurse asked them several times about taking the medication, and Resident #181 felt like the RN was calling them a liar. The document revealed Resident #181 stated the nurse asked them again to take the suppository with their nighttime medications, and the resident had agreed to the medication. A bowel movement record revealed Resident #181 had a large bowel movement on 04/07/2025 at 9:30 AM and a medium bowel movement at 2:21 PM. During a telephone interview on 12/07/2025 at 10:45 AM, RN #13 stated he had been notified by the unit supervisor that Resident #181 was on the bowel protocol due to not having a bowel movement for three days. RN #13 stated there was a printed list of residents who did not have a bowel movement, and Resident #181 was on the list. RN #13 stated he had attempted several times to administer the suppository to Resident #181, but Resident #181 had refused. RN #13 stated he was not aware of any documentation that Resident #181 had a bowel movement earlier in the day. RN #13 stated that when he administered nighttime medications, he had reiterated to Resident #181 that it was important to take their medications, and Resident #181 had agreed and accepted the medication. RN #13 stated he did not see any documentation that Resident #181 had a bowel movement earlier that day. During an interview on 12/07/2025 at 12:08 PM, Licensed Practical Nurse (LPN) Supervisor #4 stated if a resident was on the bowel program list and the resident reported that they had a bowel movement, she would do a bowel assessment and try to verify that the resident had a bowel movement. LPN Supervisor #4 stated she would talk to the assigned certified nurse aide (CNA) and review the electronic health record (EHR) to confirm whether the resident had a bowel movement prior to making additional attempts to administer the suppository. During an interview on 02/07/2025 at 12:43 PM, the Assistant Director of Nursing (ADON) stated the bowel protocol list was printed every morning and included any residents who had not had a bowel movement documented in the previous nine shifts. The ADON stated the list was provided to the nurse, who should attempt to administer milk of magnesia during the day. The ADON stated that if the milk of magnesia was not effective, the evening shift nurse should administer a suppository. The ADON stated that if a resident told the nurse they had a bowel movement, the nurse should check the EHR to see if a bowel movement was documented prior to attempting to administer the suppository. The ADON stated that if the resident already had a bowel movement, the nurse should not continue with the bowel protocol.During an interview on 12/07/2025 at 1:02 PM, LPN #14, the Quality Assurance nurse, stated the bowel protocol list was printed every morning, and any resident who had not had a bowel movement in three days would be on the list. LPN #14 stated if a resident told the nurse they had already had a bowel movement, the nurse should stop attempting to administer the medication and attempt to verify that the resident had a bowel movement. LPN #14 stated that the nurse should talk to the CNA assigned to the resident and review the EHR to determine if the resident had already had a bowel movement. During an interview on 12/07/2025 at 1:43 PM, the Director of Nursing (DON) stated the bowel report was printed every morning to identify any resident who had not had a bowel movement in nine shifts so that they could initiate the bowel protocol for the resident. The DON stated that if the resident had a medium or large bowel movement, the bowel protocol would be discontinued. The DON stated that if a resident told the nurse they had a bowel movement, the nurse should try to verify the information by talking to the CNA and reviewing the EHR for any documented bowel movements. During an interview on 12/07/2025 at 1:46 PM, the Administrator stated if an alert and oriented resident who was independent with toileting was on the bowel protocol and reported having a bowel movement, the nurse should document that the resident reported a bowel movement and end the bowel protocol. The Administrator stated if the resident was cognitively impaired or toileted by staff, the nurse should attempt to verify the bowel movement by talking to the CNA or other nurses that were involved in the resident's care before proceeding with the bowel protocol.

Based on observation, interview, and facility policy review, the facility failed to ensure that a resident's bed was maintained in safe operating condition for 1 (Resident #142) of 7 residents reviewed for environment.Findings included:A facility policy titled, Safe and Homelike Environment, revised 01/2025, revealed, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk. The policy revealed the section titled, 11. General Considerations: included, e. Report any furniture in disrepair to maintenance promptly.An admission Record revealed the facility admitted Resident #142 on 05/03/2023. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, osteoarthritis, and intervertebral disc displacement of the lumbar region.Resident #142's Care Plan Report, included a focus area initiated 05/03/2025, that indicated the resident had the potential for falls with injury related to non-compliance and with safety measures. The focus area revealed the resident kept putting their bed up. Interventions directed staff to ensure there was adequate lighting in the residents room and honor the resident's preferences in regard to usage; encourage the resident to use the call bell for assistance and to keep the call bell in reach; remind the resident of limits and to ask for assistance for transfers and mobility as needed; and for the resident to have a concave mattress.During an observation on 12/01/2025 at 11:28 AM, Resident #142's bed was found to be uneven, with a noticeable left-sided downward tilt.During an observation on 12/02/2025 at 3:46 PM, Resident #142's bed was still visibly uneven, with a noticeable left-sided downward tilt.During an observation on 12/03/2025 at 1:37 PM, Resident #142's bed was visibly uneven, with a noticeable left-sided downward tilt.During an observation on 12/04/2025 at 9:42 AM, Resident #142's bed was visibly uneven, with a noticeable left-sided downward tilt.During an interview on 12/01/2025 at 11:28 AM, Resident #142 stated that their bed had been broken for a long time, though they did not remember since when. Resident #142 stated that they told their family member and had told the staff at the facility. Resident #142 stated that they had not fallen off their bed, but since the bed was lopsided, they were scared that they would fall because of the bed.During an observation and concurrent interview on 12/05/2025 at 11:26 AM, Licensed Practical Nurse (LPN) #14 stated that he was the acting unit manager for the day. LPN #14 approached Resident #142's bed and pressed the control panel to elevate the bed. As the frame began to rise, LPN #14 stated the bed was not even and that the right side of the bed was up a little and tilting to the left. LPN #14 stated that he would tell the maintenance staff to look at it. LPN #14 stated that it was the first time he was aware of the bed being uneven.During an observation and concurrent interview on 12/05/2025 at 11:48 AM, the Maintenance Director entered Resident #142's room and observed the resident's bed. The Maintenance Director stated that the bed frame was broken. He stated he did not recall the last time they did an audit for the resident's room. Resident #142 stated the resident had told someone the bed was broken.During an interview on 12/06/2025 at 9:08 AM, the Administrator stated that the expectation was that the Maintenance Director followed the facility's policy and performed routine maintenance, and if there were any concerns they would be addressed at that time. She stated she did not have any knowledge of the bed being broken.

Number of residents sampled: Number of residents cited: Based on facility policy review, record review, facility document review, and interview, the facility failed to report allegations of abuse or injuries of unknown origin to the state survey agency within required timeframes, which affected 3 (Residents #67, #178, and #185) of 7 residents reviewed for abuse or injuries of unknown origin.Findings included:A facility policy titled, Abuse, Neglect and Exploitation, revised 05/2025, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed the Guidelines included, 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The policy revealed, IV. Identification of Abuse, Neglect and Exploitation included, B. Possible indicators of abuse include, but are not limited to, which included, 1. Resident, staff or family report of abuse, 3. Physical injury of a resident, of unknown source, 5. Verbal abuse of a resident overheard, 6. Physical abuse of a resident observed, and 7. Psychological abuse of a resident observed. The policy revealed, VII. Reporting/Response included, A. The facility will have written procedures that include, which included, 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [exempli gratia; for example], law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.1. Resident #185's admission Record indicated the facility admitted the resident on 02/26/2025. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus, cirrhosis of the liver, and aphasia.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/04/2025, revealed Resident #185 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment.Resident #185's Care Plan Report included a focus area revised on 08/25/2025, that indicated that the resident had a behavior problem of refusing medications, weights, showers, repositioning, and hygiene care related to their disease process. Interventions initiated 07/20/2023 directed staff to anticipate and meet the resident's needs, provide the opportunity for positive interaction, and to explain all procedures to the resident before starting and to allow the resident to adjust to changes. Resident #185's Progress Notes revealed a note, dated 08/10/2025, that revealed the Medical Director (MD) assessed Resident #185 following an incident with staff earlier in the day. The note indicated that there were no reports of injury, and the resident appeared to be at their usual baseline and denied any complaints. Resident #185's Progress Notes revealed a note, dated 08/11/2025, that revealed the MD followed up with the resident following an incident over the weekend, and the resident remained unaffected with no new injuries. Certified Nursing Assistant (CNA) #2's typed statement, dated 08/10/2025, revealed that CNA #2 asked Licensed Practical Nurse (LPN) #1 at 5:30 AM to assist her with Resident #185's care due to the resident being combative. Per CNA #2's statement, LPN #1 called Resident #185 an expletive and ignorant, and hit the resident on their hand and their face. The statement indicated that CNA #2 did not intervene and protect the resident because she was in shock. Registered Nurse (RN) Supervisor #3's undated typed statement indicated that CNA #2 asked to speak with her after her shift was over on 08/10/2025 and reported to her that she and LPN #1 were in Resident #185's room providing care earlier in the overnight shift. Per the statement, CNA #2 further reported that she witnessed LPN #1 hitting Resident #185 on the body and yelling at them. The statement indicated that CNA #2 then asked RN Supervisor #3 not to say anything until after LPN #1 was out of the building before anyone was notified.A typed Interview with [Resident #185], dated 08/10/2025 at 12:41 PM, indicated that #185 stated yes, when asked if they experienced any issues overnight but could not further elaborate. An Incident Reporting System report, completed by the Director of Nursing (DON) indicated that CNA #2 reported that Resident #185 was combative during care, and LPN #1 was allegedly rough with the resident while assisting CNA #2. The report indicated that the abuse allegation was discovered on 08/10/2025 at 9:07 AM, over four hours after the alleged incident. During an interview on 12/03/2025 at 8:01 AM, the DON stated that she received a call from RN Supervisor #3 on her way to work on 08/10/2025. Per the DON, RN Supervisor #3 reported to her that CNA #2 came to her and told her she felt LPN #1 was rough with Resident #185 when providing care. The DON further stated she expected CNA #1 to have notified RN Supervisor #3 immediately instead of waiting until after her shift was completed. The DON then stated that she reported the staff-to-resident abuse allegation at 9:07 AM on 08/10/2025 to the state agency because that was about the time she found out about the alleged incident. During an interview on 12/03/2025 at 11:04 AM, the Administrator stated CNA #2 reported that she observed LPN #1 strike Resident #185 after they completed their overnight shift on 08/10/2025. Per the Administrator, CNA #2 could not explain why she waited to report it and requested RN Supervisor #3 to not address the situation until LPN #1 was out of the building. During an interview on 12/03/2025 at 11:22 AM, RN Supervisor #3 stated CNA #2 pulled her aside on 08/10/2025 at the end of their overnight shift. Per RN Supervisor #3, CNA #2 reported that she and LPN #1 were changing Resident #185 when LPN #1 tapped the resident's forehead with two fingers several times and yelled at the resident. RN Supervisor #3 further stated CNA #2 did not want the allegation to be reported right away because she did not want LPN #1 to retaliate against her. RN Supervisor #3 then stated that she reported it to the DON, and they handled the situation from there. During an interview on 12/05/2025 at 12:21 PM, the DON stated she expected allegations of abuse to be reported to the state survey agency within two hours. The DON further stated that if there was suspected abuse, the alleged perpetrator and the victim needed to be separated, and the allegation needed to be immediately reported so they could start an investigation. During an interview on 12/05/2025 at 12:34 PM, the Administrator stated that an allegation of abuse needed to be reported to the state survey agency within two hours. 2. Resident #178's admission Record indicated the facility admitted the resident on 04/24/2025. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus, hypertensive heart disease with heart failure, and periprosthetic fracture around the internal prosthetic right hip joint.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2025, revealed Resident #178 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.Resident #178's Care Plan Report included a focus area initiated on 05/01/2025, that indicated that the resident required assistance and had the potential to restore function for mobility as evidenced by declines from prior level of functioning (PLOF) related to a recent fall with periprosthetic fracture. Interventions initiated 05/01/2025 directed staff to encourage and praise activities of daily living (ADL) participation, give pain-relieving medication prior to activity and monitor for expressions of pain, and therapy treatment and evaluation as ordered. An Incident Summary Report, dated 05/09/2025 and completed by Licensed Practical Nurse (LPN) #14, indicated that Resident #178 had a dislocated femur following a routine X-ray ordered by their orthopedist on 05/08/2025 at 1:00 PM. The report indicated that Resident #178 was their usual state, participated in therapy with no complaints of pain, and denied any trauma or falls. The report indicated that the injury of unknown origin was not reported to the state survey agency until 05/09/2025 at 3:00 PM, 26 hours after the dislocation was identified. During an interview on 12/05/2025 at 1:00 PM, LPN #14 stated the current Administrator and the Director of Nursing (DON) were not employed at the facility on 05/08/2025, so since he was available, he reported Resident #178's dislocated femur to the state agency. LPN #14 further stated he did not know why he reported the injury of unknown origin 26 hours after it was identified. During an interview on 12/05/2025 at 9:38 AM, LPN #14 stated that when a resident had an injury of unknown origin, staff were expected to immediately report it so they could start an investigation into what may have caused it. During an interview on 12/05/2025 at 12:21 PM, the DON stated that she expected allegations of potential abuse to be reported to the state agency within two hours. During an interview on 12/05/2025 at 12:34 PM, the Administrator stated that injuries of unknown origin needed to be reported to the state survey agency within two hours. 3. An admission Record revealed the facility admitted Resident #67 on 11/01/2023. According to the admission Record, Resident #67 had a medical history that included diagnoses of major depressive disorder and cerebral infarction (a stroke).A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/2025, revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition.An admission Record revealed the facility admitted Resident #161 on 11/24/2020. According to the admission Record, Resident #161 had a medical history that included diagnoses of aphasia, bipolar disorder, and dementia.An MDS, with an ARD of 07/09/2025, revealed Resident #161 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated that Resident #161 exhibited no behavioral symptoms during the seven-day look-back period.An Incident Reporting System document submitted to the state survey agency, revealed that an altercation between Resident #67 and Resident #161 occurred on 06/27/2025. The document indicated that Resident #161 entered Resident #67's room on 06/27/2025 at 12:00 PM and pulled Resident #67's hair. Per the documents, staff intervened and separated the residents. The investigation documents indicated that law enforcement, physicians, and responsible parties were notified.Resident #67's Progress Notes revealed a Nurses Note, dated 06/27/2025 at 12:28 PM, that indicated Resident #67 was heard screaming, and a nurse entered the room to find Resident #161 pulling Resident #67's hair. The note indicated that the residents were immediately separated.An Incident Tracking report indicated that the incident between Resident #67 and Resident #161 occurred on 06/27/2025 at 12:00 PM. Per the report, the incident was submitted to the state survey agency on 06/27/2025 at 3:16 PM, over three hours after the incident.In a concurrent interview with the Administrator and Regional Clinical Consultant (RCC) on 12/06/2025 at 10:12 AM, the Administrator stated that she expected allegations of abuse to be submitted to the state survey agency immediately, and there was no such thing as too early. The RCC reviewed the nurses' notes and confirmed that the report was late. The RCC stated they had been notifying everyone of the incident and moving the resident's room, and that may have been the reason the report was late.

Number of residents sampled: Number of residents cited: Based on facility policy review, record review, facility document review, and interview, the facility failed to thoroughly investigate an allegation of staff-to-resident physical and verbal abuse for 1 (Resident #185) of 7 residents reviewed for abuse or injuries of unknown origin.Findings included:A facility policy titled, Abuse, Neglect and Exploitation, revised 05/2025, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed, VI. Protection of Resident, which included, The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.Resident #185's admission Record indicated the facility admitted the resident on 02/26/2025. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus, cirrhosis of the liver, and aphasia.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/04/2025, revealed Resident #185 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment.Resident #185's Care Plan Report included a focus area revised on 08/25/2025, that indicated that the resident had a behavior problem of refusing medications, weights, showers, repositioning, and hygiene care related to their disease process. Interventions initiated 07/20/2023 directed staff to anticipate and meet the resident's needs, provide the opportunity for positive interaction, and to explain all procedures to the resident before starting and to allow the resident to adjust to changes. Resident #185's Progress Notes revealed a note, dated 08/10/2025, that revealed the Medical Director (MD) assessed Resident #185 following an incident with staff earlier in the day. The note indicated that there were no reports of injury, and the resident appeared to be at their usual baseline and denied any complaints. Resident #185's Progress Notes revealed a note, dated 08/11/2025, that revealed the MD followed up with the resident following an incident over the weekend, and the resident remained unaffected with no new injuries. Certified Nursing Assistant (CNA) #2's typed statement, dated 08/10/2025, revealed that CNA #2 asked Licensed Practical Nurse (LPN) #1 at 5:30 AM to assist her with Resident #185's care due to the resident being combative. Per CNA #2's statement, LPN #1 called Resident #185 an expletive and ignorant, and hit the resident on their hand and their face. The statement indicated that CNA #2 did not intervene and protect the resident because she was in shock. Registered Nurse (RN) Supervisor #3's undated typed statement indicated that CNA #2 asked to speak with her after her shift was over on 08/10/2025 and reported to her that she and LPN #1 were in Resident #185's room providing care earlier in the overnight shift. Per the statement, CNA #2 further reported that she witnessed LPN #1 hitting Resident #185 on the body and yelling at them. The statement indicated that CNA #2 then asked RN Supervisor #3 not to say anything until after LPN #1 was out of the building before anyone was notified.A typed Interview with [Resident #185], dated 08/10/2025 at 12:41 PM, indicated that #185 stated yes, when asked if they experienced any issues overnight but could not further elaborate. The facility's DHCQ [Department of Health Care Quality] FRI [facility reported incident], dated 08/14/2025, indicated that CNA #2 reported that Resident #185 was combative during care and LPN #1 was allegedly rough with the resident while assisting CNA #2. The document indicated that the Nurse Practitioner (NP) and family were made aware of the allegation, and LPN #1 was immediately placed on administrative leave. Per the document, local police were notified and responded. The document indicated that after the police interview with CNA #2, and the alleged victim, the officer found no evidence of abuse or criminal activity. The MD was in the facility and conducted a physical exam on 08/10/2025 and found no evidence of abuse or trauma. A head-to-toe assessment was completed, and findings were within normal limits. Other residents with appropriate BIMS assigned to the accused nurse were interviewed, and all reported no concerns. Statements were obtained from LPN #1, CNA #2, and RN Supervisor #3, and findings were inconclusive. This abuse allegation was reported to the state agency on 08/10/2025 at 9:07 AM. The facility's investigation revealed no evidence of cognitively impaired residents being assessed for signs of physical abuse following the incident.LPN #1's time sheet indicated she clocked in on 08/09/2025 at 11:15 PM and clocked out on 08/10/2025 at 7:22 AM, over an hour and a half after the alleged incident occurred. LPN #1's personnel file included a letter from the state's DHCQ, dated 11/25/2025, that indicated the Division of Long-Term Care Residents Protection substantiated a finding against LPN #1 and added her to the Adult Abuse Registry for two years starting on 11/25/2025. The letter indicated that on 08/10/2025, a CNA witnessed LPN #1 using inappropriate language and hit a resident on the face and chest area with an open hand.During a telephone interview on 12/03/2025 at 6:41 AM, LPN #1 stated there was an incident between her and Resident #185 where the resident was combative during care. Per LPN #1, Resident #185 had a soiled brief that needed to be changed, and she assisted a new CNA with the care. LPN #1 further stated that if a staff member did not hold Resident #185 during provision of care, the resident hit staff, making providing care difficult. LPN #1 stated that during the incident on 08/10/2025, Resident #185 swung at staff and yelled expletives. She stated that they provided the needed care, and then she (LPN #1) left the room. Per LPN #1, approximately two hours after the incident, she clocked out and went home. LPN #1 stated that later that morning, she received a call at around 10:00 AM instructing her not to return to the facility and that she was suspended for four or five days before being allowed back in the facility. During an interview on 12/03/2025 at 11:22 AM, RN Supervisor #3 stated that CNA #2 pulled her aside on 08/10/2025 at the end of their overnight shift. Per RN Supervisor #3, CNA #2 reported that she and LPN #1 were changing Resident #185 when LPN #1 tapped the resident's forehead with two fingers several times and yelled at the resident. RN Supervisor #3 further stated CNA #2 did not want the allegation to be reported right away because she did not want LPN #1 to retaliate against her. RN Supervisor #3 then stated she reported it to the Director of Nursing (DON), and they handled the situation from there. During an interview on 12/03/2025 at 8:01 AM, the DON stated that she received a call from RN Supervisor #3 on her way to work on 08/10/2025. Per the DON, RN Supervisor #3 reported to her that CNA #2 came to her and told her she felt LPN #1 was rough with Resident #185 when providing care. The DON further stated she expected CNA #1 to have notified RN Supervisor #3 immediately instead of waiting until after her shift was completed. The DON then stated she was responsible for abuse investigations and obtaining statements from those staff and residents involved. Per the DON, they obtained statements from LPN #1, CNA #2, RN Supervisor #3, Resident #185, and other cognitively intact residents under the care of LPN #1. The DON further stated that she, LPN Supervisor #4, and the MD assessed Resident #185 with no injuries noted, and they contacted the police. The DON then stated she asked CNA #2 to demonstrate what she witnessed, which involved waving her hands in the air while Resident #185 was being combative during care. The DON further stated she was not sure how non-cognitive residents under the care of LPN #1 were assessed for possible abuse. Per the DON, the facility unsubstantiated the allegation of abuse based on conversations with the police, the staff involved, and LPN #1's history of no prior incidents. The DON further stated that LPN #1 was suspended pending investigation but since the allegation was unsubstantiated, she was allowed to come back to work. Per the DON, CNA #2 did not intervene to protect Resident #185 from LPN #1, but CNA #2 stated that she did not know what to do when the incident occurred. During an interview on 12/03/2025 at 11:04 AM, the Administrator stated that CNA #2 reported that she observed LPN #1 strike Resident #185 after they completed their overnight shift on 08/10/2025. The Administrator further stated that she asked CNA #2 if she intervened when LPN #1 struck Resident #185, CNA #2 replied that she did not and froze in that instant. The Administrator then stated she immediately suspended LPN #1 pending investigation once she was notified of the allegation. The Administrator further stated they had the MD assess the resident for any injuries and had the Social Services Director (SSD) interview alert and oriented residents regarding LPN #1's behavior towards them, with no substantiated findings. Per the Administrator, the SSD observed cognitively impaired residents and did not identify any concerns following the allegation. During an interview on 12/05/2025 at 12:21 PM, the DON stated that if there was suspected abuse, the alleged perpetrator and the victim needed to be separated, and the allegation needed to be immediately reported so they could start an investigation. The DON then stated thorough investigations included statements from everyone involved, notifying the police if needed, interviewing residents, and assessing cognitively impaired residents to see if they were possibly impacted. During an interview 12/05/2025 at 12:34 PM, the Administrator stated that a thorough investigation included assessing the residents, suspending the alleged accuser to protect residents from further potential abuse, and interviewing staff and any potential witnesses. Per the Administrator, cognitively impaired residents should also be assessed for any signs of distress or physical injuries as part of a complete investigation.

Number of residents sampled: Number of residents cited: Based on facility policy review, record review, facility document review, and interview the facility failed to ensure that residents were free from accident hazards related to the inappropriate use of a mechanical lift, which affected 1 (Resident #184) of 10 residents reviewed for accidents.Findings included:A facility policy titled, Safe Lifting and Movement of Residents, revised 06/2025, indicated, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The policy revealed, 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.An admission Record indicated the facility admitted Resident #184 on 04/11/2025. According to the admission Record, the resident had a medical history that included diagnoses of unspecified abnormalities of gait and mobility, unspecified lack of coordination, and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a stroke) affecting left non-dominant side.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/11/2025, revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated that Resident #184 was dependent on staff for chair/bed-to-chair transfers.Resident #184's June 2025 Documentation Survey Report, which was the resident's Kardex (a guide for direct caregivers that outlined each resident's care needs), indicated that Resident #184 required transfers with the use of a mechanical lift. The document indicated that resident transfers were to be done with the assistance of two people.Resident #184's Progress Notes revealed a note, dated 06/17/2025 at 2:45 PM, that revealed that Resident#184 was found on the floor next to the bed, still connected to their mechanical lift. The note indicated that the certified nursing assistant (CNA) was trying to transfer the resident from the chair to the bed. The note indicated that Resident #184 complained of pain to the right elbow, neck, and back at a pain level of 8 out of 10. Per the note, the resident stated that they had fallen from the mechanical lift. The note revealed that the resident was sent to the emergency room, per physician orders. The document indicated that the resident's family member was present at the time and accompanied the resident to the hospital.Resident #184's Emergency Department instructions, dated 06/18/2025 at 3:24 AM, indicated that while at the emergency department, an X-ray imaging of Resident #184's extremities was obtained and showed no factures or dislocations. The document indicated that a computed tomography (CT) scan showed no acute findings worrisome of fractures, dislocations, or bleeds.Resident #184's Progress Notes revealed a note, dated 06/18/2025 at 10:09 AM, that indicated that the Interdisciplinary Team (IDT) reviewed the resident's fall from 06/17/2025. The note indicated that a root cause analysis was conducted, which determined that the mechanical lift legs had made contact to the base of the geriatric chair, causing the resident's weight to shift and tilt the lift further, resulting in the resident being lowered to the floor. The note indicated that an assessment of the functionality of the mechanical lift was completed, with no issues identified.An Interview Statement, dated 06/18/2025 from Resident #184's family member (FM), FM #34, indicated that CNA #8 was unable to find anyone to assist her in putting the resident back in bed, so FM #34 offered to help CNA #8 transfer the resident. The statement indicated that the mechanical lift did not clear the top of the bed, and they were not able to swing the mechanical lift around. The statement indicated that CNA #8 tried to pull Resident #184 onto the bed when the resident's body shifted, the mechanical lift tilted over and fell to the side, and the resident was lowered to the floor by FM #34 and CNA #8.During an interview on 12/03/2025 at 1:18 PM, Licensed Practical Nurse (LPN) #7 stated that the facility process was that staff were to use two staff persons when operating the mechanical lift. LPN #7 stated that she was at the nurses' station when Resident #184's family member came and asked for help. The LPN stated that when she entered the resident's room, the resident was noted on the right side of the bed on the floor. She stated that there was only one staff person present in the room at that time with the mechanical lift. During an interview on 12/03/2025 at 1:51 PM, CNA #8 stated that she no longer worked for the facility and up until 06/2025, had been employed by the facility for a year and a half. CNA #8 stated that when she transferred a resident using the mechanical lift, it required the use of two people. She stated that on 06/18/2025, Resident #184 had come in from outside with their family member and needed to be transferred into the bed. CNA #8 stated that she was impatient and used the lift to transfer Resident #184 by herself, and she was not supposed to transfer the resident with the mechanical lift by herself. During an interview on 12/06/2025 at 10:49 AM, Director of Nursing (DON) stated that the facility had a process related to the use of mechanical lifts, which included that staff were to check the resident's Kardex for appropriate transfer, use an appropriate sling, get the mechanical lift, and then get a second person to help with the transfer. The DON stated that the process also included both staff assisting to get the sling under the resident and get the resident attached to the mechanical lift, then one staff operated the mechanical lift while the other staff stayed next to the resident and helped guide the resident. The DON stated that she expected all staff using the mechanical lift to transfer residents following the process for use of the mechanical lift.During an interview on 12/07/2025 at 7:31 AM, the Administrator stated that all staff were to use two people while transferring residents with the mechanical lift.

Based on record review and interview, it was determined that for one (R159) out of seven residents reviewed for hospitalization s, the facility failed to ensure that R159 received care/treatment in accordance with professional standards of practice. The facility failed to monitor bowel movements resulting in a hospitalization requiring fecal disimpaction. Findings include: Review of R159's clinical records revealed: 9/20/23 - R159 was admitted to the facility with diagnoses including Parkinson's Disease, muscle weakness and dementia. 9/20/24 - R159's admission care plans included, [R159] has potential for constipation r/t [related to] decreased motility. The interventions included, Monitor and document bowel sounds and abdominal distention if no BM [bowel movements] after 3 days or resident refuses bowel interventions. Monitor BMs and document in CNA records. 9/20/23 - R159's physician's orders included, Docusate Sodium Oral Liquid [stool softener] - give 100 ml by mouth 2 times a day for constipation and Bowel protocol per facility policy: Give 30 ml of milk of magnesia on 3-11 if no bowel movement, 11-7 give Fleets Enema if no results from 11-7, nurse will inform physician for further orders and communicate to 7-3 nurse per facility's protocol. 9/26/23 - R159's admission MDS documented a BIMS score of 3, indicating severe cognitive impairment. Review of R159's Activities of Daily Living (ADLs) flowsheets revealed: 11/2/23 - R159's clinical records documented a large bowel movement. 11/6/23 - R159's clinical records documented a small bowel movement. 11/11/23 - R159's clinical records documented a large bowel movement. The facility failed to initiate the bowel protocol for 5 days (14 shifts.) 11/16/23 - R159's clinical records documented a large bowel movement. 11/21/23 - R159's clinical records documented a small bowel movement. The facility failed to initiate the bowel protocol for 5 days (16 shifts.) 11/24/23 10:03 AM - R159's clinical records documented, .Was notified that resident [R159] was not at baseline (normal status for R159). Neck hyper flexed (extended) and unable to relax. Normally resident would be able to stand, pivot and verbalize any concerns . not able to follow commands . spoke with NP and sent out for further evaluation. 11/28/23 4:11 PM - R159's hospital records documented, . Large stool burden in the rectum with stool ball . measuring up to 7.5 cm [2.95 inches] . hospitalized for hypoactive (decreased bowel sounds), delirium with abdominal pain, both were improved after fecal disimpaction. [R159] was also treated MiraLax (medication for constipation), senna, glycerin [rectal] suppositories X (times) 2 with improvement in constipation . her mental status improved back to her baseline with treatment of her constipation. 11/6/24 10:00 AM - A review of R159's clinical records lacked evidence of documentation of a bowel movement from 11/16/23 through 11/24/23 for a total of 26 shifts. During an interview E21 (RN) stated, We run a daily report and anyone who has not had a bowel movement is put on the bowel protocol. The bowel protocol should have been started 3 days after she [R159] didn't have a BM. A review of R159's clinical records lacked evidence that prune juice, milk of magnesia or fleets enema were given per order or that the physician was notified of the lack of bowel movements. 11/8/24 2:30 PM - During an interview, the surveyor asked E22 and E23 (CNAs) what size of bowel movement would be considered a small one. E22 stated, Like a small smear on the brief. E23 stated, Small bowel movement does not count. That's not enough to say the resident has had an actual bowel movement. 11/12/24 12:15 PM - During an interview, E4 (LPN/QA/IP) stated, The bowel protocol should have been started. The facility failure to monitor and initiate the bowel protocol for 13 shifts, caused R159 have abdominal pain and to be hospitalized from 11/24/23 through 11/28/23. 11/13/24 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E27 (ADON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman office.

Based on interviews, record review and review of other documents as indicated, it was determined that for one (R157) out of six residents reviewed for hospitalization , the facility failed to provide the necessary treatment consistent with professional standards of practice, to provide pain assessments and pain medication prior to the daily wound care for R157's extensive left lower leg wounds. The result of that incomplete pain assessment and medication administration resulted in harm. R157 experienced pain when her wound care was completed. Findings include: Cross refer to F655 Review of R157's clinical record revealed: 7/27/24 - The hospital records and discharge summary revealed that R157 was admitted to the facility for wound care and physical therapy directly from a seventeen-day hospital stay. The hospitalization included an admission to the intensive care unit for the treatment of septic shock (potentially deadly condition with whole-body infection) from an infection in R157's left lower leg. R157 had surgery on her left leg on 7/17/24 to debride (remove dead tissue so that healthy tissue can grow) her left leg. The surgery resulted in R157 having three separate and large wounds to her left leg. Two wounds were located on the upper left thigh, front and back and one wound was located on the lower left leg, from her knee and extending to her heel. The three wounds were extensive both in length and width and the wounds took up most of the skin space on R157's left leg. The hospital records that were sent to the facility with R157's admission documents included 7/24/24 color photographs of the three wounds on R157's left leg. A review of hospital records for the pain medications that R157 received during her hospital stay revealed the following: Tylenol 650 mg by mouth every six hours, Oxycodone (expected pain) 10 mg by mouth twice daily as needed, Oxycodone 5 mg by mouth every four hours as needed. The 7/27/24 hospital discharge summary highlighted R157's medication changes to continue Oxycodone 10 mg by mouth thirty minutes before dressing changes. 7/27/24 - R157 was admitted to the facility with multiple diagnoses, including cellulitis (skin infection with swelling), of left lower leg, open wounds to the left lower leg, infection of the skin, a fractured spine, arthritis and dementia. 7/27/24 - A physician's order was written by E3 (Medical Director) for R157 to receive Tylenol 650 mg by mouth every six hours as needed for pain. 7/28/24 - Medication orders were written by E51 (Nurse Practitioner) for the following medications: - Oxycodone 10 mg by mouth every twelve hours as needed for pain dressing change. - Gabapentin 100 mg by mouth three times a day for nerve pain. - Celebrex 200 mg by mouth twice a day for pain. It is significant to note that according to the hospital discharge documents, Gabapentin and Celebrex were medications that R157 was taking at home before she was hospitalized on [DATE] and had left leg surgery on 7/17/24. 7/28/24 - An encounter note, written by E3 revealed that R157's wound photographs were reviewed with F2 (R157's daughter) when E3 examined R157. E3 documented that R157 had extensive wounds encompassing the entire leg and that she does have pain with dressing changes. 7/31/24 - R157's Minimum Data Set (MDS, standardized assessment forms used in nursing homes) documented the following: - BIMS score of 6, which indicated that R157 had severe cognitive impairment. - R157 had received scheduled and as needed pain medications during the last five days. - R157 was unable to participate in the pain assessment interview at the time of the comprehensive assessment; the sections for the presence and the frequency of pain were not answered by R157 herself, but were completed with a staff assessment. - It was very important to R157 to have her family involved in discussions about her care. A review of R157's wound care orders revealed: 7/27/24 - 8/8/24 - Cleanse the wounds with Vashe wound solution (hypochlorous acid with antimicrobial properties), pat dry, apply intrasite and with oil emulsion (both promote moist wound for healing), cover with Vashe soaked gauze, ABD (absorbent gauze pads) and wrap with kerlix (bandage rolls) and ace wrap (compression bandage to reduce swelling) for all wounds to left hip and lower left leg every day. 8/8/24 - 8/14/24 -Cleanse the wounds with Dakin's (bleach, acid and baking soda mixed in water to promote with antibacterial effects), pat dry, apply hydrogel AG (gel with antimicrobial properties), cover with oil emulsion dressing, ABD pad, wrap with Kling (stretch bandages) every day shift for all wounds to lower left extremity. Notify MD of worsening or signs of infection. 8/6/24 1:44 PM - A progress note was written by E6 (LPN, wound care) that the LLE (lower left extremity) calf wound from knee to back of ankle appeared to be infected due to redness around the wound, green drainage on the wound dressings, and increased drainage from the wounds. 8/7/24 11:37 AM - An encounter note written by E52 (NP) revealed Patient is being seen today for concerns of pain in her left leg. Patient has an extensive left lower leg cellulitis with multiple wounds. The daughter is very involved in her care and is requesting the patient to be medicated with oxycodone half hour before her dressing changes. This has not always consistently been done. The patient is alert and oriented she is very pleasant she is a poor historian she is seen today lying in bed in no acute distress she does not appear to be in any pain at the present time she denies fever chills chest pain shortness of breath nausea vomiting. The daughter is concerned she is not getting her oxycodone prior to her dressing changes. Given the extent of the patient's wounds this is not an unreasonable request. I will write an order for the oxycodone to be given half hour before dressing changes. A review of the electronic medical record revealed that the order was never written. A review of R157's as needed pain medication that R157 was given revealed: - Acetaminophen 650 mg by mouth was given twice in July at 7/30/24 at 9:01 PM and 8/4/24 at 9:55 AM. - Oxycodone 10 mg was given four times: 7/28/24 at 12:34 PM, 7/29/24 at 11:14 AM, 8/8/24 at 5:05 PM for pain 8/10 and 8/12/24 at 12:42 AM for pain 8/10. 8/12/24 - A progress note written by E52 (NP) revealed that E52 was called to R157's bedside because F2 was going to take R157 home and F2 wanted to speak with a medical provider. E52 arrived and found R157 with a change in mental status, increased confusion, pale skin, and she was moving all over the bed. E52 explained that from a clinical point of view, R157 would not be safe to be discharged to home because there was a concern that the left leg had a significant infection, that the wound was very complex, as it started from the groin and extended down to the foot. E52 explained that a discharge to home would be against the medical advice of the facility. F2 stated that she would then call 911 herself and that she did not want the nursing staff or the nurse practitioner to be involved. 8/12/24 10:26 AM - A nurses note documented that the medication orders, face sheet and the last provider note was sent to the hospital with the resident. A review of the hospital admission records documented that R157 was hospitalized [DATE] thru 8/20/24 for treatment of a wound infection. 11/13/24 1:40 PM - During an interview, F2 stated that because of my mother's dementia she cannot tell someone when she is having pain. I am her caregiver, and I can tell when she is in pain by looking at her eye movements and her subtle body changes. She was in pain when she had dressing changes when I was present. According to the College of Psychiatric and Neurologic Pharmacists, Mental Health Clinician Identification, Assessment, and Management of pain in patients with advanced dementia, 2016: Pain in a dementia patient is a prevalent symptom that can be underrecognized because of the ability of the patient to self-report. Health care providers must anticipate this and screen for and treat potential pain. This includes obtaining a self-report, searching for potential causes for pain, observing patient behavior, gaining proxy reporting of pain, and attempting an appropriate analgesic trial. Although R157 was a a severly cognitively impaired resident, the facility documents lacked evidence that the facility used any alternative pain assessment tools, with the exception of one tool, the Pain Evaluation for Cognitively Impair and Intact assessment tool that was used on 8/11/24. R157's harm was evidenced by the following: - R157 was a vulnerable facility resident with significant cognitive impairment and who may not have been able to adequately express her pain verbally or physically. R157 was medicated for pain on an as needed basis on six shifts out of the fifty-two shifts that she was in the facility. - R157's wound care orders were changed on 8/8/24 to Dakin's, a bleach solution. R157 received as needed pain medication only two times after that change, and apparently not prior to dressing changes on those days. - R157 was a vulnerable eighty-eight facility year old resident because of her medically fragile state and her physical frailness. It was important to R157 that her daughter (F2) participate in her care while she was at the facility. F2 expressed concern to the facility about her mother's pain, specifically that her mother was not getting pain medication thirty minutes before her dressing changes. The facility made no further changes to R157's pain medications, or to document reasons why there were no changes made. - R157's wound deteriorated during her facility admission. R157 did not appear to be responding to the prescribed antibiotics that were started on 8/6/24. R157's pain medications continued to go unchanged as R157's wound infection progressed. 11/13/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman's office.

Based on observation, interview and review of facility records, it was determined that the facility failed to ensure that a qualified person in charge was present during hours of Kitchen operation. Additionally, the facility failed to ensure that breakfast trays were provided to residents within 45 minutes of the facility's scheduled time for meals. Findings include: 1. 10/28/24 11:20 AM - In an interview, E33 (Regional Dietary Consultant) stated she was not sure if a food service member was present during hours of kitchen operation whenever E8 (Dietary Supervisor) takes off from work schedule. 11/1/24 8:45 AM - A review of the facility's dietary time cards from September 2024 through October 2024 revealed no members in the facility's food service department possessed valid Food Protection Manager certificates from an Accredited Food Safety Program on the following dates: - 9/7/24; - 9/8/24; - 9/21/24; - 9/22/24; - 10/5/24; - 10/10/24; - 10/24/24; and - 10/27/24. 11/1/24 10:21 AM - Findings were confirmed by E33 and E8. 11/12/24 2:35 PM - Findings were discussed with E1 (NHA), E2 (DON) and E47 (Regional Clinical Consultant). 2. 10/28/24 10:14 AM - An observation during breakfast on the B unit revealed that the meal delivery truck arrived after 10:00 AM. 10/29/24 10:24 AM - An observation during breakfast on the B unit revealed that the meal delivery truck arrived after 10:00 AM. 10/31/24 9:25 AM - In an interview, E63 (CNA) confirmed that the resident in the B unit were not getting their breakfast meals on time. E63 further stated, They are getting brunch and sometimes they get their breakfast meals very close to lunch time. 11/1/24 10:10 AM - Review of the facility's scheduled meal times for the residents in the B Unit, it was documented that the dinner meal was served beginning at 6:15 PM and the breakfast meal the following day was served beginning at 8:40 AM. 11/1/24 10:15 PM - Review of the facility Meal Truck Delivery Log for the B Unit from September 2024 through October 2024 revealed the following: - on 9/4/24, dinner was delivered at 5:40 PM. The following day, 9/5/24, breakfast was delivered at 10:09 AM; - on 9/14/24, no documentation of dinner delivery time. The following day, 9/15/24, breakfast was delivered at 10:36 AM; - on 10/17/24, dinner was delivered at 5:52 PM. The following day, 10/18/24, breakfast was delivered at 10:09 AM; - on 10/18/24, dinner was delivered at 5:50 PM. The following day, 10/19/24, breakfast was delivered at 10:14 AM; - on 10/19/24, dinner was delivered at 6:27 PM. The following day, 10/20/24, breakfast was delivered at 10:48 AM; - on 10/27/24, dinner was delivered at 5:14 PM. The following day, 10/28/24, breakfast was delivered at 10:15 AM and; - on 10/28/24, dinner was delivered at 6:07 PM. The following day, 10/29/24, breakfast was delivered at 10:29 AM. 11/1/24 11:21 AM - In an interview, E8 (Dietary Supervisor) confirmed that there were delays in the meal delivery times and that, . The kitchen staff need to be more efficient with time management starting at the tray line. 11/12/24 2:35 PM - Findings were discussed with E1 (NHA), E2 (DON) and E47 (Regional Clinical Consultant). 46134 2. 11/4/24 9:00 AM - During an interview, R78 stated that the lunch and dinner meals on Sunday 11/3/24 were both late in delivery and did not have reasonable portions or selection of foods. 11/4/24 3:15 PM - An email request was made to E1 (NHA) to provide the kitchen staff time cards for 11/2/24 and 11/3/24. 11/4/24 - A review of the facility dietary time cards for 11/3/24 revealed that no member in the facility's food service department possessed a valid Food Protection Manager certificate from an Accredited Food Safety Program on 11/3/24 during dinner preparation and service, between the hours 3:52 PM - 6:14 PM. 11/13/24 - During an interview, E1 (NHA) confirmed that E70 (kitchen cook), who was the cook in the kitchen during dinner preparation, did not possess a valid Food Protection Manager certificate from an Accredited Food Safety Program. 11/13/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman's office.

Based on observation and interview, it was determined that the facility failed to ensure food/items were stored and/or prepared under sanitary conditions. Findings include: 1. During the initial tour of the kitchen on 10/28/24 beginning at 9:00 AM, the following observations were made: - The walk-in freezer contained bread, ice cream, and debris on the floor; - The standard refrigerator near the entrance had a pink and orange substance spilled inside at the base; - The dry food storage room revealed three bags of onions, a bag of potatoes, and a container of icing stored on the floor; - A pan with meat that was to be seasoned was located on a table uncovered and unattended; - A prepared salad located inside the refrigerator without a date; - In the ware washing room, the table in the dish area where the clean dishes come out of the ware washing machine was covered in food debris; - In the ware washing room, clean plastic mugs were stored inside the room placing them at risk of exposure to splash and in a wet location. The plastic mugs had visible white spots on them; and - Paper towels were not available at the hand washing sink. A follow-up visit to the kitchen on 10/30/24 at 11:30 AM found: - The walk-in freezer with small containers of ice cream and muffins turned over on the floor; - A box of muffins was left partially uncovered; and - In the ware washing room, the table in the dish area where the clean dishes come out of the ware washing machine contained visible food debris. 2. 11/1/24 11:20 AM - An observation on the snack/nourishment refrigerator serving B, C, D and E units revealed a personal lunch bag and food items with no date and no label in Styrofoam inside an undated and unlabeled plastic bag. 11/1/24 11:23 AM - Findings were confirmed by E40 (RN). 11/12/24 2:35 PM - Findings were discussed with E1 (NHA), E2 (DON) and E47 (Regional Clinical Consultant).

Based on record review and interview, it was determined that for one (R125) out of six residents reviewed for transfer/discharge, the facility failed to implement a policy allowing R125 to return to the facility after his 10/31/23 hospitalization. The facility refused to allow R125 to return to the facility due to lack of a payor source and he remained unnecessarily hospitalized for an additional 91 days. The facility also failed to allow R125 to return to the facility while appealing this discharge. Findings include: Facility's Transfer and Discharge- Policy Explanation and Compliance Guidelines: . 2. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: . e. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay . Revised 9/2024 Cross refer F644, example 2 7/26/23 - R125 was admitted to the facility with diagnoses, including but were not limited to, cardiomyopathy and anxiety disorder. 9/28/23 - R125 was presented a Notice of Medicare Non-Coverage (NOMNC), which stated therapy issued LCD (last covered day) of 9/28/23 and included information about daily rates and the right to appeal. The NOMNC also documented that R125 refused to sign the NONMC. R125 stayed in the facility as private pay but refused to participate the Medicaid application process. The facility failed to issue a 30 day discharge notice to R125. 10/31/23 - R125 transferred to [hospital] for change in mental status. 11/22/23 12:35 PM- The [Hospital] Discharge Summary documented that [R125] was diagnosed at the hospital with sepsis secondary to UTI (urinary tract infection) from chronic indwelling catheter . [R125] is medically stable for discharge to SNF (skilled nursing facility) . 12/4/23 9:45 AM - C2 (hospital case manager) documented in [hospital] discharge planning notes, . Pt (patient) is medically stable for d/c (discharge) when bed available . 12/11/23 5:09 PM - C2 documented in [hospital] discharge planning notes, . [hospital] management has requested this case be escalated to complex CM (case management) for review in order to transfer pt to long term inpatient . 12/27/23 11:22 AM - C3 (hospital case manager) documented in [hospital] discharge planning notes, . Pt agreeable to providing financials for long term Medicaid. Pt reports being homeless and not having any family that he speaks to . 1/2/24 11:23 AM - C4 (RN hospital case management) documented in [hospital] discharge planning notes, . confirmed with [facility] liaison that the patient did come from their facility and that they do not want to take the patient back because he owes them money. CM (case management) asked liaison if they gave the patient a 30 day discharge notice. CM also asked if LTCM (long term care Medicaid) was obtained, would they consider taking the patient back. Per liaison, she will follow up with this CM as she will forward these questions to administration for clarity. CM to complete [NAME] (pre-admission evaluation- level of care form) and have the patient and provider sign off on it so that LTCM can be initiated. 1/3/24 9:28 AM - C5 (hospital case management) documented in hospital discharge planning note, Emailed [NAME], PASARR and clinicals to DHSS (Department of Health and Social Services) CIU. 1/8/24 12:49 PM - C4 (RN hospital case management) documented in the hospital discharge planning notes, . the patient's DE (Delaware) Medicaid app (application) was initiated today. CM asked if they can accept the patient Medicaid pending. 1/22/24 24 2:30 PM - C4 (RN case management) documented in the hospital discharge planning notes, . CM confirmed with liaison at [facility] that the patient does not have any days left and they are unable to take him back since he owes them money. 1/29/24 12:26 PM - C4 documented in hospital discharge planning notes, CM spoke to State Ombudsman [name][phone number] regarding this patient. Per Ombudsman, if the patient has been at the facility longer than 30 days and has not received a 30 day discharge notice, then the patient will have to return to [facility]. 1/30/24 2:50 PM - C4 documented in hospital discharge planning notes, . Per [facility] liaison, her administration still is declining the patient . 1/31/24 2:24 PM - C4 reported situation to DHCQ. 2/7/24 8:44 AM - C4 documented in hospital discharge planning notes, CM received call from liaison of [facility] stating that they have to take the patient back once he is medically cleared to do so . patient has another UTI, on IV antibiotics with ID (infectious disease) following. 2/15/24 10:36 AM - C4 documented a late entry in the hospital discharge planning notes, liaison of [facility] asked CM yesterday if this patient was on isolation for his ESBL (extended -spectrum beta- lactamases) UTI. CM stated patient is currently not being isolated. Per liaison, the facility isolates for this organism until the resident has completed treatment. Liaison stated [facility] does not have any isolation beds at this time but she will double check. 3/4/24 12:02 PM - C4 documented in hospital discharge planning notes, Patient for discharge. Confirmed with liaison of [facility] that they have a bed available. CM scheduled 1600 pick up time . 10/30/24 2 :46 PM - During an interview, E58 (RDO) stated, . [R125] was here on Med A rehab and burned through his 100 days. He was sent to the hospital . I don't remember why he was transferred to the hospital. He did not have a payor source so we did not want to take him [R125] back . [R125] had refused to participate in the Medicaid application process . he would not share his financial details . at the time, I and the facility did not know that you had to give a 30 day discharge to residents whether they are long term care or a rehab resident. We thought that only had to be done for long term care residents. I don't think other states have that policy. Again, we were not aware. When he was in the hospital, he was not even a paid bedhold at that time. Now he is Medicaid. We had a training session with C6 (DE Health Care Facilities Administrator), C7 (DE Ombudsman) and C8 (DE Ombudsman) regarding this. 11/13/24 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E27 (ADON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman office. 1 out of 6 residents

Based on observation and interview, it was determined that for residents rooms observed in three out of five hallways and two shower rooms, the facility failed to ensure that the necessary housekeeping and maintenance services were performed to maintain a sanitary and comfortable interior with an adequate supply of clean linens that are in good condition. Findings include: 1. Surveyor observations from 10/28/24 and 10/29/24 revealed: B hallway: - Room B1: floor in the bedroom was dirty with stains. Along the baseboard under the window was a old heating system but in disrepair where it was coming apart and dirt can be seen inside of it. The shared bathroom had a over the toilet commode with rusted legs. The bathroom door had a vent that was rusted along the top. Two plastic wash bins were sitting directly on the floor uncovered. - Room B3: floor in bedroom was dirty with stains and dust, especially the corners. In addition, there were two nails exposed on top of the windowsill and the windowsill was in disrepair as it was missing a piece of the edge. - Room B5: floor in bedroom was dirty with stains and dust. - Room B7: floors in bedroom and bathroom were dirty with stains and dust. F hallway: - Room F14: right side quarter length bed rail was laying on top of the resident's dresser as the Surveyor was told by the resident that her bed rail was knocked off . two weeks ago. On 11/7/24 from 3:42 PM to 4:10 PM - An environmental tour conducted with E17 (Regional Maintenance Director) and E18 (Environmental Services Director) revealed the following: B Hallway: - Room B1: bedroom and bathroom floors were dirty with stains and dust. The shared bathroom had an over the toilet commode with rusty legs and gray paint chipping off the legs. There were two plastic wash bins sitting directly on the floor uncovered. The bathroom door vent was rusted at the top. The old heating system (not in use anymore) along the baseboard under the window was in disrepair with dirt observed inside. - Room B3: bedroom was inaccessible during the environmental tour. Surveyor reviewed with E17 the following issues that were identified during screening on 10/29/24: two nails exposed on top of the windowsill and the windowsill was in disrepair as it was missing a piece of the edge. - Room B5: bedroom floor and fall mat were dirty with stains. - Room B7: shared bedroom and bathroom floors were dirty with stains. - Room B15: shared bathroom floor was dirty with stains and no trashcan liner was in place. E Hallway: - Room E15: bedroom and bathroom had discolored ceiling tiles and the wall against the bed had chipped paint and scratches. F Hallway: - Room F14: right side quarter length bed rail was observed still laying on top of the resident's dresser. Observations of two community shower rooms revealed: - B Hallway shower room had broken floor tile, discolored grout in the shower, the shower chair had brown substance smeared on the left side and small brown clumps were scattered on the shower floor and the ceiling light cover had evidence of insect debris. - E Hallway shower rooom floor was dirty and the ceiling light cover had evidence of insect debris. There was black debris in tile grout in many locations of the room, and it was heavier in the resident shower space, the wheelchair scale was dirty with debris, and there were shoes and wheelchair parts scattered on the floor in the toilet area. During a combined interview while on the environmental tour, E18 stated that the shower rooms get cleaned everyday. When the Surveyor asked if the facility conducts housekeeping audits, E17 and E18 were unable to provide any evidence. E17 stated that he has not been in this building for approximately one year. E17 stated that the facility has had three (3) maintenance directors over the past year and the most recent one just resigned yesterday. When asked to see the monthly maintenance audits, E17 stated that he cannot find them. E17 stated that they use an electronic system to track their work orders called Records, which has been in use for one year. All findings were confirmed during the tour. 46134 2. Surveyor observations on 10/28/24 at 2:45 PM and 10/29/24 at 3:23 PM revealed the following: C hallway room [ROOM NUMBER]: - The bathroom lacked a hand soap dispenser, and the hand sanitizing gel dispenser was empty; - Holes on the bathroom wall were present where the previous soap dispenser had been located; - The ventilation grate on the bathroom door had visible areas of rust; - The bathroom floor in bathroom appeared dirty; - The walls in the bedroom were in disrepair, with visible peeling paint. 10/30/24 8:15 AM - Observations of the E wing linen closet revealed a minimal supply of linens: - 2 fitted sheets; - 5 flat sheets; - No washcloths or towels. 10/30/24 8:20 AM - During an interview E23 (CNA) confirmed the lack of linens in the E wing linen closet. 10/30/24 2:00 PM - The observations for room C hallway room [ROOM NUMBER] were confirmed by E12 (Maintenance Director) during a tour of the C hallway room [ROOM NUMBER] bathroom and bedroom. 10/31/24 8:30 AM - Observations of the D wing linen closet revealed a minimal supply of linens: - 1 fitted sheet; - 1 bed pad; - 2 wash cloths; - No towels. 10/31/24 8:45 - During an interview, E26 (LPN) and E59 (CNA) confirmed the D wing linen closet observation and stated that in the facility, there are never enough linens, any day or at any time, and it makes it difficult to do our jobs. 10/31/24 10:09 AM - During an interview with another surveyor, E26 stated that because there were no wash cloths available to use, that E26 needed to use a towel to both wash and dry a resident while providing care to the resident. E26 stated that one side is wet and one side is dry. 10/31/24 11:17 AM - During an interview, E18 (Environmental Services Director-Housekeeping) stated that there is no overnight laundry staffing shift in place in the facility, so dirty linens do not get laundered overnight, and that affects how quickly linen closets are restocked with clean linens the next morning. The morning laundry shift must come in and get started right away to do laundry from the night before, in order to resupply the linen closets with clean linens. 11/13/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman's office.

Based on observation, record review and interview, it was determined that for one (R41) out of five residents reviewed for medications and three (R14, R67 and R76) out of seven residents reviewed for side rails, the facility failed to develop and implement individualized care plans with respect to a seizure disorder and bed rail usage that included measurable objectives and timeframes. Findings include: 1. R41's clinical record revealed: 11/22/20 - R41 had a active physician's order for Levetiracem 500 mg tablet two times a day for a diagnosis of seizure disorder. 8/9/24 - The significant change MDS assessment documented that seizure disorder was an active diagnosis. Review of R41's comprehensive care plan lacked evidence of an individualized seizure disorder care plan. 11/12/24 at 10:34 AM - During a combined interview, finding was confirmed with E2 (DON) and E4 (LPN/QA/IC). 2. Cross refer F700, example 2 R14's clinical record revealed: 11/7/24 at 4:50 AM - Surveyor observed R14 receiving incontinence care in her bed with left sided quarter length (22 inches) bed rail positioned up, stationary and padded with gray styrofoam. Review of R14's comprehensive care plan revealed the absence of a person-centered care plan for the left side quarter length bed rail. 11/7/24 at 1:50 PM - During a combined interview with E2 (DON) and E47 (RCC), the Surveyor requested R14's bed rail care plan. The facility lacked evidence that a bed rail care plan was developed and implemented for R14. 3. Cross refer F700, example 4 R67's clinical record revealed: 10/31/24 at 9:52 AM - Surveyor observed R67 in bed with the bilateral grab bars (12 inches in length) positioned up and stationary, with the right side padded with gray styrofoam. 11/7/24 at 1:50 PM - During a combined interview with E2 (DON) and E47 (RCC), the Surveyor requested R67's person-centered care plan for bilateral bed rails/grab bars. The facility lacked evidence that a bed rail care plan was developed and implemented for R67. 46134 4. Cross refer F700, example 6 Review of R76's clinical record revealed: 2/22/23 - R76 was admitted to the facility. 10/28/24 11:30 AM - During an observation a left sided quarter bed rail was in place in place on R76's bed. 11/7/24 - A review of R76's care plan revealed the lack of a care plan focus for the bed rail on R76's bed. 11/12/24 1:32 PM - During an interview, E3 (LPN) confirmed the lack of a care plan focus area for R76's bed rail. 11/13/24 at 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman's office.

Based on observation, record review and interview, it was determined that for one (R67) out of three residents reviewed for activities, two (R6, and R16) out of seven residents reviewed for bed rails, and three (R18, R55 and R76) out of three residents reviewed for enhanced barrier precautions, the facility failed to review and revise each residents' comprehensive care plan. Findings include: 1. R67's clinical record revealed: 12/19/23 - R67 was admitted to the facility with a diagnosis of dementia. 12/21/23 - R67's activity care plan with an intervention that included, but was not limited to, . preferred activities are: card/board games, exercise/sports, religious services, reading, trivia, outdoors (in appropriate weather months), gardening/floral arrangements, music, manicure, special themed events. 6/18/24 at 12:27 PM - An activity note documented that R67 . refused invitations this past quarter to arts & (and) crafts, Coral Springs Cafe, bingo, religious services, exercise, word games, reading, music, women's group, and manicure . 9/10/24 at 7:27 AM - An activity note documented that R67 . refused invitations this past quarter to arts & crafts, Cafe, bingo, exercise, manicure, outdoors, (in appropriate weather months), religious services, STARS [group program for high risk fall residents] and board games . The facility failed to review and revise R67's activity care plan since admission to ensure that it is individualized and person-centered based on resident's previous lifestyle (occupation, family, hobbies). Although the care plan stated that R67 enjoys Indian music, it does not address how and when this activity was to be provided. R67's care plan does not address the resident's physical and mental capabilities to participate in the general activities as she has dementia with a BIMS of 6. The admission MDS stated that it was very important that R67 had family involvement in her care, but the care plan does not reflect participation and input by R67's family. 11/12/24 at 9:52 AM - During an interview, E16 (AD) acknowledged that R67's activity care plan was not reviewed and revised to ensure that it was person-centered. 2. Cross refer F700, example 1 R6's clinical record revealed: 10/29/24 at 7:11 AM - Surveyor observed bilateral quarter length (22 inches) bed rails positioned up while R6 was in bed sleeping. 11/7/24 at 1:50 PM - During a combined interview with E2 (DON) and E47 (RCC), the Surveyor requested R6's person-centered care plan for bilateral bed rails. In response, the facility provided a care plan for potential for falls with injury with an intervention, last revised on 6/7/23, for a right side rail only for turning/transfers. The intervention also addressed to Ensure side rails are maintained with no gaps between rail and mattress and are secured properly. Assess need and safe use of rail quarterly and as needed for change in resident condition. The facility failed to review and revise R6's comprehensive care plan to reflect the current use of bilateral quarter length bed rails and ensure the bed rail care plan was person-centered with measureable outcomes and goals. 3. Cross refer F700, example 3 R16's clinical record revealed: 10/29/24 at 9:15 AM - Surveyor observed R16 in bed eating breakfast with bilateral quarter length side rails positioned up and stationary. 11/7/24 at 1:50 PM - During a combined interview with E2 (DON) and E47 (RCC), the Surveyor requested R6's individualized care plan for bilateral bed rails. In response, the facility provided a care plan for potential for injury related to falls with an intervention, last revised on 8/27/23, for bilateral rails as enabler to assist with turning and/or transfers. The intervention also addressed to Ensure side rails are maintained with no gaps between rail and mattress and are secured properly. Assess need and safe use of rail quarterly and as needed for change in resident condition. The facility failed to review and revise R16's comprehensive care plan to reflect that the bed rail care plan was person-centered with measurable outcomes and goals. 46134 4. Review of R18's clinical record revealed: 11/18/09 - R18 was admitted to the facility. 9/27/24 - R18's quarterly MDS documented that R18 had multiple current diagnoses including dysphagia (difficulty swallowing), right sided paralysis following a stroke and that R18 had a feeding tube. 11/7/24 - A review of R18's care plan lacked the infection control focus for EBP. 5. Review of R55's clinical record revealed: 12/13/17 - R55 was admitted to the facility. R55 had multiple current diagnoses including dysphagia (difficulty swallowing) and left sided paralysis following a stroke. and that R55 had a feeding tube in place. 9/30/24 - R55's quarterly MDS documented that R55 had multiple current diagnoses, including dysphagia (difficulty swallowing) and left sided paralysis following a stroke. R55 had a feeding tube in place. 11/7/24 - A review of R55's care plan revealed the lack the infection control precaution focus for EBP. 6. Review of R76's clinical record revealed: 2/22/23 - R76 was admitted to the facility. 9/27/24 - R76's quarterly Minimum Data documented that R76 had multiple diagnoses, including end stage kidney disease and required dialysis (cleansing of the blood by artificial means when kidneys have failed). Review of R76's care plan revealed that R76 had a dialysis port (an opening implanted into the skin) for dialysis. 11/7/24 - A review of R76's care plan lacked the infection control precaution focus area of EBP. 11/12/24 8:15AM - During an interview, E54 (RN) confirmed that the care plans for R18, R55 and R76 failed to include the care plan focus area of EBP. 11/13/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman's office.

Based on record review and interview, it was determined that for five (R15, R102, R260, R310, R457) out of seven residents reviewed for assessments, the facility failed to meet the professional standards of practice by having an LPN complete assessments in violation of the State of Delaware Nursing Scope of practice. For R260, the facility failed to have an RN complete the post fall assessment. For R15, R102, R310 and R457, the facility failed to have an RN complete the Admission assessments as required by the Delaware Nursing Scope of Practice. Findings include: 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 . Admission History Review - RN . The facility policy on falls, last updated 4/2024, indicated, When a resident experiences a fall, the facility will: a. assess the resident. b. complete a post fall assessment. The policy lacked evidence that the initial post fall assessment be completed by a Registered Nurse. 1. Review of R260's clinical record revealed: 11/19/23 1:45 PM - E24 (LPN) documented on a fall incident report, Called to assess [R260] post fall. Resident found laying on the floor in room .RN notified. MD contacted and no new orders at this time. The incident report contained VS, pain assessment, and neurological checks completed by E24 (LPN) as part of the initial post fall assessment. 11/4/24 1:00 PM - During an interview, E2 (DON) and E4 (QA) confirmed that the RN should be doing the [initial post fall] assessment. 11/4/24 1:22 PM - During an interview, E24 (LPN) confirmed completion of R260's initial post fall assessment on 11/19/23. E24 stated that any nurse can completed the initial post fall assessment. 47621 2. Review of R15's clinical record revealed: 9/20/23 - R15 was admitted to the facility. 9/22/24 to 9/26/24 - R15 admitted to the hospital. 9/27/24 - R15 readmitted to the facility after hospital stay. 9/27/24 - E55 (LPN) completed the following facility required Admission Assessments: A. Resident Basics/Vitals/Medical History, B. Sensory/Facility Orientation/Elopement Risk, C. Pain, D/E. Musculoskeletal/Fall/Lift/Side Rail or Grab/ Skin Integrity/Braden Scale, F. Oral/Nutrition, G. Respiratory/Smoking, H. Bowel & Bladder, and I. IV/Other. An LPN, not an RN as required by the State of Delaware regulation for the Board of Nursing Scope of Practice, completed the initial assessments. 3. Review of R102's clinical record revealed: 8/20/23 - R102 was admitted to the facility. 9/20/24 to 9/22/24 - R102 admitted to the hospital. 9/22/24 - R102 readmitted to the facility after hospital stay. 9/22/24 - E60 (LPN) completed the following facility required Admission Assessments: A. Resident Basics/Vitals/Medical History, B. Sensory/Facility Orientation/Elopement Risk, C. Pain, D/E. Musculoskeletal/Fall/Lift/Side Rail or Grab/ Skin Integrity/Braden Scale, F. Oral/Nutrition, G. Respiratory/Smoking, H. Bowel & Bladder, and I. IV/Other. An LPN, not an RN as required by the State of Delaware regulation for the Board of Nursing Scope of Practice, completed the initial assessments. 4. Review of R310's clinical record revealed: 10/18/24 - R310 was admitted to the facility. 10/19/24 - E61 (LPN) completed the following facility required Admission Assessments: B. Sensory/Facility Orientation/Elopement Risk, C. Pain, F. Oral/Nutrition, G. Respiratory/Smoking, H. Bowel & Bladder, and I. IV/Other. 10/21/24 - E27 (RN/ADON) completed the following facility required Admission Assessment, A. Resident Basics/Vitals/Medical History. Of note, Section D/E. Musculoskeletal/Fall/Lift/Side Rail or Grab/Skin Integrity/Braden Scale of the facility required Admission Assessments was not completed for R310's admission. An LPN, not an RN as required by the State of Delaware regulation for the Board of Nursing Scope of Practice, completed the initial assessments. 5. Review of R457's clinical record revealed: 10/12/24 - R457 was admitted to the facility. 10/16/24 - E62 (LPN/UM) completed the following facility required Admission Assessments: A. Resident Basics/Vitals/Medical History, B. Sensory/Facility Orientation/Elopement Risk, C. Pain, D/E. Musculoskeletal/Fall/Lift/Side Rail or Grab/ Skin Integrity/Braden Scale, F. Oral/Nutrition, G. Respiratory/Smoking, H. Bowel & Bladder, and I. IV/Other. An LPN, not an RN as required by the State of Delaware regulation for the Board of Nursing Scope of Practice, completed the initial assessments. 10/31/24 - During an interview, E2 (DON) stated that the facility required the following admission assessments when a resident was admitted : A. Resident Basics/Vitals/Medical History, B. Sensory/Facility Orientation/Elopement Risk, C. Pain, D/E. Musculoskeletal/Fall/Lift/Side Rail or Grab/ Skin Integrity/Braden Scale, F. Oral/Nutrition, G. Respiratory/Smoking, H. Bowel & Bladder, and I. IV/Other. E2 provided the surveyor with blank copies of each of these admission assessments. 11/4/24 3:33 PM - During an interview, E62 (LPN/UM) confirmed that she completed the facility required admission assessments for R457. E62 stated that she was not aware that admission assessments were outside of her (LPN) scope of practice. 11/13/24 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E27 (ADON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman office.

Based on observation, record review and interview, it was determined that for seven (R6, R14, R16, R60, R67, R76 and R119) out of seven residents reviewed for bed rails, the facility failed to have a system in place to ensure that each resident was assessed, risks/benefits reviewed, alternatives attempted, informed consent obtained prior to the installation of bed rails. Findings include: According to the Centers for Medicare and Medicaid Services State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, issued 8/8/24, under F700 Bed Rails, Definitions . 'Bed rails' are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of the bed. Examples of bed rails include, but are not limited to: - Side rails, bed side rails, and safety rails; and - Grab bars and assist bars . The facility's policy and procedures, dated 09/2024, entitled Bed rails stated the following: Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails/Enabler bars. If bed rails/enabler bars are used, the facility ensures correct installation, use and maintenance of the rails. Guidelines 1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails/enabler bars meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms b. Cognition c. Mobility (in and out of bed) d. Risk of falling 2. The resident assessment must also assess the resident's risk from using bed rails. Examples of the potential risks with the use of bed rails include: a. Accident hazards (e.g. falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails) b. Barrier to residents from safely getting out of bed. 3. If it is determined to be a restraint, the facility will follow their procedures related to physical restraints. 4. The facility will attempt to use appropriate alternatives prior to installing or using bed rails. Alternatives include, but are not limited to: a. Lowering the bed b. Concave/perimeter mattresses c. Enabler/grab bars 5. Alternatives that are attempted should be appropriate for the resident, safe and address the medical conditions, symptoms or behavioral patterns for which a bed rail was considered . 1. Cross refer to F657, example 2 R6's clinical record revealed: 11/7/17 - R6 was admitted to the facility. 10/29/24 7:11 AM - Surveyor observed bilateral quarter length (22 inches) bed rails positioned up while R6 was in bed sleeping. The bed rails cannot be lowered as they are stationary. Review of R6's clinical record lacked evidence of the following: - the specific date the bed rails were installed; - the medical need for the bed rails; - the attempt to use appropriate alternatives prior to installing the bed rails; - an assessment of R6 for risk of entrapment from bed rails prior to installation; - review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation; and - review the bed dimensions are appropriate for the resident's size and weight. 11/4/24 10:19 AM - The facility's form entitled Side Rail/Grab Bar Evaluation documented that R6 only had a left bed rail despite the Surveyor's observation of bilateral bed rails on 10/29/24. 11/7/24 1:30 PM - During an interview, E66 (Rehab Director) stated that rehabilitation evaluates the residents and determines if bed rails should be ordered. E66 stated that Rehab does not specify the size of the bed rails when it is communicated to maintenance that the resident was ordered a bed rail. E66 stated that he would send an email to the interdisciplinary team and maintenance staff. During this interview, Surveyors requested all therapy bed rail documentation for R6 and the email that was sent to the IDT team and maintenance. 11/12/24 1:30 PM - During a combined interview with E1 (NHA), E2 (DON), E4 (LPN/QA/IC) and E47 (RCC), Surveyors reviewed the information and assessments required prior to installing bed rails. Surveyors extended another opportunity to review facility evidence that would meet the Federal requirement up to the exit conference. The facility failed to provide evidence of the components specified in the Federal requirement prior to installing bilateral quarter length bed rails on R6's bed. In addition, the facility did not provide Surveyors with the email(s) referenced in E66's interview. 2. Cross refer F656, example 2 R14's clinical record revealed: 5/31/19 - R14 was admitted to the facility with a diagnosis of dementia. 7/30/24 - The quarterly MDS assessment documented that R14 had a BIMS of 3, which reflects a severe cognitive impairment. 10/28/24 1:01 PM - The facility's form Side Rail/Grab Bar Evaluation by E54 (RN, UM) documented, that R14 was educated on the risks associated with side rail/grab bar use despite having a severe cognitive impairment. 11/7/24 4:50 AM - Surveyor observed R14 receiving incontinence care in her bed with left sided quarter length bed rail positioned up. The bed rail cannot be lowered as it was stationary. Review of R14's clinical record lacked evidence of the following: - the specific date the bed rails were installed; - the medical need for the bed rails; - the attempt to use appropriate alternatives prior to installing the bed rails; - an assessment of R14 for risk of entrapment from bed rails prior to installation; - review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation; and - review the bed dimensions are appropriate for the resident's size and weight. 11/7/24 1:30 PM - During an interview, E66 (Rehab Director) stated that rehabilitation evaluates the residents and determines if bed rails should be ordered. E66 stated that Rehab does not specify the size of the bed rails when it is communicated to maintenance that the resident was ordered a bed rail. E66 stated that he would send an email to the interdisciplinary team and maintenance staff. During this interview, Surveyors requested all therapy bed rail documentation for R14 and the email that was sent to the IDT team and maintenance. No further information was received from the facility. 3. R16's clinical record revealed: 9/3/20 - R16 was admitted to the facility. 8/13/24 - The quarterly MDS assessment documented that R16 was cognitively intact, had a diagnosis of a stroke with right sided hemiplegia and had a functional limitation in range of motion on the right arm and leg. 10/29/24 9:15 AM - Surveyor observed R16 in bed eating breakfast with bilateral quarter side rails positioned up. The bilateral quarter length (22 inches) side rails are stationary and unable to be lowered. Review of R16's clinical record lacked evidence of the following: - the specific date the bed rails were installed; - the medical need for the bed rails; - the attempt to use appropriate alternatives prior to installing the bed rails; - an assessment of R16 for risk of entrapment from bed rails prior to installation; - review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation; and - review the bed dimensions are appropriate for the resident's size and weight. 11/7/24 1:30 PM - During an interview, E66 (Rehab Director) stated that rehabilitation evaluates the residents and determines if bed rails should be ordered. E66 stated that Rehab does not specify the size of the bed rails when it is communicated to maintenance that the resident was ordered a bed rail. E66 stated that he would send an email to the interdisciplinary team and maintenance staff. During this interview, Surveyors requested all therapy bed rail documentation for R16 and the email that was sent to the IDT team and maintenance. No further information was received from the facility. 4. Cross refer to F656, example 3 R67's clinical record revealed: 12/19/23 - R67 was admitted to the facility with a diagnosis of dementia. 10/31/24 9:52 AM - Surveyor observed R67 in bed with the bilateral grab bars (12 inches in length) positioned up and stationary. 9/2/24 10:55 AM - The facility's form entitled Side Rail/Grab Bar Evaluation completed by E54 (RN, UM) documented that R67 had bilateral half side rails despite the Surveyor's observation on 10/31/24 of bilateral grab bars. The form had grab bars as an option, but only half side rails were checked by E54. Review of R67's clinical record lacked evidence of the following: - the specific date the bed rails were installed; - the medical need for the bed rails; - the attempt to use appropriate alternatives prior to installing the bed rails; - an assessment of R67 for risk of entrapment from bed rails prior to installation; - review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation; and - review that the bed dimensions are appropriate for the resident's size and weight. 11/7/24 1:30 PM - During an interview, E66 (Rehab Director) stated that rehabilitation evaluates the residents and determines if bed rails should be ordered. E66 stated that Rehab does not specify the size of the bed rails when it is communicated to maintenance that the resident was ordered a bed rail. E66 stated that he would send an email to the interdisciplinary team and maintenance staff. During this interview, Surveyors requested all therapy bed rail documentation for R67 and the email that was sent to the IDT team and maintenance. No further information was received from the facility. 46134 5. Review of R60's clinical record revealed: 3/31/17 - R60 was admitted to the facility. 8/1/24 - R60's MDS documented that R60 had a BIMS of 10, indicating moderate cognitive impairment, and had diagnoses of high blood pressure and arthritis. 10/28/24 9:05 AM - An observation revealed a quarter length (22 inches) side rail on the right side of R60's bed. Review of R60's clinical record lacked evidence of the following: -the date that the bed rail was installed; -the attempt to use appropriate alternatives prior to installing the bed rail; -an assessment of R60 for the risk of entrapment from the bed rail prior to installation; -the presence of the informed consent for the use of a bed rail -review that the bed dimensions are appropriate for the resident's size and weight. 10/18/24 1:02 PM - The facility's form Side Rail/Grab Bar Evaluation by E21 (RN, UM) documented that R60 was educated on the risks associated with side rail/grab bar use, despite having moderate cognitive impairment. 11/7/24 1:30 PM - During an interview, E66 (Rehab Director) stated that rehabilitation evaluates residents and determines if bed rails should be ordered. E66 stated that he would send an email to the interdisciplinary team and maintenance staff. E66 stated that Rehab does not specify the size of the bed rail when it is communicated to maintenance that the resident was ordered a bed rail. During this interview, a request was made for R66 to send the surveyor all therapy bed rail documentation for R60, and the email that was sent to the IDT team and maintenance in reference to R60's bed rail. No further information was received from the facility. 6. Cross refer F656 example 4. Review of R76's clinical record revealed: 2/23/23 - R76 was admitted to the facility. 10/8/24 - R76's MDS documented that R60 had a BIMS of 11, indicating moderate cognitive impairment, and that R76 had diagnoses of renal disease and coronary artery disease. 10/28/24 9:45 AM - An observation revealed a quarter length (22 inches) side rail on the left side of R76's bed. Review of R76's clinical record lacked evidence of the following: -the date that the bed rail was installed; -the medical need for the bed rail; -the attempt to use appropriate alternatives prior to installing the bed rail; -an assessment of R76 for the risk of entrapment from the bed rail prior to installation; -the presence of the informed consent for the use of a bed rail -review that the bed dimensions are appropriate for the resident's size and weight. 11/7/24 at 1:30 PM - During an interview, E66 (Rehab Director) stated that rehabilitation evaluates residents and determines if bed rails should be ordered. E66 stated that he would send an email to the interdisciplinary team and maintenance staff. E66 stated that Rehab does not specify the size of the bed rail when it is communicated to maintenance that the resident was ordered a bed rail. During this interview, a request was made for R66 to send the surveyor all therapy bed rail documentation for R76, and the email that was sent to the IDT team and maintenance in reference to R76's bed rail. No further information was received from the facility. 7. Review of R119's clinical record revealed: 1/18/24 - R119 was admitted to the facility. 10/2/24 - R119's MDS documented that R119 had a BIMS of 10, indicating moderate cognitive impairment, and that R119 had a diagnosis of dementia. 10/28/24 10:13 AM - An observation revealed a quarter length (22 inches) side rail on the right side of R119's bed. Review of R119's clinical record lacked evidence of the following: -the date that the bed rail was installed; -the attempt to use appropriate alternatives prior to installing the bed rail; -an assessment of R119 for the risk of entrapment from the bed rail prior to installation; -the presence of the informed consent for the use of a bed rail -review that the bed dimensions are appropriate for the resident's size and weight. 11/7/24 1:30 PM - During an interview, E66 (Rehab Director) stated that rehabilitation evaluates residents and determines if bed rails should be ordered. E66 stated that he would send an email to the interdisciplinary team and maintenance staff. E66 stated that Rehab does not specify the size of the bed rail when it is communicated to maintenance that the resident was ordered a bed rail. During this interview, a request was made for R66 to send the surveyor all therapy bed rail documentation for R119 and the email that was sent to the IDT team and maintenance in reference to R119's bed rail. No further information was received from the facility. 11/13/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman's office.

Based on observation, interview and record review, it was determined that for 10 (R6, R11, R14, R52, R69, R78, R99, R103, R105 and R106) out of 13 residents reviewed for food, the facility failed to provide each resident with drinks consistent with each residents' needs and preferences. Findings include: 1. R6's clinical record revealed: 10/29/24 10:50 AM - During an interview, R6 stated that fluids are not always offered during the day. R6 stated that I have to ask. Review of the facility form entitled Brandywine 3 C.N.A. assignment, revised 5/8/23, stated, . ALL ASSIGNMENTS PASS OUT YOUR OWN WATER . 11/6/24 12:16 PM - Surveyor observed R6 in bed with a white Styrofoam cup dated 11/5/24 7-3 PM sitting on her bedside table. During an interview, the Surveyor asked R6 if she was offered fresh water since the date and shift on the Styrofoam cup. R6 said No. The facility failed to offer water to R6 on the two prior shifts. 11/12/24 1:30 PM - Finding was reviewed with E1 (NHA), E2 (DON), E4 (LPN/QA/IC) and E47 (RCC). 40264 2. 10/31/24 - An observation on the B unit from 9:07 AM through 9:55 AM revealed the following residents' meal trays which did not include coffee or tea beverages contrary to what was indicated in their breakfast meal tickets: R14 - no coffee or hot tea; R106 - no coffee or hot tea; R105 - no coffee or hot tea; R52 - no unsweetened coffee or hot tea; R103 - no coffee or hot tea; R78 - no unsweetened coffee or hot tea; R99 - no coffee or hot tea; R11 - no coffee or hot tea; and R69 - no coffee or hot tea. 10/31/24 9:13 AM - During an interview, E65 (CNA) confirmed that R14, R106 and R105 did not have coffee nor tea on their meal trays. 10/31/24 9:23 AM - In an interview, E64 (CNA) confirmed that R52, R103, R78, R99, R11 and R69 did not have coffee nor tea on their meal trays. 10/31/24 9:40 AM - In a follow up interview, E64 also stated, It happens all the time that the residents on this (B) unit are not getting their coffee or tea. If the resident requests for it, then we go to the kitchen and ask. 11/1/24 10:21 AM - In an interview, E8 (Dietary Supervisor) stated that she was not aware that some residents in the B unit did not receive their hot coffee or hot tea beverages in their meal trays. E8 further confirmed that it was a breakdown in the kitchen system and that she will need to educate the kitchen staff on the use of the coffee machine. 11/6/24 3:50 PM - During interview, E34 (Regional Dietary Consultant) stated that if a resident's meal ticket indicated coffee or tea, then the resident should have coffee or tea in his/her meal tray. In nine (9) out of 27 residents on the B unit, the facility failed to ensure that other liquids, such as coffee or tea, were provided with their breakfast meal trays to encourage fluid intake. 11/12/24 2:35 PM - Finding was discussed with E1 (NHA), E2 (DON) and E47 (Regional Clinical Consultant).

Based on record review and interview, it was determined that for eleven (R16, R18, R33, R38, R43, R55, R94, R113, R310, R456 and R457) out of forty-two residents reviewed for resident records, the facility failed to maintain complete, accurate and readily accessible resident medical records. Findings include: 1. Review of R38's clinical record revealed: 4/19/24 - R38 was admitted to the facility. 10/22/24 1:39 PM - R38's urine culture specimen that was ordered by E3 (MD) was received at the laboratory. 10/24/24 4:05 PM - R38's urine culture results were received at the facility stating 1 Organism growth. 10/24/24 11:21 PM -E52 (NP) documented in R38's EMR that the urine culture was reviewed. 11/12/24 12:53 PM - During an interview, E4 (LPN/IP) confirmed that [contracted laboratory] does not upload final culture results to the residents' EMR. The facility gets the final results and then sends the results in an email group to all the providers but it is not in the resident's records. 11/13/24 10:30 AM - The facility provided the surveyor with a copy of R38's 10/22/24 urine culture final microbiology report with sensitivity. 2. Cross refer F881, example 1 Review of R43's clinical record revealed: 9/20/24 - R43 was admitted to the facility. 10/10/24 1:00 PM - R43's urine culture specimen that was ordered by E3 (MD) was received at the laboratory. 10/12/24 3:20 PM - R43's urine culture results were received at the facility stating 1 Organism growth. 10/14/24 11:36 AM - E51 (NP) documented in R43's EMR that the urine culture was reviewed. 11/12/24 - The facility was not able to produce evidence of R43's 10/10/24 urine culture final microbiology report with sensitivity for the surveyor to review. 3. Review of R113's clinical record revealed: 11/25/22 - R113 was admitted to the facility. 10/4/24 1:53 PM - R113's urine culture specimen that was ordered by E3 (MD) was received at the laboratory. 10/6/24 3:48 PM - R113's urine culture results were received at the facility stating 1 Organism growth. 10/14/24 11:36 AM - E21 (RN/UM) documented in R113's EMR that the urine culture was reviewed. 11/12/24 12:53 PM - During an interview, E4 (LPN/IP) confirmed that [contracted laboratory] does not upload final culture results to the residents' EMR. The facility gets the final results and then sends the results in an email group to all the providers but it is not in the resident's records. 11/13/24 10:30 AM - The facility provided the surveyor with a copy of R113's 10/4/24 urine culture final microbiology report with sensitivity. 4. Review of R33's clinical record revealed: 9/30/24 - R33 was admitted to the facility with diagnoses, including but not limited to, heart failure, morbid obesity and chronic atrial fibrillation (Afib). 9/30/24 - E3 (MD) ordered in R33's electronic medical record (EMR), Rivaroxaban oral tablet 20 mg (milligrams)- give one tablet by mouth one time a day for anticoagulant. Atrial fibrillation placed R33 at risk of having her blood clot. The goal of prescribing rivaroxaban was to prevent R33's blood from clotting or to place R33 in a state of anticoagulation. Anticoagulation is not a medical diagnosis; it is a physiologic state. However, R33's medical history included a diagnosis that was a medical indication for the drug rivaroxaban, Afib. Therefore, atrial fibrillation was the medical diagnosis for R33 requiring the drug, rivaroxaban. Anticoagulant was not an adequate indication/ medical diagnosis for the order for R33's rivaroxaban. 5. Review of R94's clinical record revealed: 6/6/24 - R94 was admitted to the facility with diagnoses, including but not limited to, chronic Afib, peripheral vascular disease and rheumatic mitral stenosis. 10/8/24 - E52 (NP) ordered in R94's EMR, Warfarin Sodium oral tablet 2 mg - give one tablet by mouth one time a day every Monday, Tuesday, Wednesday, Thursday for anticoagulation. E52 also ordered in R94's EMR Warfarin Sodium oral tablet 3 mg- give one tablet by mouth one time a day every Friday, Saturday, Sunday for blood thinner. Atrial fibrillation placed R94 at risk of having her blood clot. The goal of prescribing warfarin was to prevent R94's blood from clotting or to place R94 in a state of anticoagulation. Anticoagulation is not a medical diagnosis; it is a physiologic state. However, R94's medical history of Afib was a medical indication for the drug warfarin. Therefore, atrial fibrillation was the medical diagnosis for R94 requiring the drug, warfarin. Anticoagulation and blood thinner were not adequate indications/ medical diagnoses for the order for R94's warfarin. 6. Review of R310's clinical record revealed: 10/18/24 - R310 was admitted to the facility with diagnoses, including but not limited to, chronic obstructive pulmonary disease (COPD) and history of pulmonary embolism (PE). 10/18/24 - E3 (MD) ordered in R310's EMR, Rivaroxaban oral tablet 20 mg - give one tablet by mouth one time a day for anticoagulant. A known history of PE placed R310 at risk of having her blood clot. The goal of prescribing rivaroxaban was to prevent R310's blood from clotting or to place R310 in a state of anticoagulation. Anticoagulation is not a medical diagnosis; it is a physiologic state. However, R310's medical history included a diagnosis that was a medical indication for the drug rivaroxaban, pulmonary embolism. Therefore, history of PE was the medical diagnosis for R310 requiring the drug, rivaroxaban. Anticoagulant was not an adequate indication/ medical diagnosis for the order for R310's rivaroxaban. 7. Review of R456's clinical record revealed: 10/27/24 - R456 was admitted to the facility with diagnoses, including but not limited to, chronic embolism and thrombosis and hyperlipidemia. 10/327/24 - E3 (MD) ordered in R456's EMR, Eliquis oral tablet 5 mg (apixaban)- give one tablet by mouth two times a day for anticoagulant therapy. The diagnoses of chronic embolism and thrombosis placed R456 at risk of having her blood clot. The goal of prescribing apixaban was to prevent R456's blood from clotting or to place R456 in a state of anticoagulation. Anticoagulation is not a medical diagnosis; it is a physiologic state. However, R456's medical history of chronic embolism and thrombosis was a medical indication for the drug apixaban. Therefore, chronic embolism and thrombosis was the medical diagnosis for R3456 requiring the drug, apixaban. Anticoagulant therapy was not an adequate indication/ medical diagnosis for the order for R456's apixaban. 8. Review of R457 s clinical record revealed: 10/12/24 - R457 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation and stroke. 10/12/24 - E3 (MD) ordered in R457's EMR, Apixaban oral tablet 2.5 mg (apixaban) - give one tablet by mouth two times a day for anticoagulation. Atrial fibrillation placed R457 at risk of having his blood clot. The goal of prescribing apixaban was to prevent R457's blood from clotting or to place R457 in a state of anticoagulation. Anticoagulation is not a medical diagnosis; it is a physiologic state. However, R457's medical history included a diagnosis that was a medical indication for the drug apixaban, atrial fibrillation. Therefore, Afib was the medical diagnosis for R457 requiring the drug, apixaban. Anticoagulation was not an adequate indication/ medical diagnosis for the order for R457's apixaban. 11/1/24 3:36 PM - During a telephone interview, C1 (consultant Pharmacist) confirmed that anticoagulation, anticoagulant therapy, anticoagulant and/or blood thinner were not medical diagnoses that can be used as an indication for warfarin, rivaroxaban, apixaban or any other novel anticoagulants. 46134 9. Review of R18's clinical record revealed: 11/18/09 - R18 was admitted to the facility. 9/27/24 - R18's MDS documented that R18 had multiple diagnoses including dysphagia (difficulty swallowing), right sided paralysis following a stroke, and had had a feeding tube in place. 10/14/24 - A physician's order was written by E3 (Medical Director) for enteral feed overnight, with a continuous water flush of 52 mls every hour, while the enteral feed was running, for a total of 624 mls every 24 hours. A review of the November 2024 medication administration record revealed that the enteral feed water flush total amounts for 11/7/24 thru 11/12/24 were not documented. 11/12/24 10:12 AM - During an interview, E15 (RN) confirmed that for R18's enteral feed, the total amount of water flushes on the dates 11/7-11/12 24 inclusive were not recorded. 10. Review of R55's record revealed: 12/13/17 - R55 was admitted to the facility. 9/30/24 - R55's quarterly MDS documented that R55 had multiple diagnoses including dysphagia (difficulty swallowing), left sided paralysis following a stroke and had a feeding tube in place. 10/29/24 - A physician's order was written by E3 (Medical Director) for a 50 ml water flush to be given with the enteral feed, for a total of 1000 mls every 24 hours. A review of the November 2024 medication administration record revealed that the hourly 50 ml water flush was inaccurately documented on the following dates and shifts: 11/1/24 11-7 shift - 400 ml was documented in each hourly water flush column at 1:00 AM and 2:00 AM, instead of the ordered 50 ml per hour 11/1/24 3-11 shift - 400 ml was documented in each hourly water flush column for 4:00 PM thru 10:00 PM, instead of the ordered 50 ml per hour. 11/2/24 3-11 shift - 400 ml was documented in each hourly water flush column for 4:00 PM thru 6:00 PM instead of the ordered 50 ml per hour. 11/6/24 1:30 PM - During an interview, E4 (LPN) confirmed the incorrect hourly documentation of 50 ml hourly water flushes above. 32545 11. R16's clinical record revealed: 11/5/20 (last reviewed on 6/10/24) - R16 was care planned for potential for skin impairment with an intervention to have nursing staff assist with incontinence care every 2 hours and as needed. 8/13/24 - The quarterly MDS assessment documented that R16 was cognitively intact with a BIMS of 12, frequently incontinent of bladder and required substantial/maximal assistance for toileting hygiene. 11/6/24 at 12:18 PM - During an interview with R16, the resident told the Surveyor that she should receive incontinence care every 2 hours, but this was not being done. Review of the CNA Kardex, as of 11/1/24, documented that R16 was on a Toileting Program 0500-0600 [5:00-6:00 AM], 0800-0900 [8:00-9:00 AM], 1400-1500 [2:00-3:00 PM], 2100-2200 [9:00-10:00 PM]. While R16's comprehensive care plan documented that the resident was to receive incontinence care every 2 hours, the CNA Kardex stated that R16 was on a toileting program. There was no evidence in R16's comprehensive care plan about a toileting program. The facility failed to ensure R16's CNA Kardex accurately reflected R16's incontinence care needs. 11/13/24 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E27 (ADON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman office.

Based on observation, interview, record review and other facility documentation it was determined that for one (R313) out of one resident reviewed for wandering and elopement the facility failed to provide adequate supervision that contributed to the elopement of R313 and put the resident at immediate jeopardy and risk of a serious adverse outcome. R313 was able to elope from the facility on 9/17/22 and wander to a neighborhood behind the facility, fell in a driveway and was taken to the hospital by ambulance. An immediate jeopardy (IJ) was identified starting on 9/17/22. Due to the facility's corrective measures following the incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 9/19/22. Findings include: A facility policy titled Elopements and Wandering Residents documented . This facility ensures that residents who exhibit wandering behavior and or are at risk for elopement receive adequate supervision to prevent accidents and receive in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . 1. The facility is equipped with door locks/alarms to avoid elopements . 2. Alarms are not replacements for necessary supervision. Staff are vigilant in responding to alarms in a timely manner. 1. Review of R313's clinical record revealed: 7/19/16 - R313 was admitted to the facility with a diagnosis of depression, anxiety and later diagnosed with Alzheimer's disease and dementia. 5/2/22 11:30 AM - The elopement evaluation documented 1. Resident is exit seeking . 2. Wanting to go home . 3. Watching others go out the door . 3. Independent with ambulation . 4. Elopement attempted in the last 30 days . 5. Resident is at risk for elopement. 5/2/22 - A nursing progress note documented, [R313] had increased behaviors and had wandered to the front door to leave the facility. 5/2/22 - Review of R313's care plan for elopement risk documented, [R313] is at risk for elopement related to cognitive deficits and exit seeking. Resident is observed to remove ID (Identification) bracelet frequently . 1. Resident will have no significant injury related to wandering for 90 days . 2. Engage resident in activity as needed . 3. Give fluids as needed . 4. Give food as needed . 5. Redirect as needed. 7/1/22 - Review of R313's MDS Assessment for a significant changed documented R313 was severely cognitively impaired. The facility investigation documented the following timeline for R313's elopement on 9/17/22. -4:45 PM - 5:00 PM - R313 was toileted and later observed ambulating in a hallway in the facility. -5:15 PM - Resident was offered dinner and did not eat. -5:20 PM - Camera footage showed R313 was wandering in and out of resident rooms on the F- hallway. -5:28 PM - Camera footage showed R313 wandering into room F8. -5:43 PM - Resident wandered off the facility property to a neighborhood behind the facility. The resident was seen by a homeowner walking across a driveway, the homeowner asked the resident it they needed help. The resident started walking and tripped on the sidewalk and fell face first on to the grass. -5:47 PM - The neighbor called 911 and the resident was transported to the hospital emergency room by EMS (Emergency Medical Services). -7:00 PM - A statement written by C15 (CNA) revealed, the resident was not in their room. -8:00 PM - 9:00 PM - E1 (NHA) and E2 (DON) were notified R313 was missing and 911 had been called. -10:05 PM - The ADON received a call from the Police to notify the facility that the resident had been taken to the hospital emergency room and that the facility to call the hospital. -10:10 PM - The ADON contacted the hospital and verified the resident was in the emergency room . 9/18/22 7:10 AM - The resident returned to the facility. The facilty provided the following corrective measures: 9/18/22 - Review of R313's revised care plan documented 1:1 supervision. 9/18/22 - All windows and potential exits were checked and secured on 9/18/22. 9/18/22 - R313 was placed on 1:1 supervision and was treated for a urinary tract infection. Care plan reviewed and updated by the DON/designee to reflect current wandering and elopement risk. 9/18/22 - Windows were checked by maintenance director daily for one week. Then weekly for four weeks and then monthly for the next quarter, and increased checks based on any renovations occurring in the facility. 9/18/22 - NHA/designee in-serviced maintenance department to monitor windows and doors to assure that they are secured. 9/18/22 - Elopement drill done to validate compliance with the facility policy and procedures and education provided. NHA/designee did random audits of five rooms in each unit to ensure windows are secured weekly for four weeks then monthly for the next quarter, and then routine checks every three months. In addition, findings are reviewed in the QAPI (Quality Assurance Process Improvement) meetings monthly for three months. 9/20/22 - Review of R313's revised care plan documened [R313] will not elope from the facility for 90 days . 1. ID bracelet as resident allows. 9/28/22 - Review of R313's revised care plan documented ambulate resident through the building as a redirection tool. 5/12/23 - Additionally, the facility installed a wander guard program system as a preventative measure for residents that are at risk for elopement from the facility. 11/3/23 2:45 PM - During an interview, the DON revealed, [R313] came down the hall looked in room F8 and never came out of the room and that the window was open in the room. 11/6/23 12:48 PM - A telephone interview with C15 (CNA) revealed, [R313] is always walking around in the building and on 9/17/22 after dinner C15 had checked in [R313's] room and [R313] was not in the room. In addition, C15 revealed R313 had climbed out of the window in room F8. 11/6/23 2:00 PM - During an interview MA2 (Maintenance Assistant) said, yellow caution tape had been placed across the doorway of room F8 (a room under maintenance) before MA2 exited the building on Friday 9/16/22. Additionally, MA2 revealed that on 9/18/22 after R313 had eloped, maintenance checked all the windows in the facility and had secured the latches on the windows with screws. 11/6/23 2:27 PM - During another interview MA2 said, I really can't tell you how R313 managed to get out of the window. 11/8/23 11:38 AM - Another interview with MA2 revealed, MA2 had returned to the facility on [DATE] after (R313's) elopement and checked the window in room F8 and found that the latch on the left side of the window was broken. 11/8/23 - Staff interviews with LPN7, CNA9, and MA2 confirmed staff educations and elopment drills had been conducted. In addition, education for elopement, drills, audits, 1:1 supervison for R313 and safety checks for the facility had been completed. It has been determined that the facility abated the IJ on 9/19/22. 11/8/23 1:18 PM - Findings were reviewed with NHA, Interim DON and REG at the Exit Conference.

Based on record review and interviews, it was determined that the facility failed to recognize, evaluate and address R198's hydration status to ensure R198 maintained proper hydration and health. This failure caused harm to R198 as evidenced by R198's insufficient fluid intake and diminished hydration status which resulted in R198's hospitalization with a critically high sodium level and a diagnosis of dehydration. Findings include: The U.S. National Academies of Sciences, Engineering, and Medicine determined that an adequate daily fluid intake is about 3700 cc (cubic centimeter) of fluids a day for men and 2700 cc of fluids a day for women. These recommendations cover fluids from water, other beverages and food. About 20% of daily fluid intake usually comes from food and the rest from drinks. Nutrition Calculation Reference Sheet- Determining fluid needs can be based on calorie intake OR weight .Calculation: weight in kgs (kilograms) X (times) fluid factor . Fluid factors: 25 ml (milliliters) X kg body weight for [AGE] year old or inactive . (University of California, [NAME], 10/7/2023) R198's clinical record revealed: 11/25/22 2:41 PM - The hospital History and Physical documented, .labs notable for elevated creatinine 1.3 with no known h/o (history of) CKD (chronic kidney disease) or baseline creatinine . 12/1/22 12:04 PM - The hospital discharge summary stated, .Patient (R198) was found to have acute kidney injury which improved with IV (intravenous) fluid hydration . 12/1/22 - R198 was admitted to the facility with diagnoses including but not limited to dementia, acute kidney failure, hypertension and falls. 12/1/22 6:13 PM - R198's weight documented as 198 pounds (90 kilograms). Based on the UC [NAME] Nutrition calculation reference sheet, R918 required 2250 mls of fluid intake per day. 12/1/22 - E2 (DO) ordered a no added salt diet, regular texture, regular consistency for R198. 12/1/22 - E2 (DO) ordered, Administer a minimum of 120 cc of appropriate fluid per shift with medication administration unless ordered otherwise. Every shift if resident consumes less than 120 cc document per shift in progress note. 12/1/22 - R198's care plan stated, resident has ADLs (activities of daily living) care deficit and listed an intervention of staff to assist with ADLs as needed. 12/7/23 - R198's admission Minimum Data Set (MDS) documented her functional status for eating (how resident eats and drinks, regardless of skill) as limited assistance, one person physical assist. Limited assistance is defined in the MDS for this skill as the resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance. R198's Minimum Data Set (MDS) documented a Basic Inventory of Mental status (BIMS) score of 8, which was indicative of moderate cognitive impairment. 1/3/23 11:48 AM - RD documented, Per SLP (Speech therapy) recommendations, liquids (for R198) downgraded on this day to NTL (nectar thick liquids). Diet : regular/NTL. Will continue to monitor nutritional parameters and update CP (care plan). 1/3/23 - E2 (DO) changed diet order to regular diet, regular texture, nectar thick consistency (liquids downgraded to nectar thick). Nectar thick fluids are thicker than water, fall slowly from a spoon and can be sipped through a straw. 1/3/23 11:48 AM - NP evaluated R198 for new onset difficulty swallowing and ordered CBC (complete blood count) and BMP (basic metabolic panel) on 1/4/23. NP documented in the Progress Note.Physical exam: Edema- +1 edema R (right) > L (left) . 1/3/23 (revised) - R198's care plan, initiated 12/2/22, stated [R198] has p/f (potential for) Nutritional Risk and p/f fluid volume deficit r/t (related to) advanced age, cognitive impairment/dementia, varying to poor intake, AKI (acute kidney injury), hypothyroidism, edema with interventions that included: Monitor for s/s (signs & symptoms) of diet intolerance, Monitor s/s of fluid volume deficit (i.e. change in mental status, poor skin turgor, decreased urinary output, dry mucous membranes, dizziness when standing /sitting) and report abnormal findings to MD (medical doctor). R198's care plan was revised on 1/3/23 to include the intervention of adaptive equipment needed as ordered: divided plate and teaspoon. 1/4/23 - R198 evaluated by NP and was diagnosed with probable aspiration pneumonia. A CXR (chest X-ray) was ordered. 1/4/23 3:04 PM - The laboratory reported R198's serum Na 141 mmol/L (normal range 137-145), chloride 10.7 (normal range 98-107) and creatinine 1.3 mg/dL (normal range 0.52-1.04). 1/5/23 12:56 PM - NP evaluated R198 and documented in Progress Note, .CXR last evening revealed mild CHF . Plan: 1. Hypertensive heart disease with CHF- will add pulse dose of lasix 20 mg daily X 3 days, continue to monitor blood pressure and fluid status . Record review of CNA task and Electronic Medical Administration Record (EMAR) documentation revealed R198's daily fluid intake and percentage of meal eaten as: 1/1/23 - 2520 cc and 76-100% (all three meals) 1/2/23 - 2520 cc and 51-75% (breakfast), 76- 100% (lunch and dinner) 1/3/23 - 1960 cc and 26-50% (breakfast), 51-75% (lunch and dinner) 1/4/23 - 2040 cc and 76- 100% (breakfast and lunch), 26-50% (dinner) 1/5/23 - 2280 cc and 76-100% (breakfast and lunch), 51-75% (dinner) 1/6/23 - 2280 cc and 76-100% (breakfast and lunch), 26-50% (dinner) 1/7/23 - 1800 cc and 26-50% (breakfast and lunch), 51-75% (dinner) These fluid intake numbers included extra fluids given at medication pass as well as documentation by the CNAs of fluids consumed during meals and at the bedside. Multiple nurse notes between 1/5/23 and 1/10/23 documented fluids encouraged, encouraged extra fluids along with refused dinner and had a good appetite. 1/8/23 - R198 tested positive for COVID-19 virus and was placed in isolation per the facility's COVID-19 infection control policy for 10 days. 1/9/23 - R198's weight documented as 164 pounds (74.5 kilograms). Based on the UC [NAME] Nutrition calculation reference sheet and this significant weight change, R918 now required 1863 mls of fluid intake per day. 1/10/23 1:33 PM - NP evaluated R198 after being diagnosed with COVID-19. NP documented in R198's progress note, . Plan: 1. Hypertension with CHF- resident recently completed Lasix pulse dose, continue verapamil 240 mg, continue to monitor blood pressures, may trend down if resident not drinking (sic), will closely follow. Despite documenting that R198 will be followed closely, this was the last evaluation/ note written by a provider about R198 and her care until 1/20/23, the morning R198 is sent to the hospital with a mental status change. 1/11/23 2:43 PM - RD documented, .Had resident care conference on this day .Questioning weights currently .Weight fluctuations to be expected with CHF and edema. Pending reweigh .Discussed labs, diet, PO (per oral) intake. Intake does seem decreased the last few days, mainly 25-50% .Will add supplementation at this time. Will continue to monitor nutritional parameters. 1/11/23 - E2 ordered Mighty shakes two times a day for decreased PO intake, with lunch and dinner, prefers chocolate. Mighty shakes contain 250 cc of fluid. Record review of CNA task documentation revealed R198's daily fluid intake and percentage of meal eaten after her COVID infection diagnosis as: 1/8/23 - 1320 cc and 51-75% (breakfast and lunch), 26-50% (dinner) 1/9/23 - 1080 cc and 26-50% (breakfast), refused lunch, 0-25% (dinner) 1/10/23 - 2000 cc and breakfast not documented, 26-50% (lunch), 0-25% (dinner) 1/11/23 - 2040 cc and 26-50% (breakfast and lunch), refused dinner 1/12/23 - 1020 cc and breakfast and lunch not documented, 26-50% (dinner) 1/13/23 - 840 cc and 76-100% (breakfast), refused lunch and dinner 1/14/23 - 1260 cc and not applicable (breakfast and lunch), 26-50% (dinner) 1/15/23 - 1740 cc and 26-50% (breakfast), refused lunch, 26-50% (dinner) 1/16/23 - 1380 cc and 0-25% (breakfast, lunch and dinner) 1/17/23 - 1380 cc and 51-75% (breakfast and lunch), 0-25% (dinner) 1/18/23 - 1200 cc and 51-75% (breakfast and lunch), 0-25% (dinner) 1/19/23 - 1020 cc and 0-25% (breakfast), lunch not documented, 0-25% (dinner). Various nursing notes from 1/12/23 to 1/19/23 documented p/t has poor meals intake, resident ate about 25% of meal, PO fluid and food intake encouraged, refused dinner, tolerated PO medications and sips of fluids, Refused dinner, tolerated 3 spoonful's of pudding and tolerated meds and consumed approx .75% of ensure clear, however she refused to eat dinner. None of the notes contained statements that the providers were notified regarding R198's poor intake. Abrupt weight changes, change in food intake or altered level of consciousness are some of the clinical manifestations of fluid and electrolyte imbalances (Journal of American Dietetic Association 2003; 103(8) 1061-1072). Despite documentation of poor PO intake, the facility failed to produce evidence that staff recognized R198's impaired hydration status and escalated the problem to the providers for further interventions such as labs or IV (intravenous) fluids. In the 12 day span in which R198 was diagnosed and being treated for COVID-19, R198 only had 2 days (1/10/23 & 1/11/23) out of 12 in which she met her required fluid intake per day (1863 mls/day). The facility failed to recognize, evaluate and address that R198 was experiencing decreased PO intake and impaired hydration. The last time R198 had lab work to check her fluid status (BMP) was on 1/4/23, which was 16 days prior to her 1/20/23 admission to the hospital. 1/20/23 9:13 AM - RN5's nurse note documented, Resident noted with decreased responsiveness, responds to name, eyes opened on and off, skin color is pale. VS 97.7 96 20 150/78, pox (pulse oximetry) 91% RA (room air). NP called and N/O (new order) to send out to the ER (emergency room ) for further evaluation and tx (treatment). RP (representative person) made aware. Resident transported via stretcher. 1/20/23 - NP documented in Progress Note, . HPI (history of present illness): Resident lying in bed lethargic and not arousable . Physical Exam: General - Resident lying in bed unresponsive, pallor .Ears/Nose/Mouth/Throat - mucous membrane moist .Edema - +1 edema R>L (right greater than left) . Plan: 1. Increased lethargy, resident unresponsive, however vital signs remained stable, heart rate is irregular resident is a full code. We will send to the ER for evaluation . This note on 1/20/23 was the first evaluation by a provider in 10 days; the last previous provider note was dated 1/10/23. 1/20/23 9:10 AM - E13's (MD) ED (Emergency Department) Physician Record documented, .86 yo (year old) F (female) with history of hypertension, atrial fibrillation on Coumadin, dementia who is typically alert and oriented x 1 or 2 per nursing home staff. History is obtained from independent historian [facility] nurse who gives the entire history as patient is altered and unable to contribute to her history. Nurse relates that she came in for a morning shift today and found the patient to be decreased responsiveness and very generally weak .Exam reveals an elderly female who appears ill, tachycardic, irregularly irregular, diminished and coarse breath sounds bilaterally, . extremely dry mucous membranes . HR (heart rate) 125 bpm (beats per minute) pulse ox 100% Source 3L/min ( supplemental oxygen) .Assessment and Plan: Broad differential . electrolyte derangements given her significant dehydration on clinical exam, hypernatremia considered, intracranial hemorrhage versus ischemic stroke . 1/20/23 9:41 AM - The hospital laboratory reported R198's serum Na (sodium) level was 165 mmol/L; this was a CRITICAL value as the normal range for serum Na is 136- 145 mmol/L. R198's serum chloride (Cl) level was 123 mmol/L, which was a high value. (normal Cl range is 98-107) and creatinine 2.53. 1/20/23 2:54 PM - E15's (Renal MD) Consult Note documented, .Labs showed sodium 165 mmol/L creatinine of 2.53 mg/dL and elevated INR of 6.2 .Assessment and Plan: Hypernatremia: presentation sodium was 165. This is due to dehydration. Serum sodium is improved by 4 mmol with lactated Ringer (intravenous fluid) X 1 L (liter). 1/20/23 3 PM - E16's Admission History & Physical (H&P) documented, XXX[AGE] year old female .admitted for acute encephalopathy (altered mental state/confusion) and AKI (acute kidney injury) .Assessment/Plan: 1- AKI (acute kidney injury)- with creatinine of 2.53 from a baseline of approximately 1.2 .etiology from significant dehydration .2-Acute hypoxemic respiratory failure- .Suspect hypoventilation from encephalopathy resulting in atelectasis .3 - encephalopathy- Likely in the setting of significant dehydration .4 - Hypernatremia - Significantly hypernatremic likely in setting of dehydration/poor fluid intake . 2/8/23 6:21 PM - R198's Discharge Summary documented, .Patient medically stable for discharge to inpatient hospice. 10/30/23 2:55 PM - During a telephone interview, E2 (DO) stated that the practice of obtaining labs on a resident, varies from patient to patient. For some residents, it can be weekly or even biweekly (typically residents on Coumadin) but it is a provider decision. 10/30/23 3:50 AM - During an interview, CNA15 stated, I took care of her (R198) a few times. She did not have the best appetite but would eat what her family brought into her. When she was sick with COVID, her appetite went down. 11/3/23 8:23 AM - During a telephone interview, FM4 (R198's daughter) stated, Prior to the COVID isolation, we would bring in food and drinks- milkshakes, for my Mom to make sure that she was eating enough. But with the isolation, we were not allowed in and all that stopped . The doctors in the ER told me this did not happen in day .Her mouth was so dry and she was begging . 'water, orange juice, soup' .I still hear her in my dreams. She never recovered from all this . 11/3/23- 9:15 PM - Findings were reviewed at the Annual Survey Exit conference with E1 (NHA), DON, REG, E4 (Regional Clinical Director) and E5 (Director of Operations).

Based on record reviews, interviews and review of facility documentation, it was determined that for 4 (R33, R78, R105 and R147) out of 57 sampled residents, the facility failed to ensure that the residents were free from abuse. Three (3) of four (4) residents (R33, R78 and R147) sustained harm (emotional abuse). R78 sustained verbal abuse from a staff member, which resulted in emotional abuse. R33 sustained emotional abuse when a wandering resident entered her room unsupervised and shoved R33 out of the way, which resulted in emotional abuse. R105 sustained physical abuse when R105's roommate slapped her arm causing redness and tenderness. R147 sustained emotional abuse when a wandering unsupervised resident entered her room causing her emotional abuse. Findings include: 1. Review of R78's clinical record revealed: 11/22/16 - Care Plan for ADLs included an approach to assist resident in bathing as per resident needs. 11/22/16 - Care plan for potential for alteration in comfort included a goal for pain will be diminished and approaches of assessing for verbal signs and symptoms of pain and assess for possible causes of pain and interventions. 2/27/17 - Care plan for resident to establish own goals, included a problem of the resident refusing shower or bed baths at times able to make own decisions with care and approaches of involve resident in the decision making of ADL and honor preferences. 8/7/18 - The quarterly MDS assessment coded R78's BIMS score as a 10 (moderate cognitive impairment- decisions poor, cues/supervision required); there were no behaviors exhibited; and bathing required physical help during part of the activity with one staff person assisting. 9/12/18 3:47 PM - Incident reported to state agency by E3 (ADON). At 11:00 AM, on the same day, E10 (LPN) had been notified that R78 was crying after an encounter with E24 (CNA). Statements collected by the facility revealed: --9/12/18 - E10 (LPN) labeled the incident as staff to resident. E10 (LPN) revealed that R78 stated s/he asked multiple times to have the bed lowered to prevent pain and the CNA (E24) did not answer. R78 began yelling at E24. E24 insisted on giving R78 a bed bath and handed R78 a washcloth. R78 threw washcloth back to CNA. R78 then told E24 to get out of the room and CNA threw washcloth back to resident. Additionally, E10's (LPN) statement revealed that R78 requested that the CNA (E24) no longer takes (sic) care of me. E10 (LPN) stated that the resident was actively crying after the incident. E10 (LPN) consoled R78. --9/12/18 - E24 (CNA) revealed that R78 kept saying s/he was hurting because of positioning of the bed, but E24 (CNA) revealed nothing about adjusting the bed or resident. --9/12/18 - E25 (CNA) labeled the incident as verbal abuse. E25 (CNA) was present in the room just after the incident. E25 (CNA) revealed that E24 (CNA) stated that she would be leaving the building if it happened again and beating (R78's) a*% before she left. E25 (CNA) offered to complete R78's care and as E24 (CNA) was leaving the room, R51 and a visitor entered the room. The visitor asked E25 (CNA) How could we allow the caregivers to treat the patients that way cursing and carrying on? --9/12/18 - R51's visitor's statement revealed that while in the hallway, they heard the (E24) CNA get loud and nasty stating, 'if her a*% throws that wet wash cloth back at me again I'm going to throw it back at her a*%.' In addition, as E24 (CNA) was leaving the room, the visitor stated hearing E24 (CNA) say my a*% is getting fired today. 9/18/18 - A Disciplinary Notice, included at the back of the facility's Incident Report Investigation packet for this incident, noted that E24 (CNA) was terminated for threatening a resident. 10/22/18 3:08 PM - R78 stated, during an interview with the surveyor, that the morning of the incident E24 (CNA) didn't pay attention to me. E24 (CNA) wanted to wash me and I wanted a different time. R78 stated that E24 (CNA) threw a washcloth at R78 before R78 told E24 (CNA) to leave the room. R78 felt in trouble after the incident. 10/24/18 1:36 PM - During an interview with the surveyor, E10 (LPN) confirmed that after the incident R78 was visibly upset and crying. The facility failed to ensure that R78 was free from emotional abuse. Findings were reviewed with E1 (NHA) on 10/24/18 at 1:55 PM. 2. Review of R33 and R157's clinical records revealed: 7/27/18- The facility developed a care plan for the problem that R157 wandered into other rooms at times due to dementia. Interventions included for staff to provide redirection and 1:1 supervision. 8/3/18 A care plan was developed for the problem that R157 exhibited physical and verbal aggression. The care plan specified that R157 on 8/3/18 had a resident-to-resident altercation where she pulled another resident's legs and was verbally abusive. Interventions for this care plan included for R157 to receive 1:1 supervision. 10/8/18- An annual MDS assessment was completed and revealed that R33 was cognitively intact. 10/17/18 at 8:20 AM- A progress note documented that, during medication pass, E26 (RN) heard yelling and screaming coming from a room. E26 went to investigate and R157 was in R33's room. R33 tried to ask R157 to leave and R157 shoved R33 on her left shoulder. R33 was noted to be extremely upset and shaken. R157 was supposed to be on 1:1 supervision per her care plan when this incident occurred. 10/17/18 at 4:02 PM- After the incident occurred, R157 was observed by the surveyor without her care planned 1:1 supervision. R157 was seen walking by herself down the hall by the dining room towards the D/E wing nursing station. R157 then wandered into the nursing station and began putting hand sanitizer on her hands and rubbing it into a chair. At approximately 4:05 PM, staff noticed R157 and began to redirect her. 10/18/18 at 10:34 AM- During an interview, R33 stated when R157 came in her room she tried to get her to leave, but she just pushed past her. R33 stated that she did not get physically hurt this time, but she feels very scared and afraid and does not want her (R157) in her room. R33 stated that residents wandering into her room had been a problem for a while, but R157 was the only wanderer that made her feel scared because she was very strong. She stated, I can't defend myself against her. R33 stated that she was especially fearful of R157 now because she recently had a fall and does not want to get hurt again. R33 reiterated that she was very afraid and would be talking to her family about this event and stated that she already told staff that she was fearful. The surveyor reported this information to E2 (DON) who stated that he did not see this as abuse, but he would investigate further. 10/18/18 at 3:34 PM- During an interview on 10/18/18, R33 stated that staff had been in her room talking to her about the incident on 10/17/18 with R157. R33 again stated how afraid she was of R157, and commented that R157 always seemed like she was on a mission and you can't stop her. R33 stated that she worries because she cannot defend herself against R157. R33 stated that the interventions the facility puts in place, such as the stop signs across her doorway, do not help her feel safe. R33 stated the stop signs across the door do not help because they (wandering residents) just take them down. R33 stated that she and her roommate (R147) keep their door shut at night because they don't want people to come in, but they feel that they should not have to always keep their door shut just to be safe. 10/18/18 at 5:49 PM- A progress note documented that R33 was still very anxious regarding the situation that had happened yesterday .regarding the other Resident coming into her room. The note stated that R33 was to be reviewed by psych. The facility failed to ensure that R33 was free from emotional abuse. 10/25/18 at approximately 6:30 PM- Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC). 3. Review of R105 and R157's clinical records revealed: 7/27/18- The facility developed a care plan for the problem that R157 wandered into other rooms at times due to dementia. Interventions included for staff to provide redirection and 1:1 supervision. 8/3/18 A care plan was developed for the problem that R157 exhibited physical and verbal aggression. The care plan specified that R157 on 8/3/18 had a resident-to-resident altercation where she pulled another resident's legs and was verbally abusive. Interventions for this care plan included for R157 to receive 1:1 supervision. 8/8/18- An incident report summary from an event that occurred at 7:45 AM, documented that the assigned CNA was providing care to R157 when the resident became aggressive and pulled away. R157 then went over to R105 (her roommate) and began going through R105's belongings. R105 tried to stop R157 from taking her personal belongings and R157 reached out and slapped R105 on the right forearm. Staff stepped in and redirected R157 to her side of the room. R105's right forearm was noted to have redness and R105 verbalized that her right forearm was tender. The facility failed to ensure that R105 was free from physical abuse, as evidenced by, R105's roommate, R157, a known aggressive and wandering resident who was care planned for 1:1 supervision, slapping her arm causing redness and tenderness. 10/25/18 at approximately 6:30 PM- Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC). 4. Review of R147 and R157's clinical records revealed: 7/27/18- The facility developed a care plan for the problem that R157 wandered into other rooms at times due to dementia. Interventions included for staff to provide redirection and 1:1 supervision 8/3/18 A care plan was developed for the problem that R157 exhibited physical and verbal aggression. The care plan specified that R157 on 8/3/18 had a resident-to-resident altercation where she pulled another resident's legs and was verbally abusive. Interventions for this care plan included for R157 to receive 1:1 supervision. 9/10/18- A quarterly MDS assessment was completed and revealed that R147 was cognitively intact. 10/17/18 at 8:20 AM- A progress note documented that, during medication pass, E26 (RN) heard yelling and screaming coming from a room. E26 went to investigate and R157 was in the room shared by R147 and R33. R33 tried to ask R157 to leave. R157 shoved R33 on her left shoulder. R147 was noted to be upset after the incident. R157 supposed to be on 1:1 supervision per her care plan when this incident occurred. 10/17/18 at 4:02 PM- After the incident occurred, R157 was observed by the surveyor without her care planned 1:1 supervision. R157 was seen walking by herself down the hall by the dining room towards the D/E wing nursing station. R157 then wandered into the nursing station and began putting hand sanitizer on her hands and rubbing it into a chair. At approximately 4:05 PM, staff noticed R157 and began to redirect her. 10/18/18 at 3:39 PM- During an interview, the surveyor was talking to R147 about her fingernails when R147 stated that today had been a long day with people coming in and out of the room talking to her roommate about what happened the other day with R157 coming into their room. R147 stated that the incident was scary and that R157 makes her feel afraid. She stated that the facility feels like a prison because she does not feel safe. R147 stated she does not like to leave her room because someone may wander in and take her personal belongings. R147 stated that she feels bad for her roommate, R33, because she gets it even worse because she was in the first bed in their room. The surveyor reported this information to E2 (DON). The facility failed to ensure that R147 was free from emotional abuse resulting in harm, as evidenced by, R157, a known aggressive and wandering resident who was care planned for 1:1 supervision, entering her room unsupervised and shoving her roommate (R33) causing her emotional distress. 10/25/18 at approximately 6:30 PM- Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC).

Based on clinical record review, interviews, review of facility documentation and hospital records, it was determined that for one (R1) out of 11 sampled residents, the facility failed to ensure that R1 maintained acceptable parameters of nutritional status, specifically electrolyte balance, and failed to offer sufficient fluid intake to maintain proper hydration according to his estimated daily fluid requirements when R1's diet changed on 2/28/18 requiring nursing staff to provide honey-thickened fluids via a spoon for swallowing safety. R1 was hosptalized on [DATE] with [DIAGNOSES REDACTED]. This deficient practice resulted in harm to R1. Findings include: Review of R1's clinical record revealed the following: 6/28/16 - R1 was admitted to the facility with [DIAGNOSES REDACTED]. 1/3/18 - R1's nutritional risk care plan was reviewed with interventions that included the following: monitor food and fluid preferences, provide assistance as needed with food/fluids, and monitor for signs and/or symptoms of diet/supplement intolerance. 1/31/18 - R1 was care planned for being at risk for dehydration with interventions that included: encourage fluid intake from meal tray and between meals; monitor for signs and/or symptoms of dehydration: change in mental status, poor skin turgor, decreased urinary output, dry mucous membranes, dizziness when standing/sitting; monitor labs if ordered; assist with fluid intake as needed; and weight as per protocol. 2/9/18 at 6:36 AM - R1's facility labs revealed the following: - creatinine was 0.6 (normal range was 0.5 - 1.5), - sodium was 142 (normal range was 135-145), - BUN was 17 (normal range was 10-26), and - GFR was 136 (Level 90 or more was Stage 1 - healthy kidneys). 2/16/18 at 8:37 AM - The Nutrition Assessment stated that R1 was on a NAS diet, pureed texture, nectar thick liquids; 75-100% meal intake; received Ensure [MEDICATION NAME] three times a day as a supplement and his intake was 100%; had chewing and swallowing problems; and his estimated nutritional requirements for fluid intake was 2255-2600 mls per day. The nutrition plan stated, .resident continues to lose wt with 4.1% loss this month. BMI underwt for his age. He eats 75-100% of meals and drinks mostly 100% of his Ensure [MEDICATION NAME] .Wt loss may be r/t [MEDICAL CONDITION]. He also receives magic cup at lunch and dinner. Fluids usually 600ml or greater. He receives 8oz of nectar water between all meals for additional fluids r/t thickened liquids. Labs reviewed. Observed resident during lunch meal, ate very well and was able to feed self. Will add double portions with meals to provide additional calories and protein and avoid further weight loss. 2/23/18 at 12:12 AM - R1 was admitted to the hospital for shortness of breath and change in mental status. His admission labs were: - BNP = 500 high (range 0-177), - BUN was 27 high (range 8-22), - creatinine was 0.80 (range 0.70-1.30), and - sodium was 145 (range 136-146). 2/24/18 at 9:58 AM - A hospital progress note stated, .Poor nutrition .seems to have POOR PO intake .Speech did evaluate him yesterday 1) Dysphagia 1 diet with honey thick liquids- ALL PO VIA SPOON 2) Choking precautions 3) 1:1 feeding assist- pt may need verbal cues to swallow due to oral holding 4) Meds crushed in puree . 2/27/18 at 7:38 AM - R1's hospital labs prior to discharge were as follows: - sodium was 145, - BUN was 19, and - creatinine was 0.61 low. 2/27/18 at 3:14 PM - The hospital's Discharge Summary stated that R1 had the following discharge Diagnoses: [REDACTED]. 2/27/18 at 6 PM - R1 was readmitted to the facility. 2/27/18 - R1 was care planned for the Pneumonia [DIAGNOSES REDACTED]. 2/27/18 at 11:38 PM - A nurse's readmission note stated that R1's oral mucosa moist and pink. 2/28/18 at 7:50 AM - The re-admission Nutrition Assessment stated that R1's estimated nutritional requirements for fluid was 1800 - 2100 mls per day. The nutrition plan stated, s/p hospitalization r/t pneumonia. Continues on ABT and [MEDICATION NAME]. Per previous assessment, resident started on double portions with meals r/t continued weight loss to provide additional calories/protein. Observed resident during lunch today. Ate 100% of meal, does require cueing to slow down .Resident is now being downgraded per SLP to honey thick liquids. Will D/C Ensure [MEDICATION NAME] and instead add super cereal ., super potatoes at lunch and dinner ., and Ensure pudding BID Resident also receives magic cup at lunch and dinner . 2/28/18 to 3/6/18 - R1's clinical record lacked evidence that fluids were encouraged. 2/28/18 at 10:45 AM - A nurse's note stated that R1 had moist oral membrane. 2/28/18 at 3:10 PM - A Speech Therapy note stated, Diet changed to puree diet with honey thick liquids, from nectar thick liquids. Liquids to be given via spoon, for safety. Patient to receive verbal cues and prompts with swallowing; as well as verbal cues to decrease rate of intake. Meds crushed in puree. Spoke with nurse in regards to recommendations . 2/28/18 at 11:17 PM - A nurse's note stated that R1 had moist oral membrane. 3/1/18 at 10:30 AM - A nurse's note stated that R1 had moist oral membrane. 3/1/18 at 11:31 PM - A nurse's note stated that R1 had moist oral membrane. 3/2/18 - R1's ADL care plan was revised and stated that he required supervision with meals after set-up. The facility failed to revise R1's care plan on 2/28/18 when his needs changed requiring facility staff to provide honey-thickened fluids via a spoon for swallowing safety. 3/2/18 at 3:39 AM - A nurse's note stated that R1's mucus membrane was pink and moist. 3/5/18 at 11:20 AM - A nurse's note stated that R1 had a moist oral membrane. 3/5/18 (updated) - The CNA's Resident Profile for R1 under the Fluid section lacked evidence of specific care and services to be provided to R1, specifically it lacked the services to 1) encourage fluids, 2) failed to identify the type of thickened liquid he required with safety precautions, and 3) a hydration program at 10 am, 2 pm and 8 pm for R1. The Meals section stated to See Nurse for diet. 3/6/18 at 2:55 AM - A nurse's note stated that R1's mucous membranes were pink and moist. 3/6/18 at 12:10 PM - A nurse's note stated that R1 was unable to tolerate PO medications and unable to respond to verbal stimuli . The physician ordered STAT labs and to obtain a urine sample by straight cath if necessary. 3/6/18 at 2:33 PM - A nurse's note stated that a urine sample was unable to be obtained. 3/6/18 at 2:58 PM - A nurse's note stated that R1 was .unable to tolerate PO medications and unable to respond to verbal stimuli. MD made aware .Lab lady seen drawing stat labs. 3/6/18 on 3-11 PM shift Late Entry documented on 3/7/18 at 12:05 AM - A facility nurse's note stated, At start of shift, resident was in bed with eyes open. Was not responding or making eye contact. VS were 138/80 (blood pressure), 98.2 (temperature), 90 (heart rate), 18 (respirations), 91% on 4 L via NC. Sat resident up in bed and attempted to give him water. He was not responsive or cooperative with fluid intake, would not make eye contact. Took O2 sat again and it was 88% on 4L. Made MD aware. Sent to (hospital) for evaluation via 911 transport. RP made aware. Review of the (MONTH) and (MONTH) (YEAR) eMARs of R1's fluid intake during meals only and monitored by nursing staff from the 2/27/18 readmission to his 3/6/18 hospitalization at 6 PM revealed the following: - 2/27/18 = 720 mls plus 50 mls from Ensure [MEDICATION NAME] supplement, total fluid intake was 770 mls (accounted for 43% of his minimum 1800 mls estimated fluid requirements for the day). - 2/28/18 = 840 mls plus 480 mls from Ensure [MEDICATION NAME] supplement, total fluid intake was 1320 mls (73%). - 3/1/18 = 960 mls (53%). - 3/2/18 = 960 mls (53%). - 3/3/18 = 840 mls (47%). - 3/4/18 = 960 mls (53%). - 3/5/18 = 720 mls (40%). - 3/6/18 = 120 mls (15%). Despite monitoring R1's fluid intake from his daily meals, the facility failed to identify that R1's fluid intake was not meeting his minimum daily fluid needs (1800 - 2100 mls per day) after his 2/27/18 readmission to the facility when his diet changed requiring staff to provide honey-thickened fluids via a spoon for swallowing safety. The facility lacked evidence that honey-thickened fluids were encouraged and provided between meals. 3/6/18 at 5:17 PM - 911 was called for a change in R1's mental status and difficulty breathing. 3/6/18 at 6:13 PM - The hospital's ED physician note stated, .History of Present Illness: 63 y/o male with hx of EtOH related dementia presents from (facility) with AMS, [MEDICAL CONDITION] .unable to give a history .Collateral hx - via RN said EMS were unable to get much information from (facility) staff - they were not familiar with the patient and his paperwork does not show much more. Hx of [MEDICAL CONDITION]. Recent [MEDICATION NAME] on MAR from (facility) - not completed course yet .Physical Exam .cachectic .dry tongue .no [MEDICAL CONDITION] .Final Impression: End stage liver disease .Serum sodium elevated. 3/6/18 at 6:21 PM - The hospital's labs revealed the following: - sodium was 163 critical (136-146); - BUN was 60 high (8-22); - creatinine was 1.44 high (0.70-1.30); and - WBC was 15.7 high (3.9-10.6). 3/6/18 at 10:18 PM - The hospital's Goals of Care Discussion with R1's family stated, .The patient has had progressive decline over several months due to progressive dementia. Now presented with severe dehydration in the setting of poor oral intake .discussed that his dementia is progressing and is likely end stage, they do not wish to have aggressive care for him because it will not correct the underlying process. Their focus is to keep him comfortable and are willing to transition him to hospice care . 3/7/18 at 1:02 AM - The hospital's History and Physical stated, .Patient is nonverbal at baseline .referred to the emergency room tonight because of hypoxemia, altered mental status .Patient has been on [MEDICATION NAME] for pneumonia per his outpatient .records. Presents .emergency room where he is noted to have acute kidney injury, lactic acidosis, hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION], chest x-ray revealing a right lower lobe infiltrate despite outpatient oral antibiotics .Physical Exam .eyes open, looking towards the examiner, not following simple commands .cachectic in appearance, frail, ill-appearing .ENT dry mucosa .Assessment/Plan: Pneumonia .End stage liver disease .Serum Sodium elevated: Hypernateremia related to his acute kidney injury, dehydration, volume depletion .Acute Kidney Injury: .related to .above.[MEDICAL CONDITION], dehydration, volume depletion .Dementia .[MEDICAL CONDITION] . 3/7/18 at 10:31 AM - The facility's STAT labs for R1 (collected on 3/6/18 at 2:21 PM prior to his hospitalization ) were: - creatinine was 1.2, - sodium was 164 High, - BUN was 60 High, - GFR was 61.1 (Level 60 - 89 was Stage 2 - kidney damage and mild decrease in GFR), and - WBC was 14.7 High (range was 4.8-10.8). 4/25/18 at 11:30 AM - During an interview, E20 (RD #2) stated that R1 was on the facility's Nourishment List to receive 8 oz of honey thickened water at 10 AM, 2 PM and 8 PM. When E20 was asked to provide evidence of how much R1 consumed of the honey thickened water three times a day via a spoon as R1 required staff supervision for safety, E20 could not provide further information. While the surveyor was provided with a copy of the facility's Nourishment List, printed with the date of 4/25/18, with R1 listed to receive 8 oz of honey-thickened water between meals, the facility lacked evidence of R1's actual consumption of the fluids to meet his minimum fluid requirement of 1800 mls per day. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). Even with the consideration of R1's comorbidities, decline over the past several months and his current acute illness (pneumonia), the facility failed to identify that R1 was not meeting his minimum daily fluid needs (1800 - 2100 mls per day) after his 2/27/18 readmission to the facility when his diet changed requiring staff to provide honey-thickened fluids via a spoon for swallowing safety. 4/25/18 at 4 PM - Findings were reviewed with E1 (NHA) and E2 during the Exit Conference.

Based on observations, review of clinical records and interviews it was determined that the facility failed to ensure adequate supervision for two ( R8 and R9) out of 11 residents sampled. The facility failed to ensure that R8 and R9, both of whom were known to wander throughout the facility and into other residents' rooms, received adequate supervision to prevent these residents from wandering into other resident's personal spaces and creating the potential for resident to resident abuse. Findings include: 1. Review of R8's clinical record revealed the following: 10/24/17 - R8 was admitted to the facility with [DIAGNOSES REDACTED]. 10/25/17 - A care plan was developed for the problem potential for altered mood state. This care plan stated R8 was fixated on another wandering male resident ,who she believes is her husband, and often follows him which then provokes this other resident. An intervention included for this care plan stated to increase supervision with redirection in regards to this resident wandering with this particular resident. 10/30/17 - The admission MDS assessment stated R8 had severe cognitive impairment (never/rarely made decisions), wandering behavior occurred daily and placed the resident at significant risk of getting to a potential dangerous place (stairs, outside of facility), and that the wandering did not significantly intrude on the privacy or activities of others. The MDS also stated R8 was independently ambulatory in her room and in the corridor. 1/26/18 - A quarterly MDS assessment stated R8 had severe cognitive impairment, disorganized thinking, verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, cursing at others which occurred on 1 to 3 days during the 7 day review time period. This MDS also stated R8 wandered daily and was independently ambulatory. Nurse's progress notes stated the following: 3/2/18 11:00 PM - Remains on 1:1 supervision for safety. 3/4/18 10:30 AM - Continued on one to one supervision for safety. 3/7/18 9:25 AM - Found standing over roommate. Roommate stated that her chair was missing and that clothes had been moved out of the chair. The nurse also found R8 playing with her roommates balloons while standing over her. The roommate became very agitated and threatened to hit her. A request to move R8 to another room was made. 3/11/18 10:22 PM - Resident pacing up and down hallways, opens everything she can open, goes in and out of other residents rooms, yells at staff and residents, is disruptive and requires constant supervision. 3/15/18 10:25 PM - Went into other residents rooms and had many other residents upset. 3/16/18 10:49 PM - Resident ambulates through hallways and into other resident rooms, she engages arguments with other residents and staff. 3/16/18 11:35 PM - Resident has disrupted the shift many times by rummaging through drawers, and other residents rooms. She was left in her room eating, then was found in another residents room where she had defecated on the floor. 3/19/18 10:10 PM - Rummages through rooms and any items she passes, taking food. 3/20/18 9:23 PM - Has been collecting brushes in her room and continues to steal food. 3/21/18 10:10 PM - Continues to steal items out of other rooms and off carts, during dinner hour she was found in another residents room eating her food. 3/24/18 8:20 PM - Continues to go into other residents rooms, takes food from med carts, snack carts and out of other resident rooms. She has been cursing staff and residents often. 3/28/18 11:40 PM - Resident noted going into other residents room several times and eating food and drinks, redirected several times with difficulty. 3/29/18 11:04 PM - Likes going to other resident bedrooms and looks through their belongings or eats their foods or snacks. 3/30/18 4:34 pm - Continues on walking around, picking on other residents rooms, gets their food, going through their stuff. 4/7/18 12:00 PM - Spoke with several other residents on different floors, said R8 in and out of their rooms, taking things and waking them up, when approached becomes combative. 4/9/18 3:50 PM - Resident noted wandering into other residents rooms this shift. 4/13/18 7:36 PM - Another resident's family member asked her to remove R8 because she (R8) had opened the door to the conference room while a family gathering was in progress and began to disrobe in front of everyone. 4/19/18 3:01 PM - R8 was observed attempting to pull a fire extinguisher off the wall. Redirection did not work, however an offer of fluids and a snack did. 4/19/18 10:10 PM - The resident was observed entering room G16 (not R8's room) where she picked up a cup and began drinking before being able to be redirected. Although the facility developed a care plan for altered mood state upon R8's admission to the facility and noted R8's fixation on another resident, they failed to identify that R8 wandered into other residents rooms repeatedly and failed to develop a plan to prevent this from occurring. The potential for resident to resident abuse was present, yet the facility failed to identify that the need for increased supervision of R8 was needed, in an attempt to prevent R8 from entering other resident's rooms. Findings were confirmed by E1 (NHA) and E2 (DON) during the exit conference on 4/25/18 at approximately 4:00 PM. 2. Cross refer to F600, example 2. Review of R9's clinical record revealed the following: 9/2/15 - R9 was admitted to the facility with [DIAGNOSES REDACTED]. 4/11/17 created, 3/7/18 last reviewed - R9 was care planned for wandering into other rooms and wandering in the hallway. The interventions included: - redirect as needed; - 1 on 1 as needed; - encourage activities; - return to room or quiet area as needed; - toilet as needed or incontinent care as needed; - give food or fluid; - change position; - adjust room temperature; - backrub; - refer to charge nurse for further intervention; and - psych consult as ordered. 7/30/17 - A Psychiatric Follow-Up Consult stated that R9 was seen after recent medication changes, has had periods of agitation and very difficult to redirect and illogical thoughts. The plan was to continue to redirect inappropriate behavior and continue to monitor changes in mood and cognition. 11/7/17 - R9's Resident Care Profile stated under the Behavior Section that she wanders and resists care. 2/1/18 to 2/28/18 - Review of R9's Behavior Intervention Monthly Flow Record, documented by her assigned CNAs, revealed that R9 exhibited wandering behavior into others rooms or hallways on 15 out of 28 days. 2/29/18 - The quarterly MDS Assessment stated R9 had short-term and long-term memory problems, decisions were poor and required cues and supervision for daily decision making, experienced hallucinations, physical/verbal/other behavior symptoms occurred 1 to 3 days, wandering behavior occurred daily and was independently ambulatory in her room and the corridor. 2/19/18 at 2:36 PM - A Social Services note stated that R9 had short and long term memory impairment, continued to be physically and verbally combative towards staff, was combative with an outside lab technician on 2/13/18 and wanders daily. 3/1/18 to 3/31/18 - Review of R9's Behavior Intervention Monthly Flow Record revealed that R9 exhibited wandering behavior into others rooms or hallways on 12 out of 31 days. 3/7/18 - R9's care plan for wandering was reviewed and interventions remained the same. 4/1/18 to 4/23/18 - Review of R9's Behavior Intervention Monthly Flow Record revealed that R9 exhibited wandering behavior into others rooms or hallways on 2 out of 23 days. The Flow Record failed to account for R9's wandering incident on 4/19/18 during the 3-11 PM shift. 4/19/18 at 11:36 PM - A Nurse's Note stated that R9 wandered into another resident's room. While staff attempted to redirect R9, she became combative, hitting, scratching and swinging at multiple staff members. R9 was currently in her room with safety measures in place. 4/23/18 at 8:20 AM - During an interview, R7 stated last Thursday, 4/19/18, that she was asleep in her bed in the G wing with the door open. R9, a resident from F wing, came into her room and R7 told her to get out. R9 responded no. R7 pulled the call bell and stated no one responded immediately. R7 stated she told R9 to get out again and R9 responded no. R9 was at the window. R7 yelled Help and the CNAs came running. R7 stated that she was extremely upset. R7 stated that the CNAs were dragging the resident (R9) out of her room. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). Although the facility care planned and were documenting R9's wandering behaviors into other residents rooms repeatedly, the facility failed to identify the potential of resident to resident abuse by providing adequate supervision for R9 in an attempt to prevent her from entering other residents rooms.

Based on clinical record review and interview, it was determined that the facility failed to ensure that one (R204) out of 55 residents sampled was offered sufficient fluid intake to maintain proper hydration and health. The facility failed to identify R204 as being at risk for dehydration, failed to care plan accordingly and failed to consistently monitor and evaluate R204's fluid consumption. When R204's meal and fluid intakes steadily declined there was no notification of the physician and/or RD and no new interventions implemented until 1/17/17. On 1/17/17, R204 became unresponsive and was sent out to the ER where she was found to be severely dehydrated with an acute kidney injury (AKI). This deficient practice resulted in harm to R204. Findings include: Review of R204's clinical record revealed the following: 12/29/16 - R204 was admitted to the facility with [DIAGNOSES REDACTED]. 12/29/16 - The admission Nutritional Assessment stated, .Weight: 141.0 .Estimated Nutritional Requirements: Fluid (ml) 1400-1700 (amount required per 24 hours) .no nutritional problems at present. Assessment/Plan: New admit: reweight: 141 lbs .Current diet regular/thins/NAS .Resident dines independently with % meal completion 75%. Per nursing, appetite good .Resident added to weekly weights and will monitor nutritional parameters. 12/29/16 - The nursing admission assessment stated R204 appeared well nourished, had a good appetite, and was alert, but uncooperative and combative. 12/29/16 - A care plan for the problem Unable to do own ADLs without assistance stated R204 required supervision while eating and nursing was to assist the resident with her meal tray and feeding if necessary. Additionally, a care plan for the problem Resident at nutritional risk was developed which included approaches to provide diet/meals as ordered, monitor food and fluid preferences, encourage food and fluid intake, provide assistance as needed with food/fluids, and monitor for signs of diet intolerance. A care plan was not developed for the potential for dehydration. 12/30/16 - The facility completed a Functional Abilities Review, completed by the SLP, which stated R204 was tolerating the current diet texture with no signs of choking or difficulty swallowing. The review stated that speech therapy services were not warranted at this time. 12/30/16 3:41 PM - A Psychological Initial Assessment stated, .severe dementia with behavioral disturbances .Resident has been hitting staff and yelling. Has needed medication to attempt to decrease behaviors .Staff encouraged to anticipate residents needs (toileting, addressing hunger/thirst) to avoid behavioral disruption. 12/30/16 - R204's re-weight recorded as 141.0 lbs. 1/1/17 - A physician's orders [REDACTED]. 1/3/17 - Laboratory blood test results revealed the following values: Sodium = 146 (normal range: 135-145); BUN = 22 (normal range: 10-26); Creatinine = 0.7 (normal range: 0.5 - 1.5). 1/3/17 5:05 PM - A nurse's progress note stated that medication given for constipation was held due to R204 having loose bowel movements. A second note, timed 11:26 PM, stated the resident was extremely agitated .oral mucosa pink and moist, appetite fair, fluids encouraged . 1/4/17 - Laboratory blood test results revealed the following values: Sodium = 147; BUN = 23; Creatinine = 0.6. 1/4/17 - The admission MDS assessment stated R204 had short and long term memory problems, was moderately impaired for daily decision making skills (decisions poor; cues/supervision required), and was exhibiting behaviors daily. Additionally, the MDS stated R204 required extensive assistance of one staff person for walking in her room and corridor, dressing, toilet use, hygiene and bathing. R204 was identified as requiring supervision and set up help for eating. 1/4/17 12:34 PM - A nurse's progress note stated while sitting up in a wheelchair at the nurse's station, R204 appeared to be unresponsive. R204 was taken back to her room where she responded to painful stimuli, became alert but was still not responding appropriately. The physician was called and ordered R204 be sent to the ER for evaluation. 1/5/17 3:52 AM - A nurse's progress note stated R204 returned from the ER at 1:30 AM and was alert and responsive. 1/5/17 - A physician's orders [REDACTED]. 1/5/17 12:38 PM - A nutrition/dietary note stated R204's weights were being monitored weekly, however, nursing reported they were unable to complete R204's weight that morning due to her being lethargic. There was no evidence the facility attempted to obtain a weight until the following week. 1/5/17 12:43 PM - A nurse's progress note stated, Resident alert and responsive .appetite fair .assistance w/lunch .sitting quietly at nurse's station. 1/5/17 3:19 PM - A nurse's progress note stated the resident had a new order to encourage fluids every shift. Review of the corresponding MAR indicated [REDACTED]. This order did not identify how much fluid was to be encouraged, nor was there any consistent documentation as to whether R204 was accepting adequate fluids. 1/5/17 8:28 PM - A nurse's progress note stated the medication used for constipation was held due to R204 having loose bowel movements. 1/5/17 11:31 PM - A nurse's progress note stated R204 was exhibiting frequent episodes of agitation especially during care, but that her appetite was good and fluids adequate. 1/6/17 11:46 PM - A nurse's progress note stated, .appetite fair, fluids adequate . 1/8/17 10:04 PM - A nurse's progress note stated, .Decreased appetite during breakfast dinner and lunch .Husband visited .complained about her mental status . A second note timed 10:20 PM stated, Late Entry 1/8/17 Did attempt to offer alternatives and ensure (liquid dietary supplement) due to decreased appetite in presence of husband. gave alternatives to husband, but attempts were ineffective as resident continue (sic) to refuse and become combative. Despite this documented decline in intakes there was no evidence that the physician and/or RD were notified. 1/5/17 through 1/11/17 - Review of the MAR indicated [REDACTED]. However, there was no documented evidence of how much fluid was consumed or whether it was accepted. 1/5/17 through 1/11/17 - Review of the CNA ADL Flowsheet of percentage of meal consumption revealed the following for intake of solids: 1/5/17 - breakfast 75%; lunch 25%; dinner 75%; 1/6/17 - breakfast 25%; lunch 25%; dinner 50%; 1/7/17 - breakfast 25%; lunch 25%; dinner 25%; 1/8/17 - breakfast 50%; lunch 50%; dinner 25%; 1/9/17 - breakfast 50%; lunch 75%; dinner 75%; 1/10/17 - breakfast 50%; lunch 25%; dinner 75%; 1/11/17 - breakfast refused; lunch refused; dinner no % documented. Review of the clinical record lacked evidence that the physician and/or RD were notified regarding R204's fluctuating food intakes. Additionally, review of the CNA ADL flowsheet revealed that from 1/1/17 through 1/10/17, R204 was feeding herself or requiring supervision or verbal cuing only. However, starting 1/12/17 documentation revealed R204 was requiring more assistance eating, with multiple occasions noting she was totally dependent for eating. Review of R204's meal time fluid intakes (for all 3 meals) from 1/2/17 through 1/11/17 revealed the following total amounts: 1/2/17 - 720 mls; 1/3/17 - 360 mls; 1/4/17 - 120 mls; 1/5/17 - 480 mls; 1/6/17 - 360 mls; 1/7/17 - 360 mls; 1/8/17 - 240 mls; 1/9/17 - 720 mls; 1/10/17 - 720 mls; 1/11/17 - refused breakfast and lunch and no intake documented for dinner. Review of the above listed totals revealed that unless R204 was being provided additional fluids (e.g. during medication administration or between meals) ranging in amounts from 680 mls to 1280 mls, depending on the amount of fluids consumed at each meal, she was not meeting her daily fluid requirement of 1400-1700 mls to maintain good hydration and health. Although nursing staff were documenting on the MAR from 1/5/17 through 1/11/17 that fluids were encouraged there was no documented evidence that R204 was actually consuming the fluids. Review of the clinical record lacked evidence that the facility monitored and evaluated R204's fluid intakes; no evidence that they identified that her fluid needs were not being met, and no evidence that the physician and/or RD were notified in an attempt to implement new interventions. Review of the clinical record revealed that the 1/5/17 physician's orders [REDACTED]. 1/13/17 - R204's weight recorded as 140.2. 1/14/17 8:46 AM - A nurse's progress note stated, Resident alert and responsive .appetite fair .mucous membranes pink and moist . 1/15/17 7:30 PM - A nurse's progress note stated that R204 was given a [MEDICATION NAME] suppository for nausea and vomiting and that it was effective. 1/16/17 1:22 PM - A nurse's progress note stated, Resident has a new order to begin mechanical soft diet per family request. 1/16/17 - A PT Evaluation & Plan of Treatment was completed. The evaluation stated, .Reason for Referral: Received a nursing referral due to decline in function, unsteady gait and frequent falls. According to nursing, patient was previously ambulatory without assistive device upon admission to this facility, and is currently in a WC .Clinical Reasoning .difficulty participating in functional activities due to lethargy and behavioral disturbance, unable to ambulate . Review of R204's meal intake records from 1/12/17 through 1/16/17 revealed the following amounts: 1/12/17 - breakfast and lunch refused; dinner 75%; 1/13/17 - breakfast and lunch 50%; dinner 25%; 1/14/17 - breakfast and lunch 50%; dinner 25%; 1/15/17 - breakfast and lunch 25%; dinner 0%; 1/16/17 - breakfast and lunch 25%; dinner 0%. Review of R204's meal time fluid intakes (for all 3 meals) from 1/12/17 through 1/16/17 revealed the following total amounts: 1/12/17 - 360 mls; 1/13/17 - 480 mls; 1/14/17 - 360 mls; 1/15/17 - 120 mls; 1/16/17 - 240 mls. There was no evidence that staff were encouraging or that the resident was consuming additional fluids in an attempt to meet her estimated minimum fluid requirement of 1400 mls per 24 hours. The clinical record lacked evidence that the facility monitored and/or evaluated R204's fluid intakes, that the facility identified her fluid needs were not being met, and that the physician and/or RD were notified in a timely manner in an attempt to implement new interventions. There was no evidence that the RD was notified of R204's declining intakes until 1/17/17. 1/17/17 10:52 AM - A nutrition/dietary note stated, Per nursing report Resident experiencing decreased appetite. % (percent) meal completion ranging between 0-50% .added 8 oz ensure [MEDICATION NAME] PO BID .Added 30 ml Promod BID .Reviewed labs: Na 147 slightly elevated (results from 1/4/17). Wrote dietary slip to kitchen to send extra fluids on meal trays. Will continue to monitor weekly weights, encourage po food/fluids, and nutritional parameters. 1/17/17 11:01 AM - A nutrition/dietary note stated, Addendum: Diet: mech (mechanical) soft/thins/NAS. Diet liberalized and NAS d/ced to increase palatability of meals. 1/17/17 11:09 AM - A nurse's progress note stated, Resident has a new order for STAT CBC and BMP, UA C&S and Chest X ray due to change in mental status, dark foul smelling urine and cough . 1/17/17 2:55 PM - A nurse's progress note stated, Resident alert to her name .appetite poor . 1/17/17 - Review of laboratory blood and urine reports revealed results were faxed to the facility on [DATE] at approximately 5:15 PM. Results were as follows: BUN = 163 (normal range: 10-26); Sodium = 165 (normal range: 135-145); Creatinine = 5.2 (normal range: 0.5 - 1.5); UA = negative; Additionally, the chest X ray results did not identify any pneumonia or fluid in the lungs. 1/18/17 1:25 AM - A nurse's progress note stated, Resident was resting in chair with eyes closed at start of shift, attempt was made to arouse resident, change in mental status observed, unable to speak, unable to take in fluids .sent to (hospital) via 911 at 1730 (5:30 PM) . 1/20/17 1:28 AM - Late entry for 1/15/17 3-11 shift, Resident vomited a small amount of undigested soup while eating dinner, warm ginger ale offered and accepted, [MEDICATION NAME] suppository administered, no further episode of nausea or vomiting throughout shift .loose BM at the end of the shift, fluids offered and accepted . The facility failed to identify that R204 was not meeting her minimum fluid requirement and they failed to implement interventions in an attempt to meet this fluid requirement. There was no evidence that R204's oral intake was being monitored consistently and that decreased food and fluid intakes were reported to the physician and/or RD in a timely manner. R204 was sent out to the ER when she became unresponsive and was diagnosed with [REDACTED]. R204 was admitted to the hospital on [DATE]. The hospital ED Physician Record, dated 1/17/17 and timed 6:04 PM stated, .found unresponsive in her nursing home .she has been slightly lethargic for the last several days. Somnolent. She has not been taking much oral intake including food or water. She does have some mild nausea and vomiting over the weekend .severely dry mucous membranes with dry tongue .Initial laboratory results revealed significant [MEDICAL CONDITION] (sic/should read [MEDICAL CONDITION]) with sodium 171. Acute [MEDICAL CONDITION] with BUN of 156 creatinine 6.2 .She received approximately 2L (liters) of IV fluids .sodium improving to 170 .improving creatinine of 5.6 . A second hospital ED Physician Record, dated 1/17/17 and timed 6:09 PM stated, .As per the family she has not been doing well for the past 3 weeks since her admission to the nursing home .family states she has not been eating or drinking since her admission, but significantly less over the past 1 week The family states that over the past 2-3 days she has been much more altered than her baseline mental status .dry oral mucosa .After approximately 15 minutes of being in the emergency department the patient is much more awake and alert and is able to tell me her name .2L of NS (Normal Saline) was given for [MEDICAL CONDITION]ly 2/2 (secondary to) dehydration. The patient's mental status continues to improve while in the ER . A hospital nephrologist's consult note, dated 1/18/17, stated, .progressive Alzheimer's dementia, presenting to the ED yesterday evening unresponsive .recently transferred to a nursing home .Over the past few days, she reportedly became increasingly lethargic .Upon arrival to (hospital name) ED was [MEDICAL CONDITION] (rapid heart rate), unresponsive, with elevated creatinine .[MEDICAL CONDITION] .On previous visits when tested her renal function was normal with baseline creatinine 0.8 .oral mucosa dry .Assessment/Plan: 1. Acute kidney injury: This is clearly acute, with normal baseline creatinine just earlier this month. Most likely due to volume depletion .2. [MEDICAL CONDITION]: Severe at presentation sodium 171 .Attributable to poor oral intake over some time .Additional Recommendations or Comments: 5. Long-term she will require some means of reliably maintaining adequate oral/fluid intake . 7/17/17 approximately 4:00 PM - During an interview with E16 (RD) and E17 (RD), E17 stated that when she noted on 1/5/17 the order to encourage fluids, she sent a request slip to dietary to send extra fluids on the meal trays. E17 stated she was not notified that R204 was not eating well until 1/17/17 at which time she ordered supplements. After R204's meal and fluid intakes were reviewed, E17 confirmed she should have been notified sooner. 7/17/17 at approximately 4:20 PM - During an interview with E1 (NHA) and E2 (DON) regarding the facility's failure to identify R204's risk for dehydration and subsequent care planning, the facility's lack of monitoring of fluid intakes and lack of identifying that minimum fluid needs were not being met and resulting in severe dehydration, the findings were confirmed.

Based on observation, record reviews, interviews and review of other facility documents it was determined that the facility failed to ensure that 6 (R40, R71, R91, R117, R181, and R196) out of 55 Stage 2 sampled residents were free of significant medication errors. Thirteen (13) Units of Humalog insulin was administered to R196 when the blood sugar value was 88 causing R196's blood sugar level to drop to 21 resulting in the resident becoming unresponsive and requiring emergency interventions. Additionally, there was no documented evidence that R196 was receiving and/or consuming bedtime snacks. The facility failed to ensure for R71 and R181 that Humalog insulin was administered according to manufacturers specifications, specifically within 15 minutes before a meal or immediately after a meal. For R40, R91, and R117, the facility failed to ensure that [MEDICATION NAME]was administered according to manufacturers specifications, specifically within 5-10 minutes before a meal. Findings include: The manufacturer's package insert (http://uspl.lilly.com/humalog/humalog.html) for Humalog insulin stated, .INDICATIONS AND USAGE: HUMALOG is a rapid acting human insulin .DOSAGE AND ADMINISTRATION: .Administer HUMALOG .within 15 minutes before a meal or immediately after a meal . The manufacturer's package insert (http://www.novo-pi.com/[MEDICATION NAME].pdf) for [MEDICATION NAME]stated, .INDICATIONS AND USAGE: [MEDICATION NAME] is rapid acting human insulin .DOSAGE AND ADMINISTRATION: .Inject .within 5-10 minutes before a meal . 1A. Review of R196's clinical record revealed the following: 4/14/17 - R196 was admitted to the facility with [DIAGNOSES REDACTED]. 4/14/17 - A physician's orders [REDACTED]. The order stated that when R196's Accu-Chek result was 0 to 199, no SSI coverage was to be given. 4/19/17 - R196's progress notes stated: 7:00 AM - Orders-Administration Note: May initiate I.V. access in potentially critical situations as needed. Then notify physician for further orders. 7:30 AM - .I was called to pt's bedside due to AMS and low BG of 21 at approximately 0730. Nurse in charge of pt at that time stated to me that she gave pt 13 units of insulin when her BG was 88. This progress note was completed by the PA. 7:55 AM - This nurse went in to resident room to do rounds and saw resident unresponsive. Upon assessment, resident BS is 21, [MEDICATION NAME] 1 amp IM was administered and after 30 mins BS was 23, (name of PA) was in the building gave a verbal order for another [MEDICATION NAME] 1 amp IM to be administered 911 was called. At 0801 resident became responsive with BS at 224. Resident decline (sic) to go to the hospital and is eating her breakfast in her room at this time. 4/19/17 10:02 AM - A physician's medical visit note stated, .BS this am 88 but apparently given extra dose 13 units and BS dropped to 21 [MEDICATION NAME] administered; BS 200s pt denies any complaints now. Review of the facility's incident investigation revealed the following statements: 4/19/17 (Completed by E12 (Agency LPN)) - Blood sugar was checked by this nurse at about 0630 a.m. Resident is on a sliding scale of insulin, blood sugar protocol was followed as order (sic). At about 0708 Unit Manager was doing her rounds and discovered pt being hypoglacemic (sic). Followed the order/care as 13 unit (sic) of insulin was administered. While the Agency LPN wrote in her statement that blood sugar protocol was followed this was not correct since insulin was administered for a blood sugar of 88. 4/19/17 (Completed by E13 (Greenbank UM)) - I responded to a page overhead. Resident observed unresponsive. BS was in the 20's. I started an IV in the right arm. EMS arrived as soon as I finished and they took over. 4/19/17 (Completed by E3 (Staff Education RN)) - This nurse was overhead paged .Upon arriving in room noted resident in bed not responding to nurse manager. Resident had a BS of 21 .I contacted PA who was in facility who gave me order to call 911. Myself & PA (name) asked nurse how much [MEDICATION NAME] they administered and nurse went to check & returned and stated 13 units. This nurse asked nurse again did you administer 13 units of [MEDICATION NAME] to a resident who had a BS of 88 and nurse stated 'Yes she did.' I asked the nurse again if she was sure & she stated 'Yes.' 4/19/17 12:45 PM - The facility's Incident Report submitted to the State Agency stated, Agency Nurse administered 13 units of insulin for .88. Resident found unresponsive. According to agency nurse insulin was administered at 0630 and resident was found .at approximately 0700. IV access initiated and PA in building and made aware. Paramedics arrived and administered D50. Resident became AAO3 and refused hospitalization .resident currently in no acute distress. Agency nurse banned from building. Agency and MD aware. The facility failed to ensure that R196 was free of a significant medication error. R196 was given Humalog insulin 13 units when no insulin coverage was required. R196 became unresponsive with a severely low BS requiring the administration of 2 amps of [MEDICATION NAME], insertion of an IV and administration of D50. This deficient practice resulted in harm to R196. On 7/18/17 at approximately 4:15 PM, findings were reviewed with E1 (NHA) and E2 (DON). E1 and E2 acknowledged the findings and stated that E12 has been banned from working in the facility. 1B. R196 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to the B wing (where R196 resided) at 8:10 AM. Review of the July 2017 MAR indicated [REDACTED]. Although the Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of approximately 40 minutes before breakfast was served. R196 was receiving Humalog, a fast acting insulin, which is to be given within 15 minutes before a meal or immediately after a meal. Review of the MAR from 4/14/17 through 5/18/17 revealed that R196 received SSI coverage, signed off at 6:30 AM, on the following dates: 4/17/17, 4/18/17, 4/19/17, 4/20/17, 4/26/17, 4/30/17, 5/1/17, 5/9/17, 5/10/17, 5/14/17 and 5/16/17. R196 had a physician's orders [REDACTED]. On 5/20/17, a physician's orders [REDACTED]. This order was in addition to the Humalog SSI coverage before meals which was also written on 5/20/17 and stated to HOLD if not eating. Review of the MAR indicated [REDACTED]. Additionally, the MAR indicated [REDACTED]. The facility failed to ensure that R196 was eating breakfast before administering the Humalog insulin as it was being administered by the night shift, who were off duty at 7:30 AM, and breakfast was not delivered until 8:10 AM, a potential one and three quarter hour delay. On 6/13/17, R196 had in total, the following insulin orders before breakfast: - Basaglar KwikPen insulin 6 units daily; - Humalog insulin 3 units daily, to be held if not eating; - Humalog SSI coverage, amount dependent on Accu-Chek result and to be held if not eating. Review of the 6/13/17 MAR indicated [REDACTED] - Basaglar KwikPen 6 units, signed off given by the day shift (7 AM - 3:30 PM) nurse; - Humalog 3 units, signed off by the night shift nurse at 6:30 AM. Despite the fact that it was to be held if not eating. Breakfast trays are scheduled to be delivered to the wing at 8:10 AM, potentially one and three quarter hours after administration of the fast acting Humalog insulin. Humalog SSI coverage was not given, as R196's 6:30 AM Accu-Chek was 82 and no coverage was ordered. Review of the meal intake record for 6/13/17 revealed R196 consumed only 25% of breakfast. A progress note, dated 6/13/17 and timed 11:54 AM, stated, This nurse was called to the resident room .BS 54. [MEDICATION NAME] was given x 2. Resident was rechecked and BS was 175. Resident was seen by NP (name) and advised to be sent to ER for further evaluation. The facility failed to ensure that R196's insulin orders were followed when on multiple occasions insulin was administered when nursing staff was unaware if the resident was eating and they failed to administer fast acting insulin (Humalog) according to manufacturer's specifications. R196 was admitted to the hospital from 6/13/17 through 6/29/17. A hospital progress note, dated 6/28/17, stated, .difficult to control .diabetes .dose has been altered multiple times .usually indicative of an acquired disorder, rather than having any connection with food intake or activity. It is very difficult to control . R196 returned to the facility on [DATE]. Readmission physician orders, dated 6/29/17, included: - Humalog SSI coverage before meals, dependent on Accu-Chek results and hold if not eating; - Humalog 3 units before breakfast, hold if not eating; - Nepro 8 ounces three times a day, timed on the MAR for 6:30 AM, 11:30 AM and 9:00 PM. The MAR indicated [REDACTED]. Both of these insulin orders stated to hold if not eating, however both were signed off at 6:30 AM and breakfast was not delivered to the unit until 8:10 AM. Observation on 7/12/17 at 8:00 AM revealed R196 asleep in bed with an unopened can of Nepro on the over bed tray table next to her. On 7/18/17 at approximately 4:15 PM, findings were confirmed by E1 and E2. During an interview on 7/19/17 at approximately 4:00 PM, E3 (RN, Staff Educator) stated that Nepro was timed to be given at 6:30 AM in an attempt to decrease R196's episodes of low blood sugars. When E3 was told of the observation on 7/12/17 at 8:00 AM of an unopened can of Nepro, she stated that the nurse needs to ensure the resident drinks it. 1C. Review of the facility's B Wing Nourishment List revealed that R196 was listed as receiving an assorted 8:00 PM snack. Review of the clinical record lacked documented evidence that R196 was receiving and/or consuming the bedtime snacks. During an interview on 7/19/17 at approximately 11:15 AM, E16 (RD) stated that bedtime snacks are not documented in the clinical record, however if a resident refuses or does not consume, it should say so in a nurse's progress note. 2. Review of R71's clinical record revealed the following: R71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R71 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to B wing (where R71 resided) at 8:10 AM. Review of the April, May, June and July 1-19, 2017 MARs revealed that Accu-Cheks were completed by the night shift (11 PM- 7:30 AM) and signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of approximately 40 minutes before breakfast was served. R71 was receiving Humalog, a fast acting insulin, which is to be given within 15 minutes before a meal or immediately after a meal. Review of the April 1- July 19, 2017 MARs revealed that R71 received SSI coverage, signed off at 6:30 AM on the following dates (except 5/20- 5/24/17 when in hospital) : 4/29, 4/30, 5/1-5/3, 5/5-5/19, 5/25-5/31, 6/1-6/30, 7/1-7/19/17. 3. Review of R40's clinical record revealed the following: R40 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R40 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to C wing (where R40 resided) at 7:50 AM. Review of the May, June, and July1-19, 2017 MARs revealed that R40 received SSI coverage, signed off at 6:30 AM on the following dates (except 5/2- 5/15/17 when in hospital): 7/3 and 7/17/17. Although Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of approximately 20 minutes before breakfast was served. R71 was receiving [MEDICATION NAME], a fast acting insulin, which is to be given within 5-10 minutes of a meal. 4. Review of R181's clinical record revealed the following: R181 had a physician's orders [REDACTED]. R181 also had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to C wing (where R181 resided) at 7:50 AM. Review of the April, May, June, and July 2017 MARs revealed that Accu-cheks were completed by the night shift (11:00 PM- 7:30 AM) and the Humalog SSI if received, was signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of 20 minutes before breakfast was served. R181's standing order of 8 units of Humalog insulin if received was signed off at 7:30 AM. R181 was receiving Humalog, a fast acting insulin, which is to be given within 15 minutes before a meal or immediately after a meal. 5. Review of R117's clinical record revealed the following: R117 had a physician's orders [REDACTED]. R117 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to B wing (where R117 resided) at 8:10 AM. Review of the April, May, June, and July 2017 MARs revealed that Accu-cheks were completed by the night shift (11:00 PM- 7:30 AM) and the [MEDICATION NAME] insulin, if received, was signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and [MEDICATION NAME]given at that time, there was still a delay of 40 minutes before breakfast was served. R117 was receiving [MEDICATION NAME], a fast acting insulin, which is to be given within 5-10 minutes before a meal (although ordered to be given 10-15 minutes before meal). 6. Review of R91's clinical record revealed the following: R91 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to B wing (where R91 resided) at 8:10 AM. Review of the April, May, June, and July 2017 MARs revealed that Accu-Cheks were completed by the night shift (11:00 PM- 7:30 AM) and the [MEDICATION NAME]sliding scale, if received, was signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and [MEDICATION NAME]given at that time, there was still a delay of 40 minutes before breakfast was served. R91 was receiving [MEDICATION NAME], a fast acting insulin, which is to be given within 5-10 minutes before a meal. All findings for this citation were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 7/19/17 at approximately 6:45 PM.

Based on record reviews, interviews and review of other facility documentation including hospital records, it was determined that the facility failed to ensure three (R45, R157 and R166) out of 36 Stage 2 sampled residents, who were incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. All three residents experienced a decline in continence and developed UTIs. Two of the three residents (R45 and R157) required hospital evaluation and treatment. For R45, R157 and R166, the facility failed to comprehensively assess their urinary incontinence; failed to complete voiding diaries; failed to individualize toileting plans; and failed to prevent UTIs, resulting in the decline of their urinary continence. Findings include: The facility's Bowel and Bladder Protocol last revised in 10/2009 stated, Purpose: . to provide an individualized method to assist residents to restore bowel and bladder control . Procedure: Each resident will have . Bladder assessment completed on admission, quarterly, annually and where there is a change in condition. If it is determined that the resident may benefit from the B&B training, the charge nurse will initiate the forms and inform the staff to start the toileting process and the time span that will be used for this resident. The flow sheet will be used to record bowel and bladder function. The Unit Manager or designee will review the resident's progress and care plan. The interventions are determined to be used for the resident's individual toileting needs. The facility used the following forms as tools to assess residents incontinence: 1 - Incontinence Assessment and Evaluation (IAE), completed on admission, quarterly and PRN (as necessary). 2 - Incontinence Pattern Profile also known as the voiding diary. It stated to Check resident every two (2) hours, place an x in the appropriate box (toileted, Void, BM, Wet, Dry, R if refused to be toileted). According to the American Medical Directors Association's (AMDA/The Society for Post-Acute and Long-Term Care (LTC) Medicine) Clinical Practice Guideline for Urinary Incontinence stated, . Urinary incontinence should be managed, can often be modified, and sometimes be significantly improved or eliminated in frail older adults, including people with dementia who reside in LTC facilities. Use of the systematic approach . should help caregivers and practitioners optimized the management of urinary incontinence in the LTC setting . A bladder record or voiding diary may help to characterize the patient's incontinence . Outcomes that may be expected from the implementation . include . Better identification of individuals who have a reversible urinary incontinence problem. More individualized approaches to urinary incontinence management . Reduction in the number of significant complications of urinary incontinence . Refer to: http://www.amda.com/tools/guidelines.cfm 1. The following information was found in facility documentation for R45. 1/14/15 - admitted to the facility. Nurse's note, dated 1/14/15 timed 5:10 PM stated, Admitting DX: dementia, memory loss, [MEDICAL CONDITION], hematuria . 1/14/15 - admission bladder incontinence assessment via facility's Incontinence Assessment and Evaluation form scored resident as frequently incontinent. The assessment identified that a Voiding Diary was indicated. 1/14/15 - 3-Day (72 hours) voiding diary was initiated at 2:00 PM and completed on 1/17/15, to help identify R45's voiding pattern and to develop an individualized toileting schedule. Review of R45's voiding diary indicated that the facility failed to complete all areas of the assessment. The voiding diary completed by the CNAs revealed that R45 was not toileted and/or checked every 2 hours for 21 out of 40 opportunities (52.5 %). In addition, review of the CNA ADL Flowsheet used to record bladder function for each shift, for the dates of 1/14/15 through 1/17/15, revealed that the CNAs documented that R45 was continent of bladder 16 times and was incontinent 5 times, which contradicted the 3-day voiding diary. 1/21/15 - The admission MDS assessment stated that R45's cognitive skills for daily decision-making were moderately impaired (poor decisions and needed cues and supervision). R45 used the wheelchair to move between locations in his room, needed extensive assistance of one staff for all ADLs including use of the toilet. R45 was frequently incontinent of urine. R45 was on a daily fluid pill for a swollen left leg. 1/21/15 - The facility initiated a care plan for R45 entitled, Incontinence of Bladder: Frequently with a goal based on assessed needs for Resident will remain odor free and free of skin imp. (impairment) x (times) 92 days. The goal of the care plan was not specific for resolving the triggered area to restore as much normal bladder function as possible and to prevent UTI. Approaches included: 1) Assist resident with inc. (incontinence) care as required; 2) Provide inc. products as needed; 3) Ensure residents dignity and privacy; 4) Weekly skin checks by nurse as scheduled; 5) Toilet upon request or per scheduled toilet plan; 6) Report any skin change to MD (doctor). 1/2015 CNA ADL Flowsheets revealed that R45 continued to have a mixture of continent and incontinent episodes, however, there was no scheduled toileting plan in place. 2/2015 CNA ADL Flowsheets showed that R45's voiding assessment lacked any continent episodes. R45's bladder continence declined from the admission assessment of frequently incontinent of bladder to always incontinent of bladder. 2/16/15 - care plan was revised and the following interventions were added: 7) res.(resident) continency may fluctuate up and down depending upon res. mood and willingness to participate . dementia dx; 8) Toilet every 3 hours . as res. allows. The goal of the care plan was not revised. Review of CNA ADL Flowsheet charting for 2/15, 3/15, 4/15 and 5/15, indicated that R45 was on an every 3 hour toileting program. However, it also indicated that R45 had only one episode of continent voiding. Despite the fact that the facility documented the decline in R45's bladder continency, implemented an every 3 hour toileting schedule as per revised care plan dated 2/16/15, without evidence to support documentation of a re-assessment and analysis of a 3 day voiding diary. 4/20/15 - The quarterly MDS assessment indicated that he was now always incontinent of bladder. This indicated a decline in R45's urinary continence from previously frequently incontinent on admission. 5/11/15 - A nurse's note, timed 1:25 PM, stated that R45 had blood in his urine, clots and the physician was called. R45 was subsequently sent to the ER for further evaluation. Review of the hospital record revealed that R45 was admitted to the hospital on [DATE]. 5/20/15 - Hospital Discharge Summary stated, . The patient was seen by . urology. It was concluded that this patient's hematuria was perhaps due to hemorrhagic [MEDICATION NAME] because of the [MEDICATION NAME] (name of organism causing infection) UTI. The patient had a cystoscopy . evacuation of clot and fulguration (destruction of tissues by means of a high frequency electric current). Condition of discharge: stable. 7/6/15 - In an interview at 1:50 PM, E2 (DON) stated that an incontinent assessment and evaluation is initiated on admission, quarterly and as necessary. If a resident was found incontinent, a voiding diary is initiated over 3 days; 1-2 hours on the first 3 days and the marking of findings are captured in the voiding diary and the care plan is customized accordingly. Whenever we notice changes in pattern, we do a voiding diary. It was unclear how the facility could proceed with an individualized toileting program without a complete voiding diary. Although the facility had a system in place to provide restoration of bladder function and/or to prevent UTIs, the facility failed to ensure their system was appropriately implemented for R45. As a result, R45's urinary function declined from being frequently incontinent to always incontinent of urine within 90 days of admission to the facility. Additionally, R45 had to be hospitalized due to symptoms of hematuria and he underwent surgery to remove the blood clots in his bladder. 7/13/15 Review of the facility's Infection Control Surveillance report revealed there was a high number of UTIs from 1/15 through 5/15. 7/14/15 at approximately 3:00 PM, findings were reviewed with E2, E7(LPN/UM) and E6 (SD/IC). 2. R157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1/9/15 - The nursing admission assessment revealed that R157 was occasionally incontinent of urine. 1/9/15 - The IAE revealed that R157 was alert and oriented to person, had short and long term memory loss, required minimum assistance with ADL's including toileting, and was dependent with one staff assist for ambulation and transfers. The evaluation stated that R157 was frequently incontinent of urine, which contradicted the 1/9/15 nursing admission assessment. A 3-day voiding diary was started that evening. 1/10/15 - A nurse's note, timed 9:56 PM, stated that R157 was sent to the ER for further evaluation of her combative behavior. 1/11/15 - A nurse's note, timed 8:00 AM, stated that R157 returned from the ER at 4:10 AM. 1/11/15 - The 3-day voiding diary resumed at 4:00 AM when R157 returned to the facility. Review of the voiding diary revealed that it was incomplete as there were missing blocks of time on 1/11/15, specifically from 12:00 AM through 4:00 AM and from 3:00 PM through 11:00 PM. 1/12/15 - A physician's orders [REDACTED]. 1/15/15 - R157 tested positive for the flu and was ordered anti-[MEDICAL CONDITION] medication for 5 days. 1/16/15 - The admission MDS assessment revealed that R157 was severely impaired for daily decision making and required extensive assist of one staff person with toileting. The same MDS assessment also stated that R157 was frequently incontinent of urine. 1/16/15 - R157's UA C&S results revealed that the urine specimen had mixed flora (contaminated). E9 (NP) ordered to repeat the UA C&S on 1/16/15. 1/16/15 - R157 was care planned for frequent urinary incontinence with approaches that included assisting her with incontinence care as required and toileting her upon request or per scheduled toilet plan. The clinical record lacked evidence of a scheduled toileting plan. 1/16/15 - The CAA/MDS reference note stated that R157 was experiencing multiple behaviors since admission . (+) for influenza . will ask to toilet . some continent episodes noted . acute infection may be affecting resident . need to resolve infections & continue psych (psychological) f/u (follow up) to see if resident adjusts to LTC & (and) behaviors reduce . 1/20/15 - R157's UA C&S result was negative for infection. 1/28/15 - A nurse's note, timed 2:10 PM, stated R157 had a low-grade fever, was exhibiting tremors, was responsive, but weak, and unable to stand to transfer from the wheelchair to the bed. 1/28/15 - A physician's orders [REDACTED]. 1/28/15 - R157 was admitted to the hospital with [REDACTED]. 1/30/15 - R157 was readmitted to the facility. The nursing admission assessment, timed 6:00 PM, was incomplete as it lacked evidence of R157's urinary incontinence. However, the assessment noted that R157 was readmitted with a [DIAGNOSES REDACTED]. 1/30/15 - A nurse's note, timed 11:20 PM, stated that R157 returned to the facility at 6:00 PM with an order for [REDACTED]. incontinence. 1/30/15 - The IAE revealed that R157 was frequently incontinent of urine. The facility failed to identify if a voiding diary was initiated on the evaluation and if there were contributing diagnoses, i.e. UTI, to which the facility wrote n/a (non-applicable) despite R157's readmission [DIAGNOSES REDACTED]. 1/31/15 - Review of CNA documentation from 1/9/15 through 1/31/15 revealed that R157 was incontinent of urine on 28 out of 61 shifts (46%). 2/3/15 - R157's history and physical stated that E15 (physician) reviewed the 1/30/15 nursing admission assessment, which failed to identify that R157 was frequently incontinent of urine. 2/9/15 - A nurse's note, timed 11:30 PM, stated that R157 was having increased behavior this shift. 2/10/15 - A physician's orders [REDACTED]. 2/12/15 - R157's UA C&S result was negative with two organisms. 2/13/15 - A physician's orders [REDACTED]. x (times) 7 days . for UTI. 2/14/15 - R157's urinary incontinence care plan was revised to include the approach of toilet program added. The toilet program consisted of toileting R157 upon rising, before meals (only lunch and dinner) and at bedtime. It was unclear from R157's clinical record how the facility individualized this toileting program when R157 lacked a comprehensive assessment and a completed 3-day voiding diary for urinary incontinence. 2/18/15 - A nurse's note, timed 3:00 AM, stated that R157 remained incontinent of urine. 2/20/15 - Review of R157's MAR indicated [REDACTED]. 2/22/15 - A nurse's note, timed 10:55 AM, stated that R157 was very lethargic (drowsy and difficult to arouse) this shift. 2/22/15 - A nurse's note, timed 2:40 PM, stated that R157 was . found unresponsive . to sternal (chest) rubs . 150/65 (blood pressure), 107 (pulse), RR 22 (respiratory rate), 101.3 axillary (temperature from armpit) . (positive) emesis (vomiting) during care . appeared twitchy in face and BUE . call for Dr. gave . Tylenol suppository . axillary temp came down to 100.4. (no) twitch and became responsive to name . new order: .[MEDICATION NAME](antibiotic) . monitor for increase temperature . 2/22/15 - A physician's orders [REDACTED]. x seven days dx UTI. 2/23/15 - A nurse's note, timed 11:20 AM, stated that R157 was . refusing meds (medications) & not eating or drinking . (new order) to send out to ER for further evaluation . 2/23/15 - A nurse's note, timed 9:00 PM, stated that R157 returned from the ER with [DIAGNOSES REDACTED]. R157 continued [MEDICATION NAME] was ordered on [DATE]. The facility failed to comprehensively assess R157's urinary incontinence and failed to complete a 3-day voiding diary. 2/27/15 - A physician's orders [REDACTED]. 2/28/15 - Review of CNA documentation from 2/1/15 through 2/28/15 revealed that R157 was incontinent of urine for 83 out of 84 shifts (99%). 3/2/15 - R157's UA C&S result of 2/23/15 was positive and revealed two different organisms, that were not sensitive to the current antibiotic, Cipro. 3/3/15 - A physician's orders [REDACTED]. 3/4/15 - A nurse's note, timed 11:00 PM, revealed a new order to discontinue R157's toileting program due to it not being effective. Review of R157's clinical record revealed the absence of a physician's orders [REDACTED]. In addition, it was unclear in R157's clinical record how the toileting program was individualized, evaluated and revised to meet her needs as she required assistance with toileting before it was discontinued. Further review of R157's record revealed the absence of any further attempts by the facility to achieve and/or maintain R157's urinary function or improve as much as possible. 3/4/15 - R157's care plan for frequent incontinence of urine was revised with the statement per staff 2 person A (assist) c transfer, too weak to toilet, no participation in toileting - no cont (continent) episodes noted - d/c (discontinue) toilet plan 2o (secondary) debility & functional inc. (incontinence) r/t (related to) dementia. The care plan was not revised to reflect that R157 declined from frequently incontinent to always incontinent of urine and what intervention was implemented in place of the discontinued toileting program. 3/14/15 - The IAE revealed that R157 required minimum assistance with toileting, was frequently incontinent of urine, and dependent upon 1 staff assist for ambulatory and transfer status. The facility failed to identify if a voiding diary was initiated and if there were any contributing diagnoses. In addition, the evaluation contradicted R157's clinical record which indicated she was always incontinent of urine and required more than minimal assistance. 3/20/15 - The significant change MDS assessment revealed that R157 was severely impaired for daily decision making, had an acute change in mental status, required extensive assist with 2 staff with transfers, and required total assist of one staff person with toileting. The same MDS assessment also stated that R157 was always incontinent of urine. 3/20/15 - A CAA/MDS reference note stated that R157 had multiple infections since admission Influenza . 1/15/15, 2/11/15 UA was (-) but treated, 2/22/15 UA treated c antib (antibiotic), to ER 2/23/15 + UA cont (continue) antib, rec'd (received) C&S from (hospital ER) on 3/3/15 & needed further antib . some med changes . toileting was trialed 2/14 but then d/c'd (discontinued) 3/4/15 as resident unable to participate (secondary) debility . behaviors decreased . Review of CNA documentation for March - May 2015 revealed: - May 2015 - R157 was incontinent of urine for 93 out of 93 shifts (100%); - April 2015 - R157 was incontinent of urine for 83 out of 90 shifts (92%); - May 2015 - R157 was incontinent of urine for 93 out of 93 shifts (100%). 6/3/15 - The IAE revealed that R157 required total care for toileting, was always incontinent of urine and dependent with two staff assist and hoyer transfer. The evaluation failed to identify if a voiding diary was initiated and if there were any contributing diagnoses. Review of CNA documentation for June 2015 and July 1-10, 2015 revealed: - June 2015 - R157 was incontinent of urine for 90 out of 90 shifts (100%); - July 1-10, 2015 - R157 was incontinent of urine for 30 out of 30 shifts (100%). 7/14/15 - In an interview at 4:33 PM, E18 (CNA) stated that R157 was on a toileting program, but is not anymore. E18 also stated that she routinely checks R157 every two hours and a hoyer lift was required for transfers. 7/15/14 - At 8:59 AM, findings were reviewed with E4 (RN/UM). The facility failed to provide the care and services to maintain and/or prevent a decline in bladder function as much as possible and to prevent UTIs which resulted in a decline in R157's urinary continence from frequently to always incontinent as evidenced by: - failure to comprehensively assess her urinary incontinence since admission; - failure to complete a 3-day voiding diary since admission; - failure to implement a toileting program until 2/14/15, approximately one month after admission; - failure to monitor, implement, evaluate and/or revise approaches that were ineffective; and - failure to prevent several UTI's, two of which resulted in transfers to the hospital. 3. R166 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Assessment, dated 2/23/15, under the GU section was not completed. An Incontinence Assessment and Evaluation (IAE), dated 2/23/15, stated R166 was alert and oriented to person and place, had no short term memory loss, and required moderate assistance with ADLs. This evaluation was not completed in regards to R166's continence status. It failed to identify whether R166 was continent or incontinent, if a voiding diary was initiated, if there were any contributing diagnoses, and failed to identify how much assistance R166 required with ambulation, transfers and toileting assistance. R166's clinical record revealed that on 2/23/15 a voiding diary was started. Instructions on the voiding diary stated, Check resident every two (2) hrs, place an X in the appropriate box. R if refuses to be toileted. The diary dates listed were 2/23/15, 2/24/15 and 2/26/15 (unclear if this was a dating error and was actually 2/25/15). Review of the voiding diary revealed it was incomplete, as there was a lack of documentation every two (2) hours as directed. In fact, on all three days there was no documentation on the 7 AM to 3 PM shift. Review of the voiding diary revealed that on 2/24/15, R166 was noted wet at 1:00 AM, 6:00 AM and 3:00 PM. On 2/26/15, R166 was noted wet at 2:00 AM, 6:00 AM, 4:00 PM and 9:00 PM. Contrary to what was documented on the voiding diary, which was completed by CNAs, the CNA ADL Flow Sheet documented R166 as always continent of bladder during the MDS assessment time period (2/24/15 through 3/2/15). The facility failed to ensure a complete voiding diary was done. A care plan initiated 2/23/15 for Unable to do own ADLs without assistance . included the approach to assist resident with toileting or provide incontinence care as needed. A nurse's note, dated 2/26/15 and untimed, stated . Continent of B&B c some incontinence at times . The admission MDS assessment, dated 3/2/15, stated that R166's daily decision making skills were moderately impaired, that she required limited assist of one (1) staff for transfers, and required extensive assist of one (1) staff for toilet use and hygiene. The 3/2/15 MDS assessment also stated R166 was always continent of bladder during the assessment period (2/24/25 through 3/2/15), despite evidence of incontinence noted on the voiding diary on 2/24/15 and 2/26/15, and as noted in the 2/26/16 nurse's note. The CAA triggered the care area of urinary incontinence as a potential problem area and was checked to proceed with care planning. The Care Area Assessment Summary, dated 3/2/15, stated . B&B: cont (continent) of B&B, requests toileting on own . Per staff interview can walk some c RW to BR . toilets per request per staff, can help some and stand and pivot (turn) c grab bars in BR, needs help c clothes . On 3/2/15, a care plan for Resident is continent of bowel and bladder but needs assist to toilet was initiated. This care plan's approaches included to assist resident with transfer to toilet upon request or per toilet schedule, able to express need to toilet, toilet upon request. ADL Flowsheets, completed by CNAs, from 3/1/15 through 3/31/15, documented that R166 was always continent of bladder. Review of nurse's notes revealed the following: 3/4/15 3:45 PM - . continent of B&B c some incontinence . 3/3/15 4:20 AM - . occasional incontinence noted . 3/3/15 3:20 PM - . continent of B&B c occasional incontinence . 3/8/15 12:45 PM - . continent of B&B c occasional incontinence . 3/8/15 9:00 PM - . incontinence care provided by staff . A 3/9/15 14-Day PPS assessment stated R166 was always continent of bladder, despite documentation in nurse's notes of incontinence. There was no evidence that although there was a discrepancy between ADL Flowsheets and nurse's notes, that any further re-assessment was completed at this time. Review of nurse's notes revealed the following: 3/10/15 3:30 AM - . incontinent care provided . 3/14/15 1:45 PM - . incontinent noted occasional (sic) . 3/14/15 8:05 PM - . incontinent care provided . 3/16/15 4:35 AM - . continent of B&B c occasional incontinence . 3/18/15 3:45 PM - . continent of B&B c some incontinence at times . 3/27/15 untimed - . Incontinent of B&B . A 3/23/15 30-Day PPS assessment stated R166 was always continent of bladder, despite continuing discrepancies in documentation. There was no evidence the facility identified the discrepancies and no evidence that they reassessed R166. According to the CNA ADL Flowsheets from 4/1/15 through 4/30/15, R166 was incontinent of bladder on every single shift. Review of nurse's notes for this same time frame revealed documentation that R166 was continent despite opposing documentation on the ADL Flow Sheets. On 4/2/15, a UA and urine C&S was ordered by the physician due to a change in R166's mental status. On 4/4/15, R166 was started on an antibiotic for a UTI. A 60-Day PPS assessment, dated 4/20/15, stated R166 was frequently incontinent of bladder during the assessment review period (4/14/15 through 4/20/15). A significant change MDS assessment, dated 4/27/15, stated R166's daily decision making skills were intact, and that there was no trial of a toileting program attempted on admission or since urinary incontinence was noted in this facility. On 4/27/15, a physician's orders [REDACTED].dx urinary incontinence. Review of the clinical record revealed a voiding diary was to be completed from 4/27/15 through 4/29/15. The voiding diary was once again incomplete. On 4/29/15, R166 was started on an oral antibiotic for a [DIAGNOSES REDACTED]. Review of the clinical record revealed that on 5/1/15 at 3:10 AM, R166 was sent out to the hospital emergency room due to difficulty breathing. R166 did not return to this facility. During an interview on 7/13/15 at 11:10 AM, E14 (RNAC) confirmed she completed the MDS assessments for R166. E14 stated she reviews the CNA Flow Sheets for coding of the MDS and then she interviews staff, mainly the CNAs and UM, if there is a discrepancy in documentation. E14 stated that based on what she determined during interviews, that is what she codes. E14 confirmed the Nursing Admission assessment was incomplete under the section GU, and confirmed the Incontinence assessment and voiding diary were also incomplete and that the voiding diary noted R166 to be wet. E14 further stated that when she completed the 60-Day PPS assessment, she noted the decline in bladder continence and went on to complete a significant change in status MDS assessment. E14 stated she remembers a discussion about this significant change as the resident became incontinent, but that R166 was sent out to the hospital shortly afterwards. In an interview with E13 (LPN/UM) on 7/13/15 at approximately 11:30 AM, E13 confirmed the nursing Admission assessment, Incontinence assessment, and voiding diary were all incomplete. E13 confirmed the voiding diary noted R166 as being wet, while the same CNAs completing the diary documented this resident as being continent at those times. E13 stated it was the UM who was to review the voiding diary. E13 confirmed she had not looked at or reviewed R166's voiding diary. She stated that she tries to toilet residents for the first few days after their admission to determine their continence status and then interviews the CNAs by asking if the resident was continent or incontinent on their shift. E13 stated that it was determined that R166 was continent based on her toileting the resident herself and through CNA interviews. In an interview on 7/13/15 at approximately 2:30 PM with E2 and E13, E2 stated that she spoke with the nurse who wrote the 2/26/15 note about R166 being incontinent. E2 stated the nurse said she answered R166's call light that night, the resident was wet and she provided incontinence care, however, the nurse never informed the CNA. E2 stated a second nurse they spoke with also stated the exact same thing, that she had provided care for the resident and had not informed the CNA that the resident was incontinent. The facility failed to accurately and comprehensively assess R166's urinary status upon admission, failed to identify this resident was at times incontinent, failed to complete a voiding diary, and failed to base on voiding patterns, develop an individualized toileting plan in an attempt to restore as much bladder function as possible and prevent UTI. R166's urinary status declined after admission to the facility and the resident developed a significant UTI requiring multiple antibiotics.

Based on record review, observations and interviews it was determined that the facility failed to 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 one (1) resident (R5) out of seven (7) sampled residents. The facility failed to assess R5 thoroughly and failed to implement individualized interventions in reference to her bowel protocol and based on the knowledge of her past history. Review of the MAR for the time period of [DATE] through [DATE], the five days in which R5 was documented to have no bowel movements, revealed that the nursing staff failed to initiate/follow the Bowel Regime as indicated after 3 days of no bowel movements and/or 5 days without bowel movements. Findings include: Review of R5's medical record revealed she was admitted from home on [DATE] with [DIAGNOSES REDACTED]. Review of R5's Care Plan initiated on [DATE] entitled "Potential for Constipation" with the goal "Resident will have a BM at least Q(every) 3 days x 92 days". The interventions/approaches were as follows: 1.Monitor BM's and document. 2. Meds as ordered; 3. Consult Dietitian PRN; 4. Encourage fluids as per diet allows; 5. Follow Facility Protocol. While in the facility, R5 was sent to the hospitalER on [DATE] due to abdominal distention, loose stool x 4 days and increased weakness. At "11:15" on [DATE] R5 doubled over with abdominal pains-(R) lower quadrant "shooting" to rectum. Pain in rectum "10 out of 10" (pain scale), "(-) rebound tenderness to abdomen", "emesis (vomiting) x2 past 30 minutes". R5 was evaluated and treated at the hospital ER with [DIAGNOSES REDACTED]."Emergency Instructions" dated [DATE] stated, "Resident has been having medium-large BM'S every day all month. Called (name of hospital) to ask how they came up with this dx (diagnosis). They said it was because she appeared to have "some external hemorrhoids which are usually caused by constipation". R5 was discharged back to the facility on [DATE] and was prescribed "[MEDICATION NAME] HC 2.5 % cream bid, prn to hemorrhoids" According to R5's Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], R5's cognitive skills for daily decision-making were moderately impaired-decisions poor; cues/supervision required. R5 needed extensive assistance with personal hygiene and bathing, limited assistance in bed mobility, dressing, toilet use, independent with transfer to/from bed, chair, wheelchair and standing position and ambulation in the room. R5 was frequently incontinent of bowel (coded 3) and incontinent of bladder (multiple daily episodes). She had no swallowing and chewing problem. R5 had a weight loss problem and leaves 25% of meals. A [DATE] statement written by C17 (attending Physician/Medical Director) for the surveyor describes R5's condition which stated, "..(.R5), among other diagnoses, suffered from Type 11 DM, cerebral [DIAGNOSES REDACTED] with dementia, [MEDICAL CONDITION] and as part of that ischemic bowel syndrome (loss of blood flow to the intestine and can cause intestinal tissues to die, perforate and severe infection) was most probably one of her comorbidities. In fact it is consistent with irregular bowels, abdominal pains, discomfort and bouts of constipation as well as loose stools at times...Furthermore her history of [DIAGNOSES REDACTED] is consistent with symptoms and signs of irregular BM's that require enemas, laxatives and other chemical or physical techniques to keep a regular bowel discipline...her symptoms seem to fit the pattern ileus, itself a comorbidity of ischemic [DIAGNOSES REDACTED] and, again in a larger picture, general clinical decline". If the facility and C17 (MD) were knowledgeable of this condition, it is unclear why R5's care plan was not revised. "Symptoms of chronic intestinal ischemia can include; abdominal cramps or fullness, abdominal pain, fear of eating, unintended weight loss, diarrhea, nausea and vomiting and bloating" (www/Mayo Clinic.com/health/intestinal ischemia/D 9). "Symptoms of fecal impaction are similar to those of constipation, but are complicated when the impacted stool presses on other tissues. Solid stool and other materials can back up in the colon, while liquid stools moving past the impaction can cause diarrhea or uncontrolled leakage of stool". Common symptoms of fecal impaction include abdominal pain or cramping, back pain, change in bowel habits, diarrhea, small or thin, semi-formed stools. Serious symptoms that might indicate a life-threatening condition includes, "greatly reduced or no urine output, severe abdominal pain, severe vomiting, inability to pass stool or gas." (http://www.bettermedicine.com/article/fecal-impaction/symptoms). The initiated care plan dated [DATE] was not revised on [DATE] after her re-admission to the facility and failed to be individualized to reflect and/or identify R5's clinical cause of constipation/ hospital and [DIAGNOSES REDACTED]. For example to monitor/ focus on signs and symptoms of irregular bowel movements or monitoring of her hemorrhoid and other symptoms such as diarrhea, unintended weight loss, nausea and vomiting, bloating and/or abdominal distention that may require enemas, laxatives and other chemical or physical techniques or treatments to maintain a regular bowel discipline. R5's "Nutritional Assessment" dated [DATE] stated, "...Resident continues to have episodes of loose stools/diarrhea. At this time will add lactose-free to current diet to see if resident has lactose intolerance". R5 was on regular NCS (no concentrated sweets) therapeutic diet. A Nutritional Progress Note dated [DATE] stated, "...this writer was notified on this day that resident is still experiencing some loose-stools, however decreasing in frequency. Will continue with lactose free diet and will add Resource Breeze (Fruit-Flavored, Clear-Liquid Nutritional Beverage) at this time to increase PO intake" Nutrition note dated [DATE] indicated that R5 weighed 132.5 from an admission weight of 141.4 that reflected a decline of 8.3 lbs in 3 months ([DATE]) and 5 lbs (3.6%) in one month. R5's appetite was poor. R5's weight continued to decline from 134.9 lbs in [DATE] to 128.6 on [DATE]. R5 was first diagnosed with [REDACTED]. According to R5's MAR (Medication Administration Record), this resident was receiving "[MEDICATION NAME] (stool softener) " for constipation twice a day PO (by mouth) since [DATE]. Review of R5's July/2010 C.N.A. BM (bowel movements) flow sheets revealed that she was having regular bowel movements (BM) (small, medium, large) at least two to three times per day. Review of R5's BM flow sheets for [DATE] revealed that from ,[DATE]-[DATE], R5 was only having medium sized BM's regularly once a day on the ,[DATE] PM shift instead of two to three times a day. Then from [DATE]-[DATE] her BM's were irregular (0-small, medium and large once or twice a day). R5 had 0 Bowel movements for 5 days from ,[DATE]-,[DATE] (5) and followed by irregular bowel movements from [DATE] to [DATE] per CNAs ADL flow sheets. The type or consistency of the stool was not identified. Review of facility policy dated ,[DATE] entitled "Bowel Regime" (to avoid constipation and fecal impaction) stated, " Resident bowel movements will be documented by the C.N.As and documentation will be reviewed by the licensed nursing staff every day. " "The Unit Clerk will notify Unit Manager/Charge Nurse if resident has not had a bowel movement in (3) three days. The Unit Manager/ Charge Nurse will ensure Bowel Regime is initiated. Interviews on [DATE] with E16 (Nurse) and E17 ( RN Unit Manager) revealed that the unit clerk comprises the BM list on a daily basis in the morning for review by the nurse.The facility's Bowel Regime/Protocol was as follows: * ,[DATE] nurse will give Prune Juice by morning medication pass, if no results this shift; * ,[DATE] nurse will give MOM (Milk of Magnesia) 30ml (Milliliters) (Standing Order policy) by evening medication pass, if no results this shift; * ,[DATE] nurse will give Fleets Enema (Standing Order policy) by first medication pass, if no results on ,[DATE] shift; * ,[DATE] nurse will notify physician. All nurses must document appropriate intervention on MAR (Medication Administration Record), Bowel Regime Intervention Form and 24 hour report. Resident will remain on the 24-hour report until resolved. Additionally, "[MEDICATION NAME] HC 2.5 % cream bid, prn to hemorrhoids" was not documented as being administered for the months of [DATE] and [DATE]. An additional [DIAGNOSES REDACTED]. A nurse's note dated [DATE] stated that "Resident complained (c/o) back pain and was medicated with Tylenol 650 mg po (by mouth), refused dinner. On [DATE] R5 was given ,[DATE] pint of milk for lunch, magic cup (contains skim milk, non-fat dry milk and not lactose free per Hormelhealthlabs.com/product) and ice cream. On [DATE] at 0100 (1:00 AM) R5 complained of pain and discomfort, vomit x1 moderate amount of brownish liquid with odor of feces. Upper and lower extremities mottling, bowel sound diminishing, vomiting and low pulse ox and she was sent to hospital ER for evaluation. According to the hospital's Discharge Summary dated [DATE], R5 presented to the hospital in severe septic shock with a distended abdomen. A CAT scan of the abdomen showed a severely dilated left colon with free air in the abdominal cavity. R5 underwent an exploratory laparotomy and was found to have extensive contamination of the abdominal cavity. She underwent an extended left hemicolectomy and found to have an ischemic-appearing small bowel as well as stomach. R5 expired at 1822 (6:22 PM) on [DATE]. Discharge Diagnoses: [REDACTED]. The facility failed thoroughly assess R5 and failed to follow the facility policy for bowel regimen. Although the facility identified R5's clinical cause of constipation per hospital evaluation including the [DIAGNOSES REDACTED].

Based on closed clinical record review and interview, it was determined that the facility failed to ensure that one (1) resident (R1) out of 7 sampled, who entered the facility without pressure sores did not develop pressures sores unless the individual ' s clinical condition demonstrates that they were unavoidable. According to R1 ' s admission Minimum Date Set (MDS) assessment dated [DATE], R1 had no pressure ulcer but was at risk for developing pressure ulcers. However, on 10/15/11, R1 was found with a blister on his left heel and was assessed by the wound care nurse on 10/17/2011 as Stage 2 left heel pressure ulcer measuring 5.0x4.0 cm with macerated surrounding skin. The wound was treated with Collagen (highly absorbent material converts to soft, gel sheet that stays in intimate contact with wound bed as it absorbs exudate) On 11/8/11 this left heel pressure ulcer was assessed again by the would care nurse as unstageable with serous-sanguineous drainage, macerated surrounding skin and 50% necrotic and treated with Santyl (ointment, an active enzymatic therapy that continuously removes necrotic tissue). On 11/14/11, R1 was sent to the hospital for signs and symptoms of dilated, non-reactive to light of the right pupil after an incident of fall and returned to the facility after 7 hours. While in the hospital, R1 ' s body was assessed by a Forensic Examiner and found with a previously undocumented Stage 4 pressure ulcer on the buttocks. Per Weekly Wound Assessment documentation, on 11/21/11 the wound care nurse had observed and evaluated R1 ' s right heel and found a stage 2 pressure area (pink) measuring L2.0xW.5xD2. Findings include: R1 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. According to the facility ' s admission " Skin Integrity Action Sheet " assessment dated [DATE], R1 had hematoma (contusion) from his upper buttock down to his mid leg, bruises on his left arm and a skin tear on his right buttock as a result of a fall at home. R1 was assessed as a low risk (scored 19 on Braden scale for pressure sore. R1 ' s admission Minimum Data Set (MDS) assessment dated [DATE] indicated that his BIMS (Brief Interview for Mental Status) score was 07 out of 15. He had no behavior problem. He was independent non-ambulatory, needed extensive assistance from staff with bed mobility, (moves to and from lying position, turn side to side, position body while in bed), transfer (to or from bed, chair, wheelchair, standing position), dressing and toilet use. R1 was totally dependent upon staff for his personal hygiene. R1 had no pressure ulcer but was at low risk for developing pressure ulcers. The facility initiated a care plan dated 9/28/11 on " Potential for alteration in skin integrity, " " Adm. (admitted ) with skin tear, buttocks, " " Refusing to turn and wants to be in bed all the time except for therapy (Physical and Occupational Therapy). " The care plan goal was: Resident ' s skin will not show signs of breakdown x 92 days. The 9/28/11 care plan interventions/approaches included: Nurse will assess resident ' s skin on admission, readmission, every week, and as needed. Staff to assist resident to the extent required with turning and positioning every 2 hours and prn (as needed). Staff to check skin every 2 hours and report changes to nurse/DR. Pressure reduction mattress. Heel protectors while in bed (heels have relatively little surface area, it is difficult to redistribute pressure on this surface) Keep skin clean and dry Keep bed linens wrinkle free Encourage mobility Monitor and assist with food and fluid intake Consult dietician as needed In an interview with E15 (RN, Staff Development) on 12/20/11 at about 8:35 am confirmed that the CNA ' s were taught to check skin for pressure areas, reddened areas and/or anything abnormal during daily care of residents (i.e. washing, showering, turning and repositioning). Skin assessments are done from head to toe by Nurse and CNA ' s. Another care plan was initiated on 9/28/11 on " Potential for injury related to S/P fall prior to admission from home with interventions that included " Encourage appropriate footwear with ambulation and one (1) person assist with roller walker (RW) " Review of R1 ' s CNA ' s October 2011 ADL (activities of daily living) Care flow sheet included the ADL care to " Turn and Reposition and Skin Assessment every 2 hrs and report any skin change to Nurse " Each daily block of the 10/2011 and 11/2011 flow sheet were signed off as completed by the CNA ' s in all 3 shifts (the every 2 hours skin assessments and turning and repositioning). However, the " heel protectors and while in bed " as per care plan were not addressed in the CNA ' s ADL flow sheet as part of the care. In addition, the weekly skin assessment blocks in the 10/2011 and 11/2011 TAR (Treatment Administration Record) were initiated by the licensed nurses as completed each week from 10/5/11 through 11/30/11. As per facility ' s " Weekly Skin Assessment " policy " If there is no problem with skin integrity, document on the Weekly Full Body Assessment form in the designated space for description, location and evaluation. " There were no " Weekly Full Body Assessment " forms found for 10/5/11, 10/12/11, 10/19/11 and 10/26/11 and/or documented results of nursing skin assessments/comments at the designated space at the back of R1 ' s TAR and/or nurses ' notes. A nurse ' s not dated 10/8/11 stated, " Res. (Resident) c/o (complained of) #6/10 (pain scale of 6 out of 10) throbbing pain to (R) leg/heel/ Heels off-loaded, repositioned Res. and applied lotion to BLE (bilateral lower extremity). Medicated Res. with PRN [MEDICATION NAME] 5/500 mg. po (by mouth) and on F/U (follow up) Res. stated " Pain down to #2/10 and I need something to take away this pain. " A nurse ' s not dated 10/15/11 timed 1240 stated, " ...Resident received shower today ...He has a blister on (L) heel, informed treatment nurse (name) " Per " Weekly Wound Assessment " form, E4 (Wound Care Nurse) documented that she first observed the left heel blister on 10/17/11 and assessed it as a Stage 2 pressure ulcer, size L.50xW4.0 cm with serous-sanguineous drainage, pink color of the wound bed, surrounding skin macerated and treatment of [REDACTED]. R1 intermittently complained of right foot pain, right leg, toes, ankles and foot accompanied by constant moaning and crying without tears (nurses ' notes 10/15/11, 10/16/11, 10/17/11, 10/26/11 and 10/27/11). [MEDICATION NAME] and [MEDICATION NAME] 5/500 tab were administered twice plus " skin prep) a liquid dressing that leaves a clear, waterproof, and breathable film barrier to protect intact and damaged skin from irritation). Subsequently, review of R1 ' s TAR revealed that on 10/17/11 the following care was prescribed/initiated: a. Off load heels/ B/L (bilateral) heel protectors on at all times b. Apply skin prep to (R) heel q (every) shift c. Cleanse (L) heel with NSS (normal saline solution), apply collage and foam dsg (dressing) QD (every day) and PRN (as needed " Review of R1 ' s left heel " Weekly Wound Assessment " record revealed the following findings by e$ (wound care nurse): a. 10/24/11 assessment stated, " Stage 2 pressure sore, size L2.0xW1.8, no drainage, pink wound bed, surrounding skin unremarkable, treatment Collagen. " b. 10/31/11 assessment stated, " Stage 2 pressure sore, size L1/5xW1.3 cm, bloody drainage, pink wound bed, treatment collagen. " c. 11/8/11 assessment stated " unstageable with serous-sanguineous drainage, macerated surrounding skin and 50% necrotic measured L2.4xW1.6xD.2 cm. Santyl was the treatment of [REDACTED]. d. 11/21/11 unstageable, 80% necrotic, unremarkable surrounding skin, color of wound bed was black/pink, worse, measured L3.0xW2.5xD.2 cm. Santyl remained as the treatment of [REDACTED]. The area of the left heel was seen by C16 (Wound Care Specialist, D.O) on 11/21/11. According to his assessment the left heel wound size was L3xW2.5xD0.2 cm; surface area 7.5 cm2, no exudate, 80% thick adherent devitalized necrotic tissue, 20% granulation tissue. Additional information: wound started from trauma from shoes. (Per E2, DON written statement dated 12/22/2011, R1 was out of bed frequently for therapy (Rehabilitation) and ADL ' s throughout the day and was wearing his shoes appropriately.) Procedures - surgical excisional debridement of subcutaneous tissue of the left heel was done on 11/21/11 by C16 (D.O) with the family member ' s consent. Recommendations: off load wound, no shoes until fully healed, float heels in bed, bilateral heel protectors, protein supplementation and consult for E-Stimulation Treatments. Additionally, according to the " Weekly Wound Assessment " sheet, E4 (wound care nurse) documented that she first observed the right heel wound on 11/21/11 and was assessed as a Stage 2 pressure sore. On the same day, 11/21/11, C16 ' s (wound care specialist - D.O) assessed this right heel wound. Per C16 ' s evaluation this right heel wound measured L2xW1.5xD0.2 cm, surface area 3.0 cm2, no exudate, granulation tissue 100%, dressings weekly with [MEDICATION NAME] absorbent. On 11/28/1 E4 (wound care nurse) observed the right heel wound and assessed it as unstageable (U), size L1.5xW1.2xD.2, black/pink, worse and treated with Santyl. The wound care specialist evaluated it as follows: size L1.5xW1.2xD.2 cm, surface 1.80 cm2, no exudate, 10% thick adherent devitalized necrotic; 90% granulation tissue, decreased surface size and improved. Recommended dressing daily with Santyl; off load wound, float heels in bed, heel protectors to off load wounds, no shoes until fully healed. According to the Weekly Wound assessment dated [DATE] of the right heel by E4 (wound care nurse) the wound was (U) unstageable, size L1.4xW1.0xD.2 cm, serous-sanguineous drainage, black/pink wound bed, necrotic tissue 10%, improved, treatment -Santyl. " Pressure ulcers are sores that occur when pressure cuts off the blood supply to the skin. The stress that is caused by the body ' s weight, and the impact of the food striking the ground can place the big toe, the heel and the ball of the foot at greatest risk for pressure ulcers ...Red " hot " spots on the skin are signs of pressure or friction. They are warning that you need to take care of your feet. If pressure is not relieved, a hot spot is likely to blister. Left untreated, a blister can turn into an open wound ... " (Foot Care Library/Foot Care Center <http://www.bunionbusters.com/footcare/ulcers.asp>). According to the facility ' s Weekly Wound Assessment guidance, " Stage 2: a partial thickness loss of skin layers that presents clinically as an abrasion, blister or shallow crater. " In addition, the facility ' s policy on Skin Care Protocol provided to the surveyor by the facility included an attachment entitle " JAMA Vol. 289 no. 2, January 8, 2003) the facility ' s guide on Pressure Ulcers. It stated " Stage 1-an observable, pressure related alteration of intact skin, whose indicators ...may include changes in one of more of the following parameters: which included " Sensation (pain, itching); and/or a defined area of persistent redness may appear ... " A typed written statement submitted by E2 (DON) dated 12/22/11 to the office of the DLTCRP was reviewed. According to the statement, " R1 was out of bed frequently for therapy and ADL ' s throughout the day and was wearing his shoes appropriately when out of bed. " R1 ' s skin was checked per facility policy and skin was noted to be intact from 9/28/11 until a small blister was noted on his left heel on 10/17/11. Review of R1 ' s record revealed that the facility had a care plan in place to address R1 ' s problem related to his " Potential for alteration in skin integrity " and put in place preventative measures such as " Nurse will assess resident ' s skin on admission, readmission, every week, and as needed, " Staff to assist resident to the extent required with turning and positioning every 2 hours and prn (as needed) " and " Staff to check skin every 2 hours and report changes to nurse/DR. " However, the facility failed to recognize and/or identify signs and symptoms of impending risk factors such as reddened skin and/or callous or anything abnormal during every 2 hour skin assessment, as directed in the October, 2011 CNA ' s ADL Care Flow sheet prior to 10/15/11. In addition, one of the preventative measures identified in the care plan dated 9/28/11 was the use of heel protectors while in bed (off load the heels). The facility failed to demonstrate that this preventative measure was consistently implemented before 10/17/11 and CAN ' s ADL Care Flow sheet. The " heel floats " were included in the CNA ' s " Resident Care Profile " on 11/16/11 when it was updated and on TAR to ensure that this preventative device was consistently implemented. The pressure sores on the right heel and left heel were discovered as Stage 2 and eventually declined into an unstageable stage. Review of R1 ' s " Weekly Full Body Assessment " the location on the body diagram of the left and right heel skin issues (circled) indicated the underside and back of the heels. The implementation of the heel protectors/loading to bilateral heels was initiated on 10/17/11 as documented in the TAR when R1 ' s Stage 2 right heel wound was identified/evaluated by the wound care nurse. Again, it was not included in the CNA ' s ADL Flow sheet even though the CNA ' s provided the daily care for R1 to ensure that R1 had the heel protector device and/or the off load consistently. Additionally, R1 was admitted to the facility on [DATE] with a skin tear on his right buttock. On 11/7/11 a note was documented on the " Wound Notes " which stated, " Received report of open area on sacrum. Upon assessment bilateral buttocks, red, non blanchable with excoriation across area ...New order received - cleanse buttocks with soap and water-apply [MEDICATION NAME] (moisture barrier cream). According to the 11/2011 TAR, treatment was being applied3 times a day (all 3 shifts). However, there was no record found of a weekly wound assessment/daily nurse ' s notes on the condition of this excoriated buttocks in the resident ' s clinical record as required by R1 ' s care plan. On 11/14/11 at 0140 AM, R1 was sent out to the hospital after an incident of fall. According to the hospital record ' s " Forensic Evaluation " dated 11/14/11, R1 was assessed with [REDACTED]. R1 returned to the facility on ,[DATE] at 0900. No record of assessment was found related to the hospital findings on the buttocks.

Based on record review, staff interviews, observations, and review of facility investigation documentation, it was determined that for one (1) resident (R4) in the sample of seven (7) the facility failed to provide adequate supervision to prevent accidents. R4 was known by the facility to be at risk for falls based on her history of falls with injury; left sided weakness as a result of a stroke (cerebral vascular accident); impaired memory with attempts to ambulate without first calling for assistance; and unsteady gait. The facility failed to develop and implement a plan for frequent staff supervision (more often than every 2 hours) and supervised ambulation of R4. Nursing documentation and interviews revealed a lack of effective communication between the physical therapy staff and nursing staff which resulted in R4 having access to use her rolling walker without staff supervision. On 1/30/11, R4 exited her room unsupervised, walked down the hall approximately 15 feet to the next door, and entered a stairwell through an alarmed door. A motion sensor in R4 ' s room sounded an alarm but there were no staff members close enough to R4 ' s room to hear this alarm. Staff members did hear the stairwell door alarm and a staff member responding to this alarm arrived at the door in time to hear R4 falling down the stairs with her walker. R4 landed on her back at the bottom of the stairs sustaining a large hematoma of the forehead. R4 was then transported to the hospital via 911. Findings include: R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. R4 was at risk for falls at the time of admission and remained at risk for falls according to the following facility documentation: -a fall at home two days prior to admission resulting in bruising (12/3/10 4:15 PM nursing note); -a fall in the facility on the day of admission (12/3/10 10:56 PM nursing note); -left sided weakness (multiple nursing notes including 12/3/10 4:15 PM, 12/10/10 2:15 PM); -an unsteady gait at times (multiple nursing notes including 12/3/10 10:56 PM, 12/7/10 10:16 PM, 12/8/10 10:30 PM, 12/20/10 11:21 PM, 12/27/10 11:18 PM, 1/7/11 11 PM); -forgetfulness (multiple nursing notes including 12/3/10 10:56 PM, 12/6/10 11:41 PM, 1/12/11 6:30 AM); and -confusion (multiple nursing notes including 12/3/10 10:56 PM, 12/4/10 4 PM, 12/6/10 11:41 PM, 1/9/11 2 PM, 1/12/11 6:30 AM, 1/17/11 8:15 PM, 1/21/11 3 PM - 11 PM shift). On 12/15/10, R4 was discharged from skilled physical therapy " due to insufficient progress being made. (R4) has maximum difficulty with weight shift onto the left lower extremity and tends to resist efforts to get her to do so at times, making ambulation unsafe. (R4) requires assistance to ambulate. She does not use an assistive device " . No equipment was recommended for R4 according to this discharge summary. The Acting Rehabilitation Director (E4) stated to the surveyor on 2/16/11 at 3:40 PM that she had called R4 ' s husband and asked him to take R4 ' s walker home but she did not know if or when R4 ' s husband had done so. Nursing notes dated 12/20/10 11:21 PM, 12/27/10 11:18 PM, 1/7/11 11 PM, indicated that R4 did have access to and was using a walker. In an interview with the surveyor on 2/17/11 at approximately 9 AM, E5, the Physical Therapist who routinely treated R4 stated that R4 ' s husband had returned R4 ' s walker to the facility at some point because the nursing staff used it to walk R4 to meals. E5 stated that he did not expect the walker to be left at R4 ' s bedside and that it should have been folded up and off to the side of the room out of R4 ' s sight. When reviewed during the survey, the care plan and CNA documentation forms did not include any instructions related to where the nursing staff should have kept R4 ' s walker when she was in her room. According to the initial MDS assessment for R4 completed on 12/16/10, R4 was not independent with ambulation. R4 required limited assistance of one staff member for transfers, ambulation, and toileting according to this assessment. This assessment also indicated that R4 had a history of [REDACTED]. The care plan developed for R4 by the facility also indicated that R4 was not independent with ambulation. According to the care plan developed on 12/3/10 for R4 ' s " potential for injury related to: weakness, history of falls and fracture, psychotropic medication use, unsteady gait " instructed staff to " assist resident with transfers as appropriate, 1 person supervision " . The care plan developed on 12/3/10 addressing " (R4) unable to do own ADLs (activities of daily living) without assistance, (R4) requires minimum to extensive assistance care from staff, care needs fluctuate " instructed staff to " assist resident (R4) with mobility as to extent required, 1 person assistance- supervision to minimal assistance " and provide toileting assistance every 2 hours. The care plan did not address the issue of frequent staff supervision of R4 who was known to have confusion, forgetfulness, and an unsteady gait. The Monthly Functional Care Summary completed by the facility ' s RNAC on 1/3/11 (4 weeks after R4 ' s admission to the facility) indicated that R4 always required physical assistance with walking; needed supervision with toileting; and was " very unsteady " with " no short term memory " . As of 1/3/11, the care plan for R4, however, still did not include a specific, individualized plan for frequent staff supervision of R4. According to a 1/5/11 5 AM nursing note, R4 " was found on the floor during our routine rounds " and had hit the right side of her head resulting in swelling near her eye and a 1.5 cm by 1 cm by .5 cm laceration. Paramedics were called to the facility and R4 was transferred to the hospital. Following this fall, the therapy staff completed a " Therapy Fall Screen " and documented that R4 had lost her balance and had attempted to get up on her own although she required staff assistance. When R4 was readmitted to the facility on [DATE], she had a new [DIAGNOSES REDACTED]. R4 returned to skilled physical therapy on 1/11/11 and in a progress note, E5 (PT)documented that R4 " appears to be orthostatic, which may explain recent bouts of falls and (R4) reports ' dropping suddenly ' " . New care plan interventions implemented by the facility following R4 ' s 1/5/11 fall included: moving R4 ' s bed against the wall and adding a bed alarm. No plan for increased staff supervision was implemented although R4 was now known to have the additional risk factors of syncope and orthostatic blood pressure changes. R4 had an episode of syncope according to a 1/11/11 9:30 PM nursing note and " staff was able to assist (R4) to chair without incident " . On 1/12/11 at 6:30 AM, a nurse documented that R4 needed " constant reminder to maintain safety " . As of this date, however, R4 ' s care plan did not include more frequent staff supervision than the routine every 2 hour rounds to provide assistance with toileting. R4 was " found lying on floor alongside bed " according to a nursing note dated 1/23/11 and timed 7:25 PM. Following this fall, the facility added a motion sensor to R4 ' s room as documented in the care plan, however, increased staff supervision was not implemented. In a progress note dated 1/25/11, E5 (Physical Therapist) documented that R4 had a " poor short term memory " . According to the PT Discharge summary dated 1/27/11, a rolling walker was recommended for R4. The last note documented by E5 indicated that he had been notified by nursing staff that R4 " was seen ambulating throughout the unit today without complaints of pain, but that (R4) fell asleep in someone else ' s bed " . E5 documented that a " Restorative Nursing Program for ambulation was completed " . As of 1/27/11, there were no specific nursing instructions for the staff to follow concerning where to keep R4 ' s walker when she was in her room. E5 confirmed to the surveyor during the survey in an undated written statement that there was no clear plan communicated from the rehabilitation staff to the nursing staff regarding this issue. E5 further wrote that a new process to promote improved communication between the two departments was being developed. The Restorative Nursing Program (RNP) form completed by E5 instructed the facility nursing staff to " please ambulate (R4) with close supervision and rolling walker " starting 1/27/11. In the written statement provided to the surveyor, however, E5 wrote that he had filled out the RNP form but had not established the program with the nursing staff and the program had not been implemented on 1/28/11, 1/29/11, or 1/30/11. The facility ' s RNP nurse, had stated to the surveyor on 2/18/11 at 2:40 PM that the RNP for R4 had not been communicated to nursing and had not been implemented prior to R4 ' s fall on 1/30/11. As a result, R4 did not have a plan in place to received supervised staff ambulation on 1/28/11, 1/29/11, or 1/30/11. On 1/30/11 at approximately 10 PM R4 " went through the (stairwell) door and fell down the stairs " sustaining a moderate injury (hematoma to forehead) according to the facility ' s report to the State survey agency (DLTCRP). In the 5-day follow-up report to the State survey agency, the facility reported that the " staff was alerted to the stairwell by the fire door alarm. She (R4) was found at the bottom of a stairwell that was located outside of her room on the other side of a locked / alarmed fire door. She (R4) was lying on her back with her legs up on the bottom two steps along with her walker. There was no LOC (loss of consciousness), she was awake and conversing with staff. (R4) had a hematoma on her forehead and a skin tear to her left arm " . The facility further reported that following this fall, R4 was to be moved " to a room that was visible from the nursing station and away from the stairwell. (R4) uses a walker for ambulation but is to have assistance " . In an interview with the surveyor on 2/16/11 at 1 PM with the facility ' s ADON (E3) present, E7, the RN Unit Manager for R4 ' s unit, stated that staff heard the stairwell door alarm at the time of R4 ' s fall but had not heard the motion sensor alarm that was also sounding from R4 ' s room. E7 explained to the surveyor that the motion sensor alarm could only be heard if staff was close to R4 ' s room and could not be heard down the hall at the nursing station. Surveyor observations revealed that the room where R4 resided at the time of the 1/30/11 fall was down an angled hallway from the nursing station. The door to R4 ' s room could not be visualized from the nursing station due to the angle. E7 confirmed that on 1/30/11 the staff at the nursing station could not hear the motion sensor alarm that was in the resident's room. Observations on 2/18/11 at approximately 3:20 PM revealed that the stairwell door was the next door to the left of R4 ' s room at the time and was located approximately 15 feet down the hall from her room. In an interview on 2/18/11 at approximately 1:30 PM, E2 (DON) told the surveyor that 4 months ago the facility had obtained a motion alarm system that had a transmitter device which would allow the alarm sound to be heard at the nursing station. E2 explained that there were issues related to the proper functioning of the system and it was not in use for R4 as a result. E2 further explained that R4 had a pressure alarm on her chair and a pressure alarm on her bed in addition to the motion sensor meaning that 3 different alarms were in use. According to a written statement dated 1/30/11 by E11, the RN who first responded to R4 after the fall down the stairs, E11 had heard the stairwell door alarm sound at approximately 10 PM and saw the " rear stairs " light on at the nursing station. E11 wrote that she went quickly to the stairwell and saw E12, a CNA from another unit, arriving at the stairwell door ahead of her (E11). E11 wrote " Just as he (E12) looked through the door window, I heard the sound of (R4) falling down the stairs. I went to (R4). She (R4) was lying flat on her back with both legs resting on the bottom 2 steps. Her walker was at the bottom of the stairs between her legs. She (R4) was dazed but conscious. She had a skin tear on left lower arm, large hematoma on mid-forehead. Asked her why she wanted to go downstairs. She didn't answer why. As time passed she (R4) became more alert and wanted to get up " . E13 (the RN shift supervisor) wrote in an undated note that she had turned off the motion alarm in R4 ' s room after R4 ' s fall confirming that the alarm was sounding but no staff had responded because no staff was close enough to R4 ' s room to hear it. In a written statement dated 1/30/11, E10 (RN) documented that she had last seen R4 at approximately 9:35 PM (about 25 minutes prior to the door alarm being heard) and that R4 was " laying in bed with clothing on and no covers " . According to the Patient Care Report completed by the EMTs (Emergency Medical Technicians), R4 reported pain of the neck, back, and head upon their arrival at 10:07 PM on 1/30/11. The paramedics arrived at 10:14 PM and in their report wrote that " Nursing home staff advised patient (R4) was found at the bottom of the stairs unresponsive " . The paramedics also documented that R4 " presented with a long fall, about 10 steps, positive loss of consciousness and unresponsive for nursing home staff " . At the hospital emergency department (ED), the physician documented that R4 had a large hematoma of the forehead and abrasions of the left forearm and left gluteal area with a pain level reported by R4 as a " 10 " out of 10 on the pain scale. According to the Emergency Physician Record, the ED physician ' s clinical impression was concussion with loss of consciousness. R4 was discharged from the hospital the following day and returned to the facility. During the survey, it was determined through interviews that facility nursing staff caring for R4 did not understand R4 ' s need for staff assistance and supervision when ambulating or using the bathroom. These interviews further revealed that staff did not understand R4 ' s memory impairment which caused her to attempt to ambulate on her own without first calling for staff assistance by activating her call bell. For example: -E8, the CNA assigned to R4 on 1/30/11 when she fell down the stairs stated to the surveyor on 2/18/11 at 3 PM (in the presence of E3 (ADON) that R4 could use her walker independently and that R4 used the call bell to call for assistance. E8 further stated that the walker had been left near R4 in her room and that R4 was checked on routine rounds every 2 hours or when R4 activated her call bell; -E9 stated to the surveyor on 2/18/11 at approximately 3:20 PM (in the presence of E3) that he left R4 as she was going into the bathroom on the evening of 1/30/11 (approximately 45 minutes prior to R4 ' s fall down the stairwell). E9 ' s statement to the surveyor was consistent with his written statement dated 1/31/11 in which he wrote that he " left her (R4) standing outside of the bathroom " . E9 further stated to the surveyor in the 2/18/11 interview that sometimes R4 needed staff assistance and other times she did not; -E10, the nurse assigned to R4 on the evening she fell down the stairs, stated to the surveyor on 2/23/11 at 11:45 AM that she worked on various units in the facility but was familiar with R4. E10 stated that the walker was usually left near R4 and that R4 was able to use the walker independently. E10 stated that R4 was checked every 2 hours which was the usual routine in the facility. At the exit conference, the surveyor was advised by E2 that R4 ' s access to her walker had been reviewed and a new plan had been developed. In documentation subsequently provided to the surveyor, E5 (PT) documented in a progress note dated 2/24/11 that following consultation with a Clinical specialist, it was determined that " a walker at the bedside may best mitigate the risk of falls as long as staff respond to alarms, and that alarms are working " . E5 also documented that the facility was " ordering a helmet as well to protect (R4 ' s) head " .